“Not as a matter of charity”

Building a healthier world as a matter of social duty.

Recently, I have been writing some reflections that are spurred by the moment, focusing on how we need to make health a priority in our politics, and on my concerns about ensuring our politics are informed by an appreciation of their effect on people’s lives and health. Today, I want to reflect on perhaps some of the genesis of the current actions we are seeing at the federal level, actions with deep implications for national and global health. As the new US federal administration has begun making sweeping cuts to federal programs, one cannot help but feel that these programs are being cut, in part, because they are seen as being “charitable” and that charity, when times are tough, or when ideology shifts, is no longer regarded as a tenable motivation for large-scale federal expenditure. This matters for public health because much of what we do can indeed be interpretated as, at core, charitable in intent, with all the baggage this can carry in the national political debate.

Given this reality, it is worth asking, first, should what we do be seen as a work of charity? In 1931, Franklin Roosevelt, then Governor of New York, said to the state assembly that the crisis of the Great Depression required a vigorous government response, “not as a matter of charity, but as a matter of social duty.” This has stayed with me and infuses how I have long thought of public health. Public health is the work of creating the conditions for people to be healthy. Often, lack of health is due to lack of resources—these can include a good income, a good education, access to nutritious food, clean air and water, and other tangible necessities. Creating a healthier world means engaging with the distribution of these resources, at scale, to ensure all can access what they need to be healthy, with particular focus on the marginalized and vulnerable. This entails what can look like charity, in which we give to those in need. Yet charity alone—which, when practiced at the individual level, can be fairly straightforward—can be an unsteady foundation for large-scale, collective work, including the work of public health.

At the level of politics, for example, the model of top-down distribution of resources through federal programs and agencies has come under heavy scrutiny. In recent weeks, we have seen efforts by the new administration to reevaluate how the federal government allocates resources nationally and globally. These efforts have intersected with a range of programs and government departments, with particular relevance for global health aid, where the administration has imposed a spending freeze, with some waivers for vital global health work. The administration has said these steps are being taken to curb wasteful spending and because some of these programs have been using this money for ideologically motivated projects and to fund work that runs counter to American interests abroad. These are complex, charged allegations which demand a high standard of proof to justify the administration’s actions, and it is right that there should be a robust national debate over what we are seeing unfold. For the purposes of this essay, it is worth noting that these spending cuts seem to reflect a hostility to the notion of charity that underlies much of what these organizations and policies are meant to do in their efforts to distribute resources to those who have little and need much.

This hostility is not new in American politics. We have long seen programs criticized for giving money and resources to populations that some characterize as “the undeserving poor.” This was the focus, for example, of the long debate over welfare, in which arguments over who merited federal assistance often served as proxy fights over whether the government should even be in the business of providing such assistance at all. This debate in many ways culminated in the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, which made welfare time-limited and tied to a work requirement. It is notable that while the act reflects many conservative arguments, which were prevalent particularly in the rhetoric of Ronald Reagan, it was ultimately championed and passed by Bill Clinton, a Democratic president. This reflects the reality that when a program appears to be “a matter of charity” alone it will likely always be politically vulnerable. I do not say this as a criticism of the instinct to be charitable, only as a pragmatic acknowledgement of the political realities that shape all we do. Public health must engage with these realities if we are to ensure our work has a solid foundation in the years to come. The speed at which we are seeing a rollback and potential dismantling of programs that are informed by a spirit of what we might call political charity suggests now is a time for taking an honest look at what it means when we see our work primarily as a matter of charity and for asking whether there may be a sounder philosophical and moral basis for our efforts.

Merriam-Webster defines “charity” as “generosity and helpfulness especially toward the needy or suffering.” There is no question that there is an element of this in the work of public health. We see people in need and are motivated to help them. However, contained within the definition of charity can be an implicit condescension, a sense that it is something we deign to do from a position of superiority, as a kind of noblesse oblige that the privileged do for those “lower” on the ladder of economic and social success. And, if we are being honest, public health at its least self-reflective can indeed tip into this territory, as much as we may wish to avoid it.

That therefore is where social duty comes in—our obligation to do our work not as a matter of charity but as a function of something more egalitarian, something that reflects the dynamics of the world we are trying to build rather than the world as it is. This turns us to the definition of “duty,” which is, “conduct due to parents and superiors : respect.” This is a striking contrast to the definition of charity. Where one reflects a group of people looking down at those lower on a ladder, the other has people looking up. Where charity implies compassion and obligation, duty demands action from a sense of respect. When we act from a sense of “social duty” we are acting not from a place of condescension, but from a recognition that the communities with which we engage deserve respect, dignity, and the capacity to live healthy, autonomous lives. To engage with these communities from a sense of duty is to look them in the eye rather than to look down on them, with the understanding that our health is connected, that we are all in the same boat when it comes to health, and that, regardless of how high the tide lifts our boats, as long as anyone’s health is held back, we still have work to do.

This understanding reflects the reality that a healthy world is good for everyone. So, each time we do something to improve the health of vulnerable communities, we are doing something for ourselves as well as for the people with whom we engage. This is reflected at the level of basic economics. A healthier population means a healthier economy, with a healthier workforce helping to drive economic growth. Health is also, of course, interconnected at the biological level. As we saw during the COVID moment, when there are pockets of poor health in a society, it means everybody’s health is vulnerable. The social duty to promote health, then, is a duty we owe to ourselves as much as to others.

What are the implications of this? What does it mean to pursue our work as a matter of duty rather than just as a matter of charity? Centrally, it implies a particular vision of the world, one where it is our duty to ensure that no one is held back due to avoidable differences in health, and hence we have a duty to uphold this same vision through our actions. As we see efforts to dismantle many of the structures meant to support health and wellbeing in the US, it is worth remembering why many of them were established—from a sense of duty to ourselves and to our neighbors nationally and globally, to ensure that, in a world of much abundance, everyone has a chance to share in the resources that help us all to live healthy lives.

A final word about charity, one that is relevant to this moment. There are other definitions of “charity,” which include “benevolent goodwill toward or love of humanity” and “lenient judgment of others.” Such definitions are, perhaps, at the heart of the famous verses from 1 Corinthians:

“Though I speak with the tongues of men and of angels, but have not charity, I am become as sounding brass or a tinkling cymbal.

And though I have the gift of prophecy, and understand all mysteries and all knowledge, and though I have all faith so that I could remove mountains, but have not charity, I am nothing.

And though I bestow all my goods to feed the poor, and though I give my body to be burned, but have not charity, it profiteth me nothing.”

It is interesting that, in these verses, charity is framed as distinct from giving to the needy. It is charity in the larger sense, charity that sees the best in others, that gives them the benefit of the doubt, and that extends goodwill even to those we may consider foes. Such charity, which could well be said to inform a spirit of mission that is rooted in duty, has much to teach us in this moment. It offers a framework for words that truly resonate, that drive change rather than “become as sounding brass or a tinkling cymbal.” It reminds us that a healthier world starts with a vision of serving others for their sake and for our own. Health is not a matter of charity alone, yet an expansive vision of charity, one that places us at the service of others rather than as aloof, self-appointed (and perhaps, at times, self-centered) benefactors is essential to the creation of a healthier world.

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Also this week

It was a privilege to share some thoughts on the moment and on the future of public health with the WashU community, at our recent Assembly Series talk. A film of the talk is available here.

It has been a joy speaking with WashU faculty about their research, as part of our Public Health Ideas series. View the conversations here, with more coming soon.