Interview with Jordi Sunyer: "I Feel Part of a Generation that Has Brought Public Health and Preventive Medicine Back to its Former Level".

Jordi Sunyer, ISGlobal researcher and professor at the Universitat Pompeu Fabra (UPF), has been awarded the Jaume I Prize for Clinical Research and Public Health.

I recognise him by his slender, agile silhouette as he walks down the corridor against the light. He is almost 67 years old and is rarely seen in his office at the PRBB (Barcelona Biomedical Research Park). He comes over to let me know that he has arrived, he just needs to drink some water after two hours of teaching. Then, he tells me, he will follow my orders and do what I tell him to do.

Jordi Sunyer is a world authority on environmental epidemiology. In 2014 he won the prestigious Goldsmith Prize, last year he received an honorary doctorate from the University of Hasselt (Belgium), and now he has just been awarded the Jaume I Prize for Clinical Research and Public Health. A medical doctor by training, most of his extensive scientific work has focused on the relationship between air quality and health and the role of the environment in early life.

-What kind of air did you breathe as a child?

-It’s not easy to say. I used to live near Plaça Lesseps in Barcelona, and at that time there were only gardens in front of my house. Now there’s the Ronda del General Mitre, with lots of cars. We heated ourselves by burning almond shells. And I still remember the lorry unloading coal, which means that in winter there must have been a lot of pollution from burning coal. But the fact that there were far fewer cars meant that for most of the year pollution levels were probably lower than they are now. It is true that in the city of Barcelona we still had a lot of textile industry and the thermal power station, but they polluted locally, not over the whole city. Nowadays, the main pollution comes from traffic and is spread all over Barcelona. In other words, in my case I probably breathed better air than my children would have if we still lived there.

-Why did you become interested in air pollution as a field of research?

-Somehow, it's where life has led me. I entered the world of public health through the asthma epidemics in Barcelona in the early 1980s. It was a time when efforts had been made to move industry out of the cities and away from coal to other fuels, and the air had improved. Nevertheless, the epidemics that caused so much concern were suspected to be caused by pollution. We at the Municipal Institute of Health (now the Barcelona Public Health Agency) showed that they were caused by a biological protein that was spread when ships unloaded in the port, but we also discovered that at the end of the year the impact on asthma of air pollution from combustion sources (traffic, thermal power stations, etc.) was much greater than that of the allergen, and this was an invisible problem. We were basically pioneers in looking at whether air quality was safe for health or not, and that was the beginning of a journey. When I think about it now, I realise that I have always been concerned about the environment. Even when I was a junior doctor, I would go to the medical school sections and talk about the environment and health. I had an intuition that nature had something to do with health, just as the Greeks did three thousand years ago. And this intuition is something inside you, you don't know where it comes from. I think it was this: the path I found myself on and something that was there before.

The mountain: freedom and challenge

-What contact do you have with nature?

-I can't live without it. I spend a lot of my weekends in the mountains. My way of letting off steam is to climb mountains - let's see if I can go back to Nepal this autumn!

-Mountaineering?

-Yes, to walk, not to climb peaks. I don't like to play with death. I don't want to put myself in danger to climb the Everest, although I've been told I would be able to. I've reached the Everest’s foot, but I haven't climbed higher because it doesn't appeal to me.

-And what do you like about mountaineering?

-It is very difficult to explain. First of all, I feel very good. It's probably where I feel the best in life. It gives me a sense of freedom, of challenge. And then, hiking, climbing an accessible mountain, is a lesson in life: how to manage endurance, how to know your limits, how to find the energy to overcome problems, how to lead a group, how to be there for the others...

-Do you apply what you learn in the mountains to your work?

-Absolutely. Research has a bit of that: you need resistance, resilience and to know how to overcome difficult moments, to face them. That is what the mountains teach you.

A path, rather than a career

-Have you had any difficult moments in your career?

-No. And I prefer to talk about my path rather than my career, because I have never had the feeling of competing with others, I think I have competed more with myself. As for the difficult moments, I only had a small crisis when I started doing research, because I missed clinical practice very much, I had a great medical vocation. Until the day came when I realised that I had discovered a second vocation, which was research. I did not know how to combine the two, it was very difficult for me to be competent in both areas, and at that time we did not have the research structures that we have now. So maybe it was a moment of crisis, but I didn't experience it in a very negative way. After that, everything went smoothly. And I was also very lucky, because all the studies we carried out produced results that confirmed our hypotheses. It never happened to me that I spent four years on a research project that later produced null results, and that could have happened to me.

-That happens all the time in science.

-Yes, but we have been lucky to coincide with the development of a whole new field of research: the role of our environment in health. For example, epigenetics has emerged, which shows what we already suspected, that there is an interaction between our genes and the environment. This confirms that the environment plays a very important role in the development of disease.

The creation of CREAL, an emotional milestone

-Do you remember any particularly happy moment over the years?

-Looking back, I think the creation of the Centre for Research in Environmental Epidemiology (CREAL) with Josep Maria Antó and Manolis Kogevinas. In part, we were picking up a hidden legacy that had been taken away from us. The civil war had destroyed preventive medicine and public health in our country, which had been highly respected since the 18th century, with people who had collaborated with Pasteur and Germany. The war made all the professors disappear. I feel that I belong to the generation that brought public health and preventive medicine back to its former level. It is wonderful what we have achieved with Josep Maria and Manolis. By the way, CREAL was one of the founding nuclei of ISGlobal. Without CREAL, there would be no ISGlobal.

-The three of you are at the PRBB today!

-Yes, by chance. I have been working with Josep Maria since 1985, when he hired me to study asthma epidemics. During my residency, I had done a distance learning Masters in Epidemiology at the Pierre and Marie Curie University, because we had no training in community medicine. In other words, my knowledge was modest, but the country was at zero! I learned the word epidemiology almost in the third year of my residency. We have come a long way since then to have a CREAL, an ISGlobal and many centres doing public health research.

-Did you have a different way of working than the current generation?

-I don't know. One of the characteristics of CREAL, which has been maintained at Parc Salut Mar (and every researcher from outside emphasises this), is the collaboration between researchers. This way of working was very much our own and I see that it has been maintained.

One road, three turning points

-What other milestones would you highlight in your journey?

-I have experienced three important events. As a young man in a hospital ward, I began to wonder if the sick were not arriving too late and why we could not prevent these diseases. In the 1970s, we saw a lot of sick people dying. But for me, the studies of asthma epidemics were fundamental. We saw that with a cheap intervention, the installation of filters to prevent the spread of the allergen generated when ships unloaded, hospital admissions for asthma fell in Barcelona. For me, the power of prevention was like an epiphany. Then you realise, for example, that if you want to prevent the effects of air pollution from traffic, everything is much more difficult to implement. The case of asthma epidemics was a fairly simple model. But it was a turning point for me. The second was when we discovered that pollution plays a bigger role in asthma than the allergen. And the third was when we realised, by studying the origins of asthma, that we had to go back to early life. And, again, I saw the confirmation of a hypothesis: what happens early in life is more important for health throughout life than what happens later on. And it also means that there is a greater capacity for prevention: intervention at the beginning has a much greater impact than intervention at later stages.

-Is this early stage of life sufficiently taken into account?

-I have just come from a course with a doctor from the Sant Joan de Déu hospital who has set up an environmental health unit. In other words, there is a growing interest and sensitivity. The pity is that in Catalonia there is only this unit and another one in Olot. There are none in primary care centres, so we are still at the beginning. In recent years, we have created a new cohort of newborns in the city of Barcelona, and many of the mothers who participate are already very much aware of the effect of managing their diet, the materials they use, pollution, radiation, etc. during pregnancy. A part of the population already understands this. But we still have a very important part of the population that is not concerned about feeding their children with ultra-processed foods, even though we know that they play a role in systemic inflammation and will lead to various diseases, including obesity. We have more and more scientific evidence every day, and it is being transferred to the health system and to the population, but still very slowly. .

A scientist as an artist or a mystic

-And this is discouraging for a scientist?

-No. We have to be resilient. What drives a person to do science is something very deep inside, similar to what drives an artist to do art, or even a mystic to shut himself up in a cave or a monastery. These are inner things that motivate you to use knowledge to solve problems. One of the great problems of humanity is the planetary crisis.

-What are the others?

-Another is the lack of justice. We already have a lot of knowledge to solve problems, the question is how to apply it in an equitable way. A large part of the population is a victim of what a minority produces.

Two serious problems: communication of results and underfunding

-What is science missing?

-There are global problems. One serious internal problem is the communication of results. The system we had has gone into a fierce capitalism and at the moment it costs a lot of money to communicate your results. The whole peer-review process is becoming very complicated because it is very difficult to find reviewers, there are more and more journals.... Another very important issue is the creation and retention of talent. I don't know if young people are as attracted to science as they were 15 or 20 years ago. And above all, our system is very unfair to them: we train them very well and then we throw them out. I think that happens a little bit in the United States. And then we have an external problem, more common in Europe, which is underfunding. The European Union has made it possible to create human and professional networks between people from many countries, but we have always carried out projects with scarce resources, and this, which makes you spend many more hours than would be reasonable, also has an impact on the quality of the projects. This is a big difference from the United States.

-Nevertheless, the results are very good for the low level of funding.

-That is the paradox. This year, Catalonia is one of the leading regions in Europe in terms of attracting resources. So, let's fund science properly! Let's bring our spending up to the level of Germany or Switzerland! We have a structure, but we must believe in our research system, which is the Catalan CERCA system.

Learning from the Anglo-Saxons

-How do you remember your time in the United States?

-Going abroad is very important. It was a before and after experience for the whole family. And the Anglo-Saxon world is very illuminating for research. Hume and the English laid the foundations of empiricism. The whole of Anglo-Saxon society is very focused on this positivism: problems are solved on the basis of evidence, knowledge is used and the production of knowledge that has value in society is encouraged. To do science, it is very useful to go to these countries. And in the United States they have a level of funding that we don't have. They teach you rigour, good practices, the proactive attitude of tackling problems. Here, at least before, there was a very tragic, defeatist feeling about life. A lament. And maybe there is another way to look at life, although American optimism is almost naive. Anyway, then you discover that science can't answer everything, that there are other ways of thinking, like intuition, experience, art, that play their part in life and in questions that science probably can't answer. I am also curious about other ways of thinking. I am excessively curious.

Not being an obstacle for those who come after me

-Are you slowing down now?

-I have been delegating responsibility since before I was 65. I didn't want to be an obstacle to the professional development of those who came after me. And there comes a time when you lose your faculties, there is an exhaustion, even though your analytical skills are still very good and that can be useful. But with an attitude of service. I am here as long as they want me. I have already served.

-What do you have left to do?

-I still have to publish the results of the BISC study from the last few years. But soon it will be my turn. I am one of those who will stop. Because that's it. And I want to do other things with my life.

-What is that?

-Ah, to live! Maybe it's that the level of ambition drops a lot. And to prepare for a period of decline, and in a few years to understand better what death and the end of life are all about. I don't know, a bit like that. To occupy my time and continue to be creative, I have activities. I'd like to play the flute again, and I continue to sing in the choir of the Sant Cugat Conservatory. I'm also very interested in being with my grandchildren, that's a priority for me. And since the start of the COVID-19 pandemic I have been writing every day and I would like to write more.

-Your creativity has many facets.

-Yes, I don't know if it's good or bad!

-Because of the dispersion?

-No, not that. I have concentrated a lot on the work. I feel I have spent a lot of hours on research. It's time for others to do it.