Looking back at 2023 through the lens of The Healthiest Goldfish
Looking back at 2023 through the lens of The Healthiest Goldfish
Reflecting on the thoughts that emerged over the past year.
My new book, Within Reason: A Liberal Public Health for an Illiberal Time is out now. Public health is fundamentally a story, and Within Reason is about how we can ensure that story is guided by our values.
Here is a reading from the chapter “Not in the Name of Public Health.” Thank you for supporting the ideas in The Healthiest Goldfish, and those in the book. Within Reason can be ordered here.
This is the last Healthiest Goldfish essay of the calendar year 2023. As I was considering topics for this piece, I thought that, rather than introduce a new subject, I would look back a bit on all I wrote over the past year and on the conversations these reflections helped inform. The Healthiest Goldfish has, from the start, been organized around key themes and a certain spirit of inquiry. These themes include looking back on the COVID moment, to understand what we did right and what we did wrong, trying to better balance our values and data in pursuit of our mission, avoiding the pitfalls of communication in an age of social media and the attendant moral grandstanding that can undermine the humility and genuine moral courage that are central to scientific work, engaging thoughtfully with the foundational drivers of health, and shaping a philosophy that can support an effective, pragmatic public health mission to generate transformative change in this post-war moment. I have tried to engage with these topics in a spirit of self-critical reflection. Such reflection can be difficult, uncomfortable. But I do so out of a belief that it is necessary to become better in our pursuit of health.
As these essays have engaged in this reflection, they have been enabled, informed, and at every turn made richer by you, the reader. The capacity of any piece of writing to help shape the public debate is only as good as its audience’s willingness to engage in good faith with a wide range of topics, even when these topics are difficult. I am immensely grateful that The Healthiest Goldfish has an audience that is game for such discussions. You have challenged me, made me think, made me better. Through your engagement, you have supported the kind of conversations that can help generate light, not just heat, in this polarized moment when it can feel like so much is being said to so little effect. To the extent that these essays are of use, it is largely because of you, the reader. Thank you.
I am also aware that the publication of Within Reason and the conversation it has informed have brought new readers to The Healthiest Goldfish. To those who are joining the conversation for the first time: welcome. It is good to have you here. I look forward to hearing from you, as you add your voice to the ongoing discussion that is at the heart of these writings.
Core to this discussion has been a willingness to grapple with complexity. I started the year with a piece about welcoming back complexity in 2023. The foundational premise was that, after three years of the acute phase of a pandemic, we lost much of our ability to engage with complexity, to weigh data and tradeoffs in a context of uncertainty. I suggested that we were in a moment—and I believe we are still there—that calls on us to reengage with complexity, to bring nuance and reason back to our conversation about health. I introduced the notion that we are in a “post-war” moment when the experience of COVID—the trauma and disruption of the pandemic years—created space for new thinking about health, informed by the hard lessons of what we have been through and the possibility COVID created for envisioning radical change. My goal with the writings of the past year has been to articulate elements of a vision for supporting such change pragmatically—a practical philosophy for health. Clearly, that is a big agenda, and it remains very much a work in progress, but, looking back, it seems to me that the pieces I wrote in 2023 coalesce around four thematic areas which, together, reflect the basis for such a philosophy. They are “Foundations,” “Finding the right conversation for health,” “Understanding the structures that generate health,” and “Values to animate us.” These values represent the planks of a vision for health which can, I think, bear the weight of the road ahead; they are also the organizing principles of the book I am writing expressing this new philosophy as we move forward, collectively, in this moment. In the spirit of reflection and organization that are hallmarks of welcoming a new year, I will here look back on 2023’s writing through the lens of these four areas, with an eye towards deepening these reflections, with your help, in 2024.
Foundations
On a new practical philosophy of health
This essay articulates a vision for public health in the wake of the pandemic years and suggests now is the time for shaping a new philosophical approach, integrating the lessons of the past with the opportunities of the moment.
The potential, and limits, of science
This essay argues that supporting progress in the post-pandemic era requires a science that can engage with complexity and recognize the reality of limits, informed by the humility that should animate all we do.
Thoughts on embracing a more realistic engagement with risk, informed by the lessons of the COVID moment, as a tenet of a post-war philosophy of health.
Revisiting the question of “why health?”
On asking perhaps the most foundational question of all: why do we wish to be healthy? The answer, I argue, is that health is fundamentally a means to the end of living a rich, full life.
The moral, aesthetic, and intellectual case for health
On creating a philosophical foundation for health rooted in ideals of truth, beauty, and justice.
On the motivation behind writing my new book and why public health can only succeed when it rests on a foundation of free inquiry, open debate, and the reasoned pursuit of truth.
Finding the right conversation for health
The ineluctable role of persuasion
Promoting the ideas that support a healthier world means working to convince, rather than compel, in our engagement with the public debate.
Centering human rights and autonomy for all
On balancing what is good for the collective with what is good for individuals, while always respecting the dignity of the populations we serve.
On engaging with community voices from a place of humility, respect, and mutual understanding.
Anticipating and addressing some of the criticisms of Within Reason, towards a more constructive dialogue about the future of public health.
Why we should work with people in places we disagree with
On keeping the lines of communication open with people in places that might not share our views, towards promoting the respectful engagement that truly changes minds.
Motivated by recent events in the Middle East: On shaping better conversations about emotionally charged issues by taking a moment to pause and reflect before we speak.
Having the conversations we should have when we can have them
More reflections motivated by the Israel-Hamas war: on creating space for conversations that advance understanding and progress in difficult moments.
Understanding the structures that generate health
Centering proportionality in public health thinking
On maximizing our capacity to do good in pursuit of health, while minimizing the likelihood we will cause harm.
Public health is concerned with the large-scale forces that shape health, but it is important to also engage with the ineluctable role of human behavior and our human tendency to sometimes make choices that harm our health.
Reconciling context, effort, and ability
On shaping an understanding that recognizes both the structural drivers of health and the role individual initiative can play in creating the circumstances that generate health.
The biases we bake into our systems
How our individual biases can become embedded in the systems and institutions with which we intersect, with implications for how these forces shape health.
The astonishing privilege of living in a high-income country
On the unique perspective living in the high-income world affords and how this perspective can shape our pursuit of health at the individual and collective level.
Again and Again. Mass Shootings Continue Unabated in the United States
A reflection, following the mass shooting in Lewiston, Maine, on the structural drivers of gun violence in the US and the reasons to hope we are making progress on this issue.
On creating a world where imperfection does not mean poor health.
On shaping an investment that balances the pursuit of health with the enjoyment of what health enables—the living of a rich, full life.
Values to animate us
When our biases get the better of us
Acknowledging, and correcting for, the often-invisible biases that can influence our work.
“Just because we can doesn’t mean we should”
On embracing humility and restraint as core values for our pursuit of health.
The right amount of performance
On the utility of performance in the pursuit of health and the importance of ensuring the roles we play align with our best values.
Leaving behind values disguised as science
Acknowledging the intersecting, at times competing, imperatives of what we know is right and what, through our science, we simply know.
On shaping a pragmatic, values-informed definition of what is reasonable in our pursuit of health.
When our values are not shared
On engaging with populations whose fundamental understanding of what is right may be at odds with our own.
Radical incrementalism, the case for
On embracing pragmatism as a core value, wedding a radical vision to the realistic steps that can help us get there.
The integrity of the mission to promote health
Towards shaping a public health values system with integrity at its heart.
On creating conversations that are not dominated by the most extreme voices, by reaffirming the value of respect and moderation in service of good ideas.
Two thoughts in conclusion. First, the end of this year also saw the publication of Within Reason: A liberal public health for an illiberal time. The book is a mosaic of ideas I had put forward in Goldfish essays from 2021 and 2022 broadly, pushing on the notion of our need for a return to a public health grounded in reason, a topic I addressed explicitly in this essay, recognizing that it may occasion disagreement. It has been gratifying to read reactions to Within Reason. These reactions have, of course, included disagreements, but it has been encouraging to see how they have largely been offered in a spirit of reflection and good faith. It has been good to see there does remain space for ideas, for generative thought that can move our thinking forward. I look forward to continuing these conversations in the new year.
Second, I realize that in some ways these musings are abstract and can perhaps seem removed from some of the contemporary concerns that public health contends with. While a selection of these essays does engage with such issues, I generally share thoughts about more contemporary issues in my writing of Dean’s Notes at the Boston University School of Public Health (see some examples here, here, and here). This is a deliberate choice, keeping the Goldfish space intentionally removed from the white heat of issues of enormous contemporary importance. This reflects an aspiration to use this space to slowly create a foundation of shared thinking that informs how we think about and deal with contemporary issues when they emerge. It is my attempt at first principles thinking, which can be difficult to engage in while grappling with complicated issues in real time. Carving out space to take a step back, to think through the intellectual substrate of issues, seems to me to be well worth it. It is also true that such thinking can be a luxury in a busy, disorientating era like ours, and moments when we can indeed think deeply about issues should be seized whenever possible because we cannot know when they will come again. That many Goldfish essays in 2023 were able to delve deeply into the philosophy of health reflects how the year, for all its incident, provided time and space for such exploration. 2024, with its promise of more complexity, more social and technological disruption, and a looming federal election the US, may not be as conducive to such thinking—I will reflect more on this at the beginning of the year.
For now, it is enough, I think, to end 2023 on a note of reflection, one that is informed by our responsibility to do right by our mission to create a healthier world for all. I hope that everyone has a restful holiday season. Thank you for being a part of the journey of The Healthiest Goldfish, for reading, reflecting, and sharing these thoughts with others. I look forward to reconnecting in 2024.
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Also this week.
I have the privilege of chairing The National Academies of Sciences, Engineering, and Medicine Committee on Assessment of the Impact of Social Media on the Health and Wellbeing of Adolescents and Children. Our recent report, “Social Media and Adolescent Health” examines social media’s effects on the mental and physical health of young people and makes recommendations for better use of these platforms.
New in The Milbank Quarterly, thoughts with George Annas on where our priorities should lie as we work towards a world that is no longer vulnerable to pandemics.
Finished this chapter yesterday - on “thinking in groups” right now.
Lots of sticky note thoughts, so progressing slower than expected. Interesting book so far, just ordered a few more from your expansive back catalog too.
https://imgur.com/a/GSubjGJ
Balancing thought, reflection and action - a complex but necessary jiujitsu in a complicated world. Thank you, Sandro, for reminding us that reality is multi-layered and rich. Sharing our perspectives respectfully is a vital aspect to communication and discourse. May we continue to learn and enact these practices.