Why do we wish to be healthy? What is health for? What does it mean to pursue health in this moment, with the memory of COVID still fresh and public health facing political headwinds and a collapse in public trust?
These questions have been central to my thinking over the past few years, as I have tried to reckon with this unstable time for public health. This post-pandemic moment—which I and others have characterized as a “post-war” moment—is a chance for reflection, for evaluating what is fundamental about our field, the philosophy that animates our work at the deepest level.
When we look at the sweep of public health’s history, we see a field that has had remarkable successes. The treatment, even eradication, of deadly diseases. The doubling of global life expectancy. The development, and widespread dissemination, of vaccines. These successes rank among humankind’s greatest achievements. They were won by a combination of knowledge, values, and approaches which have long served public health well.
But we are in a new era. We can no longer assume the thinking that sustained us in the past can reliably do so in the present and future. Proof of this is in the challenges public health faces, its ongoing identity crisis in which our field remains a shadow of the confident, trusted, outwardly engaged movement it once was.
This is fixable. We can not only regain our footing, we can also build new foundations on which to stand. I serve as dean of the Andrew M. and Jane M. Bursky School of Public Health at Washington University in St Louis. Each day, I have the privelege of seeing our students grow into the public health leaders this moment needs. Their talent, their comittment to the work of public health, their keen understanding of this moment give me confidence that public health will find itself again.
These rising leaders deserve a field that is worthy of them. A field that draws from the best of its past, that learns from both its successes and its shortcomings, that is fully engaged with this moment in all its complexity.
Public health can do better. But for public health to change what it does, it must first change how it thinks. We need a new philosophy of public health.
That is why I wrote my upcoming book, Why Health? What We Need to Think About When We Think About Health.
The book, which launches on September 1, makes the case for a practical philosophy of public health that is informed by the lessons of the moment, that engages with complexity, that is confident in its convictions even as it considers different points of view, and that can build a big tent movement for creating a healthier world in the 21st century. The book works to define and develop this thinking through a series of essays adapted from writing that first appeared here in The Healthiest Goldfish.
At the heart of these essays is the question: why health? Why does health matter and what steps should we take, and not take, in our pursuit of it? Had we more deeply thought through these questions before the pandemic, it is possible we might have avoided some of our missteps during that period and the subsequent public backlash we have faced. But it is not too late for this process of reevaluation, for working through what we should think about when we think about health. As I tried to do so in the book, six themes emerged which can, I think, serve as a philosophical framework for a new public health.
Why Health?
The pursuit of health, I have long argued, is not an end in itself. It is a means to an end. That end is the living of a rich, full life. Public health should aspire, always, to strike a balance between protecting health and enabling what health is fundamentally for. When the pursuit of health interferes with the pursuit of happiness—the capacity of many to do as they wish, to make choices, even when these choices are not in the best interest of their health—then we should pause to recalibrate our actions. We are in the business of promoting health, and health is in the business of promoting living. We should not forget this.
Foundational values
Public health aims to create a healthier world for all by creating the conditions for better health and by working to eliminate health gaps. This focus has guided public health throughout its history, and we should stay grounded in this central aspiration going forward. Public health can and should change to meet the needs of the moment, but it should not deviate from the core values that constitute the field’s essential identity, and our values do not get more fundamental than our mission to build a healthier world for all.
Health at all costs?
I have argued for a muscular public health, and I continue to think the world is best served by a public health that is bold, ambitious, and radical in its aspirations. Yet it is important to temper this with moderation, with a willingness to act pragmatically and take a measured approach. If we neglect moderation, we risk advocating for steps which may go too far, sacrificing in the name of health much that makes life worth living.
The potential, and limits, of science
Science—the pursuit of truth through reason—is the bedrock of public health. Everything we do depends on generating data that reflect the truth about the world. We need to continue leading with our science, while being honest about what we know and what we do not. A trustworthy public health is one that follows the data wherever they lead, and, when data are lacking, admits this limitation.
The actions that generate health
Public health is mission-driven and our mission is the creation of a healthier world. Everything we do should point towards this goal. This means aligning our research priorities with what can do the most good on issues of consequence for health and aligning our practice with the pragmatism necessary to create tangible, real-world change. We can build a healthier world through a strategy of radical incrementalism, taking practical steps toward our goal, compromising where we must, without sacrificing our radical vision of better health for all.
Uncomfortable ideas for health
Public health evolves and improves through its engagement with data and ideas. But data and ideas do not always align with our preferred narratives about the world. For public health to progress, it must be willing to pursue the truth, and to have the hard conversations that sometimes come with this pursuit. We should remember that engaging with ideas does not mean embracing them and that an intellectually robust movement for health can, and should, take on this engagement.
I realize that these points pose challenges for public health. They are, fundamentally, a call to update how we think about what we do and, in some cases, to change the actions that are downstream of this thinking. But, as we have learned, change can come to us regardless of whether or not we choose to embrace it. The changes imposed on the field in recent years should move us to lean into this moment, in the spirit of revival, to shape a better, more resilient public health. This means taking an honest look at ourselves, fixing what is broken about our field, shoring up what works, and moving forward, boldly, towards the better world it is our mission to build. I wrote Why Health? to help start a conversation that might inform this process.
I look forward to continuing this conversation in the coming months, both here in The Healthiest Goldfish, and at a series of virtual and in-person book talks. Dates and times for future talks will be available here. Thank you to everyone who helped sharpen my thinking about these ideas over the past few years. I have found that the most constructive ideas are often those which emerge from a process of conversation and debate, and that when these conversations are uncomfortable, even slightly contentious, this can be a sign that they are generating the light we need rather than the heat we so often get. The extent to which we can have these conversations within public health is the extent to which we can start to emerge from the shadow of our shortcomings and build a new, better public health.
My hope is that Why Health? can help to catalyze these conversations, to help us navigate the challenges of this moment and seize its opportunities, to build a brighter future for our field and a healthier world for all.
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The means-and-end framing is the part worth sitting with. In anesthesia the same recalibration happens in miniature: I tell patients my job is to keep them safe and comfortable, in that order, and comfort is the word that gets treated as optional when resources are short. Your "health at all costs?" section is where I would put the shift of surgery out of hospitals, because nobody has answered who is doing the recovery care at home or what we are quietly expecting of families. Radical incrementalism could start with saying that part out loud.
Congratulations on this remarkable achievement! In my opinion, the book offers researchers and practitioners a valuable opportunity to rethink conventional perspectives and adopt a more realistic, evidence-based framework for understanding and addressing real-world challenges.