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Information as a Determinant of Health

About Episode 40

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Dr. Garth Graham, the Director and Global Head of Healthcare and Public Health Partnerships at YouTube, has long espoused the belief that information is a social determinant of health. We had the chance to talk with Dr. Graham at HLTH 2023 in Las Vegas about this concept, as well as the topics of medical misinformation, health literacy, and the role, influence, and responsibility of YouTube – the world’s most popular online video platform – and its parent company, Google, in creating a space where high-quality, evidenced-based health information gets to the eyes and ears of those who need it.

Carol Vassar, producer

Guest: Garth Graham, MD, MPH, FACP, FACC, cardiologist, researcher and public health expert; Director and Global Head of Healthcare and Public Health Partnerships at YouTube


Carol Vassar, podcast host/producer:

Welcome to Well Beyond Medicine: The Nemours Children’s Health Podcast. Each week we’ll explore anything and everything related to the 80% of child health impacts that occur outside the doctor’s office. I’m your host, Carol Vassar, and now that you are here, let’s go. (singing).

What exactly are the social determinants of health? The World Health Organization defines it as “the condition in which people are born, grow, live, work, and age, which are shaped by the distribution of money, power, and resources.” For Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube, information falls squarely into that definition. We had the chance to talk with Dr. Graham last month at HLTH 2023 in Las Vegas about the concept of information as a social determinant of health, as well as medical misinformation, health literacy, and the role, influence, and responsibility of YouTube, the world’s most popular online video platform and its parent company Google, in creating a space where high-quality evidence-based health information gets to the eyes and ears of those who need it.

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube

The idea here is there are a number of things that impact health outcomes that are nonclinical in nature. There’s a wealth of data around food, housing, education and how those play a role in the health outcomes, particularly of marginalized communities. Information is a whole different aspect, meaning if you think about our day-to-day lives, it’s information that people receive that allows them to grasp and understand health information and other kinds of information. They make the right decisions based on it. It’s why we’re all concerned with health literacy and reading levels and the ways in which people get information. It’s why also during COVID, I say as a global healthcare ecosystem, we were sometimes caught off guard that people didn’t always grasp and understand and follow some of the public health recommendations because in many cases people were grappling with understanding the information, understanding how it applied to them, understanding what is the science behind that and their understanding of science.

And so too in many ways, information has and always will be an overlying influencer and have an impact on health. As healthcare leadership, we’ve really spent a lot of time focused on, like I said, reading literacy levels, health literacy as the main definer of that. But truth is, people consume information that they’re not reading. They may be video, it may be even conversational, and so the concepts of understanding health information goes beyond health literacy at a reading level, and genuine health literacy in terms of all the different factors that drive information of change of health information. And so all of this is why information has always and continues to be a important component in health outcomes.

Carol Vassar, podcast host/producer:

And many people will go right to YouTube-

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube That’s right.

Carol Vassar, podcast host/producer:

… To find out what kind of information they may want to know even before going to the doctor. We’ll get to that in a moment. I do want to talk about Dr. Larry Moss, who’s our president, and CEO here at Nemours said in his presentation here at HLTH that there is no health without health equity information quality information equity. Those are pillars of what you do at YouTube and your health information strategy. Expand on each of those pillars and how YouTube is addressing them.

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Sure. Equity is driven by the fact that we know that there are communities that are disproportionately impacted by health outcomes, and then we start to think through how do we reach those communities. There’s an interesting paper that came out in JAMA, Journal of American Medical Association a couple of weeks ago that showed patients are more likely to trust video information from providers who are from similar racial backgrounds and similar backgrounds in general. And it just goes to show you how the health equity in both information exchange has a lot of different contexts. It’s both, again, how we reach people, but also who is providing information, what’s the trust level in that and how engaging is that information.

So that’s one aspect. So for us, we’ve been working and funding and really trying to engage diverse voices to help deal and spread health information globally. We’ve also been purposefully looking at how we can even translate health information or have health information in a variety of different languages. In some instances. Recently we’ve been talking about how artificial intelligence can do it to help us do that, but in other cases, just having different voices with a representation of both racial and language, different populations as well. Okay, so that’s health equity.

Information quality. So how do you make sure that the information that the person gets is not just evidence-based, but engaging and relatable? So we work with a National Quality Forum, recently to publish what are all the components of quality health information online. And it really defines it, again in the aspect of both equitable, but making sure it’s engaging, evidence-based, and is understandable for communities. And so a lot of the partners we’re working with, a lot of the voices that we’re trying to elevate are hopefully voices that represent that component of information quality. For us, all of these components make up a viewpoint of information and getting information to communities at scale. There are 2 billion people in the world that use YouTube on a regular basis, that is about a third of the world’s population. And so we know that we are a primary source for engagement and decision making that people make in a variety of different ways. And the thing is, how do you do that responsibly?

Carol Vassar, podcast host/producer:

As a consumer of YouTube, I have my own YouTube account personally. I have it for some of my clients as well. How can I discern what is quality versus what is misinformation?

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Yeah. Misinformation has been and continues to be enigmatic. It was present in a variety of different ways before the kind of use of technology and the way we use it now, but it’s certainly become more of a conceptual challenge with the use of technology overall. And so we define the concept of misinformation as information that is contrary to established evidence, scientific consensus. And a lot of that, how that’s articulated by government institutions like the CDC, or World Health organizations and others. But again, misinformation is not easily defined except it is really that concept of information that is contrary to what you think of as established science.

Now, as a consumer, we in general have to be very direct in terms of how we educate communities around misinformation, quality information, and also how they’re able to understand how that information applies to them. So for us, we’ve been very proactive in trying to help develop some of the tools and educate patients in the community on that. But as a user, the thing that I often say to even my own family is learning how to discern the evidence that backs the information that’s being presented to you, and being able to then understand what are the differences and what’s the source quality, what is the source of information being articulated? And again, to balance what that information then leads you to do.

Carol Vassar, podcast host/producer:

Which are really the basic tenets of health literacy overall.

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube 100%.

Carol Vassar, podcast host/producer:

How do we expand and get people to know those tenants, know health literacy a little bit better?

Carol Vassar, podcast host/producer:


Carol Vassar, podcast host/producer:

Are we falling down on the job here as a nation?

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Ha, ha, ha, ha. I would say these are global problems, and I would say we need to be more engaged globally, particularly healthcare leaders. We need to educate the world as particularly the patients and communities who rely on the science to save their lives. Meaning if they’re going to take this medication, if they’re going to follow this advice, they need to trust and believe it. So we need to be there in the conversations and be present in the places where people are getting information.

That’s what drew me to this role is we have to be a part of patient’s journeys. And the patient journey is partially that small amount of time they’re in a clinical setting. A lot of it is outside in the world, some of it is online, as many of us are online. When we look up how do we order food, what are we going to do tonight? All of those things, that’s a journey that we’re on. And so for us to be thinking that the patient is going to wait for us to publish it in a journal, and then they’re going to somehow go and pick up their latest issue of the high-impact journal and discern what the Kaplan-Meier curves are, or what the P values are, that’s not practical. So how do we deliver scientific information that’s engaging at scale?

Carol Vassar, podcast host/producer:

How do you ensure that those high quality evidence-based videos or even podcasts, because YouTube is one of the biggest podcast providers in the world, rise to the top.

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Yeah. Oh, one of the things we started, I done is about, geez, about a year ago we worked with the National Academy of Medicine to try to identify credible health sources and a definition for credible health sources. So they came up with a basic definition of credible health sources having a lot to do with this idea of checks and balances internally, and that was for institutions. And then more recently, we’ve taken it to the World Health Organization, others, we’ve taken it to individuals. And so we identify credible health sources. We identify licensed doctors, or nurses, or family therapists, marriage counselors, the people who have credentials, and they get labeled on our platform as this information comes from a licensed doctor, this is an accredited health institution. And they show up early in search results. If you go to YouTube, you’ll see something that says from health sources, and that shows up for anytime people are searching on major health conditions. That is information that is coming from accredited sources, or licensed clinicians, nurses, doctors, therapists, et cetera.

Carol Vassar, podcast host/producer:

When we talk to our patients, we survey our patients quite often. We found that one major barrier to access has been a lack of high-speed internet, of course.

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Of course.

Carol Vassar, podcast host/producer:

Videos take a lot of bandwidth. Even podcasts can have some heavy lift in terms of bandwidth. What can be done to help overcome that issue, especially in rural areas of the nation, or the world?

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Or the world. Investing in broadband or quality infrastructure is important not just for health, but education, particularly where you have younger populations in general that require a diversity of educational resources, and a lot of that’s available online. So I think for us, we continue to advocate for the idea that building up the infrastructure that folks have access to information in a more equitable way. You know what’s funny, when you look across the world, there’s a lot of interesting things where you sometimes go into a village, or a rural community in India, or you’re going into even some countries that would otherwise be thought of as disadvantaged in Africa, or other places. And you see people with phones with, you’re getting information, and they may not have all the other interesting kind of components that you would think of in life that you may need, but that phone becomes a central part of their window to the world and their window to engage. And so the idea of building broadband technological and access to that is really about giving people opportunities in ways that would not come without a tool like that.

Carol Vassar, podcast host/producer:

How does YouTube work on the global level? We think of it here in the U.S. very English-based nation, though we speak many languages in the U.S., but you go outside of here and we’re influencing health across the world. Talk about YouTube’s influence.

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Yeah, our team is global. So we have a team in France, a team in Germany, a team in the UK. We have a team in Brazil, a team in Indonesia, a team India. So across the world in different locations. Where the similar work that we do here, they’re working with the local health authorities, local hospital systems, local healthcare creators like the doctors, nurses, et cetera, to help build that ecosystem because all health is local and there’s a lot of nuances. A lot of the things I’ve just articulated to you, our things that we have also launched in the UK, in France, Canada, Mexico, Brazil, Indonesia, Japan, and all the other different locations across the world.

And that’s because as you just pointed, our onus, our work is entirely global. But I’ll also tell you that healthcare information is shared globally. So you may have Spanish-speaking individuals in Mexico who are sharing content with Spanish-speaking individuals in the U.S. or just even sharing information. You may have French-speaking people in France and French-speaking populations in Quebec, and they may be accessing health content that is language-based in general. So sometimes when we think about how we create health information, because of the nature of online information, you’re not just creating it for this one population, you’re creating it for the world in terms of where other language similar populations are to access that information.

Carol Vassar, podcast host/producer:

Across the world, do you know of any examples of healthcare professionals who are really re-imagining how and where high quality information is shared?

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Across the world. Oh, my goodness. It is happening not just here in the U.S., but it is literally happening across the world. We see some just amazing set of folks, particularly in the UK, in India, in some of these other locations of France where you have clinicians who understand the impact of reaching people with information online. And then here in the U.S. you have both hospital and other organizations that similarly are committed. So these are definitely not regional, local, national. These are global concepts and efforts, but healthcare is local and it is very language-based, so you have to make sure that these are global concepts, but that the information, and the cultural nuances, the engagement is very much more locally focused as well.

Carol Vassar, podcast host/producer:

Is YouTube involved in research at all in the healthcare field? Talk about that.

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Of course. Yeah. There different kind of ways. There’s a lot of people independently of us who do their own research on healthcare information on YouTube, which is also great. We also work with a number of academic institutions on either questions that they may have, questions that we may have. But some of the best research comes just from people who are … Because they know that YouTube is a source of health information, they are doing that. In fact, there was an interesting paper that was published by a group the other day, again, independent of us, showing where consuming YouTube-focused content around physical activity led to an appreciative, statistically significant engagement around physical activity across a variety of different populations. And so that research was independent of us, but interesting for both us and others to look at to see what are the kinds of things that people look at that then lead them to engage in behavior change.

Carol Vassar, podcast host/producer:

Artificial intelligence, it seems to be the flavor of the month in terms of-

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Of the year.

Carol Vassar, podcast host/producer:

… Of the year. Everywhere we turn. How is Google or YouTube together using AI to improve global health?

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Yeah. So broadly Google-wide, the thing you hear us talk about at Google often is responsible AI, meaning how do you utilize these tools appropriately at the Google level, there are a bunch of different things that we have announced and talked about in terms of AI. One of the things is creating a medical specific large language model, it’s called Med-PaLM that has a more validated and a more scientifically sound way of processing and capturing and evaluating data around healthcare information. And then we were using that to apply to different ways on YouTube. And about three weeks ago we announced some work we’re doing where we’re using artificial intelligence with some partners to help dub and translate information from videos into other language health information. An idea here is again, if you have a world expert who is articulating some very valuable information, it’s in English, how can we make that more helpful to Portuguese-speaking, Brazilians, or Spanish-speaking populations, both here in the U.S. and abroad? So the idea of how AI can help expand equitable access to health information is one thing that you see us doing.

Carol Vassar, podcast host/producer:

In terms of YouTube, in terms of Google, where do you see your healthcare involvement nationwide and globally in the next 10 years?

Dr. Garth Graham, Director and Global Head of Healthcare and Public Health Partnerships at YouTube Oh, I love that question. On the Google level, I think we’ll continue to create and bring to scale solutions that work to improve health outcomes in a variety of different ways. We see some ways in which Google search has continued to help people identify where to go, doctors, whether they accept insurance community, health centers, locations, all the kinds of things that a consumer would need to make a decision about their own healthcare. And on the YouTube side, I think in the next 10 years independent of YouTube, what I do see is an ongoing healthcare ecosystem where people are creating information and delivering it to patients in the way that patients get information. So I often say gone are the days of pen and paper and billboards. When was the last time I say to people, when was the last time you looked up, found a textbook or an encyclopedia to read about some issue that you were worried about?

They’ll be like, “Man, I wonder. I’m not going to look it up online. Let me go find a Encyclopedia Britannica and find the chapters to read about.” That doesn’t happen anymore, right? You have a question, you look it up, you go, that’s the answer. And in the world, people use video as a big part of that. And so even health literacy has to evolve to video literacy. And over the next 10 years, I think the whole healthcare ecosystem is going to evolve to be where patients are and where patients are, sometimes it is in your office, sometimes they are looking something up. And we have to figure out how we’re present in all of those places to be able to meet them where they are.

The other opportunity here is this creates a way for even the generation of healthcare leaders that come behind us, the younger pediatricians who are in either training, or are burging pediatricians now who want to maintain their authenticity and reach communities and spread their voice at scale, but still continue to take care of patients. This is an evolution of allowing them to bring their talents in a multitude of different ways and not have to squash who they are. And so creating health information for those that is a passion can and should be a part of their professional profile. And I hope to see that grow with more mentors and mentees and more validation in that ecosystem over the next couple of years.

Carol Vassar, podcast host/producer:

Dr. Garth Graham is Director and Global Head of Healthcare and Public Health partnerships at YouTube.

Well Beyond Medicine. What more do you think YouTube can do to ensure that health information on its platform is accurate, evidence-based, and culturally appropriate? Leave us a voicemail at nemourswellbeyond.org and you may hear your ideas shared on an upcoming podcast episode. Nemourswellbeyond.org is also where you’ll find all of our previous podcast episodes. When you visit, please be sure to leave a review and subscribe to the podcast too.

Join us next time as we talk with Dr. Stephen Klasko, former president and CEO of Thomas Jefferson University and Jefferson Health in Philadelphia, and currently Executive-in-Residence at the private equity group, General Catalyst, which at HLTH 2023 announced the formation of the Health Assurance Transformation Corporation. We’ll talk health assurance and disrupting the current U.S. healthcare delivery model with Dr. Klasko, on our next episode. Here’s a preview.

Dr. Stephen Klasko, Executive in Residence at General Catalyst and former President and CEO, Jefferson Health:

45 years ago, one of my mentors at Wharton wrote a book called Medicine’s Dilemmas: Infinite Needs versus Finite Resources. Sound Familiar? He talked about the iron triangle of access, quality, and cost. And he said, “If you remember your ninth-grade geometry, if you increase access, you have to increase cost or decrease quality unless you’re willing to disrupt the system, and that’s going to be painful.” He said, “If anybody ever tells you that they’re going to increase access, increase quality, and decrease costs, and it’s not going to be painful, can’t be.”

Carol Vassar, podcast host/producer:

Dr. Stephen Klasko, next time on the Nemours Children’s Health Well Beyond Medicine podcast. Thanks to our production team for this episode, Cheryl Munn, Che Parker, Susan Masucci, and our onsite engineer, Adonis Vera from Clarity Productions. I’m Carol Vassar. Until next time, remember, we can change children’s health for good, well beyond medicine. (singing).

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Meet Today's Guests

Carol Vassar

Carol Vassar is the award-winning host and producer of the Well Beyond Medicine podcast for Nemours Children’s Health. She is a communications and media professional with over three decades of experience in radio/audio production, public relations, communications, social media, and digital marketing. Audio production, writing, and singing are her passions, and podcasting is a natural extension of her experience and enthusiasm for storytelling.

Garth Graham, MD, Director and Global Head of Healthcare & Public Health at Google/YouTube

Dr. Garth Graham joined Google in 2020 as Managing Director and Global Head of Healthcare and Public Health at YouTube. He previously served in two U.S. administrations as U.S. Deputy Assistant Secretary for Health, and was Assistant Dean for Health Policy and Chief of Health Services Research in the department of medicine at the University of Florida School of Medicine. Most recently, he served as President of the Aetna Foundation as well as Vice President & Chief Community Health Officer at CVS Health.

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