“Just because we can doesn’t mean we should”
On the virtue of exercising restraint, towards better advancing the long-term goals of public health.
I have long argued for a muscular public health. We should be proactive in using the levers at our disposal to shape a healthier world. This includes shaping public policy, working within institutions to reorient priorities towards health, and maintaining clear communications with the public. A muscular public health is one which engages, out of necessity, with power, using it to generate outcomes that we believe support a healthier world. Much of public health’s successes have happened because of such engagement. There is less smoking in the US, roads are less hazardous, regulations have been put in place creating safer neighborhoods and workplaces because reformers, including many in public health, acted, because they were not shy about making choices in the context of a given historical moment which advanced a healthier present and future. Insofar as action serves such a vision, it is to be embraced.
However, as a perhaps necessary counterpoint to this, I have been thinking more and more lately about the value of restraint and how it can help guide our efforts in public health. I have long liked the aphorism, “See everything, overlook a great deal, correct a little.” I have always found this a useful summing up of how to navigate from a position of leadership the work of trying to improve systems. We may wish to correct much, but restraint helps us to recognize how trying to do everything at once could, in fact, be self-defeating. In doing less, we help ensure that the actions we do take are most effective.
In keeping with these thoughts about restraint, I recently read with interest Princeton President Eisgruber’s comments about restraint in the context of academia and university leadership. He wrote, “When I consider whether to speak on an issue, I begin from the recognition that my principal responsibility as president is to ensure that the University remains an impartial forum for vigorous, high-quality discussion, debate, scholarship, and teaching.” This reflects an important quality of restraint—it returns us to the first principles of our work, as we ask ourselves whether a given action genuinely helps advance progress within our professional sphere.
Restraint has long been recognized as a key component of well-balanced individuals, leaders, organizations, and societies. Among the four cardinal virtues cited by classical philosophy, temperance—which could be read as moderation or self-restraint—is a pillar for sustaining a virtuous life. The value of restraint also appears in literature. Shakespeare wrote, “[I]t is excellent / To have a giant's strength; but it is tyrannous / To use it like a giant.” This is to say it is not wrong for us to develop power and influence in pursuit of a worthy goal like healthy populations. Indeed, it is necessary. But in acquiring “a giant’s strength” we have a responsibility to avoid using it “like a giant”—capriciously, crudely, without regard for those we might inadvertently trample in striding towards our goals. Restraint, then, is not about doing what one cannot do. It is about not doing what one could do, when such an action may prove unjust or counterproductive to the long-term success of our mission.
A useful example is public health’s engagement with stigma. Throughout its history, public health has occasionally used stigma to make certain harmful behaviors, such as smoking, less socially acceptable. For this reason, stigma has, at times, a role to play in public health communication. At the same time, stigma can do harm, deepening the social marginalization that creates poor health—a subject I have written about. This is why it is necessary to use stigma with restraint, mindful that too much finger-wagging risks tipping us into the moralism that can undermine our efforts. Were we to stigmatize every behavior that puts people in danger of sickness or injury, we would risk being seen as nothing more than scolds, and many would tune us out. Through restraint, we can more effectively reach people when it counts.
How are we to know when restraint is called for and when we should take decisive, immediate action? We might take a cue from the Jesuit order, which embraces a practice known as discernment. To the Jesuit, discernment is the careful weighing of choices in a context of prayer and self-reflection. A secular version of this might involve weighing whether a given action really does serve our long-term goals. When considering any step, large or small, we should always pause to think about possible choices in the context of where we want public health to go. The following considerations could help guide this reflection:
We should practice restraint in order to pave the way for larger action, avoiding taking small steps that could undermine our capacity to take bigger ones later on.
We live in an age of instantaneous everything, in which the quality of an action is often defined by the speed at which it is performed. Yet the better action is sometimes the one which has been seasoned by delay. When we are hungry, we may be tempted to eat some fruit before it is ripe. If we do, however, the fruit may not taste as good. It is occasionally better to wait a little, to maximize our action when it is taken. We also see this in public health’s frequent engagement with politics, a field full of examples of the importance of sometimes delaying action until the proper time. Former House Speaker Nancy Pelosi has a maxim, “You get the votes and you take the vote.” The implication is that you do not take the vote until you have in hand the votes needed to win—timing is everything. This suggests the importance of restraint, of waiting until the moment is right.
We should practice restraint when doing so is necessary for keeping public opinion on our side.
Throughout history we have seen how public opinion can be slow to support certain policies, even when these policies, like universal healthcare, seem self-evidently beneficial to all. Yet when the public is finally behind an issue, change can be quick and durable. It is necessary, then, to respect the public’s deliberative process, frustratingly slow as it can be. This means taking care not to say or do anything that could turn the public away from our side. This kind of restraint can take deep self-reflection and a willingness to listen to alternative points of view. It can be easy to convince ourselves that our favored policies are more popular than they are, which can cause us to act before the wind of public opinion has fully filled our sails. We need to try to see beyond the bounds of our ideological bubbles, to cultivate a sense of when the public supports a given action and when restraint is called for as public opinion takes the time it needs to coalesce.
We should practice restraint when there may be some who would like to support our efforts but are not yet ready to fully commit and premature action might destabilize their willingness to join us.
When engaging with public opinion, it is important for us to be mindful of two categories of potential allies. First, there are those who have not thought much either way about public health. The work of engaging with these people is largely still to come. Then there are those who have already thought much about our efforts and who may be close to supporting us, even as they are not yet completely in our camp. For this class of potential allies, it is particularly necessary to engage carefully. There is a saying attributed to Napoleon: “Never interrupt your enemy when he is making a mistake.” We might modify this to: “Never interrupt your potential ally when they are coming around to your point of view.” This means exercising restraint. There may be, for example, many with whom the environmentalist case for regulating pollutants has resonated. Perhaps they never considered themselves to be environmentalists, but they have been listening to the case for addressing climate change and they have seen the effects of respiratory illness in their community, and they are now newly open to federally directed solutions. In this context, restraint could go a long way towards making those who are close to being with us take those final steps.
Throughout its history, public health has enjoyed periods of power and influence. We are arguably in one of those periods now. The pandemic saw us amass great sway within government and key institutions, and our recommendations have led to sweeping actions at the policy level affecting millions of lives. At the same time, we have seen examples of overreach and backlash, as we have not always acted with restraint. It seems to me that public health is well-served when it tempers its power with restraint, so we can better support the long-term efficacy of our field and the health of the populations we serve.
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Also this week.
Thoughts in The Hill on reimagining our approach to immigration with public health as a guide. This work is informed and inspired by our recent book, Migration and Health, co-edited with my good colleagues Catherine Ettman and Muhammad Zaman, with contributions from authors from all over the world. Thank you to all who have been part of this project.
Bechara Choucair and I write on how the private sector can continue building the partnerships that can get us to a healthier world.
Over the past several months I have had the privilege of serving as Chair of The Association of Schools and Programs of Public Health Gun Violence Prevention Task Force. Our new report has recommendations to schools and programs of public health on how to optimize the pursuit of gun violence solutions.