Today the US celebrates its 250th birthday. It is notable that the US marks as its founding not the anniversary of the victory of the continental army at Yorktown, nor the adoption of the Constitution, the seating of the first Congress or the inauguration of the first president, but, rather, the day when the delegates of the Second Continental Congress formally approved the Declaration of Independence. That moment marked the birth not just of a new country, but of a new idea—that an assumption of basic human equality could serve as the foundation for a state, and that the state should be a safeguard of the rights such equality demands—namely rights to “life, liberty, and the pursuit of happiness.”
Thinking about America, celebrating America, then, means engaging with the ideas that is has introduced into the world over its 250 years of existence, starting with its founding idea of fundamental equality. We should engage with these ideas not uncritically—just as we should not think about the US, or any country, uncritically—but with a realistic appreciation for the good they have brought into the world. This is particularly true this July 4, when we reflect on America’s past and present, and all that it offers the world that is worth celebrating and preserving.
In the spirit of this, I would like to take the occasion of this milestone in America’s history to reflect on one specific subset of its global influence—how America has advanced science, health, and human flourishing. In doing so, I will start—as America started—with ideas. Many of the conditions that shape health are not medical at all, but ideational: self-government, individual liberty, pluralism, the rule of law, free inquiry. America did not invent these ideas, but it staked a national experiment on them at scale, and the world’s health has been shaped by that political and intellectual choice.
How has this influence unfolded over the last 250 years? I will answer by addressing four of America’s core ideas—the principle of liberty and self-determination, the principle of free inquiry, the principle of material prosperity as a central good, and the principle of openness and personal mobility.
First is the principle of liberty and self-determination. This principle is encoded in the American founding through the Declaration of Independence (which asserts the inalienability of this principle and the British Crown’s traducement of it as a key reason for the colonies’ political separation from England). It has been exported throughout the world by both America’s example—a stable and prosperous system other countries have chosen to imitate—and, at times, by force (as in Iraq, for example, and America’s imposition of democracy on occupied Japan after World War II). Even acknowledging the harms at times associated with the latter, there is little question that the stability and prosperity that often emerge from systems based on the principles of liberty and self-determination make the ideas potent influences for good health.
Amartya Sen’s observation, “Famines are easy to prevent if there is a serious effort to do so, and a democratic government, facing elections and criticisms from opposition parties and independent newspapers, cannot help but make such an effort” makes the point and the facts bear this out. If we look at the world today, we will find most, if not all, famines are occurring in war zones, autocracies, or otherwise closed systems. The reasons for this align with Sen’s point: when people have liberty and political self-determination, they can hold governments accountable for the policies which lead to preventable tragedy at scale. To the extent that the US has played a role in the proliferation of these political conditions, it has done a great service for health around the world.
Second is the principle of free inquiry as the essential engine of discovery. Free inquiry is, of course, an idea that long predates the American republic. Its roots go back to the Scientific Revolution and the Enlightenment. But the US placed the principle of free inquiry at the heart of much of its investment and infrastructure. This arguably began when Thomas Jefferson, as president, commissioned the Lewis and Clark Expedition as, in part, a journey of scientific discovery. It was notably carried on by the 1863 creation of the National Academy of Sciences and has continued in America’s funding of open science—nationally and globally—in the 20th and 21st centuries. This has yielded world-changing dividends, including the space program, the development of essential vaccines, the eradication of diseases, and the scaffolding of basic scientific research that others have built on all over the world.
Third is the principle of material prosperity as a central good worth pursuing. I realize this principle may strike some as controversial, given this pursuit’s capacity to underwrite unchecked materialism and inequality. This critique is correct, and always worth bearing in mind. However, it is also true that expanded access to relative prosperity that came first with the advent of industrial capitalism and, later, with America’s embrace of this economic model, has created the conditions for better health for many. Economic dynamism and the flow of productive forces have, for all their unevenness, created the material conditions that underwrite health. These conditions include greater access to the basic necessities of life—climate-controlled homes, nutritious food, technological conveniences—as well as the prosperity that underwrites greater access to education, employment, and civic participation.
Fourth is a principle which has been stress-tested in recent years, but which is nevertheless fundamental to the American project—the principle of openness and personal mobility, particularly with respect to immigration. America is a nation premised, however imperfectly, on the proposition that where you are born need not determine your fate—that you can come to America and create a better life for yourself and your family. It was this ideal that brought me as an immigrant to the US and this idea continues to have unique power in the world. It is worth noting, for example, that America’s chief rival, China, which is neck and neck with the US in so many domains of global competition, has nowhere near the influx of immigrants enjoyed by the US. The immigrant dream, in some ways, also extends to American citizens who, while Americans by birth, may feel far removed from the prosperity and success so many seem to achieve in the US. To those people, America at its best says “You need not be alienated from the fruits of this land. Work hard, seek opportunities, and you too can build a better life. It may not be one of fabulous wealth and professional success, but it might be, and even if it is not, it will very likely be a better life than the one you leave behind in order to pursue it.” This promise, this American Dream, imperfectly realized as it often is, has nevertheless been, as an idea, a powerful engine driving individuals to improve their lives and driving political movements to shape policies that make this pursuit easier and accessible to all.
All of these ideas have a complicated legacy. This is evident, for example, in the country’s dramatic swings between moments when it has opened its arms to immigrants and moments when it has all but sealed its borders. It is also evident in how America’s promise has been withheld from many over the course of its history—for many of the 250 years we now celebrate, African Americans, women, LGBTQ+ communities and other marginalized groups were denied their full rights to life, liberty, and the pursuit of happiness. This legacy has shaped present-day inequities, including health gaps and the democratic strain that has roiled our politics. Just as we should be honest about the country’s virtues on its 250th birthday, we should be honest about the ways it has fallen short, in both the past and the present. One is honest with those that one loves; to love America, then, it to be honest about it, both its good and bad.
But historical context should also be part of any conversation that critiques this country’s contributions. Birthed in an era when exclusion was common and widely accepted (though not by all), America has consistently been a force for deepening the definition, and expanding the reach, of human freedom. A significant reason we now have the modern mindsets that lead us to, at times, critique the past is because of the slow, imperfect, but nevertheless revolutionary American project shaping the consciousness not just of Americans, but of the world, broadening our moral imagination of what freedom can mean.
I realize that celebrating the ideas that have shaped America and their influence on health can sound like self-congratulation. But this is not the case. It is important to note that while the ideas I have mentioned here are integral to America’s formation, they are not America’s property, nor are they the property of any movement or political party. They are, fundamentally, small-l liberal ideas. Human liberty, free inquiry based on reason, rejection of the belief that there are preexisting hierarchies into which we are born—these ideas are our common inheritance. They have flourished in America, but they remain on the move, shaping a better world by their influence.
Naming these ideas on July 4 is a way of reclaiming a less sectarian and less partisan account of how these concepts have helped make this country great and the world healthier. Even recognizing that we still have to do much better, if health is one measure of whether a set of founding propositions have proved their worth over time, then America’s founding ideas have been successful indeed. This 250th anniversary is an opportunity to recommit to these ideas, to continue the unfinished work of building a more perfect, healthier union—and world.
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Also this week
With Debbie Cheng and Madhu Mazumdar in American Journal of Public Health (AJPH) Trustworthy Artificial Intelligence in Health Requires Public Health Leadership
New on Ideas Matter, a conversation with Stanford University’s Lukas Althoff about inequality and opportunity in America.
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Goldfish takes a break
As we enter the slower part of the academic calendar we shall stop publishing The Healthiest Goldfish for a few weeks. We shall return in early August. I hope that everyone has a good, restful few summer weeks.
A thoughtful and hopeful reflection. I wonder if one more principle belongs on the list: our responsibility to one another.
Liberty, free inquiry, prosperity, and mobility create opportunity. But better health also depends on what we choose to build together: clean water, public education, vaccines, worker protections, and access to care.
America’s history is full of contradictions. It has promoted freedom while at times denying it, both at home and abroad. It has also been a place of refuge and opportunity for immigrants, refugees, and people escaping persecution.
Perhaps the unfinished task is not simply to celebrate liberty, but to make it more sincere, more compassionate, and less tied to narrow self-interest. Liberty is strongest when it is widely shared and joined to genuine responsibility for others.
This is a powerful reminder that healthcare and health are not the same.
As healthcare leaders, we often measure activity—admissions, procedures, waiting times—because they’re easy to count. But what ultimately matters is whether our systems create more health, prevent harm and reduce the years people spend living with disease.
Perhaps it’s time to stop asking, “How much healthcare did we deliver?” and start asking, “How much health did we create?”