On changing when we should change

Part 1 of 2. The importance of reimagining public health in an uneasy time

This piece was co-authored by Dr Nason Maani

Public health is at an uneasy juncture. Its central institutions face diminished public trust. The CDC has faced unprecedented cuts and challenges to its remit and organization. Funding for public health research has been under strain. Presidential declarations on diseases and vaccines have, at times, run directly counter to expert consensus. While understandably dominating the headlines, this is by no means a US-only trend. In more subtle ways, public health is being undermined in the UK too. Public Health England was disbanded, presented as a technical re-organization to strengthen pandemic preparedness, but also serving as a way of deflect criticism over COVID-19. This change replaced an arms-length organization that led campaigns and produced authoritative reviews with one embedded within health and social care, without budgetary independence or the ability to act autonomously. Two years later, a long-planned white paper on health disparities was scrapped. At the global level, health funding has been dramatically curtailed since January 2025. The immediate consequences of all this are increasingly visible: declining confidence in science and government institutions, resignations, confusion, policy vacuums, and a heightened vulnerability to mis- and disinformation.

This is indeed a moment of challenge. And in such a moment there are in some ways two competing impulses. The first, should we rethink what we do, how we do it? Are there things we should do differently and why? And the second can we have the courage to stand for things that matter to us? How do we find that courage? So, two pieces this week and next. First, about evolving and changing. And then, about courage.

It is a truism that times of crisis demand reinvention. And this is indeed a time of crisis for public health, perhaps even more than we in the field can observe or wish to admit. And yet the challenge is, at times, so daunting—the error of the ways of those who challenge the field so apparent—that it is easy for us to create moats and walls, to involute, to protect who we are and how we do things, and wait for the assault to pass. That instinct is fair and reasonable. After all, the world is always going to need public health, is it not? With that confidence in hand, do we really need to rethink what we do, or can we simply weather the moment and go back to doing what we have long been doing? We argue for the former, that this moment should push us to reexamine and reimagine, that we should be using the moment to ask of ourselves hard questions. To be unafraid, yes, of calling out errors of the world around us as they unfold, but also to look inward and to use the moment as a call to do better. Who among us truly thinks that the answer lies in going back to the way the world was in 2019?

As we have been reflecting on this, we thought it would be useful to think back to other institutions and ideas that once seemed strong, how ideas that once seemed unassailable can ultimately prove fragile, vulnerable to shifts in evidence, culture, or politics. History offers plenty such reminders of how whole scientific movements can rise and collapse.

Take the example of phrenology. In the early nineteenth century, phrenology—measuring skulls to understand character and ability—commanded extraordinary authority. Learned societies multiplied, books and pamphlets circulated widely, and prominent figures lent their endorsement. By 1836, physician and phrenologist Hewett C. Watson could write with confidence:

“In ten years from this time the public laugh or the public pity will be freely bestowed upon the anti-phrenologists. In another ten years, anti-phrenology will exist in the last decrepitude of age. And in ten years more, it will be a subject for the historians of things that have ceased to be.”

Watson was right about the stakes, and even the timelines, but entirely wrong in his choice of side.

For a time, phrenology looked like a dominant science. Dozens of societies flourished, with members drawn from physicians, lawyers, clergy, and the professional elite. George Combe’s Constitution of Man sold tens of thousands of copies and is thought to be one among the most widely circulated books of Victorian Britain. Lectures filled halls, pamphlets reached working-class audiences, and even Queen Victoria and Prince Albert invited a leading phrenologist to examine their children’s heads. Phrenology was policy, science, debate, and public explanation. And then, within a generation, it collapsed under the weight of better evidence, leaving behind an object lesson in how an enterprise once seen as vital could be relegated to historical curiosity.

We should be clear that public health is, of course, not phrenology. We have a large and multi-disciplinary evidence base of solid science, evaluation and practice. The field has made unquestionable, tangible contributions to the advancement of human civilization.

But phrenology is an example of a dominant construct that seemed at times unassailable, but all of a sudden was not so robust after all, in spite of what its proponents may continue to feel and believe. Public health, as defined by Acheson, is about improving health through the organized efforts of society. This is indeed, a discipline build on solid empiric foundations, but it is also built on the notion that society should organize in ways that improve health for everyone, that health is not something that can be solely defined at the level of the individual. That aspect of our mission, that posture, is by no means sacrosanct. That can be undermined or cast aside as a principle, particularly in a time of polarization, disinformation, and othering.

Here and now, in public health, we face our own tests. We have had enormous successes: the doubling of life expectancy, protecting the world from infectious disease, improving maternal and child health globally, and perhaps most centrally in offering the leading articulation of an aspiration towards a world that generates health for all. Yet, despite these successes, we face the challenges of the moment and a wall of political opposition that casts doubt on our purpose. The uncomfortable question arises: are we in danger of becoming the phrenology of the 21st century—in our case not because our science is wrong, but because we fail to adapt, fail to meet the moment, failed to realise the undermining of our foundational values, and lost relevance before we realized it?

The easy response is to dismiss attacks on public health as short-term, cynical manipulation. Many surely are. But if we are to take our future seriously, we must also ask hard questions of ourselves. What have we done, and what can we do differently? Does how we perceive ourselves differ from reality on the ground? How can we reinvent how we think about and practice public health, to ensure that the field not only survives but thrives in uneasy times, to the benefit of wider society?

That reinvention will not be simple. It requires reimagining our role in ways that cut across bitterly divided politics, engage transparently with communities, and embrace humility as well as evidence. It requires seeing threats to credibility not only as external assaults but as internal challenges to improve. It requires dealing with abrupt changes and attacks, while also seeing the long-term trends that may have led to such moments. Much of our own writing in these fora aims to contribute ideas to that collective rethinking, to find points of nuance and unity around which such work can be anchored. Others have been doing the same—there is a flourishing of thoughtful writing on health in new venues, including Substacks and independent publications, where creative voices are trying to imagine what a renewed public health might look like, in conversations that are not limited to those who can access academic conferences, journals or jargon.

The point of this reflection is not to offer a definitive roadmap. That will need to emerge over time. Rather, it is to emphasize that in a moment of strain we are probably well served by embracing the challenge to do better. To seeing the foundational causes, however stinging and urgent the acute symptoms. No field is guaranteed survival in its current form. The test before public health is whether we can adapt and reimagine what we do with seriousness and ambition, so that when future generations look back, they see not a discipline that lost ground and became obsolete, but one had the courage to evolve and emerge stronger through a period of unprecedented turmoil.

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Also this week

With Dr Mohammed Abba-Aji, The health implications of US federal changes to non-health structures and policies in the Journal of Health Politics Policy and Law. https://pubmed.ncbi.nlm.nih.gov/41059526/