Thinking about health tomorrow
Concluding a cycle of essays, reflecting on the ideas they surfaced about building the future of health.
Over the past year or so, these essays have tried to articulate a new practical philosophy of health for this moment, engaging with topics of consequence for how we conceptualize health, towards better understanding what we think about when we think about health. In this sense, they represent a cycle, just as past writings in The Healthiest Goldfish have been a cycle, most recently with the essays which informed my last book, Within Reason. These reflections on shaping a new practical philosophy of health were meant to be useful, to help inform conversations towards building stronger foundations for our pursuit of health going forward. Having engaged with this theme for a while now, it seems a good time to review some of the ideas that have emerged over the course of this writing. I do so today with an eye towards concluding this cycle of essays, as I think about evolving my Goldfish writing and thinking, in a period of personal reflection and reassessment.
Why health?
I will start with the core question linking really all I have written over the course of this cycle: why health? These essays seek to engage with the fundamentals of our thinking about health, and no question is more fundamental than: why do we wish to be healthy in the first place? Is health an end in itself, or is it a means to an end? I have long felt that health is a means to an end and that end is living a rich, full, meaningful life. We want to be healthy so we can have more time to do what we want to do with the people we care about—to do what makes life worth living. Our pursuit of health should always support this aspiration. There are times when it, arguably, has not, when we have pursued health for its own sake, at the expense of all that health should enable. This poses a challenge for public health. It is on us to strike a balance between supporting the measures that safeguard health and creating space for people to live rich, full lives even when doing so comes at the expense of total safety. Because we could, after all, seal everyone in a bubble and ensure complete imperviousness to disease and preventable harm. But this would mean sacrificing everything that health should support. We might say, in response to this, “No one is advocating sealing everyone in a bubble.” This would be true, but it is also true that the spirit that might inform such a radical move does occasionally hold sway in our thinking about health. This is why it is so important to continually revisit the question of “why health?’ to make sure we never lose sight of what health—and, by extension, public health—is fundamentally for.
Foundational values
Everything we do in our pursuit of health is shaped by our values, the foundational principles we embrace, and that guide our steps towards a healthier world. These values are, centrally, a commitment to creating healthier populations with a focus on advancing health equity, to eliminate the health gaps that can exclude certain groups from health. We pursue this goal by engaging with the structural drivers of health, with the understanding that we cannot be healthy until we have shaped a much healthier world. The building blocks for this world are the data we generate—the science that guides our inquiries into the drivers of health. We generate these data through a process of reason and analysis, a process which we aspire to keep free from the biases and priors that might influence our conclusions. Our work is best served by a commitment to maintaining the integrity of this process while we remain firm in the values that help us decide the uses to which we put our data and methodologies. We should not let our values sway our science just as we should not be afraid of moral clarity in our words and actions and an activist orientation to our work. Creating a healthier world—the central value of those of us who work in health—means staying grounded in the values that animate us while aspiring to an ideal of empiricism in our scientific endeavors.
When we think about health, particularly our own and the health of those we love, it is hard to imagine putting a price tag on the ability to live a healthy life. It follows, then, that health might be considered priceless. But this can conflict with the reality of our society in which we do put a price on health—and that price is often high. We see this price in astronomical health care costs, in the calculations made by insurance companies and federal agencies charged with allocating resources, and in the vast sums being spent by the very wealthy to reverse the effects of aging and even “cure” death. In public health, we see it in our occasional willingness to embrace measures which prioritize health at the expense of practically everything else—of living the kind of lives health enables. It is on us to strike a balance in our pursuit of health, in which we create a world that supports health for all while also supporting our ability to live rich, full, dignified lives. It is right that we should value health, but health should never come at the expense of living—that would be too high a price indeed.
The potential, and limits, of science
Science can be a tremendous force for good in the world and has played a significant role in ushering in progress—in areas like health, medicine, technology, and living conditions—that makes this, arguably, the healthiest time in human history. Yet science also has limits. We practice science in contexts of complexity, where simple answers can be elusive, and it is not always clear what our data are saying. As scientists, and as humans seeking answers to fundamental questions, we look for linear equations where X leads to Y, with the work of public health the work of engaging with X to generate the Y outcomes we want. But the world does not always work that way, and neither does science. The world is complex, and the science of health needs to engage with this complexity without reaching for easy answers. As we do, it is on us, as scientists, to be forthcoming about what we do not know, acknowledging our limits even as we seek to push the boundaries of what we know, to the ultimate good of building a healthier world.
The actions that generate health
The pursuit of health is fundamentally mission-driven. We think about health, we study health, we talk about health with the goal of building a healthier world. This means that our thoughts, our conversations, and the research directions we consider should all be rooted in a pragmatic vision that helps get us to the world we wish to see. I have long argued for a consequentialist approach to health, in which we align our research with what can do the most good on issues that matter for health. We have a responsibility to maintain a pragmatic focus in what we do, avoiding spherical cows and the trap of forgetting that all the good intentions in the world can do little if they are not wedded to a practical plan for implementation. It is important, also, to remember that pragmatism does not mean compromising on a radical vision for a healthier world. I have made the case for radical incrementalism in our pursuit of health, in which we maintain our commitment to building such a world while taking the sometimes-small steps necessary to get there, moving always in the right direction even when progress is slow.
Uncomfortable ideas for health
Academic fields and disciplines grow and develop through a process of reflection and self-critique. This process can be uncomfortable, showing us what we are doing right but also what we are doing wrong. We improve when we do not turn away from what is uncomfortable, engaging with good faith criticism in the spirit of trying to be better, always. That is why these essays have at times been critical of our approach to health. I suppose this criticism is in some way implicit in the overarching project of the last year. Trying to shape a new philosophy of health means, at least in part, that there was something insufficient about the old one. But it is necessary to engage with what is uncomfortable in order to grow. Just as we sometimes criticize the behavior of our kids because we want them to grow into good adults, we should be willing to engage with criticism of our collective pursuit of health because we care deeply about the quality of these efforts. It is also true that the job of science is to pursue the truth, and the truth is not always comfortable. It does not always conform to our view of the world, nor does it always make us feel good about the direction in which the world is headed. Nevertheless, we should be able to engage with truth in our pursuit of health, regardless of how uncomfortable the truth can sometimes be. Doing so keeps our thinking sharp, our ideas reflective of the world as it is, positioning us to take pragmatic, truth-based steps towards making the world as it should be.
A new cycle
I see this essay as closing a bit of a cycle, one that began with my reflections on what I called the “post-war” era, when the pandemic years started winding down and my thinking about health was deeply informed by the hard-won lessons of COVID. Now, as we enter the twenty fifth year of the century, I am taking some time to take stock of my thinking, pausing on my current The Healthiest Goldfish cadence as I transition my work, taking on a new role as dean designate for Washington University in St. Louis’ planned School of Public Health. I am using this time to reflect on the areas of public health I would like to focus on next in these essays, and on how to best communicate the ideas of health in this moment, both here and in other contexts. I shall reach out from time to time as topics arise—as I am sure they will—with enthusiasm, as always, for engaging with you, the reader, on issues of consequence for health. I look forward to continuing the conversation as the world evolves, and our thinking evolves with it.