Reconciling context, effort, and ability

Can we expand our thinking to better engage with the full range of forces that shape our lives, and our health?

In recent years, a highly polarized political discussion has emerged about meritocracy in the US. On one side of the debate is what might be called the classic view of American meritocracy, the Horatio Alger-esque story of striving one’s way to success through individual ability and effort. In this framework, all have more or less equal potential to rise, and it is only differences in individuals’ talent and effort that shape differences in life outcomes. This has arguably long been the dominant narrative about meritocracy in the US. More recently, however, a new narrative has emerged, one that in many ways aligns more closely with our public health paradigm. This narrative says that what has passed for merit (for example, doing well on exams, being promoted, or simply being healthy) principally is a product of engrained social systems. Structural forces—such as systems of historical injustice, present-day inequality, or marginalization due to identity status—have created a context which advantages some and disadvantages others. Forces like structural racism or class endowments which one is born with can generate both privilege and marginalization, and these are the key factors that determine how one does in life. While individual ability and action has a place in this framework, it is considered less significant than is the context within which we operate. This then leads us to an understanding of the world where seeming differences in ability and achievement are mostly differences in an individual’s relation to the foundational forces that shape our world. We should, this thinking goes, always take this into account in evaluating and rewarding what might seem to be the fruits of individual effort alone.  

I summarize these frameworks here not to argue for or against their finer points. Any reader of this column will readily recognize that I think that, yes, context, the world in which we are born, matters enormously to what we achieve, to our health, well-being, and essentially everything else in our life.  We in public health are well familiar with the many structural factors which shape context to prevent equality of opportunity for all. I have written previously about the veil of ignorance, John Rawls’ thought experiment in which we are invited to design a new world. The world can be as equal or unequal as we choose to make it, with the catch that we will design it from behind a veil of ignorance that prevents us from knowing where in the world we will be born. This should caution us to create a world where opportunity is as evenly distributed as possible, to maximize everyone’s chances of being born into a context that supports human flourishing. An honest assessment of the world as it is will likely acknowledge that we are far from a world designed thoughtfully from behind the veil of ignorance. Instead, we live in a world where the likelihood of being born into a context which disfavors the living of a healthy life is still high, unacceptably so. In this world, anyone born to privilege—born into the majoritarian group, into groups with more assets and resources, etc.—has a better chance of achievement and health. As such, our role in promoting health is to address the structural factors that create gaps in populations’ capacity to flourish.

It makes sense that this perspective, aligned as it is with our goals in public health, has shaped our attitude towards achievement and merit. So deeply versed are we in the forces that shape these gaps, in their profound influence on the health of populations, in their persistence in our society, and in the urgent necessity of closing them, that it can be difficult to see beyond this focus, to consider other factors that influence life outcomes at the level of individuals and populations. Indeed, it can be uncomfortable for us to engage in conversations about these factors for much the same reason that it can be uncomfortable for us to talk about the role of behavior and poor choices that can lead to disease and preventable harm. Yet it is precisely now, in articulating a post-war, practical philosophy of health, that we have an obligation to tackle what is difficult, uncomfortable, towards shaping the intellectual foundations of the next phase of public health achievement. For these foundations to be as strong as possible, they must be rooted in truth and a forthright consideration of all the factors that influence health, not just the ones we are comfortable discussing. We need to talk about the subjects we do not talk about enough. It was with this in mind that I wrote the most recent column addressing how we may reckon with the role of behavior in shaping health. It seems a natural continuation of this discussion to now address, perhaps uncomfortably, how, apart from context, effort and ability also play a role in shaping life and health outcomes, and how we can balance a concern for all three of these factors. This line of thinking requires us to think critically about the intersection of context, effort, and ability, and to acknowledge two truths—first, if all things are equal (thus, if context is removed from the equation), people will have differing levels of effort and ability, and, second, all things are not equal. It is the role of public health to hold both truths and to create conditions that work towards an “all things being equal” world, but also to promote dignified life paths for people of all levels of effort and ability.

First, on effort. The role of effort in shaping the trajectory of our lives and health is obvious to most people but often neglected in the mainstream health conversation. This is, perhaps, understandable. To discuss the importance of effort is to run the risk of seeming to stigmatize those who may not apply the same level of effort as others. To speak of effort, after all, is to speak of something which is, to a large extent, within our power to influence. Anyone who has lived a life knows the value of hard work, yet it can be difficult to acknowledge this collectively, as a field. This difficulty is, in part, due to concerns about harmful prejudice, and, in part, because of how effort has been weaponized in bad faith by political actors trying to justify disinvestment in the social safety net and other policies that support health, much like how concerns about “personal responsibility” in the area of health-related behavior have been used to attack the policies we favor. Justifiable concern for not giving fuel to these attacks has informed a hesitance to discuss effort forthrightly. Yet, as I wrote recently, just because something can be used in bad faith does not mean it is not true, and to refuse to engage with uncomfortable but empirically grounded topics gives opponents of public health the greatest possible gift: the ability to say that they are the ones engaging with truth while we are running from facts, from the science. When truth is suppressed for ideological reasons, it does not eliminate inconvenient facts, it just drives them underground where some truly unsavory actors lurk. We cannot afford to cede the territory of truth to such people. So, we must acknowledge that effort and hard work do matter, and do make a difference, independent of context. That, all context being equal some people do choose to eat healthier, exercise more, smoke less.  And all of this seems worth acknowledging in our individual spaces, recognizing that what we understand, what we talk about, shapes how we think and how we move the field forward.

Now, moving to the equally tricky concept of “ability.” The idea of ability is simultaneously obvious and anathema to our foundational thinking about health. It is obvious, for example, that I can never achieve stardom in basketball, grazing 5’10’’ as I do on a good day. But it is also obvious in other ways. I grew up playing soccer, loving soccer, trying my best to be great at soccer. And from an early age, it was clear to me that, despite my effort, I did not have whatever ineffable inner geospatial awareness is required to touch a ball with your feet and have it go where you wish it to go, to be successful as a player. And every kid who has ever played a sport knows this—ability is part of who we are, what makes us. We can work hard, we can improve, but some people are simply born with “it” while others are not. One is reminded of what the gifted musician says to an ambitious but less-talented colleague in the film The Gig, “It isn’t a religion…devotion isn’t enough.” We can deconstruct the idea of talent all we want, but that does not change the fact that talent is real, and unequally distributed, as anyone who has encountered the outer limit of their ability in a given field and found it wanting knows.

Such limits are not confined—there is no reason they would be—to the pursuit of elite status in sports or music. They also influence individuals’ ability to do the jobs that provide access to perhaps the most important resource for achieving health: money. An unequal distribution of ability means the unequal distribution of being able to pursue certain professional trajectories. This matters for health because different careers require different skills, and it is simply the case that some careers bring in more money than others. Whether that is as it should be is another matter. But, in the very real world we live in, while we may work hard and make progress in developing our skills, we will always likely be at a disadvantage compared with those who are born with natural ability that aligns with the making of money. As I wrote in the last column, individual behavior is a product of a range of influences, including genetics. The same is true of our abilities; skills such as mathematical proficiency have been shown to be heritable. This fact has deep implications for life outcomes at both the individual and population level. At the same time, it should not distract focus from public health’s engagement with the contextual factors that influence health. Public health should maintain a focus on the upstream drivers of health as core to our mission. We should always keep front-and-center how these forces drive health gaps, towards providing dignified pathways for people of all abilities to live good lives supported by good health. We can help provide these pathways through policies that expand access to the material resources that support health—policies like a higher minimum wage, affordable housing, and a more robust social safety net. Such policies are good for everyone but can do the most for those who need them the most, a need likely shaped by a combination of context, effort, and ability.

Nothing I am saying obviates the overarching influence of context in deciding who we are, how our lives are shaped. One, for example, cannot pursue a passion for soccer, no matter how gifted or committed one is, if one lives in a context of war, malnutrition, and the likelihood of a sick life and early death. But my point is that holding context constant, there remain differences in ability and effort, and we in public health have much to lose by not facing this fact.

Having labeled two topics that we seldom touch on in public health, how, then, can we engage with the influence of ability and effort while keeping in mind, always, the ineluctable role of context? To my thinking, we can do so in two ways.

First, we can keep focus, always, on our core mission of ensuring everyone can live a healthy life. We can do so with a clear-eyed understanding of what health is for—to enable the living of life as we wish to live it, to be able to actualize what we want to actualize, pursuing meaning and connection. While ability and effort have profound sway in narrow domains (i.e., the ability to be good at skill x or y), they have less influence on this broader goal. Everyone should have the resources to live a rich, full, meaningful life, whether they are a soccer star or not. We can address this by shaping a better context. Our job is to make sure that the world is structured such that we maximize context (the one element we have control over, or at least some control over) so that we generate health, or the opportunity for health, for everyone, regardless of ability and of effort. At the extreme I have written about the importance of moving beyond traditional notions of “disability,” but here I am talking about much subtler differences, reflecting the need for a politics that creates pathways for a stable job, a good income, and education for those with all levels of innate ability. I have gone so far as to say that promoting dignity for all is one of the three core roles of politics and I continue to believe that.

This leads to my second point, and now I come back to the current political and cultural argument that I was anchoring this piece around—the argument about how we think and talk about meritocracy. We can work to shape a healthier world by creating a healthier context without minimizing or speaking ill of hard work and effort. F. Scott Fitzgerald wrote “The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time, and still retain the ability to function.” Here, then, are some seemingly opposed notions we should hold in our mind as we pursue the most effective functioning of our work. Should we have systems that reward effort? Absolutely. Is there such a thing as advancement based on merit, i.e. effort? Absolutely. But all of that is superimposed over the unearned advantages of context and ability, and it is our job to structure the world such that the benefits that accrue to effort (the “meritocracy”) are not such that they obviate the benefits that should accrue to all. This aligns with public health’s core mission of making sure that we do not create health gaps—everyone should have access to health—and making more effort to ensure that those with disadvantages have more resources to help them achieve health. We pursue this mission with the understanding that there are many who could indeed benefit from policies which acknowledge how context can create cycles of disadvantage. But we should also allow space for those who, context permitting, do get up earlier and exercise to be healthier and we should recognize that this is not to be discouraged. Allowing this space does not mean embracing an argument that says acknowledging merit means pretending that ability is the sole driver of success. Indeed, rejecting such zero-sum thinking is core to the broader project of shaping a philosophy of public health that can create a better world in this polarized moment. We can create opportunities and address the effects of societal and individual shortcomings without saying these shortcomings are bad. We can valorize ability and encourage effort without stigmatizing and abandoning those who stumble or lack an excess of inborn ability. A mature public health can hold all of these truths, and we need a mature public health indeed to meet the challenges of the moment.

__ __ __

Also this week.

A Dean’s Note on celebrating Pride Month in a context of gains and setbacks for LGBTQIA+ rights.

BUSPH researchers have launched Data for Global Health Equity, a repository of global Social Determinants of Health data that builds on the work of the Rockefeller Foundation – BU 3D Commission. Thank you to the Data for Global Health Equity team for this tool, for all you are doing to advance our understanding of the forces that shape health.