How Place Shapes Health: Dr. Rebecca Boulos on Optimism, Stress & the Power of Small Shifts

And today I have with me Dr. Becca Boulos, who is the Executive Director of the Maine Public Health Association. And I'm really interested to talk to you because public health is, I have an MPH and in Maine we have a now very strong public health infrastructure set up, but that hasn't always been true, and I suspect you've been right there trying to build that infrastructure. So I want to hear about your experience. Yeah, yeah. So I mean, I just really want to thank you so much for having me on the podcast. And I think one of the things that I like the most about public health is when people work together, when they have a shared goal, and we really see that across Maine at the local level. And so to your question around infrastructure, one of the examples of that that I think really resonates is during COVID around the state, local community groups really wanted to help their community. And some of these were folks who had expertise in public health and some weren't. And they just formed, they got together and they worked together to figure out what was going on with vaccines or how to support people if they had to isolate or get access to food or whatever they needed. And I just loved that convening of local people coming together to solve a common problem. And that's really what we see, I think, around the state with our broader infrastructure, our people coming together both within government and outside of government for different nonprofit organizations, just different parts of society coming together to solve really complex issues that we're seeing around the state. So you and I both having been doing this for quite a while, for you, two decades for me, a little longer, but who's counting really? We both, I think have seen this evolution of what is now being, I believe called social drivers of health. I think for a while it was social determinants of health. Before that was, I think it was just called things that caused people not to be healthy, that weren't specific to their, I don't know, lab work. I don't know what exactly it was called, but these, as you said, complex. Wow. I mean social drivers of health are anything from literacy levels, education levels, access to clean water. I mean, where do you start when you are in public health? And these are all the things, it's literally people's entire context that you are dealing with. I think the first thing is just raising awareness about that. I mean, I think it can be easy to not recognize all those different factors that impact us. Mean like you mentioned our income or our education, but it's also marketing. It is social media. I mean, it's so many different pieces of the way and where we spend our time. And so I do think part of it is just raising awareness. And then the other part of it is those same strategies that can harm our health can also help our those same avenues. And so part of it is kind of flipping the switch on those things. And we look at policies around housing, around education, around allocations of our budget. We can switch those. And I think a lot of it again kind of comes from what I was saying before, people coming together to solve really complex issues. And the other part of it that I would think too is there is a tension when we talk about the social drivers, when we talk about other determinants of health, there's kind of this tension and belief about individual choice and someone's choosing to do X, Y, and Z, and then these other contextual factors. And there is some tension there. I mean, at the end of the day, any day someone can decide, I'm going to go home and watch TV, or I'm going to go home and go for a bike ride or go for a walk. And yeah, that is a choice. At the same time, if where they live to go for that walk or that bike ride is really beautiful, it's safe. There are sidewalks, there's some kind of separation between cars and where they're cycling or walking, that's great. And if where they live, it's not like that and there's a lot of air pollution or there's community violence or there's a lot of traffic, whatever it is that can influence that decision. And that's not necessarily within their control, but those are policy levers that we can pull to change that dynamic. And so when I think about public health, and when I think about addressing these drivers, there are certainly individual choices, but there's also a lot that we can do as society to address these different determinants to help really lift, raise all boats in that kind of framing. I love the hopeful approach. I think that is really important. It would be easy to say, well, I can't change everything, so I'm not going to change anything. And saying, well, there are levers that can be pulled, there are processes we can follow to actually enact change. As somebody who's been in leadership who's been working on enacting change, what are some of the things that you have found to be successful in moving those levers? That's a great question. I think there are a few things. So I think at the individual level, just as an individual, you can look at the choices that you can make, that you really can make because there are some, and there are some that you can't, but there are some you can make that when you make that choice, you are making some incremental change in terms of improving your health. And an example for me really comes down to stress. It's an area I studied for my PhD. It's an area I care a lot about. Today, I was running late and I was stressed because I knew I was going to be late. So my heart rate was up, I was kind of anxious, whatever, but I'm not actually, me being late was not actually going to cause something really bad from happening. And when you think about our flight or flight response, which I was experiencing in that moment, we kind of evolved to this place where we have constructed external stressors that really they activate our internal fight or fight response, but they aren't actually going to harm us. We're not running on a tundra from an animal that's trying to eat us. And so an individual choice there really is kind of reframing those stressors and thinking, is there a different way I could respond right now? Can I leave a little bit earlier? Can I call and let someone know that I'm running late? I think that because we've evolved to this place where we aren't having to worry about our safety from a natural predator, we've kind of constructed these reasons to be stressed out or to have kind of exclusionary relationships with other people. So I think part of it in terms of starting at the individual level is really kind of reflecting on that and what can I do differently? How can I interact with people differently? How can I cope with stress differently? And then when I look at the state level and the policy levers that we can pull, one of the challenges that we're facing right now in public health and really just in society more broadly is around communication and it's around misinformation. And some of that is intentionally spread for whatever reason. And so when I look at the policies that are being proposed and passed, the challenge is around evidence and what is the science behind this and is there a reason to think that this actually will achieve the aim that we're trying to achieve and will it benefit health? And so a lot of my time really at the State House is spent researching, looking at the literature, what does this policy say? Why would we think this would improve health? Why wouldn't it? And I love getting to use my research background for that. I find it really valuable for me personally to get to do that. But it's hard. It's hard to pass really good public policy. There's a lot of different interests and different perspectives, and it's not a soundbite. It's really hard to pass comprehensive, really thoughtful policy and thinking about the different impacts that it could have for different populations around the state. It's not a uniform necessarily uniform impact. So that's an example I think of a policy lever is just paying attention, like I said, to the research and the science and how do we make sure we're passing evidence-based policy. So you talk about the research and understanding and having the knowledge, and then you've also mentioned communication, social media, and one of the things that I know we've found challenging is really how knowledge and information has become divisive. And it causes people who you really want to engage in the change process with you to have an opposing view because they've taken their perspective of the information. And so the idea isn't that we show up and say, no, you are wrong, and I'm right going to convince you that I'm right and you are wrong because that's not useful. So how do you approach having a conversation around information so that you try to understand where somebody else is coming from and they understand where you're coming from and you are actually able to impact that change? The biggest part of that is actually having that conversation. That doesn't always happen. It can be so easy behind a keyboard, especially to just keep throwing stuff out and not actually engaging. And so I don't engage on social media with that. If I have a policy debate or discussion, my response is always, let's talk about it in real life for a lot of reasons. I think that you can have this kind of back and forth where someone shares their perspective. I share mine, we look for either commonality or where we disagree, and it happens in real time without these delays. And anyway, I think that taking that debate out of the social media space is really important and having it in real life. There's also the human connection element. When you're seeing someone face to face, it's a little bit harder to maybe say some of the things that you might be saying behind a screen. I also think that, I mean, this is where art I think comes into it is with imagery, with storytelling, with videos, photo, voice, example. Example that really sits with me is that there was a research project when I was at UNE when I was on faculty, there was a project with people who were living in some homes around the university. And one of the submissions that someone did was they took a photo of a fence, a chain link fence in their neighborhood where they lived and ask people, what do you think about this? And a lot of the people in the audience thought that that was an indication of stay out, stay out of my property. This fence is here to keep you out. And that was not how the person who took the photo felt, they saw it as safety, I'm protected by this fence. And actually, I mean, I just got goosebumps. I just think about how we have these images that we see and maybe someone shares it on social media, maybe we see it in advertisement, and we can take different things away from that. But having the conversation to learn and understand, what did you see here? What did I see here? And where is there some synergy or an opportunity to learn or grow or understand someone's perspective? I think that's really important. And we used to have that, and I think that we've kind of gotten a little fractured, but I think we can come back to that. One of the things we're doing at Maine Public Health Association is my colleague Matt Wellington started, he has his own podcast or we have one, it's called Healthy Maine Talks. And through that, the point is to go on the road and to talk with people about what matters to you in your community, what's on your mind. And we've just found so many people want to talk about connection. They want to talk about relationships, they want to talk about connections with humans, but also with nature. And so we are craving that even while we're kind of in this ecosystem of divisiveness, we crave the connection piece. And so part of it really is figuring out how to continue facilitating that and building it back up. I think that's so powerful, the idea of a conversation. It seems like such a basic thing it does to do. And yet for some reason we've gotten away from it. And I'm glad to hear that you're coming back to it. And also, I love the idea of incorporating images When I'm, as somebody who is still practicing medicine and I go online and I look for information, it's largely words, words, words, words, words, words. And I think patients, even when they're searching, there's a lot of words, but what's really powerful when I want to diagnose a rash is to see a picture. Here's A picture of this thing. Oh, that's what it's caused by. Thank you very much, Dr. Google for helping me out, for reminding me of something that I learned in medical school. So I think also meeting people where they are from a communication standpoint, whether it's auditory for them or visual or kinesthetic. So are there other things that you're doing with the Maine Public Health association that kind of fall under that umbrella? Yeah, our annual conference this year is exploring just that. It is exploring community connection through a few different ways. So some of it is visual, it is auditory, it's through conversation, whether it's through the podcast. But I also, one of the things I really love are community spaces that we go to without formally thinking, oh, I'm looking for community. I mean, bingo halls come to mind. That's a place to have community. They're all kind of competing. They want to win the bingo card, but they have their community there. I love that. My friend is a flamenco dancer, and I went to her show last weekend. It was such a beautiful, I mean, it was emotional. It was such a beautiful performance, and there were people there of all different ages and skills, and it was very intimate. It was in a small space. And so I mean, with dance, you can connect with each other with that too. And then there's obviously the health component of being physically active and using your brain in different ways. And so I just think there really is a place and intersection between the arts and health and between connections with one another through different modalities. The other thing that comes to mind is I used to race a little bit more competitively than I do now, but I always loved it at triathlons in particular, you saw everybody. I mean, there was everybody there and everyone was just there for their own health, their goals that they were achieving. It's very emotional to see that and to share in that space with all these other people that are doing the same activity you're doing. But we're all there to advance our own health goals. So when I think about what MPHA is doing, it is trying to be in these different spaces. It's trying to be both in community, it's trying to influence public policy, it's trying to do it through education. And then when I think about it, like I said, with us as individuals, it's looking for that in our own places too. What you're describing, this being kind of pulled emotionally towards something is an important thing for us all to remember is that as much as we can be influenced by words and ideas from a rational standpoint, the emotionality of something, it just reaches us in a different way. So my husband and I were down in DC over Memorial Day weekend and they had the rally of veterans and people who support veterans that were wanting to show support for veterans. And I've never been on a motorcycle. I think it'd be kind of fun to go on a motorcycle. I'm sorry, I know you're in public health. Probably not a political thing to say. But anyway, just the fun side of me is I think that'll be fun to try someday. Anyway, but watching people, there were just so many people that came out not only to be on the bikes, but also to be watching. We were standing on the corner, we were right across from the capitol building or watching the people go by. They had dogs, they had flags, they had partners. And I actually, I started crying because, and I don't know why, but there was something about it that just was like, wow, these people are doing this amazing thing and they've put so much into it. And I wonder if that's the way to help people with public health is to say, alright, we want to move towards this thing, this commonality. Yes. And I think it is through that community building. I mean, people want that. It's more harmful to our health when we're not connected, when we're socially isolated, that is worse for us than to be connected. There's a lot of research that has looked at that. So feeling socially isolated as akin to smoking a pack of cigarettes a day in terms of our health, I mean, it's really significant. The stress that is associated with it is also significant for our health. So I do think working toward community is important. The other day I was driving and I was at a four-way intersection at a red light, and I just was struck by how much about that intersection required us working together. I was struck by me stopping the other people stopping. We were obeying this light, this red light and the other cars in green were going. And I was struck by that, and I was struck by the sidewalks and the park and the businesses, the school, there was so much about that intersection, the crosswalks, the signage. I mean, we all worked together as a society to create that. And we're all working together as a society to maintain it without people running through lights. And so when I think about your story, your example about seeing people at a parade and having community, I also think we have that just in the way that we can operate with each other, just being respectful, obeying traffic laws. But we've all just committed to trying to have a better, higher functioning society and continuing to do that and continuing to try to find ways to work together to see each other, to connect in real life, not always on online. I know there is certainly a place for that. I don't mean to make it sound like I don't think that, but I think we've kind of gone a little bit too far maybe in that direction, need to come a little bit back. And the other example that I think about is I lived in Maine in 1998 and there was this epic ice storm. The ice storm of 98. Everyone still talks about it. That was here. I was there. Yeah, here I was here. Yeah. Right. So you remember, I mean, it was shut down. Nobody had power, no one had anything. And people helped each other. People who had generators helped each other, people checked on their neighbors. And it was a long time for some people that didn't have power, but I really felt like the state came together, people came together to support each other. And that happens a little bit. We've seen that a little bit with some of the storms that we've been having, the more extreme weather events, a little bit of that happening, but it's not quite the same extent as I distinctly remember it back in the 90's again, trying to build upon that. We've been here before, we've been supportive before. How do we get back to that? I think we want it. It's just figuring out what's that path look like. You have a very impressive background. You have starting from your top degree, your terminal degree, they call it your PhD in food policy and applied nutrition from Tufts. You have a master's in public health in social and behavioral sciences from Yale. You have a BA in communications from George Washington University and you completed a USDA doctoral fellowship in obesity. That's a lot of years of, it's a lot of time, a lot of of education. And it sounds like you've been able to draw on not only your education and your background to really put this to good use, but also you're a lifelong mainer. Talk to me about that maine connection and how that has woven into the approach that you've taken with your professional life. Yeah, yeah, thank you. It's a good question. I love Maine. When I was growing up, I actually couldn't wait to leave. I was ready to go live someplace else, be someplace else, but then I couldn't wait to come back. I mean, even my first semester of college, I was coming home quite a bit. I just really missed it. What I love about, there's a lot of things I love about Maine. One of the things that really resonates the most with me and that I think about for my own self too, really is this dual ethos of self-sufficiency and wanting to take care of yourself. And you are going to chop your own wood or do whatever it is, oops, I'm sorry, live off the land. Just have your own, some self self-sufficiency, but then also the community support and how to, going to shovel at your neighbor, see if they need anything from the grocery store. We were just talking about the ice storm. There's that kind of dueling piece of both wanting to be independent, but also wanting to care for other people and being able to accept help when you need it. And that's how I think about myself too. When I look about my academic background or my professional, whatever it is, I try to have that same piece where I do my thing and I try to work really hard and have some intrinsic motivation, but then also not being afraid to ask for help and to look for it. And I feel like with every achievement that's been there, there's always community support. It's impossible I think, for us, anywhere in our lives to do things totally independently. And so that's one piece of me that I really love. I also love that Maine's called one big small town because so many of us have connections, and I've absolutely found that. And I like that. I like sense of community that we have and that when something impacts one community here, you can kind of feel it around all the other communities. And I really appreciate that social fabric. And one of my favorite parts of my job, I was talking earlier about going to use my research background, but the other part of it is I care a lot about Maine. I care a lot about the mission of Maine Public Health Association to advance the health of people in places in the state. And that's because that's also my personal mission. I love that. I love getting to weave those together in terms of what I'd get to do every day for work, but also what I find valuable for myself. I just love our state. I just think we live in a really beautiful place, and I think there's some really wonderful people who live here. Where did you grow up? I grew up in Cape Elizabeth. Both of my parents were from Portland. My mom went to Deering High School and my dad went to Portland High School. They met at Friendly's. So when I was in high school, I didn't have a boyfriend. They were like, you got to go to Friendly's, meet your boyfriend. I didn't. But it was really funny that that was their view. And I really do come from a long line of people in Maine. A lot of their families, a long way back are from Maine. And yeah, I graduated from Cape Elizabeth High School, and my siblings, I'm the oldest of four, and they're all out of state now, except me. I'm the only one, like I said, that couldn't wait to come back. They're all like, oh, we're going to go someplace else. One of the more impactful experiences in terms of me being a little bit more oriented toward those social drivers of health was our senior year of high school. We did some type of learning project. I don't remember what we called it, but we had to pick some kind of community service activity. And I volunteered in a school, and it was really the first time that I started to kind of understand where we live impacts our health. And it wasn't very far away. It wasn't far from Cape, it was within driving distance, but I saw the difference of the neighborhood. I saw the difference of traffic of the school facilities. And I just at 17, 18, I just hadn't seen that before and I hadn't really thought about it. So it was really my first time. And then I went to school in DC and it was much more pronounced for me to see what the difference is by neighborhood. You're on one street and you feel safe and you go to the next neighborhood and you maybe feel a little bit not quite as safe. And I did AmeriCorps while I was there. I volunteered in a Head Start classroom, and it just kind of continued, like I said, for me to grow a little bit in terms of understanding where we live, where we go to school, what opportunities are available to us, and the adage that our zip code is a stronger determinant of our health status than our genetic code really made sense to me seeing that. The other thing that I learned in college, and this kind of feeds into my interest in social and behavioral sciences, was I was teaching weight training classes at the gym, which is kind of funny. Now I don't do very much weight training anymore, but I used to be really into it. And my students were actually fellow undergrads, and they would come in with all these articles that they read and shape and women's health and fitness, all those magazines you see at the checkout counter. And they'd be really worked up about fat in avocado. I'm not going to eat avocados anymore. There's too much fat in them. But they'd go binge drinking at a party on a Friday or Saturday night. And that really stuck with me at 21, 22, just noticing that, how are you deciding that? How are you deciding that you're not going to have avocado? There's too much fat, you're going to come to my weight training classes, so you're exercising, going to the gym, and you're going to go have all this alcohol that's really not good for you either. So then that's where the social piece came in. So there's the social element of going to a party, which was more of a determinant for them than the alcohol was necessarily. So I just, between that and between the AmeriCorps experience and then growing up here, and again, seeing where we live impacts so much of our life really got me interested in social and behavioral sciences. What does that intersection look like? What impacts how we perceive the world, our attitudes, our beliefs, what we value. In grad school for my master's, I was studying optimism and I was studying how people cope with stress. If they cope with it more optimistically, then pessimistically, what does that do for their health? And then that led me to study stress for my PhD and how our stress, the nature of our stress and how we cope with it, how it impacts our weight status over time. You can see it. I mean, I think even for me, like me, when I think about the different types of stress I have, I cope with those differently. And so knowing that and knowing now that there's more research on this, what can we do? Going back to those policy levers, what can we do to influence the stressors that people experience so that we can reduce it and then provide for them healthier ways to cope with that stress. So if someone copes by eating more or someone copes by exercising more, how do we make sure that they're able to eat healthier foods or have a safer place to be physically active? And I think there is almost this sense because married to somebody from Northern Maine and Maine is very different in different parts of the state. It's a very large, geographically, it's a very big state from top to bottom. But even within Yarmouth, I mean, you can't assume that because somebody, you just said it, you can't assume that because somebody grew up in Cape Elizabeth that they grew up in the type of Cape Elizabeth that you believe that they are from, you can't assume that everybody from a town that maybe has a high net worth zip code creates the same opportunities for everybody. That's right. And you can't even assume people's backgrounds because I think you and I actually have very parallel stories. I mean, my father's from Biddeford, my mother's from South Portland, my family's been in the state for generations, and nobody in my family up until a certain point went to college, certainly did not get any beyond college degrees. So I think that even that context, that background. And so I think when you laugh, I'm thinking, yeah, I can understand why she's thinking. People will look at me and they'll say, okay, Elizabeth, what would she know about it? But you can never make an assumption. You just really never know. And I just love the fact that this is where you grew up. You had this experience, you had this interest, you took your education. You're using it to further the public health in the state of I think that your point about you can't just assume that because someone's from a certain place that they have a certain experience growing up in that place. I think that's really important. Where you grew up does matter in terms of your health opportunities, but the experience of growing up there is going to be really different for people. And I think, again, kind of having that space for some empathy or for a conversation and not having that immediate assumption is really important. I think it's really, really important. My sister and I, we like to do some kind of extreme activities, I guess, and we were skydiving and the instructor asked where we were from and we said, Cape Elizabeth. And he said, oh, you're from Massachusetts. It's this extension from his perspective that Southern Maine is an extension of Mass. But I'm kind of going off script here a little bit, but I just think, yeah, I think that having some compassion and some space for having those conversations is really important. And I do think that you can sometimes use geography as a connector, and it's sometimes can be used as a disconnector, but there are always things that you can come back to if you want to. And having that space and giving people the opportunity to be more than what they appear to be. But that does take sitting with them and having a conversation. It is more than a soundbite because people are more than just a picture on a screen. And I think that that is for me, why I'm so pleased to hear that you have a podcast that goes on the road because not only are you providing space, but you're actually meeting people in their spaces, which is what I think in healthcare, we've perhaps done not a great job with that. We are like, well, you're over there if you want some health, you come over here, we'll help you, we'll tell you what to do. And then you go back over there. And I don't know what you're over there looks like, I don't know if you are near a pharmacy, I don't know if you have electricity in your home to refrigerate this medication that I'm prescribing for you. I dunno if you have heat, but yes, you go do that. And if you need me, I'm over here. That type of interaction. Also, one of the things we have seen in the podcast is that we do agree on more things than we think we do. And we share more values than I think we do or than I think people think we do. And again, I think that's where that tribalism that we're experiencing now is feeding into. But there are so many opportunities to rebuild that and to have more community and to meet people where they're at and to figure out what works for them. And this is what you have available to you. How can we help? How can we work together to figure out how to maximize your health in that context? I love that. And the fact