Radical incrementalism, the case for

On successfully achieving the goals of an aspirational public health.

It is not difficult to feel, these days, that we are living in a revolutionary moment that demands a re-ordering of the status quo and a re-thinking of how we structure our world. 2020 brought with it a novel coronavirus pandemic that claimed nearly seven million lives worldwide. The consequences of COVID-19 and the subsequent economic upheavals were not evenly felt, with their burden falling disproportionately on persons of color and persons with fewer socioeconomic resources, occasioning civil unrest that rivaled any the US has seen in the past 50 years. Three years on from the acute phase of the pandemic, we face again a presidential election with the potential to upend the status quo, with the perennially disruptive figure of Donald Trump possibly on the verge of a return to the White House. Living through this moment suggests indeed that much is awry with the world, that transformative change is needed to move us to a better place, and that the turbulence of the moment may provide a once-in-a-generation opportunity to bring about such a change.

Health, and the sharply felt divides that characterize it, has been at the heart of the storm we have lived through in the early years of the 2020s. The pandemic served as a powerful reminder of two long-ignored, yet fundamental, realities: Health is shaped by inequity, and poor health anywhere is—to borrow from Martin Luther King Jr.—a threat to health everywhere. It seems appropriate, therefore, to think of the pursuit of health as a catalyst for necessary transformations, for the creation of a world that is resilient to future pandemics, and one that apportions assets in such a way that the disproportionate burden of poor health does not accrue to a few groups, and that all have the opportunity to aspire to, and fairly achieve, a richly realized life, free of unnecessary and preventable illness.

We can perhaps take the argument a step further and suggest that it is our responsibility in public health to see the opportunity in the moment, that anything short of seeing the moment as a chance for transformation makes us complicit in the structures that hold back the achievement of a healthier world. This calls for public health to engage forthwith in the project of creating such a world by envisioning it and helping to bring it to fruition. Such an engagement would build on a conversation that has been ongoing in modern public health. The past few years—in some cases, predating the COVID moment—have seen many calls for a re-imagining of public health to embrace a forward-looking and aspirational agenda, one that sees as its role the creation of the structures that generate health. These calls have argued for an engagement in creating the systems and structures—like safe housing, good schools, livable wages, gender equity, clean air, drinkable water, a fair economy—that foster health in populations. This thinking—re-anchoring public health in some of the earliest conceptions of the field as inextricably linked to the cause of social justice—is well in line with the sentiment of the moment, and positions public health to be a catalyst and also a participant in the currents of the 2020s and beyond. This surfaces, then, not questions about our vision, commitment, or intent, but questions of execution. These questions ask: How do we get to the sort of world to which we aspire?

This is where we have been far less clear as a field, and where clarity about the the approaches we can take to achieve our radical vision would serve us well. Public health is fundamentally concerned with collective action that can generate health, which, by extension, must involve the creation of structures that generate, rather than hinder, health. We should make no mistake about it: It is a radical vision, one that departs from the more recent understanding of a public health grounded in core functions of assessment, policy development, and assurance. This approach envisions a substantial expansion of engagement for public health, where public health recognizes that it cannot achieve its core purpose without working in sectors such as housing, finance, transportation, and education to bring about its aspirations of creating a healthier world. It is an approach which moves us beyond seeing the social determinants of health as one part of public health, to embracing social and economic foundations as integral to any public health thinking, removing any demarcation between social determinants and behavioral or endogenous factors, and making it clear that there can be no health for individuals—regardless of our efforts at promoting health-producing behavior—without our collective engagement with the forces that create health in the world around us.

But, to paraphrase the oft-quoted aphorism, vision, without execution, remains hallucination. How then do we go about achieving this radical vision? How does public health move from a field that, until relatively recently, was seen by the public, and in large part saw itself, as being concerned with core functions of disease control and prevention, to one that is seen, and sees itself, as engaged in the business of creating social structures that generate healthy populations? This is where, I would argue, we need to marry our radical vision with an incremental approach that recognizes the complexity of the task at hand. I recognize that this may seem like an inopportune political and societal moment to suggest incrementalism of any kind. Revolutionary times call for bold and dramatic actions. In this context, suggesting the value of incremental change can seem to reflect a want of boldness of vision, a failure to see past the moment to the opportunity it represents. But I would argue that it is precisely because we should be bold and serious in our intent to achieve our radical vision that we should embrace the path of incremental change to get there.

If we understand that health is shaped by a complex set of powerful forces, we need to also understand that these forces reflect structures which themselves reflect interests that have much to gain by maintaining the status quo. If we are to put health at the heart of policy actions around areas as disparate as transportation and education, we will need to learn how to work with those who have been in those arenas for decades, who have been socialized to think about education and transportation in a particular way, and for whom health has never been more than a secondary concern consigned to someone else’s area of focus. Engaging stakeholders in these sectors requires patience, persuasion, empathy, and persistence. It requires us to adopt a posture of learning. It requires, perhaps above all, our willingness to accept small changes that together accrete to create bigger change, one step at a time. It requires us to bear witness to forces long-ignored in the pursuit of health. And it requires our unflinching commitment to achieving our radical vision, recognizing that doing so takes years and decades. We could well learn from Frederick Douglass, who, in reflecting on Abraham Lincoln’s embrace of conciliation and incrementalism in politics, said:

“He never shocked prejudices unnecessarily. Having learned Statesmanship while splitting rails, he always used the thin edge of the wedge first, and the fact that he used this at all meant that he would if need be, use the thick as well as the thin.”

It seems to me that a radical incrementalism in public health—defined as the articulation of a radical vision combined with an incremental approach—stands to best capitalize on the promise of the moment. Embracing such an approach takes courage and boldness on two fronts. It takes courage to say that health should be a motivational force behind how we build our world and, as such, should be integral to the breadth of sectors that create such a world. It also takes boldness to say that, in order to get there, we will need to create the partnerships that take time to forge, to re-think how we teach and learn public health, and to make changes one at a time that eventually will see our vision flourish. The hard work of advancing a radical vision lies with the small incremental gains that accrue every day as we work to transform complex systems that are not likely to yield quickly, consistent with the sociologist Max Weber’s observation that “Politics is a strong and slow boring of hard boards. It takes both passion and perspective.” A radical incrementalism in public health stands as a viable, tractable agenda, consistent with our aspirations, and attuned to the realities within which we operate. It means applying “both passion and perspective” to the hard work of building a healthier world.

An original version of this piece appeared in The Milbank Quarterly Opinion on October 29, 2020.

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Also this week.

Thank you to all who have supported my upcoming book, Within Reason: A Liberal Public Health for an Illiberal Time, by preordering a copy in advance of its December 1 release by The University of Chicago Press. The book aims to shape a conversation about how public health can return to its small-l liberal roots to create a healthier world in this moment. Preorders can amplify the book’s impact, helping to bring more people into the conversations we have been having in this newsletter about how to create a healthier world by creating a better public health. Those who have not yet preordered a copy can do so now, using the code WTHNREASON23 for a 30% discount on the book. Please note that this discount code only applies to the paperback format (not to the e-book or PDF). Review copies of Within Reason are also now available. Please direct press inquiries and requests for galleys to press_publicity@uchicago.edu.