Everything, everywhere, all at once? Or not?

On conserving our energy and resources for where they can do the most good in the moment, without compromising our long-term vision for a healthier world.

Regular readers of these essays will recognize that a core theme of much of my writing is that the business of health is the business of being concerned about the world around us. The air we breathe, the water we drink, the food we eat, the places where we live, work, and play, politics, the economy, the environment, and the broader geopolitical issues of war and peace—these forces are fundamental to whether we can live healthy lives. They are, to return to the central metaphor of The Healthiest Goldfish, the water in which we swim. Creating a healthy world means attending to these forces, optimizing them for health, to ensure our water is “clean.” This work requires an intellectual and practical commitment to engaging with a “big picture” vision of health. A healthier world is a world where we tackle forces as foundational as climate change, structural racism, and individual behavioral choices, all of which affect health.

The danger of embracing such an approach, perhaps obvious to those who are practically minded, is captured by the question: does this mean that we should engage with everything? If nearly everything matters for the health of populations, do we then take on everything, always, to fulfill our mission? Should our job be, to quote the title of a popular film of recent years, to do everything, everywhere, all at once? Can we actually tackle the full range of forces that shape health at any time? Or are there some forces that we should not tackle, at least at a given moment? Should we arrange our priorities such that we pause on some issues we know matter while we tackle others? If so, what should guide these choices? And is tiering our priorities in this way somehow making us complicit in not addressing issues that matter?

I suppose a careful reader will quickly surmise, due to the very fact that I am asking these questions, that I do not think that we should tackle everything all at once, and that, in fact, I think that trying to do so would be a mistake. This perspective suggests, I think, two questions, both of which I will try to answer in this essay. First: why should we not try to tackle all matters that could benefit from our engagement at the same time? Second: if we accept that we cannot do everything, everywhere, all at once, how should we choose what we tackle and when?

Responding to the first question, there are a couple of reasons why I would suggest we should not do everything all at once. First, we, all of us, have only so much energy. Tackling everything diffuses our efforts, making it impossible for us to do anything as well as we might were we to devote to it all of our focus—we would risk being “Jacks of all trades, masters of none.” Of course, the health field is large, and there are many who care about these issues nationally and globally, but the field still has finite energy, and it is simply impossible to tackle all at once the full range of ubiquitous forces that matter for health.

Second, tackling everything all at once can simply be much less effective at advancing the ideas and the actions that can move the needle on these forces. Why? Well, for one, the world only has so much attention span, and whether we like it or not, regardless of how important we think our mission is, the world has only so much tolerance for any one particular do-gooderish agenda, intellectual or practical. There is a fuzzy line between using our voices to advance the ideas that create health and generating so much noise so that the world shuts us out, but it is a line nonetheless, so there is wisdom in not trying to tackle everything at the same time. It is also true that we can only juggle so much while still maintaining a high level of performance. The forces that shape health are formidable; addressing them, even one at a time, can be a taxing, long-term process. Trying to do too much at once can mean we are not able to do right by our mission by concentrating our energy and attention in ways that truly make a difference. This should give us pause. To borrow from an unlikely source, in The Art of War, Sun Tzu recommends trying to divide an opposing force so it cannot concentrate its energies on victory. If we allow our focus to become divided, we risk being ineffective in our efforts, to the detriment of achieving the victory we seek—a healthier world. 

Now, if we acknowledge that we cannot do everything all at once, how do we prioritize? How do we choose what to do and when? First, as I have argued before, we should focus on what matters most for health. I have made these arguments mostly mathematically, focusing on ubiquitous macro-social forces, towards a policy of “nudging” which stands to make an enormous difference to many people. By applying our quantitative methods to our analysis of the forces that shape health, we can gain a better sense of what indeed matters most—what issues affect the most people, where population health crises are most acute, and how we can do the most good in our interventions. Over the last fifteen years or so, the field of health has made progress in evaluating—in concrete, numerical terms—the effect of large-scale social forces on health. A bit more than 10 years ago, for example, colleagues and I published a study which estimated deaths due to social factors in the US. We found that in the year 2000, 176 ,000 deaths in the US were attributable to racial segregation, 245 ,000 to low education, 133, 000 to individual-level poverty, 119 ,000 to income inequality, 39 ,000 to area-level poverty, and 162, 000 to low social support.

Such numbers can help clarify where we should direct our efforts. Reducing the impact of, for example, structural racism, will improve the lives and health of literally millions, making that, in my assessment, a priority. Climate change is another threat to the health of populations which has been well-quantified by the scientific community, urging us to make it a priority. Taking this quantitative approach to evaluating problems calls for a measure of dispassionate assessment of forces that matter for health, which admittedly can be difficult. We are concerned with health because we feel strongly about the issues that shape health, and these emotions, while good and necessary, can make it hard to be dispassionate about what we do. Nevertheless, we can still learn much from following the numbers in our engagement with issues of consequence to health, as we decide what to put front and center in our agenda.

Second, it also is important to tackle what pragmatically makes sense, with an eye towards laying the foundations for what may not yet be feasible but could be in the future. In choosing what to focus on in the moment, we are out of necessity making choices about our energy and resources in the here and now. But creating a healthy world is a long game, and we can make choices about the present while thinking about the future. Just because we may not be able to devote ourselves fully to a problem right now does not mean we cannot be thinking about how to do so when action becomes feasible, laying the vital intellectual groundwork for addressing these problems in due time. This is why, for example, we host a range of conversations about key issues at the Boston University School of Public Health. By the end of spring, we will have hosted conversations about AI, the challenge of misinformation, population aging, the economy and health, mental health, and efforts to end HIV globally. We conduct these conversations to help lay the intellectual foundations for addressing key issues, even as we understand that progress proceeds at different paces, with some of our ideas taking root immediately and some needing to wait a bit for the moment to become ripe for their widespread adoption. So, work on improving livable wages for all, creating stable housing for everyone, ensuring opportunities for early education—all of this matters. What we pragmatically tackle may, in part, be driven by what is possible at a moment in time. The world evolves, moves forward, and events far out of our control dictate what may be possible. We live in both the space of ideas and the space of action, and we should attend to both while understanding the difference between what is possible to make tangibly real and what must remain, for the moment, vision only.  

I quote here, as I have before, another unlikely source—Milton Friedman, who said “Only a crisis - actual or perceived - produces real change. When that crisis occurs, the actions that are taken depend on the ideas that are lying around. That, I believe, is our basic function: to develop alternatives to existing policies, to keep them alive and available until the politically impossible becomes the politically inevitable.” I generally agree with this but would take it a step further. We can be most effective when we recognize what is politically and practically feasible at a point in time, devoting energy to just that, doing what we can in the present—actions which are subject to limits—while continuing to think broadly about everything everywhere, so that when the time comes for us to act to make a difference, we will be ready.

So, to come back to the question with which I framed this essay, no we should not try to do everything, everywhere, all at once (though it was a fantastic film). But we should be doing what we can, guided by data, practicality, and the thoughtful allocation of resources. At the same time, we should be thinking about everything, everywhere, all at once. Such thinking is our collective responsibility, particularly for those who are privileged to work in the idea space for a living. Such thinking allows ideas and actions to continue to flourish, until the moment for them to truly take hold becomes “inevitable.” In this way, we can aspire to engage with everything, everywhere, all at once, even as our thoughts may at times serve as placeholders for action.