It is in relationships where trust is strongest that it is often most unspoken. We generally do not spend our days saying “trust me” to our spouse, to our children, to friends who have known us for a long time. Trust is implicit, understood, tested over years of relying, and being relied on. It is simply a fact of these relationships, something we take for granted. If we find ourselves having to say, “trust me,” it is likely something has gone wrong.

For a long time, public health enjoyed the kind of trust that does not have to say, “trust me,” in which the public understood it could trust what we say and do without having to be reassured of our honesty. Public health institutions had credibility because they were seen as broadly nonpartisan, guided by scientific rigor, towards the goal of keeping populations safe.

Just think back to movies, like 1995’s Outbreak or the 2011 film Contagion, in which public health officials are portrayed as competent, data-driven professionals, the heroes of the story. What is striking about these portrayals is how unmarkable they seem. There is a sense in these films that of course public health officials would be portrayed this way because of course this is how they conduct themselves—as sober professionals, trustworthy in pursuit of their mission.

But while fictional virus outbreaks can see public health’s reputation burnished, the recent real one opened a gap between what we say and the public’s willingness to trust us—a gap which has arguably widened in the years since the pandemic.

Survey data have shown significant declines in trust in public health since 2020. One study, for example, found “Between February and May 2020, the percentage of respondents reporting high confidence in the CDC decreased from 82% to 68%, before dropping to 56% in 2022.” This has happened in a context of declining trust in science generally, with the share of US adults with a “great deal” of confidence in scientists falling from 39% in 2020 to about 23% in 2023. But these declines in trust are only part of the story. Perhaps equally, if not more, significant is the sharp polarization of Americans’ trust in science, with just 52% of Republicans viewing research scientists as honest, compared with 80% of Democrats. More recently, however, that pattern has begun to invert and trust among Democrats has declined sharply after the change in federal administration and the accompanying shifts in health policy.

All this has meant that public health is, increasingly, in the position of having to say, “trust me,”. This is not sustainable. Trust is essential to the work of public health. Without it, we cannot do what we do. It is not enough for half the country to trust us while the other half doubts our honesty. Building a Purple Public Health means ensuring that this trust is shared across both red and blue America. The first step to rebuilding trust is to ask ourselves honestly why we may have lost it, owning up to our shortcomings. We recognize that trust in public health is also shaped by forces beyond our control like deliberate disinformation campaigns, changes in media ecosystems that reward polarization, and a broader erosion of trust in all kinds of institutions. These factors matter, and we do not mean to minimize them. But they are not the part of the picture we can change from within the field. Our focus here is on what we can change: the choices, habits, and practices that are ours to reckon with. With this in mind, we suggest the following three reasons why we have lost much of the public’s trust and why this loss has so strongly intersected with the country’s political divide. We do not think, in any way, that these are the only reasons, but rather they are three reasons that we think matter and that are important to discuss within the public health community, to think of ways in which we can address them, simply to do better.

Partisanship

Public health has long been perceived to lean to the progressive left. However, during the pandemic years, and as part of the broader polarization of the current era of US politics, this bias became more explicit in our words and actions. Such bias can be seen, for example, in the CDC shaping guidance about school reopening with significant input from teachers unions—arguably placing the priorities of a political interest group over what the data said about the complexities of reopening schools during COVID. It can also be seen in public health’s widespread comfort with the language, attitudes, and priorities of the political left, and its discomfort with the signs and symbols of the political right—or, at times, of even the moderate left.

None of this is necessarily bad. We are not saying public health should not have a political perspective. It should—and this will not make it unusual. Institutions and individuals have personal beliefs about issues and there is nothing wrong with that. We may know, for example, that a teacher or a newscaster feels a certain way about politics. We can still trust them, however, when we can feel secure that their personal beliefs do not unduly influence their work. A history teacher may feel like the New Deal was a failure, but she can still expose her class to a range of views about it, keeping her personal perspective to herself. A newscaster may feel the US should rarely, if ever, get involved militarily in other countries, while giving airtime to those feel differently. Personal belief only becomes problematic when it seems to be shaping what we do in the course of our work. It is when perspective becomes outright partisanship that we risk the integrity of our efforts and the public’s trust in what we do. To the extent that we have run this risk in recent years, we need to rethink our engagement with politics to ensure we can still lay claim to a level of neutrality in our work, even as we stay true to our values and their policy implications.

Inconsistency

Consistency is a companion of truth, and trust. We trust people in the moment because they have demonstrated trustworthiness over the long term. Rare is the person we meet and immediately feel like we can trust with what is most precious to us—and that, we should remember, is what we are asking the public to do, to trust us with what is most precious to them, their health. Earning this kind of trust means behaving consistently, over time, in a trustworthy way. It means that whenever we make recommendations based on incomplete information, we are up-front about what we know and what we do not know. It means always following the data, even when the data lead us to places that challenge our ideological priors. It means, when we fall short of the highest standards of trust, when we do something partisan, or shortsighted, or just plain wrong, we are quick to own our mistake, to explain why we made it, to commit to doing better, and then to actually do better—consistently, over time. Have we always conducted ourselves this way? An honest reckoning with recent years suggests we have not. Perhaps the central example of this during the pandemic was our attitude towards public gatherings. In the early days of COVID, public health was very critical of groups of people who congregated in defiance of advice about the dangers of doing so. Particular criticism was directed at those who attended the Sturgis Motorcycle Rally in South Dakota. However, after George Floyd’s murder in May of 2020, public health was broadly supportive of mass rallies across the country. It is hard to overstate how much this inconsistency eroded the public’s trust in us by contributing to the view that we place activism above science and that our activism skews one way—to the left. Many in public health argued that the imperative of addressing systemic racism, and the fact that the protests were outdoors, made gathering in protest worth it, despite the risks. Nevertheless, this seeming inconsistency that has had consequences for how half the country hears us, and we must reckon with this if we are to earn back the trust we have lost.

Lack of transparency

A hallmark of trustworthy action is transparency. Research has shown, for example, that managers who are maximally transparent are more trusted by their employees. We build trust when we are willing to share data, share the reasons why we do what we do, and act in ways that subject us to the accountability that comes with working out in the open. However, we have not always embraced transparency. Rather than share our data and reasoning, we have been quick to claim that we speak for “the science” and that this should be enough of a justification for what we wish to do. Rather than work in the open, where the public can fairly judge what we do, we have embraced a bureaucratic vision of power, pursuing our interests through institutions and funding structures whose workings have not always been easily viewable or understandable by the public. An example of this has been the public conversation, which has widely occurred outside the public health “bubble,” about the origins of COVID-19 and whether US public health agencies may have leveraged the opacity of the funding process to support research that was not being conducted safely and which may have led to the inadvertent leak of the virus from a Chinese lab. This may be an uncomfortable topic to raise within institutional public health, but, outside our spaces, it is very much a live issue, with genuine political force, fueling the view that public health is not transparent and that this lack of transparency can, and did, place the public at risk. We cannot pretend that this conversation is not happening if we are to build back the trust we have lost. Rather, we should engage with it (even as we acknowledge its potential to be weaponized by bad faith actors), embrace accountability, and learn the lessons of the last seven years, to ensure the COVID moment represents the nadir of the public’s trust in us, rather than the edge of a cliff off of which we continue to freefall.

Trust is built slowly, but it can be lost quickly. Rebuilding trust is a painstaking process. It will not be easy to reclaim the credibility we have lost. But the path is there for us if we wish to walk it. It entails taking an honest look at ourselves and then being honest with the public about what we see. It means having uncomfortable conversations which some in our field—in our organizations, our offices, even our friend circles—may not want to have. And it means, having identified where we have fallen short of full honesty, taking pains to not fall short again. If we can do this, we can rebuild the public’s trust in us and remain worthy of it in the years ahead. That will have been worthwhile work indeed.

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The Purple Public Health Project

This piece is part of the Purple Public Health Project. The Purple Public Health project is a multiyear, multimedia effort to re-establish public health’s legitimacy, broaden its reach, and shore up its foundations in this moment and beyond. The project engages with topics that are core to shaping a more heterodox public health. Previous essays and other material related to the project are available on the Healthier Futures Lab webpage.

One of our Purple Public Health products is an ongoing podcast. This month, Salma’s guest is Erin O’Malley, executive director of the Coalition for Trust in Health and Science, a coalition of more than ninety organizations working to enhance public trust in health and science. Erin brings nearly two decades of experience in health policy, advocacy, and cross-sector partnership, and she leads an organization that is grappling daily with the question at the heart of this month’s work: how do institutions that have lost public confidence go about becoming trustworthy again? The conversation explores what the coalition does, what Erin has learned about the mechanics of trust-building, and what she thinks the path forward looks like, including the practical question of how any of us can navigate an increasingly complex information environment.

Listen to this episode on Apple Podcasts, Spotify, Amazon Music, Podbean or wherever you get your podcast. You can also watch the episode on YouTube.

Each month, we will also highlight perspectives that inform or complicate the month’s theme. These are meant as starting points for deeper engagement with the ideas the project is exploring. This month’s perspective is from Dr Matthew Motta, Associate Professor at Boston University’s School of Public Health, about communication across values and trust in public health.

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Also this week

Delighted to announce the launch of Ideas Matter, a new podcast I am hosting at WashU. The podcast features conversations with experts about the ideas and forces shaping this moment. The first episode is a conversation with Alexander Kustov, an expert in public opinion and democratic governance and a professor of global affairs at the University of Notre Dame, about immigration in a changing world.

Also, in JAMA Health Forum: The Year We Lost Medicaid

Spoke with Bryant Furlow in The Lancet Child & Adolescent Health about social media use and youth mental health.

What gives you hope? Over the past year, I have had the privilege of speaking with colleagues about the work they are doing at the WashU School of Public Health. I always end these conversations by asking what gives them hope in this moment. Here are their replies

In January, we launched the Purple Public Health Project with the aspiration of shoring up the field’s foundations, rebuilding the public’s trust in what we do, and reorienting the field around core values that can help guide public health in this moment and beyond. Today, we would like to discuss these values, and how they align the larger forces that can support social and political progress in this moment.

We suggest that the values of public health are, and should continue to be, the values of small-l liberalism. What do we mean by small-l liberalism?

While there are several definitions of the term liberalism, in this article we refer to a system where political tensions are resolved through persuasion rather than the exercise of raw power, where ideas win out in the long term because they are better, not because they are imposed from above (or from below).

It is where the purpose of government is not to enforce virtuous behavior. It is to prevent major injustice and crime and otherwise remain subject to limits that protect the rights of individuals, even when these limits allow for citizens to pursue happiness in ways that may be self-destructive.

It is where minority rights matter. We understand that, while we may be in the majority today, political and social winds change quickly, so we should speak softly when in power and maybe leave the big stick at home.

It is where free speech means free speech for all (with narrowly defined exceptions), particularly for the people we do not agree with, whose ideas may even be repulsive to us. Safeguarding speech means making sure such views can be heard (and rebutted, sunlight being the best disinfectant for bad ideas).

It is where we proceed with prudence, because we know it is better to lose than to win by breaking the system – a liberal system being the best guarantor of justice and freedom over the long-term.

This is liberalism. It is an inheritance of the Enlightenment, which birthed many of the ideas which would find political and social expression in liberal societies over subsequent generations. Liberal systems provide the necessary, if imperfect, framework for correcting our own failures. The rise of liberalism helped usher in an era of human rights, safeguarded and expanded the reach of representative government, protected free markets, and stood against totalitarian systems. This is not to say that liberalism is a perfect or even a naturally “good” system. History is full of instances where liberal societies have failed to live up to their own stated values, and where liberal theory itself was complicit in exclusion, providing cover for atrocities. However, the arguments that eventually dismantled those exclusions were won within liberal frameworks of reason and rights. That capacity for internal reckoning is precisely the point. Unlike postliberal or authoritarian models that often view dissent as a defect, liberalism is designed to be “wrong” frequently, provided it maintains the mechanisms for the public to demand that it eventually gets it right.

How can the values of small-l liberalism inform and sustain the work of public health? We argue they can do so by helping our field remain pluralist and consequentialist, and through our revived investment in the processes of liberalism, towards generating durable outcomes in support of a better world. We recognize that liberalism has been concerned not only with protecting individuals from arbitrary power, but also with creating the material conditions for freedom to be meaningful, and that public health has long operated within this space. Our focus here, however, is on the procedural values of liberalism. The ones our field most urgently needs to recover.

We suggest public health should be pluralist because what we do in public health is downstream of what, and how, we think. The best thinking is done in the context of different ideas and perspectives, in the company of people who think like us and people who do not. It is worth remembering that, for all our aspirations of political and social unity, our system was not designed for the cultivation and maintenance of unanimity. It was designed so that people with very different views and values can nevertheless cohere just enough to move through history together. Liberalism does not demand that we agree all the time, or even ever, on all issues. It provides, instead, a context where deep disagreement can exist without undermining civil society, so that the ship of state might sail on even as there is dissension on deck. In the United States, at our best, we take this a step further and affirm our fractious diversity is a source of strength. We may point, for example, to the immigrant who came here to build the world-changing tech company, to the critical bill co-sponsored by Democrats and Republicans, or to the country’s founders — who, with their competing ideas about how government should work (to say nothing of their personal enmities), managed to create a political system that derives strength from its capacity to channel towards productive ends the constant tension at the heart of American life. Public health is likewise well-served when it is able to welcome the tension that comes with competing views, embracing the creativity and intellectual rigor that comes from a free marketplace of ideas.

We suggest public health should be consequentialist because we are, and always have been, a mission-driven field, and that mission is the creation of a healthier world. Every step we take —the research we conduct, the ideas we embrace, and the practices we implement — should be in the direction of such a world, towards improving the health of all. In this sense, the mission of public health echoes the establishment of the US Constitution, which was an effort to channel revolutionary ideals into the consequentialist pursuit of a “more perfect union.” This is a seemingly modest goal for such a key document in the history of liberalism. It aspires to build not a perfect union, but a more perfect one. Yet history is filled with the examples of states that gunned their engines towards utopia only to end up in a totalitarian ditch. The modest—but ultimately effective—consequentialism of the US Constitution reflects our goal in public health of creating a healthier world. A consequentialist pursuit of such a world means taking pragmatic steps towards our goal, refusing to let the perfect be the enemy of the good as we engage with the compromises and tradeoffs that constitute the daily pursuit of progress. It means putting our ideas to work towards our shared aspiration of better health for all, orienting all we think, say, and do in the direction of a healthier future.

Finally, we believe that, for public health to flourish, it should remain invested in the norms and procedures through which liberal systems generate outcomes as much as in the outcomes themselves. This is perhaps counterintuitive, particularly after we have just argued for a consequentialist approach to our work. Yet such an approach depends on liberalism’s long-term viability. Public health is most effective when it is aligned with liberal norms of reason, free and open debate, and an embrace of pluralism. And while, at times, our pursuit of progress may take longer within liberalism than within other systems, progress achieved this way is arguably more durable for having the support, painstakingly cultivated, of the public—and, at the political level, of democratic majorities. We argue that public health’s vulnerability in recent years has been partially a result of our relative disengagement from the values and processes of liberalism. We have, at times, been hesitant to engage with different points of view. We have not always done the work of persuasion, choosing instead to exercise power in pursuit of our goals. We have preferred bureaucratic opacity to democratic accountability. And we have been uneasy in our engagement with the economic fruits of liberalism – slow to acknowledge the role of free markets in creating the material conditions for healthier populations. The free market can be a double-edged sword for public health. On one hand, liberal economies have produced the industrial externalities, environmental degradation, and the commercial determinants of disease that define our modern burden of illness. However, it is these same liberal systems that provide the conditions, scientific innovation, and the surplus wealth required to solve those very problems and prosper beyond them. To ignore the role of the private sector is to ignore the reality of how progress is funded and scaled. We must acknowledge this tension, seeking to harness the creative power of the market while maintaining the regulatory vigilance necessary to protect the public from its excesses.

The illiberal slide we have witnessed in recent times reflects a straying from our core values and has undermined our capacity to pursue a pluralist, consequentialist vision of health. We may have thought that sacrificing pluralism in this way can be a consequentialist gesture, a way of advancing our mission by denying bad ideas the oxygen they need to survive. This may have made sense in the short-term, but now, several years on from the emergence of these tendencies in public health, we can see how they exacerbated a decline in the public’s trust in us and ultimately empowered a political movement that has done deep harm to our work.

In a sense, public health’s diversion from liberalism, and the challenges this has created, mirrors liberalism’s broader crisis in the US and globally. Over the past decade, liberalism has seemed to be in retreat, as its critics on the left and right flirt with forms of “postliberal” political organization. Critiques of liberalism often contend that its proceduralism atomizes communities, erodes solidarity, and advantages certain ways of life while pretending to remain neutral. It is easy to see such alternatives may appeal. It is true that liberalism’s failures are real, but they are best addressed through liberalism’s own capacity for self-correction, not by discarding the framework that has, however imperfectly, delivered the conditions for contestation and progress. Liberalism is hard work. It is hard to try to win arguments rather than simply ban points of view we dislike. It is hard to do the work of correcting injustice within a liberal, democratic system when more authoritarian models could give us the power to quickly reshape society however we choose. It is hard to embrace caution and prudence when so much about our moment seems to call for swift and zealous action. All this has left liberalism vulnerable, seemingly in retreat.

Yet liberalism has, in addition to its capacity to generate progress, the power of self-renewal. It is a strength of liberalism that it can hold a mirror up to itself and honestly reckon with what it sees — even if this reckoning sometimes takes a long time. It can self-correct, consolidating its strengths - defending the gains it has made, the progress it has delivered - as long as we remain invested in it, keeping faith in its capacity to build a better world as it has in the past.

The Purple Public Health Project aims to help us keep this faith, to ensure we remain rooted in the liberal values that have long sustained our field, especially in an increasingly complex 21^st century. Will we remain committed to pluralism, to reason, to the balancing of social and political tensions in the pragmatic pursuit of a better world? Or will we conclude that liberalism has failed us — too slow, too procedural, its promises too often broken — and reach for something more certain and more swift? How we answer these questions will decide much about our present, and even more, perhaps, about our future.

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The Purple Public Health Project

This piece is part of the Purple Public Health Project. The Purple Public Health project is a multiyear, multimedia effort to re-establish public health’s legitimacy, broaden its reach, and shore up its foundations in this moment and beyond. The project engages with topics that are core to shaping a more heterodox public health. Previous essays and other material related to the project are available on the Healthier Futures Lab webpage.

One of our Purple Public Health products is the ongoing podcast, Complicating the Narrative, hosted by Salma. This week, Dr. Itai Bavli—Research Associate and lecturer at the University of British Columbia and the author of the Substack When Public Health Goes Wrong—joins Salma to discuss public health errors of commission and omission, the importance of these errors for trust and polarization, and the relevance of prioritizing the identification of these errors versus assigning blame. The discussion tries to go beyond ideological, partisan, and professional lines, to understand, identify, and rectify public health errors to improve the health of populations.

Listen to this episode on Apple Podcasts, Spotify, Amazon Music, Podbean or wherever you get your podcast. You can also watch the episode on YouTube.

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Also this week

Delighted to announce the April 7 launch of Teaching Public Health (vol. 2). The book builds on the first volume to discuss the evolution of public health pedagogy and where public health teaching might go in its next evolution. Thank you, Lisa Sullivan, for leading our work on this over the years. Teaching Public Health (vol. 2) can be preordered here.

ICYMI, spoke with Nicholas Lemann for The New Yorker about this moment in higher education.

In JAMA Health Forum:

Keeping Health Equity at the Forefront of the Artificial Intelligence Revolution in Medicine and Health

For more about this topic, see the latest JAMA Health Forum Conversation, featuring Dr. Kevin Johnson, of the University of Pennsylvania.

Public health is in a time of challenge. During the pandemic, public health came to be seen as aligned with particular partisan interests, which led to an erosion of the public’s confidence in what we do. Complicating the moment, the new federal administration has imposed changes on the public health system that have further eroded confidence in public health among much of the public and made an evidence-based consensus increasingly difficult to achieve. Last month, we introduced the Purple Public Health Project as a response to this challenge, aiming to rebuild public health’s legitimacy, and the public’s trust in us, through both genuine ideological openness and clarity of purpose. Each month this year, we will engage with a topic that points towards a more heterodox public health. This engagement will include a Substack essay, a podcast conversation, suggested readings, a teaching guide, and more. Material related to the project can be found here.

The project’s ethos is, at core, an effort to address a central question: what is public health for? Are we a special interest group, a pipeline between politicians and the think tanks and academic institutions with which their ideas and policies align? Are we for serving just those who are already inclined to agree with us? Or are we for something else – something broader, deeper, more inclusive in our pursuit of a healthier world for all?

This month’s Purple Public Health topic, then, is an effort to answer the question, “what is public health for?” Doing so means engaging with the field at its most fundamental level, where public health thinking is conceived and actualized. Public health rests on two essential pillars, both core to its function: academic public health and public health practice. Understanding what public health is for means understanding what these domains do and the occasional tension they navigate as they engage with the values and data that drive our work.

Academic public health generates data through a process of rigorous scientific inquiry into the causes of health and disease and the effectiveness of interventions. The aim of this work is fact-driven inquiry that produces data and policy options without necessarily prescribing what society should do with this information. But academic public health does not stop at generating data. It also interprets it through ethical frameworks and urges action towards achieving public health goals, aiming to align societal values with health imperatives (e.g. valuing prevention, solidarity, and equity). This complements academic public health’s empiric commitments by articulating the goals we should collectively pursue to create better health for all.

These domains, the scientific and the values-driven, are both essential, yet must remain conceptually separate for our work to maintain credibility. The processes of evidence generation and value promotion demand different approaches and guardrails. Public health scientists must keep objective analysis separate from advocacy to ensure that data are not distorted by ideology. Likewise, value-driven discussions should be transparent about what they are, rather than present themselves as “the science.” This clear separation helps preserve the integrity of research and ensures values arguments are respected for what they are rather than distrusted for posing as what they are not.

The line between values- and data-driven actions presents a similar complication for public health practice. Public health agencies and professionals that do much of the work of practice build on academia’s work in two key ways: by implementing data-informed programs and policies, and by advancing values-based messaging and norms. This can lead to more values-data tension. On one hand, health departments use research evidence to design interventions (for example, using epidemiological data to shape vaccination campaigns or environmental health regulations). On the other hand, they engage in trying to influence community values and behaviors (for example, crafting messaging that emphasizes collective responsibility for health, or establishing norms around issues like smoke-free environments). In doing their work, practitioners must integrate evidence and values without conflating them – values may guide where and how data are deployed, but the public should never be unclear about whether we are engaging from a place of judgment or fact.

In both academic public health and public health practice, we can face the challenge of conflating data and values, of our efforts becoming too ideological at the expense of the rigor that should inform our science and the inclusivity that should characterize our engagement with communities. Mixing up the domains of values and data, treating value judgments as facts, or vice versa, undermines public health’s legitimacy and effectiveness, especially in polarized contexts. When public health science is perceived as a cover for political or moral agendas, trust in the data falls. Conversely, when we claim a values-based position is simply a matter of settled “science,” we fail to have honest value debates. Clarity and honesty in keeping these spheres separate fortifies public health’s authority, helping us to more effectively support the health of the whole population – which is what we are for.

Of course, we may say “this is all well and good in the abstract, but what about when the rubber meets the road of making policy in a messy, polarized world?” Let us tackle this question in the context of three real-world examples.

Gun violence research and work

Public health research provides robust data on firearm risks and interventions. For example, evidence shows that certain gun regulations can reduce injuries and save lives. However, gun policy is also deeply entwined with core American values such as individual rights and liberty. Second Amendment advocates often view public health gun control proposals not as neutral safety measures but as value-laden attacks on personal freedom. This tension means that if public health experts present gun restrictions as purely data-driven necessities, we run into public skepticism and political backlash from those who prioritize gun rights. Successful navigation of this issue requires acknowledging both the empiric findings and the value debates. We can provide factual impact analysis, while separately engaging in an open, values-based dialogue about rights, responsibility, and safety. Only by keeping these threads clear can public health avoid feeding perceptions of partisanship and, instead, inform a constructive policy discussion.

Obesity policy and the “nanny state” debate

There is strong evidence that policies like sugar-sweetened beverage taxes can improve health outcomes by reducing consumption. Yet, interventions along these lines can trigger the “nanny state” objection - the argument that public health is overstepping by infringing on personal choice and autonomy. Critics, sometimes supported by industry interests, frame such measures as paternalistic government control (e.g. “the government is telling us what to eat or drink”). This exemplifies a values clash: public health values population well-being and prevention, whereas some opponents value individual freedom and limited government. If health officials present their data with a tone of strident moral urgency (coming across as preachy or coercive), they risk alienating segments of the public who feel their lifestyle choices are under attack. A better approach is to keep the empiric rationale separate, clearly communicate the health data (e.g. obesity rates, costs, the effectiveness of interventions), while also respectfully addressing values-based concerns (emphasizing personal agency, fairness, and why society has an interest in healthier choices). By clearly partitioning “the evidence for action” from the debate about “the role of government,” public health can make its case without falling into ideological traps, thereby maintaining legitimacy even among skeptics.

Harm reduction initiatives.

Public health has championed harm reduction strategies (such as needle exchange programs, opioid overdose prevention sites, and drug decriminalization) because evidence shows some of these approaches save lives and reduce disease transmission. However, harm reduction is often controversial due to moral and cultural values surrounding drug use. Some community members or policymakers view approaches like safe injection sites as enabling immoral behavior or “sending the wrong message,” preferring an abstinence-only stance rooted in their values. Notably, even within the harm reduction movement, there has been debate on how to present the case – whether to use a value-neutral, scientific framing (focusing on cost-benefit and outcomes) or an openly moral framing (emphasizing compassion and human rights). Keeping empiric claims distinct (e.g. “This program reduces harm by X%”) from value appeals (e.g. “We believe every life is worth saving, regardless of drug use”) allows health officials to build broader support. If they were to blur the two – for instance, by overstating the data to win a moral argument or dismissing opponents as simply “ignoring science” – they could further polarize the issue and lose credibility. A clean separation between facts and values here can help in finding common ground, or at least mutual respect, even amid polarization.

We end by returning to our central question: what is public health for? Public health is for creating better health for all. It does this by doubling down on its dual commitments: uncompromising scientific rigor in generating data, and earnest, transparent engagement with values in shaping discourse and policy. In a polarized world, a “purple” public health approach – one that speaks to everyone by presenting evidence objectively while also addressing diverse value perspectives openly – offers a path to rebuilding credibility. By being mindful of our core purpose in both realms, public health can better unite communities behind effective actions and continue its mission of improving population well-being without political or ideological distortion. The charge, moving forward, is to remain both scientifically sound and values-conscious, while never confusing the two.

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A databyte

In a national survey we conducted recently of public health experts, nearly 60% of respondents said public health institutions are evolving only ‘slightly well’ or ‘not at all well’ to meet the changing needs of the public. These results suggest the field itself recognizes the need for reimagination and may be ready for it. Full survey results will be released later this year.

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The Purple Public Health Project

This piece is part of the Purple Public Health Project. The Purple Public Health project is a multiyear, multimedia effort to re-establish public health’s legitimacy, broaden its reach, and shore up its foundations in this moment and beyond. The project engages with topics that are core to shaping a more heterodox public health. Previous essays and other material related to the project are available on the Healthier Futures Lab webpage. Suggested readings, a teaching guide, and other material related to this month’s topic can be found here.

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Also this week

In JAMA Health Forum:

A Role for Market Forces in US Health Care-Principles and Guardrails

Spoke with Daniel Vergano in Scientific American about changes in federal health institutions over the last year.

America needs public health. It needs public health to address urgent challenges—from obesity and cardiovascular diseases, to gun violence, to mental health and addiction, to persistent health inequities shaped by factors like economic status, race, and geography. It needs public health because we have already seen one global pandemic in the 21st century and will likely see more. It needs public health because climate change is real and poses significant risks for health, including for the health of the growing population of migrants forcibly displaced due to climate-driven shocks. It needs public health because the world needs public health, and America, for all the ruptures of recent years, still has the capacity to underwrite much that is good for the world.

America needs public health. Unfortunately, American public health is facing some daunting challenges.

First and foremost we are facing a political crisis. The current administration has launched what amounts to an all-out assault on public health as it has long been practiced in this country. From mass layoffs at the CDC, to changing vaccine guidance, to cutting funding for science more broadly, the administration has challenged public health in ways that are unprecedented in recent memory.

This political crisis emerged from another, arguably deeper, problem that public health has faced in recent years. It is a crisis of trust, in which we keep talking but people increasingly tune out what we have to say. Public health messages and policies are received differently across political identities. Despite public health’s long record of improving population wellbeing, whether the field is trusted now often depends on where those to whom we speak stand on the left-right spectrum. Over the past few years, Republicans’ trust in public health institutions has decreased steadily, hovering well below 50% when this administration was elected. This has enabled the administration to dismantle many of the policies and organizations tasked with supporting health in the US and globally, and to plausibly claim that, in doing so, it is acting on its electoral mandate. These efforts had the opposite effect on Democrats; a poll earlier this year showed that Democrats anticipate losing trust while Republicans anticipate gaining trust in public health institutions under the new leadership. Public health, meanwhile, looks around to find it does not have as many friends as it thought it had.

For better or for worse, we need to confront the reality that moving forward, regardless of the political affiliation, about half of the country will not trust public health institutions if nothing changes. Whether this distrust is earned or manufactured, it constrains our ability to protect people’s health. We cannot do our jobs if half the country would not listen. This is clear in recent polling data. In a November 2025 survey of registered voters, 46% said that public health officials “often hide or distort information for political reasons,” compared with just 42% who said public health officials usually act in good faith, even when they are wrong.

There are many reasons why this has happened. There is of course a constituency that holds world views that are fundamentally opposed to the goals of public health and the role of academia in societies. And we should push back against bad-faith efforts that are currently threatening the health of the public and the progress public health has made.

But that is not the only answer. Now is the time to take a moment to look at ourselves and our own engagement with politics over the last decade. When we do so, it is possible to detect a partisan fault line running though our efforts. The uncomfortable truth is that we are now seen by many, for reasons which The Healthiest Goldfish has explored, as, functionally, an extension of progressive politics. This created a permission structure for those who do not share these political commitments to regard us as ideologically compromised and to treat us not as sources of information and guidance but as political foes to be distrusted and, in the context of partisan competition, beaten.

Academia, which develops the ideas and talent that support so much about health at the institutional and policy level, has felt its own foundations shake. It, too, has faced accusations of partisanship, of bias so deeply rooted that nothing less than a counterrevolution led by the President of the United States can right the ship.

In moment like this, we should then take seriously the accusations being leveled at us and ask: have we created an intellectual environment that makes these accusations plausible, even when they are exaggerated?

The data provide, perhaps, a partial answer. We are not primarily concerned with the political leanings of those in public health—although we do need more diversity in politic views; a 2018 survey of members of the Society for Epidemiologic Research found 72.4% described their political orientation as “liberal/left-leaning,” while less than 5% described themselves as “conservative/right-leaning.” We are more concerned with whether public health, and the larger academic environment, is receptive to arguments from all parts of the political spectrum. A 2022 study of academia from across the anglosphere found that 41% of academics say they sometimes feel the need to self-censor their views on campus.

We have seen this dynamic first-hand. Both of us have, from time to time, spoken with colleagues who have shared, in confidence, some view which diverges from accepted opinion in public health circles. This is often accompanied by a lament that such views cannot easily be shared in our field’s current climate. “I worry I will lose my public health card,” said one colleague after expressing an opinion that would not be deemed particularly heterodox among much of the broader public but, in the context of public health, was positively heretical. There have been similar responses, over the years, to some Healthiest Goldfish essays which have surfaced views not always easily discussed in public health.

We may think that our views are correct. But how can we know without testing these views against counterarguments? We need the best possible ideas to shape the best possible approaches in public health. We need to be able to implement these approaches in a context of trust and public buy-in. We need America to be on our side, so we can do right by America and by the world. Public health should not be red or blue. It should be purple. It should draw on a diversity of ideas and perspectives, take actions that then enjoy broad public support because people trust that different perspectives were considered, and be able to explain these actions with words that are understood and trusted.

That is why we are launching the Purple Public Health project. The Purple Public Health project is a multiyear, multimedia effort to re-establish public health’s legitimacy, broaden its reach, and shore up its foundations in this moment and beyond. We are calling it Purple Public Health not because we are trying to create a more “centrist” public health, or in any way move the field away from its core values – many of which are, and should remain, progressive. We believe in a radical vision of a healthier world, and that public health exists to build such a world, even when it does so incrementally, pragmatically. We believe in generating data that support policies and approaches that help get us to this world, ensuring that our progress is built on foundations durable enough to survive political cycles. Values help guide us, and we will continue to follow them while rejecting bias in our work. A purple public health is simply a field that engages with ideas and perspectives from all sides of the political spectrum. It is this engagement which is, we argue, too often lacking in public health today.

The Purple Public Health Project aims to restore and deepen this engagement. We will do this, first, by starting a conversation. Each month in 2026, the project will engage with a topic that is core to shaping a more heterodox public health. These topics will include the role of ideological commitments in public health, the central place of autonomy – as conceived by both left and right – in health policy, the role of disagreement in creating a healthy climate of ideas, the work of re-centering a focus on the social determinants of health in a politically sustainable way, and the challenge of mission creep in public health. Each month will feature weekly engagement with these topics through a range of media, including a Substack article, a podcast, a teaching guide, and suggested readings. Much of this material will be found on the Healthier Futures Lab webpage. As the project unfolds, we will look to establish additional features, including events, new content across a range of media, and more. For now, we start with a simple invitation. We hope you will join the conversation, as we work to shape a better public health, for a better, healthier future.

The goal of this conversation is to influence not only what we say, but what we think and do. Over the years, and particularly since the 2024 election, an idea has circulated that public health’s problems are fundamentally issues of communication. Public health, we have heard, is too steeped in the jargon of the faculty lounge and of elite progressive politics, too disconnected from how most people outside these spaces talk, and that is why they tune us out. We agree with this diagnosis but argue that it is incomplete. Yes, public health needs to change how it communicates; yes, it has become too reliant on signs and symbols that do not help advance our mission. But public health must also change how it thinks. It should have the courage to engage with people and principles that are genuinely outside the range of how many of us are disposed to see the world. This requires distinguishing between good-faith ideological disagreement—where we disagree about methods or priorities—and bad-faith efforts to undermine the health of the public. We need to listen, really listen, if we wish others to do the same. People can tell when we are engaging in a spirit of genuine openness and when we are not, and they calibrate their responses accordingly. We should have the courage to listen as if what we hear might change our mind – because it occasionally may. That is what true engagement looks like, the kind of engagement to which individuals and communities respond. It is perhaps only when we run the risk of being persuaded ourselves that we can truly persuade. This does not mean abandoning our values or our commitment to equity. It means recognizing that how we achieve health for all might look different than we assumed, and that the communities we aim to serve might have insights about what works that conflict with our theories.

America needs public health. And public health needs America. It needs the political support of the American people. We need the researcher exploring the link between climate change and health, the city health commissioner trying to reduce gun deaths through firearm regulation, the economist showing how inequality makes us all less healthy. But we also need the policymaker who thinks the key to keeping urban communities safer is better policing, the scholar who thinks that certain charter school programs improve educational outcomes for low-income students, and the Students for Life member who dreams of a social safety net that reduces abortions by supporting mothers and families.

They are all America. They should all be public health.

This does not mean that public health must agree with every idea with which it engages or deviate one inch from its core values. Who we are as a field, as a community, will not change. We are committed to creating healthy populations, with no one excluded from the assets and opportunities that support health. We pursue this mission through rigorous science which generates the data that support better pathways to health at the local, national, and global level. These values will continue to animate all we do. The Purple Public Health Project is about enabling us to express these values to their fullest extent in a challenging, changing world. We will do this through listening and learning, through leaning into science, through telling the story of health, and through holding fast to the values that guide us.

We recognize that even if public health becomes more ideologically diverse and intellectually open, some of the distrust we face is manufactured for political gain. There will always be those who benefit from undermining expertise and sowing doubt in institutions. But we cannot control their actions, only our own. By ensuring our house is in order, by modeling intellectual humility and genuine engagement, we remove legitimate grievances that make bad faith attacks credible. And we give those who are open to persuasion reason to trust us again.

We look forward to continuing the conversation in the months and years to come.

For a longer-form discussion introducing this project, you can watch the companion podcast on Youtube, or find it on Apple Podcasts, Spotify, Podbean, and wherever you get your podcasts.

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Also this week

In JAMA Health Forum:

“In Search of Pharmaceutical Policy Innovation in the US” – with Julie Donohue.