“We must disenthrall ourselves”

On letting go of habits and ideas that do not serve us in this moment.

In his second annual message to Congress, Abraham Lincoln wrote:

“The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty, and we must rise with the occasion. As our case is new, so we must think anew and act anew. We must disenthrall ourselves, and then we shall save our country.”

I have been reflecting on these words lately. This moment, for all its challenges, is not the same as the one with which Lincoln contended — we do not face a crisis of slavery and civil war, though the legacy of both continues to echo through history. However, our occasion is “piled high with difficulty,” and our case is indeed new. We face a range of intersecting, novel challenges that has made this an era unlike any other. Political disruptions, climate change, technological developments such as AI, and global conflict have made this a time of difficulty, a stormy present. These challenges beg important questions: How should we respond in this moment? What should we — can we — do to build a better world when the one we have seems to be so much in extremis?

We can start to answer these questions by first taking stock of who, and where, we are and how we got here. We are centrally concerned with improving the health of populations, narrowing health gaps, and doing so through the creation of rigorous, high-quality science. These values have long intersected with movements and social trends that have helped make this the healthiest time in human history. It is important to remember this progress, particularly when times are difficult, so that we remember that positive change is indeed possible and that we already have done much to bring such change about. Making a constructive difference right now means, in part, acting in accordance with the values that have long guided our efforts, and that have informed many time-tested approaches that still have much to offer in this moment. We should remain centrally concerned with scientific rigor to the end of improving population health and narrowing health gaps. These values should not change, even as the changes of the moment continue to evolve and accelerate.

Yet staying true to our values is not the same as staying fixed in our approaches — as eschewing new ways of thinking and acting in pursuit of a healthier world in this moment. Lincoln suggested that to think and act anew in the face of novel challenges, it is necessary to “disenthrall ourselves.” Merriam-Webster defines enthrall as “to hold spellbound; charm.” Lincoln is saying, then, that acting constructively in a difficult historical moment means first breaking a kind of spell, one that keeps us enthralled by “the dogmas of the quiet past.”

What might it mean to be enthralled by something that, in an earlier era, may have served us well but that now no longer helps us and may even hold us back? I will answer by way of a story. Imagine a guitar player in a quiet, picturesque town by the sea. Each day he sits on a street corner to make music for the passersby. He loves to play for the people and be heard by them. What is more, he loves the idea of himself doing this, the romantic notion of being a troubadour playing beautiful melodies on his acoustic guitar. It is a lovely instrument, given to him by his father. Time passes — decades go by — and the town grows increasingly popular with the tourist set, becoming very crowded. The hubbub on the streets is such that the guitar player, with his acoustic instrument, can no longer be heard. It never occurs to him that an electric guitar could solve his problem. He cannot separate his reality from the dream of himself as a rustic troubadour. Eventually, the dream becomes more real to him than what he is actually doing, which is plucking strings no one can hear. This is not quite a sad ending to his story. He is happy in his dream. But the people are denied some truly lovely music.

We can sometimes find ourselves in the position of the guitar player, enthralled by a vision of who we are and what we are doing that was formed in a very different context than the one in which we are living. Responding to the moment, doing what we need to do to make a positive difference, means first recognizing that we are in a time of change and that this change has implications for what we do and how we do it. Just as the guitarist’s acoustic playing once served him well, that same playing proved inadequate to the future in which he found himself. A fairly simple change — switching from acoustic to electric — would have solved his problem, allowing his music to be heard once more. Yet he was so enthralled by a certain vision of himself that he was unable to even consider making this switch, ultimately consigning his music to irrelevance.

Leaning on this metaphor, where might we look to find some of the ways in which we are enthralled by ideas and approaches that are holding us back? I suggest the following five areas.

First, in our understanding of what health is fundamentally for. Health is not an end in itself, but a means to the end of living rich, full, happy lives. This means we should pursue approaches that support living, rather than simply take health as an end in itself, which can lead to a pursuit of safety at all costs, including at the cost of the interactions and experiences that give life meaning. It means that we recognize that health is one of many societal values — not the only value — and that our role is to guide with the best evidence and engage in — but seldom dictate — what societies should do. By disenthralling ourselves from outdated, overly paternalistic views of health, we can shape approaches that can help propel health, and living, in this moment.

Second, in recognizing that health is a product of context in concert with the individual and in shaping interventions with this in mind. Public health is centrally focused on the role of context — on how health is created by the conditions in which we live, conditions such as politics, place, economics, and social networks. This focus is appropriate — such forces are, overwhelmingly, the core drivers of health. However, health is also a product of the choices of individuals, of the behaviors we embrace or avoid, and the intersection of these behaviors with our context. We should disenthrall ourselves from the idea that engaging with context alone is a sufficient focus for building a healthier world. Our scope needs to include both context and individual behavior, and our science should reflect this. Striking this balance will not always be easy, and may make us uncomfortable, but it is essential to shaping an approach to health that is truly comprehensive.

Third, in the spirit of discomfort, we need to disenthrall ourselves and embrace being comfortable with uncomfortable ideas. I have written frequently about the importance of respectful disagreement and good faith debate to the process of generating ideas that support a healthier world. These conversations can be difficult, uncomfortable, and, for this reason, we occasionally have found ourselves too quick to avoid having them. We need to disenthrall ourselves from the notion that every conversation must be comfortable, or that we can work in the world of ideas without engaging with perspectives with which we disagree. Certainly, we are under no obligation to give all voices a hearing, and we should exercise discretion and good judgment in deciding which ideas to platform in our spaces. Yet our bias should always be toward having the conversations that support a robust climate of ideas, even when these conversations are uncomfortable.

Fourth, in the methods we adopt to do science of consequence for health and translate that science for policymakers and for the public. In this dynamic moment, we face a range of challenges for health. We have just seen a global pandemic that intersected with challenges including chronic disease, global aging, and deep health inequities. In this moment, our science needs to be nimble, engaged with the central issues we face, and responsive to the needs of policymakers, particularly in the global context of evolving crises such as pandemics. We should double down on the standards of rigor and inquiry that support good science while pursuing research areas that reflect issues of contemporary concern. If we disenthrall ourselves from a belief that our science must inevitably face an ongoing loss of influence in this new political era, we can lay the intellectual foundations for a radically healthier world.

Fifth, in embracing better approaches to communicating. I have written about shaping approaches to communicating that aim to persuade rather than scold, that make the moral case for health without tipping into the moral grandstanding that can alienate communities. Communicating better also means being willing to make our case to people with whom we may disagree, to engage in places where we might not encounter audiences that are entirely friendly. We need to disenthrall ourselves from the idea that we should only go where we are welcomed, and from embracing language and symbols that only resonate within our narrow circles, to instead reach out to build a big-tent movement for health.

None of this is easy. It is hard to recognize when something that may have worked for a long time is no longer fully supportive of our efforts, and harder still, perhaps, to change our behavior. Yet doing so will allow us to recreate ourselves at this inflection point, to build a healthier future. We are in a moment when there is much happening that does not bode well for health, a moment that is intersecting with a long history of poor health in the U.S. and globally, to say nothing of the recent history of COVID-19 and other perturbations. It is on us to lean into this moment, to assume a posture of hope and constructive action. This takes recognizing where old approaches might be modified or replaced to reflect the needs of right now, even as we acknowledge that public health has had many successes that have been based, at least in part, on these very approaches. To continue achieving much on behalf of health, we need to recognize where we might adapt our thinking to rise to this difficult occasion. It is through so disenthralling ourselves and then we can improve the health of our country and world.

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Also this week

New in Observing Science, with Michael Stein: on whether it is reasonable to pursue faster, more efficient science at the expense of more patient approaches.

With Amal Khan and Ivar Mendez in Digital Health, “Five steps for the deployment of artificial intelligence-driven healthcare delivery for remote and indigenous populations in Canada.”

With Kenneth Ruggiero, Arthur Andrews, Tatiana Davidson, Yulia Gavrilova, Brian Bunnell, Jennifer Dahne, Matthew Price, Zoe Brier, Gregory Cohen, Dean Kilpatrick, and Ron Acierno in The American Journal of Psychiatry, “Randomized Controlled Trial of ‘Bounce Back Now,’ a Mobile App to Reduce Post-Disaster Symptoms of Posttraumatic Stress, Depressed Mood, and Sleep Disturbance.”