When our values are not shared

On the misalignment of values that can cause the public to reject our efforts.

When we understand that the health of populations is shaped, in large part, by the world around us, it becomes clear that our work is to create a world that generates health. Concretely this means a world with less violence, safe water to drink, clean air to breathe. Creating such a world requires the promotion of a radical vision of the right way to create health and commensurate efforts to discourage approaches that harm health. Reduced to its core element this becomes work that is engaged with a fundamental conflict between right and wrong.

How do we determine what we consider to be right?  In large part that emerges from the empirical foundation of population health science that should be core to all we do. But, data alone cannot tell us everything about which actions to take. Our choices about what is best for the health of populations should be shaped by a balance between our data and our values. This pushes us then to ask: what are the values we embrace in public health and adjacent fields that take as their core goal the creation of a healthier world?  Through this recent set of essays on shaping a new practical philosophy of health I have been hoping to support a process of reflection about this question. But, of interest today, and just as importantly, what should we do when our values are challenged, even forcefully rejected, by the populations we aim to serve?

From opposition to bans on harmful substances like cigarettes and sodas to widespread resistance to the COVID vaccine, the work of public health has long faced these moments of rejection. What can seem at first like run-of-the-mill political debates (about, say, taxation), are often fundamentally about values. The fact is, many populations do not share the values of public health and this mismatch can create impasses which complicate our ability to be effective in our work. This leads to notions that populations are working against their own interests, that somehow populations misunderstand the values that they should hold to. That populations are thinking the “wrong way” and that our work rests on righting these misunderstandings.

But perhaps there is a different, more productive way, of understanding values that differ than ours. Cast in a different light, we can move beyond seeing values clashes as a conflict between good and bad (with public health on the side of good), and rather see these conflicts as being between two different understandings of what is right.

I realize that in saying this, I have opened myself to the criticism that I am embracing relativism, that I am saying “There is no right and wrong, really, only differences in points of view, in values, and the issues on which we see deep disagreement are, at core, merely misunderstandings.” This is not my position. I am not saying there is no good and bad, right and wrong—there is, and certain positions do align with the good while others do not, and we should be clear about this. What I am saying is that even when we feel we are engaging with an issue where right and wrong are clearly defined, we would always do well to see the values that underly all points of view.

I have long been inspired by the story of British Prime Minister Clement Attlee as an example of how to strike this balance in the political space. Attlee was an unassuming man, with few of the charismatic gifts we associate with transformative leaders. However, he had a talent for engaging with all sides of the political spectrum, working pragmatically to advance change without compromising his core progressive principles. As a result, his government passed much of what would become the basis for the UK’s robust social safety net, including the National Health Service. In his review of a biography of Attlee, Adam Gopnik wrote:

“[T]he true progressive giants are radicals of the real—those who accept that democracy implies pluralism, and that a plural society is self-evidently made up of many people and kinds, only a few of them truly exploitative and criminal, most just pursuing their own version of the good life as tradition and conviction has offered it to them. The oscillation of power among them is not a sign of failure; it is a sign of life. Attlee’s example reminds us that it is possible to hold to moral absolutes—there was no peace possible with Hitler, and it was better to go down fighting than to try to make one—alongside an appetite for conciliation so abundant as to be more prolific…than merely pragmatic.”

This is, I think, a powerfully stated theory of the case for a constructive engagement with values. Some values are fundamental, inalienable. They include respect for personal autonomy, for inclusion, for kindness, and for reliance on data and fact. These echo core Enlightenment values, including those reflected in our country’s aspirational promise of “life, liberty, and the pursuit of happiness.” At the same time, we should be animated, always, by an “appetite for conciliation” informed by a willingness to acknowledge the validity of different values, different points of view, and to see how these values can inform a framework which may be no less ethically grounded than our own, even as it supports different conclusions about the right course to pursue.

Such an approach can help shed light on even the most intractable of debates. During COVID, we saw clear examples misalignment of values, as public health’s prioritization of stopping disease spread above all else conflicted with the value many populations place on being able to do everything that masking and lockdowns prevented. So core is prevention to the work of public health—particularly in the midst of a crisis like a pandemic—that we had trouble engaging with a values system that embraced other priorities. This made it harder for us to have conversations about tradeoffs around how much we were willing to give up, collectively, to slow the spread of disease. This engendered a toxicity around conversations about measures like lockdowns, school closures and masking which a deeper consideration of values might have helped mitigate.

It is clear that values vary throughout the country, a difference made particularly stark during the COVID moment but long reflected in public opinion on a range of issues. In 2019, Pew Research Center released data on polarization in the US. It found that across 30 political values—reflecting feelings about issues like immigration, guns, foreign policy, and race—the average partisan gap is 39 percentage points. This gap reflects a country in which we cannot monolithically apply any one set of values to the whole population. What, then, is public health to do? How can we support health in a country, and a world, where populations can have such vastly different values? How can we move forward in moments when data do not align with values? I suggest there are three points to keep in mind as we navigate these waters.

First, we should not pretend that everyone shares the values of public health. This is important because if everyone did share our values—shared our understanding of what is in the best interest of the public good—it would mean that anyone expressing views contrary to these values could indeed be accused of working in bad faith, rather than simply acting in accordance with their own set of values. For example, if we all agree that vaccines are good and that the data support their safety and efficacy, then someone who advocates against vaccines might well be accused of knowingly spreading disinformation rather than expressing skepticism due to a genuinely different set of values. By rejecting the fiction that we all share the same values, we can avoid the waste of time and energy that comes with demonizing those with whom we disagree because we will be able to see where their disagreement is rooted in a difference in values and work to address it. While we may never share these values, we can respect how a different set of values can reflect our common aspiration for a better, more just world, even as we may disagree on the right path to get there.  

Second, we need to shape a public conversation that is capacious enough to acknowledge different sets of values with an eye towards understanding them better. At a practical level, this means public health cannot just “preach to the choir” if it is to build a movement that can truly shape a healthier world. Those of us in public health tend to run in circles with those who share our values; we need to open ourselves to other populations with all the humility—and courage—such outreach entails. The work of public health is not a theoretical exercise. It is the work of compassion and radical solidarity. It means putting ourselves at risk. Not just the risk of far-flung travel or contact with disease, but the risk of having our assumptions challenged, our convictions tested by those who do not share them. A simple exercise can help inform this engagement. The next time we encounter someone espousing a view which reflects a set of values different from our own, it could be worth taking a moment to think through the best arguments in favor of their point of view. In doing so, we can begin to better understand the values of the person we are dealing with, and perhaps even clarify our own thinking about what we believe. This reflects a process of outward-facing engagement which can help us stay oriented towards the core mission of public health—serving all populations, no matter who they are or what they think.

Finally, we need to work to shift hearts, to move the Overton window towards the widespread embrace of values that support healthy populations. This does not mean trying to impose our values on those who do not share them. It means engaging in dialogue and participating in a national debate in which we respect difference, prioritize empathy, and demonstrate that we see and understand the values of others even as we advocate for our own values with conviction and clarity. Progress comes from this process. An appreciation of the ideas that create a better world emerges as a result of patient work over-time, and the most enduring wins for health are those which are rooted in changes in our collective values, not just in our laws. This is the case, for example, in the change of values around the issue of same-sex marriage, in which changes in law aligned with changes in public attitudes about the issue, so that when progress was threatened, as it was last year, bipartisan majorities came together to safeguard it. Such progress depends on engagement, persuasion, a willingness to listen, and a commitment to understanding the values of those with whom we may disagree. It is only by understanding these perspectives that we may, in the long term, be able to change them. 

Core to all these steps is the importance of striking a balance between values and data. This means recognizing that there will be times when our data do not align with the values of the populations we serve. When these moments arise, we should not close our minds and refuse to engage. Instead, we should reach out and recognize where our own understanding might be limited by our assumptions about those who reject our efforts.

I will end with a bit of music trivia which, I think, well illustrates what can come from a more open engagement with different values. In the late seventies, Bob Dylan entered what would become known as his “Gospel period.” While he had long engaged with Biblical themes in his music, this period saw him explicitly embrace born-again Christianity in his art and life. He attended a Bible study course and wrote a string of albums with overtly Christian themes. When Dylan took his Gospel turn, many of his fans rejected his new music, outraged that an icon of the counterculture would embrace religious orthodoxy—a microcosm of a central dividing line of the mismatch of values in the US and globally, the line between religious and nonreligious. But the songs of Dylan’s Gospel period have since been embraced—including by some of the fans who initially rejected them—as among his finest. This suggests that a mismatch of values need not, should not, be the end of a conversation. Rather, it should be the start of a new one, as we remember that our job is to improve the health of all populations, not just those who share our values.

__ __ __

Also this week.

I have expanded my communication now to include Threads.

I recently had the pleasure of speaking with Dr. Helen Crompton about the challenges and opportunities that AI presents in the context of higher education and public health. I also had the privilege of speaking with Dr. Seth Berkely, CEO of Gavi, The Vaccine Alliance, on global immunization. Listen to our conversation here.

Steve Woolf and I partnered on a commentary for JAMA Internal Medicine on the persistent challenge of preventable death in the US. A kudos to Wayne R. Lawrence, Neal D. Freedman, Jennifer K. McGee-Avila, and colleagues for their original paper, Trends in mortality from poisonings, firearms, and all other injuries by intent in the US, 1999-2020, that this commentary reflects on.