Towards a new radicalism

On striking a balance between engaging with upstream and downstream forces, to create a fundamentally healthier world.

The Oxford English Dictionary defines “radical” as

“of change or action: going to the root or origin; touching upon or affecting what is essential and fundamental; thorough, far-reaching.”

This definition aligns well with the work of public health. We are centrally concerned with “going to the root or origin”, with “what is essential and fundamental.” We pursue our work with the understanding that the creation of a healthier world is, by definition, engagement with the foundational drivers of health. This is reflected in a metaphor I have long used to explain the work of public health. It is that of standing on the bank of a river, seeing people falling in and pulling them out one by one before realizing that the more fruitful action is to address what is throwing them in the river in the first place. This metaphor serves well for explaining what we do to those who are new to public health and has an important place in illustrating the philosophical underpinnings of our work. It reflects the necessity of dealing with the root causes of poor health, the structural forces that decide whether we are healthy throughout our lives.

Importantly, the metaphor is compelling, helping convert people to the cause of public health. It illustrates how the mission of public health is, at core, a matter of aspiration, and one of common sense. After all, who would be foolish enough to just keep pulling people out of the river rather than making the effort to figure out what or who is throwing them in the river, and then working to stop the cycle?

Therein lies the crux of our engagement with the forces that shape health. Our work, in public health, our cause, is righteous and good, and what we do can be deeply motivating. It is that way for me; it is that way for many of us. But, of course, as with many metaphors, this one is limited in some ways. It presents the mission of public health as a binary choice—do we keep pulling people out of the river, or do we go upstream to figure out who or what is throwing them in? This framework suggest that we must do one or the other, that the options before us are somehow mutually exclusive.

But are they?

It is tempting to say “yes,” feeling perhaps that to say otherwise would be to compromise on the radical vision for a healthier world that is core to all we do in public health. Such a vision seems to leave no room for measures that are not wholly focused on making the big, structural changes that can get us to the world we want. However, there is a distinction to be made between different forms of radicalism, just as there are distinctions to be made between the strategy and tactics that can help make the world we want a reality. I have previously suggested that the work of public health is about radical incrementalism—the articulation of a radical vision and the hard work of getting us there. There seems to me no question that the radical vision is one where no one is thrown in the river to begin with, where everyone is as healthy as possible for as long as possible. Embracing such a vision can come with the conviction that nothing less than its realization will do; that half-measures in pursuit of health are really no measures at all and that an incremental approach is not true to the spirit of our work.

It is also true that elevating this vision in the public conversation has been, for many years, an uphill climb. For a long time, society’s collective focus has been overwhelmingly on pulling people out of the river through medicines and treatments—through healthcare—rather than on creating a world where no one is thrown in the river in the first place (i.e. creating a world that is fundamentally healthy). In attempting to reorient the public conversation about health, we have as a field, out of necessity, emphasized in recent years the structural drivers of health more than we have engaged with the means of pulling people out of the river—doctors and medicines. To this end I have long tried to help support a public conversation that focuses more on the upstream drivers of health.

At the same time, it has always seemed right to me that we aspire to a balance between engaging with upstream forces and working in the here-and-now to help as many people as we can by pulling them out of the river. This belief has, for example, informed my engagement with the conversation around precision medicine. I have never argued we should not invest in precision medicine or that it does not have the potential to improve our collective health. But our focus on precision medicine should not distract us from also investing commensurately in creating a world where the diseases that treatments like precision medicine aim to cure do not emerge in the first place. What we should aspire to, fundamentally, is a balance in what we pursue. For a long time, this balance was lacking, and attention was disproportionately on pulling people out of the river at the expense of keeping them from falling in. This necessitated, in public health, an effort toward a course correction involving an emphasis on upstream factors as we tried to achieve balance. As we pursue this emphasis, we should be careful in our approach, bringing nuance and balance, reconciling a focus on downstream factors (i. e. changing behavior and creating better treatments for disease) with a recognition that health is shaped by upstream factors, by context, and we cannot create a healthier world without addressing what is upstream.

Centrally, there are, I think, three reasons why we should aspire to a balance between the upstream and the downstream.

First, well, there are many people in the river already, and saying we are not going to get them so we can focus upstream elides the fact that there are many to be helped in the short term, that upstream work alone is just not good enough, particularly for those who are actively drowning. We have a moral obligation to help all people as much as we can. Ignoring those who are drowning now abrogates that. Going beyond the river metaphor, regardless of how optimistic we are, it is going to take decades to achieve a world where no one is unstably housed, where everyone has a stable income, etc. because inequities are so entrenched that even if we dropped everything else to focus on them, there is no reasonable universe where we can imagine that they will change quickly. So, there are going to be people affected by them who we can help now, and we should do so. I am aware there is a philosophical objection to this, informed by the Marxist belief in “heightening the contradictions,” which is to say, in a sense, letting inequities persist and deepen in the hope that they get so bad, so glaring, that they eventually spark revolutionary change. This approach has always struck me, and I am sure many others, as, frankly, wrong, letting as it does many drown in the moment in the hope of instrumentalizing their pain towards future strategic success.

Second, much of the work of public health depends on engaging people in what we do, and people are more readily engaged in the day-to-day business of helping those who are in the river. This is why service organizations thrive, why community members dedicate time and resources to them, and why we should engage with and support that. It builds our capital in public health to solve the immediate problems, capital we can then leverage towards persuading people to follow us as we move to our radical vision. Helping those who are drowning now builds trust and buy-in for our long-term efforts towards a healthier world. We should also consider how seeming to be indifferent to those who are in the river now may look to the public we want to engage with. If we look like we are more concerned with abstract aspirational goals than we are with human suffering in the present, we run the risk of appearing callous. Such a perception does not serve our movement. If the river metaphor is compelling, something to draw people in, seeming to stand back as people in distress flow by is the opposite, something to repel and, for this reason, a story we should not want told about our work.

Third, the people who are downriver have their own ideas about how to get out of the water, and their own ideas on how to keep out of the water once they get out. Indeed, there are whole industries dedicated to keeping people healthy. A capacious public health needs to recognize that people are going to engage in behaviors, and pursue solutions, that they see as good for their health, and it behooves us to, whenever possible, meet people where they are, towards the goal of getting all of us where we hope to be.

It is possible, of course, that there may always be a degree of tension, in the pursuit of health, between upstream and downstream. Such tension is perhaps natural, even generative, helping us imagine and implement new approaches to pull people out of the river and keep them out of it. We can accept this while also aspiring to bridge gaps and ease some of the intensity of this tension. What matters most is our radical vision of a healthier world. There are many paths to this world. Some engage with upstream factors, some with downstream. It is truly radical to do both. In part, I am trying to suggest here the good work of many who focus on the downstream. I do not think we should exclude that work, nor do I think that a balance between approaches in any way undermines our efforts. On the contrary, it supports them, reflecting a new radicalism based on a synthesis of approaches that can help advance our mission in this post-war, post-COVID moment.

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Also this week.

Special thanks to Pamela Paul and Sir Michael Marmot for their thoughtful engagement with the ideas in Within Reason.

I recently had the pleasure of speaking with Joel Brown for a BU Today Q&A about Within Reason.