Health as infrastructure, not intervention

Ebola reminds us of the need for the scaffolding we often do not see until it fails.

As of now, over 1,400 suspected or confirmed cases of Ebola, and at least 200 deaths from the disease, have been reported in the area of Congo and Uganda. Outbreaks like this are challenging in the best of times, as communities and health workers do all they can to contain the spread. Such efforts helped to limit and ultimately end the 2013-2016 West African Ebola outbreak, which could have been far worse without the presence of global health infrastructure—the network of NGOs, government agencies, public and private investment, and international bodies dedicated to supporting health and preventing disease around the world. When such programs are well-funded and working, the world is a safer, healthier place. When they are not—when they are subject to firings and funding cuts and a collapse of political support, as they have been over the last year or so—this creates a difficult context for global health. That the present Ebola outbreak has emerged in such a context is cause for concern indeed. That we have entered a time of disinvestment in global health infrastructure reflects what could be fairly called a blind spot in how we in the US think about health and the infrastructure that supports it at home and abroad.

We tend to treat health like something to be fixed when it breaks. Under this paradigm, we are healthy until we are not, and it is then that we should apply the best possible healthcare solutions to return us to the world of the well. Our investment in health largely follows this lead, with vast sums going to the development of the drugs and treatments that do this work of fixing. To be clear: there is nothing wrong with having the best possible healthcare at our disposal when we are sick—there is nothing wrong with fixing. Indeed, my early training is as a doctor, and I spent the first part of my career engaging in the work of repairing health when it “breaks.”

Yet, as an overarching framework for how we think about, and invest in, health, this model can fall short. It is not enough to have the best possible fixes if this comes at the expense of addressing the root causes of health and disease in society. Just as, in individuals, we would not be content just to treat the symptoms of disease and leave the underlying problem unaddressed, in societies, we should not put all our eggs in the curative basket without investing in the prevention that makes cure less necessary, populations healthier.

This suggests the need for a new paradigm around health. Rather than treat health as something to be fixed when it is broken, we should treat it as we treat the roads, the water system, and the electrical grid: as a public scaffolding that decays without continuous investment, that requires vigilance long before failure, and that is the necessary, if quiet, condition of everything else that we want to do. On the most basic level, this means bearing in mind, collectively, something I have long argued—something which is, indeed, in the mission statement of The Healthiest Goldfish: the reality that health is not healthcare, but, rather, a product of foundational forces, the social, economic, and political conditions in which we live. However, for the purposes of this essay, I would like to push past this familiar, though still necessary, framing, to engage with the more concrete question of: what it would actually mean to fund, govern, and live as if health were infrastructure rather than healthcare alone?

We can answer this question, first, by defining and understanding the role of infrastructure. This is, in some ways, most clearly done when infrastructure breaks: in the bridge that collapses, the water main that breaks in the cold, the power grid that goes down in a storm. Infrastructure is something we often notice only in its absence. We tend to treat our own health and the health of our communities the same way. We only fully see it when it fails—in the heart attack, the overdose, the outbreak—and we mostly do not see the long, slow, public work that kept the failure from happening sooner, or the lack of investment that allowed it to happen at all. This suggests that the central reframe we want to make in the conversation about health may be this: to insist that health belongs in the infrastructure conversation, not only in the conversation about intervention, rescue.

This is a big ask, for us and for others outside the health field. We are deeply invested in the intervention paradigm. Most of what we call a health system is actually an intervention system, built around acute care, organized around episodes of poor health, paid for through reimbursement, justified through downstream outcomes. The intervention frame has accomplished much and should not be dismissed; modern medicine is a profound achievement, practically and morally. But the intervention frame quietly determines what we perceive—what we think about when we think about health. It makes the cardiologist visible and the housing inspector invisible. It makes the new drug a breakthrough and the bus route a footnote. The intervention framing teaches us that health is what happens after something goes wrong, which is precisely the wrong place to direct our energies if we want a healthier population.

We can see this clearly by way of a conceptual detour into the world of physical infrastructure. Infrastructure, in its ordinary sense, is the layered and largely invisible scaffolding—roads, sewers, water, electricity, broadband, public transit—that supports the activities we can more readily understand that the often-hidden mechanics that underlie them. It is public or quasi-public, durable, long-horizon, expensive to build and more expensive to neglect. Eric Klinenberg’s work on social infrastructure (libraries, parks, schools, community centers) extends the concept in exactly the direction we need: the scaffolding that supports human connection is no less real, and no less consequential, than the scaffolding that supports human movement. Health belongs on the same conceptual map.

This idea may seem like an expression of futurism, but it is actually a lesson of history. The great population health gains of the nineteenth century did not come from clinical breakthroughs; they came from infrastructure. Edwin Chadwick on sanitary conditions, Lemuel Shattuck on the Massachusetts Sanitary Commission, John Snow on the Broad Street pump—these were conversations about pipes, drains, ventilation, housing, and the public works that made disease less likely. Thomas McKeown later sharpened the case that the modern rise of populations owed more to social and environmental conditions than to medicine. Geoffrey Rose’s distinction between sick individuals and sick populations belongs in this lineage. The twentieth century’s pivot toward medicalized health was, among other things, a forgetting, a reframing that obscured what the sanitarians had always known. We are now in a moment that requires remembering.

What does this frame shift imply? Time horizons that stretch from budget cycles to generations, where we plan for what a community will need in forty years, not what an insurer will reimburse next quarter. Maintenance that becomes a central activity rather than an unsexy afterthought—the steady work of sustaining clean air, walkable streets, mental health services, food systems—and trust being recognized as the core work of health, not incidental to it. Public investment in infrastructure that becomes the natural mode for policymaking rather than an exceptional ask. Decay becoming a threat we are organized to watch for, with surveillance that is anticipatory rather than reactive. A professional class that expands to include engineers, planners, urbanists, social workers, teachers, and community organizers working inside the health enterprise, not adjacent to it. Accountability that shifts from outcomes in individuals to conditions in communities.

This change in investment starts with a change in thinking, in culture. A culture that overvalues innovation will underinvest in maintenance, and a culture that underinvests in maintenance will keep being surprised by collapse. Andrew Russell and Lee Vinsel, in their work on The Maintainers and in The Innovation Delusion, have made this case directly for infrastructure; Steven Jackson’s thoughts on rethinking repair make the deeper philosophical version, arguing that maintenance and repair are not secondary activities but constitutive ones. It is not just the wider culture that needs to change how it thinks about health and infrastructure. Public health can fall into the same pathology of thinking about health as the bright shiny thing we see rather than the more understated necessity we do not. We celebrate the breakthrough drug, the new program, the bold initiative; we underfund the bus route, the housing inspector, the school nurse, the public health workforce, the libraries and parks and clinics that constitute the actual scaffolding of community health. The frame shift we need, then, is, in part, a cultural one—learning to honor the steady, undramatic work that holds the world up.

I realize there are strong counterarguments to this. One is that the infrastructure metaphor risks flattening health into something purely physical or technical, when health is also relational, cultural, and contested. But infrastructure has never only been physical. Also, the state cannot or should not carry so much of the burden—or accrue so much of the power—that comes with running this kind of massive, comprehensive investment (or what critics might call “social engineering”), especially in a political moment skeptical of public investment. But infrastructure is one of the few domains in which the case for public investment has held across political traditions—conservatives and liberals have both built bridges—and a health-as-infrastructure framing may travel more easily across the political spectrum than the partisan public health framings that have eroded trust. When we see health in these terms, we can then build a world that better supports health at every level of experience, and invest accordingly, so that our collective health rests on the strongest possible foundation.

__ __ __

Also this week

Enjoyed speaking with Tom Frieden on his podcast, The Formula, about the forces shaping public health in this moment and pragmatic steps we can take towards a healthier world.

Public Health Progress and Pragmatism