On a new practical philosophy of health

Public health after COVID-19 is in a ”post-war” moment, a time for revisiting the philosophical underpinning of our field, to ensure it aligns with the evolution of our collective values.

Recently, it was announced that Noma, often called the world’s best restaurant, is closing. This announcement was even more notable for the reasons behind it. Noma is not closing due to lack of demand—which, given the restaurant’s reputation, remains high. Nor is it closing because the co-owner and head chef, René Redzepi, is retiring. He is still relatively young and has already stated his intention to turn the Noma brand into something new, transitioning to a food lab with occasional pop-up restaurants. Instead, Noma in its current form is closing because Redzepi feels the business model is unsustainable, resting as it does on punishingly long hours and the labor of interns who, until recently, went unpaid for sometimes grueling and monotonous work. Redzepi said of this model, “Financially and emotionally, as an employer and as a human being, it just doesn’t work.”

I have written previously about how, in past eras, we have seen a similar reevaluation of the values that underlie much in our society, including the relationship between employer and employee. Often, these reevaluations follow disasters or social shocks which jolt us out of old ways of thinking and make us see how the status quo is unsustainable. For example, the disaster of the Triangle Shirtwaist Factory fire helped shape the labor movement and the Progressive Era in the US. Then there was the publication of Rachel Carson’s Silent Spring, which addressed the environmental harm caused by widespread pesticide use and helped usher in the environmental movement. These moments saw us awaken to a status quo that was not serving health, a status quo caused by a dysfunction in fundamental values. In the case of the labor movement, it became clear that our understanding of the relationship between companies and employees needed drastic updating. In the case of the environmental movement, we saw how the terms of our engagement with the natural world were no longer serving us or the ecosystems of which we are a part. Each case was what we could call a “post-war” moment, in which a sudden shock or challenge created space for a realignment of collective values—a shift in consciousness on core issues.

If we look carefully, we can see that these changes and reevaluations are growing in places close to “home” for public health. In the UK, for example, the National Health Service, long a source of national pride, has come under unprecedented strain due to a combination of COVID, years of austerity, crowded hospitals, and intense work for healthcare providers. In Canada, the country’s publicly-funded healthcare system is facing similar strain. These challenges have intersected with a healthcare labor force that is protesting for better working conditions, with strikes happening in the UK and new conversations occurring about burnout among healthcare workers. Underlying all this is the COVID moment, when we applauded frontline workers as heroes as they faced steep challenges, then arguably did not do enough to meaningfully support them. The contrast between the applause of the early COVID era and the subsequent lack of change in workplace conditions has led to a conversation about fundamental expectations in the healthcare field. Should the field really operate as a pressure cooker, like the kitchen of a high-end restaurant? Or might there be new ways of imagining what healthcare could be, guided by a concern for the wellbeing of both providers and patients?

Such questions reflect a return to first principles, as we determine whether the values and assumptions that have long guided us are indeed serving a vision of a better world. This means asking questions that address nothing less than the fundamental nature of existence: How should human beings treat each other? What are the best ways of organizing communities? What are the values that should animate our pursuit of excellence? Questions like these are at the heart of the discipline of philosophy. For thousands of years, we have pondered how to organize a state, how to pursue virtue as individuals, and what constitutes a good life. Philosophers like Socrates and Plato provided some of the earliest and most enduring answers to these questions. But these philosophers pursued their inquiries at a time which countenanced much injustice, even as it produced durable intellectual systems. This is partly why we have had to continually revisit core philosophical assumptions about the nature of existence as we have onboarded new historical experiences, emerging technologies, and an expansion of our collective moral imagination.

Working in public health, I have long been concerned with how to improve the health of populations, with particular focus on the marginalized and vulnerable, towards narrowing health gaps as much as possible. This work is fundamentally shaped by philosophy, subject to the same process of reevaluation that shapes every intellectual system over time. The time is ripe for just such a moment of reevaluation. This is particularly clear when we consider that we have just been through a disaster on par with any prior shock that has motivated deep structural change. As of this writing, COVID has killed nearly 1,100,000 people in the US and about 6,700,000 people globally. After such devastation, it is not inappropriate, I think, to regard the present as a kind of “post-war” moment, when we should pause to take stock of what we have lost and work to establish the foundations for a better future.

The challenge of the pandemic exposed much that is wrong with our collective approach to health, and much that could specifically be better about public health as a field. As public health worked to address the pandemic, we struggled, coped, and, at times, simply muddled through. We did much right, but it is also fair to say that we were found wanting in many respects. Sometimes, this was because we lacked the material capacity or political support to pursue solutions to the pandemic at scale. Other times, our efforts were hindered by the limits of our philosophy. There were occasions when we simply lost much of the public, our recommendations falling on largely deaf ears. Our voice tended to carry most when it aligned with partisan dynamics, as public health became more polarized along political lines.

This is perhaps why we were not quite up to the task of making a truly compelling case for some of what we asked of the populations we served during the pandemic. There have been populations throughout history that have mobilized to a staggering degree for the sake of the principles that animated their collective life. Leaders were broadly aligned with these principles and could appeal to them when addressing the population, to accomplish miracles of mass effort. Yet we in public health struggled to encourage people to wear a mask and get a vaccine that would protect them from a dangerous pathogen. This reflects more than a failure of know-how or communication. It is a philosophical failure, a failure to effectively engage with the norms that shape the beliefs, behavior, and, ultimately, health of populations.

For this reason, it is more important than ever for us to engage with the philosophical questions that define our work at the level of first principles. Informed by the success and failures of the COVID moment, the evolution of values that shape the issues that matter for health, and the broader social and political disruptions of recent years, we need to ask the questions that can get us to what is next for public health. Here, I suggest, are some of them:

What is the potential of science in this moment? What are its limits?

How can we advance a vision of diversity that truly bridges divides?

In a time when public health has much power, can we re-embrace the humility that allows us to accept uncertainty?

How can we address the historical biases that have long shaped our institutions and systems of thought without jettisoning the best of our traditions?

How can we create pathways to dignity and health for all at every stage of the lifecourse?

What does it mean to articulate a radical vision for public health when these radical perspectives can lead us to impracticable places?

These are just some of the questions we need to answer if we are to shape a new vision for public health. I have long felt that we in public health have a responsibility to periodically revisit the philosophical underpinning of our work to ensure it remains fully supportive of the healthier world we seek to build. Towards this goal, I have written two books—Healthier: Fifty Thoughts on the Foundations of Population Health and Well: What We Need to Talk About When We Talk About Health—suggesting directions for contemporary public health. The book that followed, The Contagion Next Time, aimed to apply these suggestions to the pandemic moment. I am in the process of publishing a new book, Within Reason, which will be an effort to address some of the mis-directions that hampered public health during the pandemic, so we might correct course and move forward. It is now time for what is next.

So, in the spirit of what is next, for the next year in The Healthiest Goldfish, I will engage with some of the questions I have raised about the future of public health in this time of possibility and challenge. The ideas and conversations that emerge will ultimately go into shaping a book on a “post-war” vision for what is next in public health. Of course, such issues are too big for any one person to fully address. That is why I hope readers of this newsletter will join me in thinking through what this new vision for public health might look like. As always, I welcome your comments and feedback, and I look forward to learning from you.

I will end on a geological note. According to a recent study in Nature Geoscience, earth’s rotating inner core may be changing its spin. While this sounds alarming, scientists believe this change may be part of a regular cycle, with changes in the core’s rotation occurring every 60 or 70 years. These findings reflect how, while the ground we walk on may seem solid, unchanging, it is, in fact, supported by geological processes that are always in flux. This dynamism likewise underlies the assumptions we accept as foundational about the nature of our work, our society, our existence. What seems like solid ground only appears this way because of a process of pressure and change and the application of time. It is a process which is constantly generating new baseline assumptions, new foundations on which we proceed. Unlike the processes which shape the earth’s foundations, the work that generates the fundamentals of our field is something we can, and must, participate in. I look forward to doing so together in the coming months.

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Also this week.

Thoughts in BU Today on the recent mass shootings in California and what we know we can do to save lives.

I spoke with Nason Maani about the social and commercial determinants of health on the first episode of his podcast Money Power Health. More on this topic in our recent book, The Commercial Determinants of Health, coedited with Nason Maani and Mark Petticrew.