This is the third and culminating essay of a series on the intellectual first principles of public health. The first essay concerned the role of universities, arguing that universities do three things no other institution does together: generate ideas, teach students, and translate ideas toward a better world. The second essay argued that science, the beating heart of the ideas enterprise, is the best thing we can do for homo sapiens sapiens, the one endeavor by which the species systematically elevates its own condition.
Both of these essays were about how the life of ideas can fundamentally improve and uplift every other aspect of human life—from how we organize societies to how we pursue technological development to how we create a just, equitable economy. However, the truest measure, perhaps, of ideas’ capacity to improve human life is in their influence on health—which is to say, the means by which people live longer, better lives, unencumbered by disease, free to pursue what matters to them.
Health, in other words, is where the case for the university (the place where ideas are generated) and the case for science (the process by which ideas are generated) converge. But there is a third component to this—health as a driving force within societies, motivating changes for the better, a social purpose. Ideas are not static and the more powerful the idea, the greater its capacity to create this change. Few ideas are bigger or more powerful than the idea of health—the idea that the world can and should be radically healthier. The idea of health, then, is an upstream determinant of our collective capacity to make this idea a reality, to motivate the actions that build a healthier world.
This ties back to the first focus of this essay series, the role of universities as incubators of the ideas that shape health. If the idea of health is a central driver of the reality of health in societies, then universities, as places where ideas are generated, are, at their best, key creators and sustainers of health in the world. I will conclude this essay series, then, with a reflection on how universities fill this role—how they advance the generation of health as a social purpose, as an idea with the power to build a better world for all.
Let me start with a fact that I think frames much. Education is perhaps the single best predictor of health and longevity. This makes the university more than a generator of ideas, more than a training ground for students. It makes it an essential, direct health intervention in the lives of many. If a drug were to produce a roughly 8.5 difference in life expectancy (as universities do, with holders of a bachelor’s degree living on average that much longer than those without one) we would hail it as a breakthrough, a wonder drug. The university generates this health simply by expanding the range of economic and social opportunity through the education it provides. This puts health at the heart of all that a university does. Which raises the question: what if we took seriously the idea that the university is itself an institution where elevating health can be explicitly at the center of what we do, by embracing the role of universities not just as places where the intellectual foundations of public health are built but which are themselves, by virtue of what they do, essential determinants of health in society?
A health determinant is a force that shapes who is healthy in society and who is not. Health determinants include housing, the economy, neighborhood safety, climate, and politics. Universities fit well within the definition of health determinants. By promoting the development of critical thinking skills, by broadening access to social and economic opportunity, by aiding civic formation, and by supporting science, universities help ensure all can live better, healthier lives—principally, I would say, in the following ways.
Universities shape health through the promotion of critical thinking. Health is deeply shaped by our choices. Each day, we sort through a range of options, some of which are good for our health and some of which are bad. Whether we choose health depends on a range of factors, not least of which is our ability to think critically about data and make choices based on this thinking. For example, we maybe choose to smoke because we never learned that the practice is a health risk. It is, of course, possible to know the health risks of a given activity and still choose to engage in it—because it is enjoyable, because it is part of living the rich, full life that health enables—but, broadly speaking, the more we know, the better able we are to make the right choices for our health. By disseminating knowledge and teaching critical thought, universities help us to do just that.
Universities also shape health by broadening access to social and economic opportunity. Such opportunity is a key driver of better health for individuals and communities. A wider range of social and economic assets can help support health in many ways and universities help deliver these assets by conferring the skills and credentials that bring better jobs, better social prospects (such as being able to live in safer neighborhoods, being able to raise a family, access to leisure time and even, at higher economic levels, the funds that support philanthropy). Universities, as an engine of this mobility (see Chetty and colleagues’ work on this) help support the healthier outcomes it enables.
Universities also play a key role in civic formation. Healthy civic life is essential for healthy citizens. Democracy, voting, and self-governance all play a role in creating social stability and the channeling of public attitudes into practical politics rather than violence and unrest. These beneficial conditions are all sustained by education, which is a predictor of voting, volunteering, and associational life. These prosocial activities are not only fostered by a university education but also characterize life on many university campuses, where civic engagement tends to be the norm, making academic communities a microcosm of a civic minded community in which health can thrive.
Finally, building on last week’s essay, universities are also core to the scientific endeavor. The generation of knowledge is at the heart of universities, their intellectual center of gravity. Science is foundational for the work of public health and for the modern living standards that have drastically improved health over the last 100 years. Science is responsible for many important milestones that have improved global health. These include the development of vaccines, the dissemination of knowledge through the digital revolution, and the scaling up of industries which keep the basic necessities of life broadly available. Much of this science flows through universities, ensuring that campus academia will always remain core to the scientific progress that supports a healthier world.
Which leads us to the argument that health—the elevation of a good that enables and sustains the flourishing of the species—can and should rest at the heart of great universities. The idea that promoting social good should be central to the work of universities is not new. Indeed, some universities were chartered with an explicit social purpose. The Morrill Act of 1862 created land-grant universities precisely to serve the practical needs of the people. The Wisconsin Idea held that the work of universities should improve peoples’ lives across the region in which universities are situated. Boyer’s scholarship of engagement is an eloquent refocus of universities back to this vision of education.
This all suggests that universities’ long-standing social purpose can be well served, in our time, by centering health as a means of collective flourishing. We all wish to be healthy, for our children to be healthy. By leaning into its health-promoting role, universities can better align their core functions with something that is of central value to all, cutting across lines of human difference. In doing so, universities can broaden their scope, through a vision of interdisciplinarity in which all disciplines intersect with a pursuit of health with wide popular appeal.
This is not to say that universities should only concern themselves with health. Far from it. Universities are at their best when their horizons are constantly expanding, probing new frontiers. An engagement with health is perfectly compatible with these ever-expanding horizons. Health is big. It touches just about every aspect of human life. To focus on health, then, is, in a real sense, to focus on everything, the full range of factors that decide who gets to be healthy in society.
Universities shape the world in which we live. They are upstream of science, industry, politics, the arts, social change, and much more. They have underwritten human progress for almost 1,000 years. Defending universities—funding them, supporting them—is an investment in the continuation of this progress and a recognition of its core importance to our world. In a moment when universities face challenge, it is important to keep in mind their fundamental indispensability, a feature which is most clear, perhaps, in universities’ intersection with health.
__ __ __
Also this week
In JAMA Health Forum:
Centering Corporate Activity in the Population Health Research Agenda – with Nason Maani
Thank you, Nason, for leading us on this.
New on Ideas Matter, a conversation with the University of Michigan’s Josh Ehrlich on why global health research matters for US health.
Enjoyed speaking with Brinda Adhikari, Tom Johnson, and Maggie Bartlett on the Why Should I Trust You? podcast about building a better public health in this moment.
The 8.5-year figure reads differently from inside a public university. I teach nurse anesthesia at CUNY, which sits near the top of the mobility tables your Chetty reference points at, and those graduates go on to staff operating rooms in the boroughs they came from. The translation step from your first essay happens twice there: the degree lengthens the graduate's life, and the graduate's work lengthens other people's. That doubling seems worth naming in the funding argument.
I got my introduction on “Why Should I Trust You?”. Then checked out the Substack and discovered a wealth of insights. I applaud your move to St Louis and a move away from myopic, procedural, narrow focused thinking about public health.
I refer to myself as healthy obsessed recovering dietitian and because of a decision made in good faith by the FDA almost 40 years ago. The agency redefined and in the process reduced the word “healthy” to the avoidance of salt and fat. I’ve fought for a more comprehensive meaning for the word ever since.