The integrity of the mission to promote health

On being clear on values that guide both thought and action

Public health is fundamentally a story. My new book, Within Reason: A Liberal Public Health for an Illiberal Time, is about how we can ensure that story is guided by our values. Here is a reading from the chapter “What stories will we tell about COVID-19?“. Thank you for supporting the ideas in The Healthiest Goldfish, and those in the book. Within Reason will be available December 1, and can be pre-ordered here.

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In “Letter from Birmingham Jail,” Martin Luther King Jr. wrote “In any nonviolent campaign there are four basic steps: collection of the facts to determine whether injustices exist; negotiation; self purification; and direct action.” This is an interesting statement for several reasons, each deserving of its own essay. But what has long struck me most about it is its call for anyone looking to create a better world to first engage in “self purification.” I take this to indicate the importance of carefully examining our values and motivations, to ensure that they support actions that can build a better world. Such work is difficult, and it is on us to make sure that before we do anything we think deeply about the first principles of our work—the values that underlie all we do. Are we truly acting on behalf of better health for all, or are we looking to posture and grandstand?  If we find ourselves alone in taking a position, have we thought deeply enough about what we believe to be able to hold to our convictions when the winds of controversy blow? Such examination is a central goal of these essays. Values help guide our efforts, providing a lens through which to view the world, helping us determine the best application of our scientific data, towards shaping approaches that create better health for all. This is particularly true in this post-war, post-COVID moment.

Thinking deeply about values is in large part about trying to live and work with integrity. Among the values that guide our efforts, it has always seemed to me that the value of integrity is one of the highest virtues we can aspire to live with. According to Merriam-Webster, “integrity” can be defined as “firm adherence to a code of especially moral or artistic values” and “the quality or state of being complete or undivided.”

Wikipedia defines “integrity” as:

“the practice of being honest and showing a consistent and uncompromising adherence to strong moral and ethical principles and values. In ethics, integrity is regarded as the honesty and truthfulness or earnestness of one's actions.”

These definitions both point to a vision of integrity rooted in actions that are guided by values that are clear in one’s own mind. Throughout history, we have seen how certain figures and movements have lived in accordance with this vision, by aligning everything they did—actions big and small—with what they perceived as the highest possible good. We see this, for example, in Plato’s representation of Socrates. The integrity of Socrates was reflected in both his commitment to the highest ideals of truth and goodness and in the completeness of this commitment, which unified an engagement with ideals with other core virtues like intelligence, courage, and a willingness to act in pursuit of justice. Socrates was undivided in his pursuit of the Good, an example of integrity in practice from which our civilization has learned for thousands of years. Such integrity was echoed in the words and deeds of Martin Luther King, Jr., whose integrity helped him to accomplish feats, in concert with the actions of many other people of similar integrity, which seem almost superhuman in hindsight, changing in the world even in the face of violence and the threat of death. 

I note that integrity does not mean, in my assessment, holiness, and neither does it lend itself to sanctimony.  It suggests being very clear in one’s mind what values we hold dear, establishing a suite of values that should guide how we live and how we work and that then enable us to do more than we perhaps think ourselves capable of.  In the context of those who are committed to the health of populations, integrity is to act in accordance with ideals of fairness, justice, compassion, and courage in pursuit of a better world, leaving out none of the values that can support the best possible functioning of our field. This quality of leaving nothing out also reflects public health’s central commitment to creating a world where all can be healthy, leaving out none of the populations that can find themselves excluded from the conditions that create health.  

Reflecting on the poise of Socrates as he maintained his commitment to truth in the face of death is useful. But it may be more resonant to reflect on the success of the civil rights movement in creating a more just society, and the activism of the LGBTQ community during the AIDS crisis, which led to game-changing treatments for the disease and laid the groundwork for other civil rights gains, including marriage equality. Given the power of integrity to support progress at the individual and collective level, it seems worth considering integrity in the context of a post-war, practical philosophy of public health. These reflections are motivated by a belief that there is indeed integrity in what we do, that there can be clarity of the values that guide us, and that we are well served by that clarity and its application to our mission. I will anchor these reflections in three characteristics of integrity, drawing on the definitions I have mentioned (with special thanks to Wikipedia’s framing): consistency, uncompromising adherence to values, and the centrality of action guided by these principles.

I will start with consistency. Consistency has been defined as “agreement or harmony of parts or features to one another or a whole.” While consistency is oft criticized (hobgoblins and all that), I have often thought it to be a cardinal virtue.  In the context of health, consistency means working to align all we do with the values we have embraced as the guiding principles of our field. We are committed to creating a world that generates health for all. Consistency in pursuit of this goal means asking “Does this approach advance health equity?” “Are these words fully supportive of an inclusive community?” “Do these policies support the health of all or just some?” When the answers to these questions align with our central commitment, we can be assured that we are truly “walking the talk” in all aspects of our work. At the same time, in addition to being aligned with our values, our work must be effective. This means our consistency should align pragmatically with what we are trying to achieve. It is for this reason that I have argued for a radical incrementalism in our pursuit of health. We can have radical goals, informed by our vision of the highest good, which we pursue pragmatically over time. This approach can seem like compromise, an evasion of our best ideals when we accept half a loaf over none. It is important to remember that these loaves add up, and there is integrity to an approach which gets us slowly, steadily, to a healthier world, one supported by enduring change.

The second characteristic of integrity in our work is an uncompromising adherence to our values. Such an adherence suggests that we put health at the heart of all we do, achieving a healthier world by any means necessary. This is, of course, complicated by the questions of what we mean by health, what it means to create a world that balances dignity and opportunity, and what are the values we will prioritize in getting to such a world—all questions I have addressed in these essays. In engaging with values, it is important to acknowledge that others may have different values, and that what can seem at first like differences in interpretations of data—which is to say differences in intellectual methods—can reflect, more fundamentally, differences in values, and should be addressed at this level. To my mind, this means that we should have a very narrow set of values we are uncompromising about, which here I have distilled as the dignity-opportunity space creation for all. Everything else we should be willing to compromise on. Such compromise does not contradict the integrity of our efforts if it means doing what best advances our work at a practical level. To do otherwise is to risk setting our work back, which cannot be said to reflect the integrity that supports our mission.

Finally, integrity informs, and is reflected by, our actions. Integrity is not merely sitting on our ideas; it is being effective in implementing them. Integrity, for Socrates, did not just mean talking about the ideas that lead to a good life and good societies. It meant living out their full implications with the courage of his convictions. The same should be true for our efforts in pursuit of health. This does not mean that we need to find ourselves on trial for our lives, like Socrates did, to live with integrity. But it does mean recognizing that embracing the values that support a radical vision have implications that may not always be comfortable. Do we value diversity and inclusion enough to engage with those who have ideas we find objectionable? Do we value the reasoned pursuit of scientific data enough to report findings that contradict our preferred narratives about the world? Do we value being able to draw a distinction between right and wrong enough to call something wrong even when those around us insist it is right? How we answer such questions reflects the difference between living with integrity and living with just the appearance of it. The latter has its rewards, but only the former will get us to a healthier world.

While acting with integrity does not mean picking fights, it almost certainly means we will find ourselves in positions where we will be out of step with what is easy or professionally convenient. A willingness to be in these positions from time to time, then, is a prerequisite for living with integrity and getting to the better world this can lead to. To be able to act in ways that get us to this world, we need the courage of our convictions, even when this means seeming to move too slowly, or even against the grain. Vision without execution is hallucination, as the saying goes. To execute a vision for a healthier world, we need to balance consistency and uncompromising adherence to our core values with the actions that lend practicality to our efforts, even when doing so is hard, sustained by a vision of integrity that can support our efforts over the long haul.

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Also this week.

Now is the time for integrating the lessons of the pandemic into new approaches to urban health. This may mean an emphasis on the politics of urban health, health communication in cities, deployment of healthcare in urban contexts, addressing urban health inequities, and looking to the future of cities. See recent thoughts in The Journal of Urban Health, “Urban Health Scholarship and Practice in the Post-Pandemic Era."

New in JMIR Mental Health, thoughts with Catherine Ettman on “The Potential Influence of AI on Population Mental Health.”