Empathy and the Health of Populations.

Before I start today’s Dean’s Note, I wanted to note that this is the anniversary of the Boston bombings. I have written before about the consequences of mass traumas, and wanted to pause for a moment to remember an event that affected the lives of many in Boston.

Moving on to today’s topic, and starting with another mass traumatic event. At about 4:45 p.m. on March 25, 1911, a fire began to blaze at the Triangle Shirtwaist Factory in Manhattan. The factory workers, mostly young immigrant girls, rushed for the exits, only to find that the doors were locked. This was done to prevent unauthorized breaks, discourage theft, and keep out union organizers. With nowhere to go, 146 women died that day, from fire, smoke inhalation, and, perhaps most horribly, falling to their deaths as the flames forced them to jump out of the windows. For years, workers had complained about the unsafe conditions that would eventually lead to the fire—the locked doors, the close quarters, and the lack of proper safety systems—but to no avail. The disaster on March 25, however, galvanized public opinion, and led to a host of reforms that would greatly improve the lives of workers across the country.

Why did these reforms not happen sooner? Terrible factory conditions were an open secret at the time. Yet for years nothing changed. What, then, made the difference? Let us consider the following, more topical, example.

More than 4 million refugees have fled Syria since the conflict in that country began. Often, these refugees flee one impossible situation only to find themselves caught up in another. In urban Jordan, for example, 86 percent of Syrian refugees are living below the local poverty line. Despite such statistics, the international community has not rallied to the aid of these desperate people. By the end of 2015, just 61 percent of the UN’s humanitarian appeal for Syrian refugees had been funded. There was, though, one notable uptick in donations last year. It was after the body of a 3-year-old Syrian boy named Alan Kurdi was photographed lying on a beach, where he had drifted after the boat carrying him and his family away from the conflict apparently capsized. The image of the dead boy was so shocking that donations to help migrants surged in. One charitable organization, the Migrant Offshore Aid Station, reported a 15-fold donation increase within a day of the photograph’s release.

In the case of both the Triangle Shirtwaist Factory fire and the death of Alan Kurdi, we are confronted with the same question: why did these individual deaths rouse public sympathy in a way that tales of death and misery en masse did not?

It is because both stories resonate with our human instinct; both invite us to imagine ourselves in the place of the person, or people, affected, so we might begin to understand how these terrible events can occur. Our capacity for this kind of imagining is called empathy.

Empathy is “the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another … without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner.” It is a quality that has marked us as people, and that has long been admired among leaders and historical figures alike. Shakespeare, for example, pleads fiercely for a more empathetic society. In recent history, Nelson Mandela has shown us the power of empathy when it is allowed to play out on a global, political scale. As Roman Krznaric, author of the book Empathy: Why It Matters, and How to Get It, has written, “Empathy is one of the most effective tools at our disposal for shifting us from a ‘self-interest frame’ of thinking to a ‘common-interest frame,’ where our underlying mode of thought is structured by a concern for both ourselves and others.” Perhaps more resonant in our cultural consciousness are the words of Atticus Finch, as intoned by Gregory Peck in the film To Kill a Mockingbird: “You never really understand a person until you consider things from his point of view … until you climb into his skin and walk around in it.”

Why do we feel empathy? It has its structural basis in neuroscience. When we see someone suffering, the victim’s facial expression, pupil size, and body language can directly stimulate the “mirror neuron” system to trigger an empathetic response, especially if that person’s situation is similar to one we have faced in the past. We now know more about the major role of midline structures that come into play during moments of fellow-feeling. These underlying neurological mechanisms are key to our understanding of empathy. But brain chemistry alone does not fully account for this capacity. There are also psychological reasons why people feel (or do not feel) empathy towards individuals. Psychological and neurological theories suggest that there are two fundamental systems in human cognition: the experiential system and the analytic system.

The experiential system is triggered when we see, for example, the individual victim of some misfortune. When we witness suffering, our experiential system triggers the empathic part of the brain, and perhaps moves us to offer to help the person in need.

By contrast, just as it is easy for us to connect with individuals, it is often difficult for us to empathize with large numbers of people. The reason for this has much to do with the other fundamental system in human cognition, the analytic mode. The analytic mode is triggered when we contemplate populations—tending as we sometimes do to think of them as statistics. This perception can blunt our empathetic impulse, and lead to “compassion fatigue.”

This suggests that, in many ways, our own neurobiology is working against our effort to understand and improve the health of populations. It poses a challenge for us to ensure that people do not become “just numbers” to ourselves or to anyone else. It encourages us to engage with empathy on the individual level, in order to inform action that aims to help thousands of individuals, to help whole populations.

What can we in public health take from an understanding of empathy? Two implications come to mind. First, we must remain humble about how compelling individual stories can be, taking care not to assume that data alone will sway opinions in our favor. Unfortunately we, not infrequently, find ourselves at a loss to understand how so many could have for so long turned a blind eye to the problems facing populations. Recognizing the powerful role that empathy plays in mobilizing action, and conversely how hard it is to act absent a clear focus for our empathy, is a sobering reminder of the hard work we must do to engage others in our project—the creation of the social, economic, and cultural conditions that are needed to safeguard the health of populations.

Second, we must work even harder to relentlessly communicate the ongoing narrative of population health, doing so in a way that is energetic and creative. For example, perhaps the broader tale of Syrian mass migration is indeed too big for any one person to process all at once. On the other hand, the story of Alan Kurdi, dying scared and alone in the middle of the sea, is almost impossible not to connect with immediately on an emotional level. We need to tell these stories—taking great care, of course, not to be exploitative—in order to convey to the world the events and circumstances that are putting populations at risk. We must make storytelling part of our armamentarium.

At SPH, we have a strong tradition of embracing empathy. As we look to continue this tradition, we might want to regard empathy as one of the core competencies we impart to our students, and recognize its value as an indispensable part of the work of public health.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor
Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful for the contribution of Liang Chen and Eric DelGizzo to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/