Health, not all about the molecules

How population health science and biomedical science together can create a healthier world.

I recently had the privilege of interviewing Dr. Arati Prabhakar, the current Director of the White House Office of Science and Technology Policy. Our conversation was wide-ranging and I much enjoyed it (it can be viewed here on the White House website). At one point in the discussion, Dr. Prabhakar said, “Health is not all about the molecules.” I thought this was a terrific encapsulation of much of what we do in our engagement with health, a succinct distillation from someone who serves as the chief science and technology advisor to the president. Because, fundamentally of course, when we think of science and technology and health, we do often think about the molecules, about the “hard” sciences and the technological developments they yield. We are accustomed to measuring scientific advances in health as the emergence of new pills, potential genetic modifications, and biological enhancements. This perspective is understandable. Such innovations are important, and we would likely all agree that, when we get sick, we want to do so in a world with the best drugs and treatments. Yet it is also true indeed that “Health is not all about the molecules.” Drugs and treatments can help us when we are ill, but they are far less decisive in shaping the health of populations. Health, at its core, is a product of the conditions in which we live. Do we have clean air and water? Can we access nutritious food? Can we get a good education? Do we face racism, misogyny, and xenophobia? Are we financially afloat or do we lack the material resources to live economically secure lives? Such questions are at the heart of population health. They determine whether we live healthy lives or remain vulnerable to disease and preventable harm.

Consider the challenge of chronic disease in America, a subject in the news lately as part of the incoming Trump administration’s “Make America Healthy Again” initiative. Key chronic diseases in the US include diabetes, which afflicts about 38 million Americans, and cardiovascular disease, which is the leading cause of death in the country. There is a plethora of treatments available for these conditions, treatments which can indeed do much to help improve the quality of life for those who suffer. But these treatments can do little to address the structural drivers of these sicknesses—in particular, the obesity epidemic which is at the root of so much chronic disease in America, including heart disease and diabetes. New weight loss drugs can perhaps help to address obesity, though we are still very much in the early days of these treatments. And even the best drugs do not make a dent in the drivers of obesity—food deserts, the widespread availability of junk food, and the commercial and political determinants that shape what goes into food, keeping much of it cheap and unhealthy.

And this is how biomedical science and population health science together contribute to the creation of a healthier world. While the former engages with the development of the treatments that can cure disease, the latter is the work of engaging with these structural forces to create a context where disease does not emerge at all. This means that population health science moves us beyond molecules, the pills and potions we can take when we are sick, to address the roots of health and disease.

The necessity of the work of both biomedical science and population health science has often been lost in the public imagination. The world of molecules is compelling, as we consider what is, and what someday may be, possible through technological innovation. Every day we hear of potential advances in biotech—of new drugs and novel approaches to precision medicine which, we are told, will revolutionize health. The rise of new technologies like AI has only added to the glamour and excitement of this space. The world of molecules seems to promise fast, effective solutions to health challenges. Addressing the structural determinants of health, on the other hand, is an incremental process, recalling the “slow boring of hard boards” that was Max Weber’s definition of trying to make political change. Yet doing so is as necessary to our world as politics (and is indeed often synonymous with the political process), and, while it may take incremental work, its aspirations are just as radical as those of the most forward-looking technologists. To create a healthier world is to create a world that supports health at the structural level. This means changing structures—a definitionally radical task.

What is the remit of population health science in pursuit of this goal? It is an expansive remit indeed. Our science should be about how we deliver health services, how we build resilient health systems. But our science should also be about the conditions that shape our collective health, the policies that support healthier outcomes and behavior, and the interventions that improve health in the local, national, and global community. Its areas of interest include, but are not limited to, non-communicable diseases, mental health, health systems, climate change and health, infectious disease and pandemics, and population aging. If this focus seems broad it is because health is a product of the world in which we live, suggesting that the science that informs population health should take as its subject the full range of forces that shape our world and our health. Population health science can, by generating data about these forces, inform a practice which creates opportunities to improve health among individuals and populations.

In much of my writing I have seen a population health science approach as inextricable from a consequentialist approach that can keep our science focused on what matters most for health, towards our goal of building a healthier world. Our science can only do this when it is supported by outstanding scholarship. I see such scholarship as evolving, constantly refining itself, to tackle new challenges as they emerge. In a recent viewpoint written with Mohammed Abba-Aji, we argued first that population health science needs new ways of thinking. The pandemic revealed that many current frameworks in public health, which have long served us well, are in need of updating if we are to be at our best in the coming decades. We need to address the tensions that can arise in our work, such as the tension between individual autonomy and the paternalism that can sometimes be a necessary tool in our efforts. Second, we need our science to adopt new methods and approaches, to embrace cutting-edge data science to help us better understand the health of populations and embrace health equity at the core of all we do. Third, we need science that has the imagination to tackle the urgent and the important, to generate actionable insights to inform decision-making at the policy level in real-time, particularly in moments of uncertainty or crisis like COVID. And fourth, we need and want to build this science across disciplines and intellectual pursuits, forging partnerships between academia, government, and industry, so that we can scale up our science by leveraging the expertise and resources of a diverse range of fields.

I am grateful to Dr. Prabhakar for her comments which occasioned this reflection. I particularly enjoyed thinking about this as I look ahead to the next phase of my career, and work with colleagues in St. Louis to launch an ambitious new school of public health at Washington University. I look forward to doing this while working alongside an outstanding School of Medicine and a range of other schools all of which ask and answer questions that lend themselves to understanding the structures that matter to the creation of a healthier world. Many of the ideas I write about here I have woven into some recent writing about aspirations for the work we shall be doing at WashU. I am looking forward to taking on that challenge.

This will be my last Goldfish piece of 2024, barring the moment calling for other reflections. I will end, then, with conveying my warmest wishes to everyone for the holiday season, in hopes that all have the occasion for a restful and restorative period, ahead of our work in 2025.

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Also this week

Many thanks to Dr. Tessa Matson for her leadership on our new article in the American Journal of Epidemiology, “Understanding inequitable healthcare: Methodological approaches, challenges, and opportunities.”