Admitting better, encouraging optimism
On “accentuating the positive” in our pursuit of health.
We are in the business of health. Core to this business is having conversations about how we can create better health by creating a healthier world. These conversations often involve talking about how the world is not yet healthy, about the diseases that keep populations sick and the injustices and inequities that drive this poor health. We have these conversations because we must, because we cannot solve problems without first naming them and studying them. My own writing is no exception. When I look back at my written output, I find much of it addresses how we can have less disease, with considerations of health sometimes taking a backseat to engaging with the challenges that can get in the way of health. This is perhaps as it should be. To this point, we have just published a note for our community about the threats to the values of inclusion, dignity for all, and health. This all reminds us that a hallmark of health is that we do not think so much about it when we are healthy. We want to be healthy so we can live; when we are healthy, we are often so busy living that we do not think much about the health that enables this. On the other hand, when we are sick, even a little bit, it can be hard to think of anything else.
But, as I have written previously, there is a cost when we focus narrowly on disease. It is in all the good we forget to mention. And there is much good indeed. Broadly, despite many challenges on many fronts, this is perhaps the healthiest the world has ever been, and arguably the best time to be alive in human history.
Today, then, I would like to take a moment to focus on the good in the world, towards being better at admitting much is better in this moment. In doing so, I will draw on work recently published with my good colleague, Dr. Salma Abdalla, with whom I co-wrote a paper, “The Case for Optimism in Health and Health Care.” In the piece, we argue that, for all the problems we face, there are much data supporting an optimistic view of the future of our efforts to create health. Echoing this argument, I will here present three points which, I think, support this view. I will then suggest why I think this matters, why it is important to encourage optimism in our work and to admit when we are doing better.
So, what is there to be optimistic about? First, this is indeed very likely the healthiest ever time to live in the world. The average life expectancy for a child born in 1900 was 32 years. In 2021, the average life expectancy was 71 years. The rise in global life expectancy reflects improvement in a range of areas that support the health of populations. These include improvements in nutrition, education, and medicine, and a rise in living standards supported by technological developments and the expansion of free markets and global trade. To be sure, the forces that have supported this improvement have not been unalloyed goods. Technology has made life better for many, but it has also destabilized much, creating more effective weapons of war, and underwriting societal trends that have made us more atomized and less connected to the human bonds that provide meaning. Global trade has enabled a rise in living standards, but it has not solved inequality, and, in many cases, it has deepened the divides between those with much and those with little. Nevertheless, the broad picture of the world in 2024 is one of a healthier, better place than at perhaps any time in history.
Second, and building on the first point, we can see these improvements in a range of better health indicators domestically and globally. Globally, these indicators are well captured by the below chart, which envisions how the lives of a group of 100 people might be different at different points in the last 200 years. We can see here a decline in poverty and child mortality, and a rise in basic education, literacy, vaccination, and democracy.
Source: Roser M. The short history of global living conditions and why it matters that we know it. Our World in Data Web Site. https://ourworldindata.org/a-history-of-global-living-conditions Published December 14, 2016. Accessed February 13, 2024.
Domestically, we see similar encouraging improvements. At the start of the 20th century, life expectancy in the US was around 47 years. At the turn of the 21st century, it had risen to nearly 77 years. While health in the US remains characterized by deep disparities, such as the health gap between black and white Americans, indicators nevertheless continue to improve. Indeed, even the black-white life expectancy gap is far narrower now than it used to be, going from 14.6 years in 1900 to four years in 2019. We also see improvement in other areas. For example, in 2000 about 80 percent of US residents aged 25 years or older attained a high school education, compared to about 41 percent in 1960. And about 11 percent lived in poverty in 2000, a decline from about 22 percent in 1960. Such indicators reflect a country that, for all its challenges, is in many ways much healthier now than it has ever been.
Third, we have seen a shift in the public conversation towards addressing the root causes of health in our society. When I started my career in public health two decades ago, it was not so common to hear subjects like education, politics, the economy, racial injustice, climate change and gun violence discussed as determinants of health. This has changed. Conversation about the intersection of health and the foundational forces that shape it is now well within the mainstream of the public debate. This has led to institutions taking steps to engage with these forces to create and sustain a healthier world by closing health gaps. The World Economic Forum, for example, has advanced this work in its Zero Health Gaps Pledge, through which corporate signatories pledge to place the pursuit of health equity at the heart of all they do. Such initiatives reflect a sea change in how we talk about health and how we take steps to support a healthier world across society and across sectors.
Here I will pause to note that, when we talk about causes for optimism, when we talk about gains in health, I am acutely aware that these gains are not even, that there are, as I have written before, health haves and health have nots. We have a responsibility to be always mindful of this, to do everything possible to improve health, first and foremost, for those who have been left behind. Health gaps are rampant worldwide and within the US on any number of axes, including race, education, and income. Hence, a focus on optimism and the positive should not let us forget that gains in health are not evenly shared and this asymmetry in health gains should motivate us enormously. However, it also does not serve us well to not acknowledge that there have been gains, and that these gains in fact have been experienced by all, uneven though they may be.
So, there is much to be optimistic about, even as we remain mindful of health inequities. But why does this matter? It is nice to feel optimistic, but is it necessary? I would argue that it is indeed necessary, indispensable even, to the project of creating health, for the following reasons.
First, if we are not optimistic, people will stop listening to us. After all, who wants to listen to someone who is unfailingly negative? Creating a big-tent movement for building a healthier world means projecting a sense of optimism that people want to engage with. Here we might learn from Franklin Delano Roosevelt, a leader who was noted for his ability to project optimism and good cheer, no matter the circumstances. This quality helped make him perhaps the most successful politician in American history at building and maintaining a coalition capable of delivering radical change. His election to the presidency an unprecedented four times reflects the political power of radiating optimism in the public arena. If we wish to be heard, if we wish to be effective, we should embrace similar optimism in all we say and do. Even when times are difficult, as they certainly were in the 1930s and 1940s, to be optimistic is not to deny challenges but to shine a light that can help us find a path through them. We should be in the business of shining such a light.
Second, when we do not emphasize the positive, we lose capital with political decisionmakers whose partnership we need to enact policies which support health. Politicians are accountable to voters. This means that decisionmakers must be able to consistently deliver good news to their constituents and, when the news is not so good, to project optimism in the manner of FDR. It follows, then, that they will gravitate towards what can help them provide good news. If our tone is consistently negative, not only will it misrepresent the true state of health in the present moment, it will also alienate the policymakers who can help us build on progress to make the moment even healthier.
Third, when we keep talking about bad health, we risk forgetting what health is fundamentally for—to enable the living of a rich, full, meaningful life. Imagine being healthy is like having a car. Most people would, I think, agree that the proper action to take when one has a car is to go for long, scenic drives with family and friends. It is not to leave the car in the garage while we spend all our time talking about what the mechanic had to do to get it in proper working order. Yet this is essentially what we are doing when we keep talking about poor health at the expense of the more hopeful news we could be delivering. Yes, it is important to be real about challenges, but it is also important to remember why we pursue health to begin with and why we invite others to join us.
None of what I have said in this essay is meant to obviate the importance of doing all we still have to do to create a healthier world. There is much to do indeed. The world is not as healthy as it should be and there are many who are excluded from the resources that support health. We need to work hard to close these health gaps. But we also need to recognize that the pursuit of health is also about allowing space for optimism, for joy. As Max Roser wrote, “The world is awful. The world is much better. The world can be much better. All three statements are true at the same time.” To make the world much better, we need to engage with how it is awful, yes, but, whenever possible, we need to also emphasize how it is much better, to show how progress is indeed possible even in times of challenge.