This piece was co-written by Dr Salma Abdalla and is also cross-posted here.
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 21st 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:
For more about this topic, see the latest JAMA Health Forum Conversation, featuring Dr. Kevin Johnson, of the University of Pennsylvania.
