This piece was co-written by Dr Salma Abdalla and is also cross-posted here
We all create our stories. Who we are and what we do are grounded in the foundational narratives that bring coherence to our day to day. Our work in public health is no exception. The foundational story of population health science and scholarship is that we work to advance health through the force of good ideas: the right questions rise, evidence accumulates, truth wins out. It is a flattering self-image. It is not, however, entirely accurate. Yes, there is much that we do that emerges as we follow the idea-trail, informed by our best thinking about how we generate health. But there is also much that we do that is determined by far more prosaic motivations: by what is funded, fundable, publishable, and institutionally rewarded. The “marketplace of ideas” is, in practice, a market, with budgets, buyers, and incentives. This is not a story of bad actors, but of structures. It is important to understand those structures in order to see where there are gaps in our thinking, and why it is that particular populations may be left behind in having questions that matter to them answered.
It is abundantly well-established that what is studied, and what is funded, are only weakly related to what the actual population burden of disease is. Gross, Anderson, and Powe found NIH funding tracked some measures of disease burden but diverged sharply for many conditions, with clear over- and under-funded outliers relative to need. Replications across decades have shown similar findings; Gillum and colleagues found funding poorly predicted disease burden, and a more recent analysis found very limited correlations between NIH funding and five measures of disease burden across 27 conditions.
An apposite case study on this is the case of firearm research in the US. There is little question that firearm violence is an important public health challenge in this country, with more people dying from firearms each year than do from motor vehicle accidents. Yet, research in the field has been far more limited in scope than is the problem and that is driven, in large part, by the availability of funding to study the issue. In 1996, the so-called Dickey Amendment to an omnibus spending bill barred CDC funds from being used to “advocate or promote gun control,” and Congress simultaneously stripped from CDC’s budget the exact sum that had funded firearm injury research. The text did not prohibit research, but it had a chilling effect, effectively freezing federally funded firearm research for roughly two decades, with the language later extended to NIH. The result was a measurable scarcity of knowledge. Relative to its mortality burden, gun violence was the least-researched of the leading causes of death in the US and the second-least funded, receiving about 1.6% of the funding and 4.5% of the publications its death toll would predict, funded at about 0.7% of the level of sepsis, a comparably lethal condition. Completing the experiment, when federal funding resumed about five years ago, firearm research output rose accordingly (federal funding has again stopped in 2025, further compounding this story). The moral of this particular story is that a single budget rider—not scientific judgement about importance—determined what an entire field could or could not learn for a generation. The politics of what we study sit upstream of the evidence we may wish to generate, and, as a result, of what we do.
Adding to this challenge is that established fields generate infrastructure, trainees, and political constituencies that then result in more funding. This has been referred to as the Matthew effect, i.e., to those who have, more is given. This leads to a dynamic where new or marginal question struggle to gain a foothold regardless of how important they may be. Philanthropic efforts and disease-specific advocacy can also tilt the playing field by drawing attention to sympathetic conditions with well-funded constituencies at the expense more diffuse or stigmatized problems. Finally, industry can affect what we study through funding research questions framed in a way that advance their commercial interests. The same dynamics exist globally where a small fraction of research funding focuses on the conditions responsible for most of the world’s burden of disease.
These structures determine career paths, which are built on grants won, papers published, and novelty, and far less often on the importance to public health. All of this leads to the “lamppost effect” of studying what is easy to measure rather than what matters. This behavior is all individually sensible—we suggest no critique of how individual scientists operate—but in the aggregate this results in a distorted evidence base that does not well serve the aspirations of public health.
So now we get to the heart of the argument. What of the research we do not do? What are the studies that never run, the questions we never ask, the null results we never publish, the populations we never enroll and whose challenges we do not understand? These missing elements are invisible because we do not have the attention and motivation to study them. What goes unstudied, what is not incentivized, is not random. It skews from prevention toward treatment, away from foundational structural and social forces towards proximal and pharmaceutical ones, away from stigmatized conditions and marginalized communities, and away from anything unlikely to yield publishable, positive results. These gaps become an absence of evidence, which in turn becomes evidence of absence. Unfunded questions come to look like unimportant or unanswerable ones, and deflect attention from action, even if action were indeed warranted and urgently so.
In some respects, this harkens back to our earlier writing about the values that underlie what we do and what we choose to study, with our determinative priors emerging not only from ideological perspectives but also from the very real particularities of what motivates what we do. Unfortunately, the incentives that motivate the questions we ask are not simply inefficiencies that we can organize away, or structural forces that we may want to rearrange, they align with collective value setting. It is legitimate for reasonable people to differ on the values that underlie what we do, on how we weigh the import of liberty, tractability, equity. And it is then incumbent upon us to make those weightings visible, and to make sure that as we do the science of public health, we are transparent about the motives that so underlie that very science. Transparency about how the sausage is made is, in itself, a form of integrity which we would be well served to lean into.
How does this inform a purple public health? At core this requires a doubling down on epistemic humility. It is critical to recognize that our evidence base is partial and funded by money and incentives, and that a “we don’t know” is frequently a statement about the availability of funding as much as it is about the nature of the problem. There are yes, solutions. One can imagine structural changes to federal funding to align that with burden of the problem, efforts by journals to pay attention to unfashionable, confirmatory, and null-result research, and intra-institutional efforts to carve a path for difficult-to-do-research. All of that is important, all of it potentially worth leaning into, and all of it will take time. Meanwhile, a field secure enough to admit that what it knows is the product of contestable choices is more trustworthy, not less. Inviting disagreement about what we study, accepting that the current priorities in our research agenda emerge from forces well upstream of the ideas themselves, is of a piece with our project’s argument for visible, generous disagreement, and transparency about our values and motives.
At the end of the day, our evidence-base in population health science—as it is in any other field—will never be complete. That is fine. The question is whether we are honest about the gaps and are willing to (and can fashion the means to) keep asking questions of consequence even if, and perhaps particularly if, they misalign with explicit incentives. That would be an advance for what we do 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 Dr. Michael Lauer. Almost nothing about how the United States government funds health research was chosen. Dr Lauer spent nearly two decades at the National Institutes of Health (NIH), serving as Deputy Director for Extramural Research from 2015 until 2025. He joins Salma to trace how where the structure of NIH comes from and discuss the flaws in the current system. They discuss what could be done differently, and who should decide what science gets done.
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
In The American Journal of Public Health:
A Case for a Purple Public Health – with Salma Abdalla
In Journal of Applied Gerontology:
Age, Resilience, and Hope Predict Daily Functioning After a Flood – with Katie Cherry, Matthew Calamia, Emily Elliott, Piper Bordes, and Laura Sampson
In JAMA Health Forum:
Health Policy Research Priorities Toward Improved Rural Population Health – with Tim McBride
In Psychiatry Research:
Lifetime trauma, recent socioeconomic stressors, and cumulative PTSD prevalence: a multi-country population-based study - with Salma Abdalla, Madison Pickerel, Bernard Banda, Eran Fann, and Mohammad Abba-Aji
Thank you to the many collaborators who guided our thoughts on this work.
In this Episode of Ideas Matter, I spoke with Elizabeth Currid-Halkett about seeing beyond the caricature of rural America.
On September 24, I will join Jessica Steier, of Unbiased Science, for a Substack live conversation about my new book, Why Health? What We Need to Think About When We Think About Health.
It may be difficult to persuade institutions to support ideas that do not align with their perceived interests. Nevertheless, we must find innovative ways to encourage and sustain the development of unconventional or unpopular ideas that could make significant contributions to the health and well-being of future generations.
Thanks particularly for the embedded podcast 'Rural American, Beyond the Caricature'
May I record my notes as I listen citing the minute markers what might help others approach the recording's content:
1.40 Professor Currid-Halkett https://en.wikipedia.org/wiki/Elizabeth_Currid-Halkett was born and raised in WV. Even WV - hopelessly stereotyped by generations of media, academia, etc - is very diverse. So the points that follow about the great diversity of 'rural America' are excellent. 'Rural Midwest' is very different from 'Rural American South'. 'Rural borderlands in Texas' are very different from 'Rural borderlands in New England, Minnesota, etc'
Living all of our decades in rural Virginia we've visited all around WV and enjoyed its people and stories, landscapes and recreational and cultural amenities. The spirituality of rural Appalachian church singing (often influenced by unaccompanied shape note traditions https://www.youtube.com/watch?v=8CC2f4BWhIw) is as great, in its way, as Medieval European monastic chant, as are Southern Black church traditions of gospel singing ( https://www.youtube.com/watch?v=Clu4UWVBGBY - one of the greatest films about American culture that too few people know. watch it!).
4.45 Professor Galea's suspicion of how 'we (I presume he means academia) flatten rural America' hits the mark. Scientifically, ideologically and emotionally. As you later discuss rural Americans are not of one mind, of one mood, of one purpose. We have all the different minds, moods, and purposes that might be found in NYC, etc inflected by lived experience in rural communities. 'Flattening' is how both 'Left' and 'Right' social and political ideologies (and sadly, public health ideologies) work: flattening to control what they want from us. The 'Right' has in recent times done that effectively and the 'Left' has helped the 'Right' immeasurably by 'flattening' us as angry bigots, resentful racists, inbred fools, who are also ugly and stink ... all of that making us dangerous. 'Right's' controlling narrative - 'we believe what you believe, and want what you want' - is ever more unmasked - particularly as so many rural hospitals, EMTS, pharmacies, clinics are failing and closing. So, dear 'Left': get a better narrative.
7.25 Economic opportunity discussion. Excellent overview. More people need to understand the data, and the lived experiences, of limited, constrained, burdened economic opportunity in most small towns that are not near exurbs of thriving cities (a geographical explanation of why, as Currid-Halkett say, that New England rurality or New York 'upstate' rurality' or in the environs of Washington DC can be full of charming amenities: people remote work from them, have weekend/summer homes in them, etc). Public health has been eager - correctly - to discuss 'minority stress' - but has not researched and discussed the 'minority stress' of limited across generations with the limited - and often diminishing - opportunity in rural communities. Why is that? Could it be part of 'the Left's flattening? and other biases that your 'Purple Public Health' wiki wants to explore? This is a theme of my lifetime: WHY great universities that are just 2-3 hours away from rural communities with declining health assets and health outcomes have no sustained outreach in rural communities: why no research establishment there? why no clinical, education, business, etc internships, residencies, fellowships?
12.35 Yes, you cannot ignore the religious values that shape many/most rural communities. As you say, these are among the ONLY abiding social assets, and only resources that consider the life course wholistically. It is a good thing that APHA has a strong perspective on religion/faith and health. BUT, even with that there is too much of a 'Left' allergic reaction to moral values and priorities arising from religious/faith experience. The 'Right', for many decades, has exploited the 'Left's allergy/resistance/abhorrence of rural moral values and priorities.
16.25 Thanks for speaking the quote (from President Obama). Rural places are - indeed - places where people do find a way to get along and do what we can do for one another. Here in our small rural town - and in countless rural towns - social safety nets cannot exist without getting along together. The volunteers (hundreds of us weekly, here) who make food pantries work, the volunteers who build Habitat homes, the volunteers to support rural transportation for housebound rural elderly and persons with disabilities, the volunteers to support youth groups, etc ... are from many different political positions, religious groups, points of views about public policy.
20.25 Yes, understanding 'rural aspirations' is more important, really, that focusing on 'rural deficits'. This involves, as you discuss, how metro communities/elites intentionally include rural craft, rural production, rural talent into their economies (and not just the occasional visit to a pop up 'farmers' market' or visiting a 'Halloween pumpkin patch'. And this involves how institutions that help metro communities connect, evolve together, thrive can be implanted in rural communities! DO BOTH! And yes 'education' is key. So I am a supporter and reviewer of scholarship applications of LGBTQ rural and working class students who are first generation college aspirants. And I serve on the Swarthmore (elite, yes!) College Alumni Council, where the college intentionally tries to attract and support rural and other working class students, almost all on full scholarship. How is your college or university doing?
25.40 The individualism, self-development/improvement, and adventurous inquiry of most Americans is very true. And these are aspirations and values in rural America too. Just watch many of the Youtubes of Europeans who visited America - including rural America - during the 2026 World Cup! REMARKABLE insights about Americans.
And yes, we rural Americans are not generally any of the stereotypes - racist, close minded, cruel, etc. In our small rural town there is a Pride group with an annual picnic, presence in the Christmas parade, etc. We have a rich, well known history of free Black communities before the Civil War, and triumphant intellectual and moral leadership after the Civil War ( https://archive.org/details/israelonappomatt0000elymhttps://www.aoc.gov/explore-capitol-campus/art/barbara-rose-johns-statue). We have a large Amish community (ies) - sadly that experienced a horrible measles outbreak this Spring-Summer. We have one of the largest traditional (Latin Mass) Roman Catholic seminaries in the world - sadly with some of that leadership excommunicated by Pope Leo this summer, or, rather, they removed themselves from obedience to the Church's leadership ( https://stas.org/en ). We have a Hindu ashram, now in its 40th year here ( https://www.yogaville.org/ ).
And the labor and delivery services in our small rural hospital closed last fall. Precious mothers and precious unborn infants/born infants are at risk! Next month local neurology closes. And as most rural communities, particularly in the American South, we have high prevalence of stroke, poorly treated stroke, poor recovery from stroke. So far Virginia's $189 million from the 'BBB' (Big Beautiful Bill) - Rural Health Transformation is a mystery: I am in touch with legislators from our rural region who would like to know what is happening. Large funds seem to be handed over to administrative units none of them with obvious expertise or experience with rural health systems or rural development, and none of them in rural-located universities (like the regional, rural university where I live)