What we owe, and do not owe, the past, Part 1 of 2

Reckoning with the history that shapes health in the present.

What we owe, and do not owe, the past, Part 1 of 2

Reckoning with the history that shapes health in the present.

My recent writing has been centrally concerned with the moment— the daily disruptions caused by the changing political winds in the U.S. and their effect on the work of health. This focus seems appropriate given the challenges we are seeing to the structures that support health in this country, and I will remain engaged with unfolding events as the tides of this sea change continue to shift. However, I have always tried to make The Healthiest Goldfish a place for sometimes stepping back from the immediacy of the moment to reflect on the deeper forces driving events, to pay attention to the important, beyond the urgent. This includes the history that shapes health in the present and that is at the heart of so much of what we see in our daily view. With this in mind, I wanted today to reflect on history, its implications for the present, and what we owe history as we work to build a better future.

These reflections are grounded in my reading, over the past couple of months, of two books. First was Robert Caro’s The Power Broker: Robert Moses and the Fall of New York, and second was Walter Johnson’s The Broken Heart of America: St. Louis and the Violent History of the United States. I was reading both books for different reasons. Last year was the 50^th anniversary of Caro’s book, and while I had read much of it when I was working in New York City, now more than a decade ago, I had never read it cover to cover and thought it was high time I did. The second book was recommended by many colleagues ahead of my move to WashU in St. Louis, and the recommendations turned out to be just right — it was a perfect history of the city I am now living in, and of how the city today is shaped by its history over centuries.

Because that is fundamentally what these books are both about: the past, and specifically how we can draw a clear line from the past to the present and to what we are today, or in the case of these books, to what New York City, and St. Louis, are today. What these places are — what we are — is inextricable from the past that has created this country and that shapes the lives of its citizens in this moment.

Central to the stories told in these books is how much the injustices committed in the past map onto injustices experienced vividly in the present day. Robert Moses, in the name of “urban renewal,” privileged the building of highways over people, moving whole neighborhoods, many of them minority neighborhoods, to make room for his motorways. This uprooting of communities translated into the destruction of a social fabric that has never been replaced. Present-day St. Louis is influenced by centuries of efforts to enshrine a white supremacist view of the world that put St. Louis at the heart of efforts first to eradicate Native Americans from Missouri and the region, and, subsequently and concurrently, to ensure that formerly enslaved African Americans were never fully integrated or allowed the resources that were afforded white Americans. The legacy of this institutionalized racism is a deeply segregated city with ongoing challenges to its health in the present.

I have written before about the inexorable role of history in shaping the health of populations. In our science, our team has shown, for example, how the practice of redlining, or housing discrimination, is associated with current neighborhood characteristics and health. In other contexts, we have shown that traumatic event experiences are associated with persistent poor mental health decades after the original experience. So, to my mind, the notion that historical experiences are associated with health in the present day is noncontroversial, and we must think about history, what has happened in the past, as a central part of our thinking about the etiology of disease. Conditions across generations influence population health in the present as much as conditions across the life course influence the health of any one individual.

But reading these books, and reflecting on them, pushed me to think more about a question that is related to acknowledging the influence of history, namely, accepting that history matters for the present, what do we owe the past? And, as a corollary, what do we not owe the past? Because it is easy, perhaps too easy, to consider present-day circumstances as a function of the past and, as such, indulge in thinking that castigates all that has come before us, and performatively self-flagellate for the sins of centuries past. And it is equally easy, too easy, to say that the past happened before we got here and that we, as such, are neither liable nor culpable for what has come before us. Surely the answer is more complicated; it always is. So, then, what do we owe the past? How do we recognize, reflect on, build on, correct the past, but also look forward? And how do we ensure that doing so does not leave us living in the past, but moves us to living in the present and looking to the future?

These are big questions, perhaps too big to answer in a single essay. So, I will spend the rest of this piece addressing the question: What do we owe the past? I will then tackle the second question — what do we not owe the past? — in next week’s essay.

I suggest that perhaps we can view what we owe the past through the following three lenses.

First, we owe the past, and those who have lived the past, our remembrance, our recognition of the past’s significance and our commitment to not forgetting it. I do not think that we owe the past our remembrance of it simply for operational reasons, but rather for moral reasons: We should remember the past because the past merits remembering as a foundation for all we do. Because absent an understanding of the past, we fail to understand the why of what our world is like. This means facing both the good and the bad of the past. As Marcel Proust said, “We are able to find everything in our memory, which is like a dispensary or chemical laboratory in which chance steers our hand sometimes to a soothing drug and sometimes to a dangerous poison.” We should be willing to address what stings as well as what soothes. There have been exemplars of doing so throughout our recent history, of facing the horrors of the past honestly. Germany, for example, has done much to remember the horrors the Nazis inflicted on Jews during the Holocaust. It has aimed to remember the past both through visible memorials, but even more practically through systemic efforts in its legal system that aim to remember the past in order not to repeat its mistakes. In the U.S., we are only beginning to see efforts that truly remember the past in the way it should be remembered. I admire the work that has been done to memorialize the legacy of slavery in Montgomery, Alabama, for example. Other national efforts to remember historical injustices are important, if imperfect and perhaps inevitably incomplete. And, of course, remembering does not happen only at the national level. Remembering also matters at the local and individual level, informing how we think about the histories of the places where we live and work.

Second, we should do service to the past, honoring those who suffered in the past by actually learning from the past. The somewhat trite aphorism that we want to study history so that we do not repeat its mistakes always strikes me as somewhat unhelpful, because, in truth, generations all have to learn their own approaches, and often make mistakes that indeed echo those of the past. However, there is learning to be done, and approaches that we can improve because we know what happened before. The aforementioned memorials to the Holocaust in Germany would be empty memorializing without the accompanying national effort to come to grips with systemic anti-Semitism, and the implementation of efforts to learn from this heinous past. Remembering without learning is akin to seeing without watching, listening without hearing. So, we owe the past our willingness to learn from it, and that learning is, well, difficult. It is easy to note that the past happened. It is easy to pay superficial tribute to the past and claim understanding while skimming the surface of complex histories. It is much harder to read carefully and to ask: What were the structural causes, what was the water in the particular historical goldfish bowl, and how did it contribute to what happened? This seems particularly important for contentious history, or history where decades of myth-making have promoted a narrative that is at odds with what we actually should be learning from the past, as in the case of the “Lost Cause” narrative, which long obscured an honest reckoning with the true causes of the American Civil War.

Third, we owe the past our efforts to rectify its injustices and mistakes when such solutions present themselves — and when they do not, to do our best to find them. Sometimes the past, with its horrors and its mistakes, is simply that — past. Sometimes we have to live with the consequences of the past, remember what has been, learn from it, and move on, because we cannot do otherwise. But other times there are things we can do to rectify what happened in the past, while still respecting the needs of the present. This is why I have argued, for example, for reparations for slavery. That thinking emerged from the observation of the long-standing, unconscionable chasm between black and white health indicators in the U.S., and an appreciation of the fact that much of that health gap comes from asset gaps that arise directly from historical injustice. There are potential approaches that can result in the narrowing of asset gaps, and these approaches can, plausibly, also narrow health gaps. And it is then on us to endorse and promote these approaches when we can. Recognizing that many injustices in the past were brought about by exploitation of existing legislative frameworks should also push us to understand how we can structure present-day laws to avoid such injustice, through, for example, progressive tax policy.

So, we owe the past to remember it, to learn from it, and to rectify its errors where it is feasible to do so. I suspect that most of the readers of this essay would largely agree with these points, the approach being aligned with a social justice framework that underpins much of what I write about in The Healthiest Goldfish. But, as is perhaps another theme of what I write about here, I also believe this topic is complex. Because, much as we need to recognize that we owe the past, we need to recognize that we only owe the past so much, and that a balance between what we owe and what we do not owe the past should guide how we act, which I will discuss in next week’s essay.

__ __ __

Also this week

Thoughts in JAMA Health Forum on recent challenges to the structures that support health in the U.S., and the importance of continuing the work of generating the knowledge that creates a healthier future.

New, with Dr. Megan Reynolds, in AJPH, “Advancing the Study of Power: Opportunities and Priorities for Understanding Population Health Inequities.”

As the Trump administration doubles down on a disinvestment in health, thoughts in JAMA Health Forum on the potential consequences of these actions.

I have been enjoying conversations with several WashU faculty about their work in public health as part of our Public Health Ideas series. You can find these short videos here.