Building health on shared values

Why a focus on enduring principles should underlie all efforts in health

We are in a time when much is being overturned. Policies are being rolled back, funding is being cut, long-standing institutions overhauled. Globally, it seems like the U.S. is retreating from its role as leader of the postwar international order, which for 70 years was the bedrock of a lasting, if imperfect, peace.

In health, this time of change has been acutely, painfully felt. Everyone knows someone who has lost a job or faced sudden uncertainty around the future of their work. We witness institutions that appeared broadly seaworthy — and that we assumed enjoyed public support for doing good, necessary work — enter choppy waters, with close to half the country either indifferent to their fate or actively hoping they will sink.

Beliefs that constituted a kind of collective faith — vaccines are safe and effective, the work of science can be trusted, technological progress is a net positive for society — have, for reasons understandable and less so, lost their hold on our consciousness. They were once the default opinion of many, if not most of us. No more.

Instability, churn, a questioning of much that once was taken for granted. We see this and wonder how the solid ground beneath our feet turned to so much sand. How can we build policies and institutions that last?

Answering this means confronting a stark fact: Most of what we do can be overturned. Institutions can be dismantled; policies can be rolled back. The truth is that large parts of the health infrastructure in this country are just one election, one sharp turn of public opinion, away from radical reshaping, and not always for the better.

What lasts, then, are not things but values. Equity and justice. Compassion and trust. Freedom and integrity. When such values are the basis for what we do they can create and sustain action for the long haul.

There are two ways to build a political organization. The first is to build it around issues. “We are for more affordable housing.” “For more livable wages.” The second is to build it around values. “We are for liberty, America first, and free enterprise.”

Both of these approaches have their virtues. Focusing on an issue can help raise awareness, marshal data, and apply technocratic solutions to pressing challenges. However, an issue focus can grow detached from the values of the broader public, unmoored from the realities of daily life. A day-in-day-out engagement with climate data, for example, can distract from the fact that while people may appreciate the need for “climate solutions” (a phrase that can sound abstract), they may feel more pressingly the need to safeguard what they most value — their family — by being able to heat their homes in winter, and this means cheap energy. People may take an interest in housing, but be more concerned with the value of self-determination, of being able to buy their own home and see its value increase over time without worrying about a new development driving down prices in their neighborhood. People may listen to arguments for lower taxes, but value education more, and so want to keep in good order the schools, the local library, and the roads that lead to these places.

The policies and programs that support our preferred approach to isolated issues can be overturned. But values cannot be overturned — particularly when these values are embedded within the broader culture. It should be our business, then, to ensure that the values that promote health take hold, to build our approaches on these values, and to speak the language of values in our engagement with the public. People might be skeptical of a particular program or mandate. People may feel, for example, social safety net programs like the Supplemental Nutrition Assistance Program (SNAP) are entangled with too much waste and fraud. Such feelings can inform partisan division and weaken the foundations of needed initiatives. However, when seen through the lens of values — such as the belief, inspired by compassion, that no child should go hungry — such programs take on new significance and are likelier to be viewed not as the pet projects of political foes, but as expressions of our common hopes, aspirations, and concerns.

Health is a value. Perhaps it is a foundational value, in that being healthy enables us to live guided by other values, a necessary condition for everything we do. And for this reason, a values-based approach favors the work of health. We can bring to the table a value that everyone shares. Clearly articulating this value can bridge divides and create a sense of shared purpose, making bipartisan health action likelier — and partisan rollback of health initiatives less so.

There have been many examples of movements that have led with values to create a better world. For example, Mothers Against Drunk Driving (MADD) helped build a national campaign against impaired driving. Since 1980, MADD has saved over 300,000 lives and helped pass over 1,000 new laws to address drunk driving. The organization speaks to the value of family — it is right there in its name — and the importance of creating laws and policies that ensure no family will face the devastation of losing a loved one to drunk driving.

The Children’s Health Insurance Program (CHIP) is another program that reflects the value of family and our shared commitment to ensuring the well-being of our kids. At the global level, the President's Emergency Plan for AIDS Relief (PEPFAR) has long been an expression of our collective values — notably, the values of health and compassion — and the program has enjoyed bipartisan support. It is perhaps due to this basis in values that PEPFAR proved more resilient than other programs in the face of the Trump administration’s global aid cuts.

What happens when we do not have clear values to guide us? In some sense, the answer is: the last five years happen. During COVID, we did not always lead with our values in our engagement with the public, and this contributed to the polarization of that moment, and to the deficit of trust public health now faces. We told people what to do, but we did not always tell them why, beyond assuring them that it was for their own good. We did not connect our asks with the unifying values that could have coalesced broad public support. Had we done so, we might have avoided the polarization that warped the conversation around mask-wearing and other public health measures such as vaccines.

The data reflect this. A 2021 study on reducing resistance to mask-wearing among white evangelical Christians found “messages that align with individuals’ core values — in this case, religious tenets and patriotism — can shift certain views on mask use and government mask policies to combat COVID-19, even among a comparatively mask-resistant group.” We — those of us in public health — support measures such as mask-wearing and vaccines because the science supports them. But purely scientific appeals are not enough to convince the majority of the population to share these views. If they were, the story of COVID would have been quite different. We saw this, too, in the debate over the Affordable Care Act, a law that became polarizing in part because it was debated in technical or partisan terms rather than as a value (that we should care for one another’s health).

America itself started with a values statement. We are a nation of laws and institutions, of scientific and technological achievement, of social and political progress unfolding over generations. Driving all of this is a set of values, articulated at the very outset of our national experiment, before independence had even been won. And it was this set of values that ultimately laid the foundation for the endurance of the American republic. I always thought that Abraham Lincoln captured this well when he noted:

"All honor to Jefferson — to the man who, in the concrete pressure of a struggle for national independence by a single people, had the coolness, forecast, and capacity to introduce into a merely revolutionary document, an abstract truth, applicable to all men and all times, and so to embalm it there, that to-day, and in all coming days, it shall be a rebuke and a stumbling-block to the very harbingers of re-appearing tyranny and oppression.”

What kept the country and its vision together was fundamentally an appeal to core values, binding the cause of America to an expansive definition of human freedom.

The choice of the founders to make this appeal reflected the Enlightenment values of thinkers such as John Locke, who wrote, “No one ought to harm another in his Life, Health, Liberty, or Possessions.” The Enlightenment era produced the concept of a social contract and the common good, laying the groundwork for liberalism and, eventually, modern public health. These values are in the DNA of public health, just as they are central to the American experiment, voiced in both the Declaration of Independence and the Constitution, with the call to “promote the general Welfare.” This country has rallied to these values throughout its history — providing mutual aid and charity in times of crisis, organizing in support of social movements such as civil rights and anti-poverty programs. Justice, liberty, compassion — these values are core to American life and core to the work of public health. Our appeals to the public should reflect this alignment, our calls echoing what is already in the hearts of our fellow citizens, as we work to mobilize on behalf of a healthier country and world.

We want health policy, health institutions, to last. What lasts? Fundamental values embedded within communities and populations, values that have long advanced human progress, values that are broadly shared between individuals of many different identities and across partisan lines.

I have often written of these values, most comprehensively in my book, “Well: What We Need to Talk About When We Talk About Health.” They include equity and justice — a commitment to fairness so that everyone (especially every child) has the basics, including food, care, and the opportunity for health. Then there is compassion, capturing the idea that we should protect each other and prioritize the most vulnerable, that we are all in this together. Freedom (from preventable harm) is another central value, balancing individual liberty with the shared responsibility to ensure people are free from avoidable disease and injury, reflecting the understanding of freedom as the ability to live a healthy life. Finally, we should be leaning into the value of trust, emphasizing honesty, scientific integrity, and transparency as guiding values so that policies are grounded in evidence and earn public confidence.

All this suggests to me that we want to aspire, always, to build health on a shared values framework, but particularly now, in this divided moment. In particular it behooves us to focus on values that unite as the basis for creating resilient policies and institutions. In a time of instability, we can and should build our house on the strongest possible foundation. One hopes that that is the way to ensure that that when the ground shakes and shifts, the work of health will remain standing.

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Also this week

I generally am not writing The Healthiest Goldfish to be responsive to events in the moment, but of course I am living in the real world and what is happening around us as we all are. It should not need restating that violence of all kinds is abhorrent, and the type of political violence we saw this week, with the death of Charlie Kirk, and recently, of Melissa Hortman, is equally so and threatens the very fabric of political conversation in this country. I have written extensively both about the consequences of violence and about the challenges of gun violence, and it is horrifying to see gun violence escalate so in the public space. I continue to think that our goal should to be find the values and ideas that unify, not divide, and that we should not allow hate to have a voice. And that we do so best by insisting on liberal values: respect for a plurality of perspectives, a commitment to fact, and to the hard work of building a better world together. And that slowly, right and reason will prevail. Meanwhile, our thoughts are always with those whose lives are affected by violence, every day, in this country and worldwide.