Why I wrote Within Reason

Holding a mirror to ourselves, to the end of being better at what we do.

My new book, Within Reason: A Liberal Public Health for an Illiberal Time is out now. Public health is fundamentally a story, and Within Reason is about how we can ensure that story is guided by our values.

Here is a reading from the conclusion. Thank you for supporting the ideas in The Healthiest Goldfish, and those in the book. Within Reason can be ordered here.

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This week saw the release of my book, Within Reason: A liberal public health for an illiberal time. For the past few weeks, we have been running brief readings from the book together with The Healthiest Goldfish, so readers of these essays will, by now, have an idea of what the book is about. As the book is released, I thought I would summarize here the core argument of Within Reason, the motivation behind it, and the ideas that I hope the book will encourage discussion about, even if I realize that some (many?) may not agree with these ideas.

I start with the premise that, in many ways, COVID-19 was public health’s finest hour. Confronted with an unprecedented crisis, we marshaled the full resources of the field to protect the health of populations in the US and globally. We did so despite facing not just the virus, but a host of other, intersecting challenges. They included deep political polarization, the cynical willingness of elected officials to exploit these divides, a president with a taste for chaos and a disdain for science, the spread of misinformation, and an ideological resistance on the part of many to public health best practices. Even in the context of these challenges, public health was able to rise to the occasion and do incredible work protecting the vulnerable, developing and delivering vaccines, and tackling the structural inequities that left us vulnerable to a pandemic. Public health did all this while being systematically underfunded, and many public health professionals have faced opprobrium for their heroic work during COVID-19. This success in the face of challenges speaks to the extraordinary work done in the field, all laudable. As we move into a post-COVID-19 moment, public health professionals throughout the country and world continue to do vital work in pursuit of our core mission to create healthy populations.

As we have reflected on the pandemic years, many in public health have correctly pointed out the challenges we faced during COVID-19. These reflections—necessary as they have been—have largely focused on external threats to public health’s ability to do its job. I agree that we faced challenges during COVID-19, and nothing I write here obviates the importance of acknowledging them. However, focusing, as many in public health have, primarily on external threats reflects an incomplete engagement with the reality of the challenges before us. Much recent writing on public health has neglected key internal challenges to our field—areas where we ourselves need to do better if we are to effectively support health in the years to come.

In my role as dean of a large school of public health, I see every day the good work being done by colleagues to address challenges to health. For my part, I have quite frequently pushed against many of the forces that hinder public health’s ability to function in a world that is sometimes hostile to our efforts. But I also strongly feel that for us to do ever better by our mission it is insufficient to think only of external challenges. Our job is to also look internally, to ask ourselves what should we be doing better? Within Reason therefore is an effort to articulate the elements of public health thinking and function that have leaned on approaches that do not serve our mission. This is reflected in the book in a range of ways, but, broadly, I concentrate on five areas where public health has fallen short. Again—I offer these observations in a spirit of self-reflection, with the hope that they can help shape a reevaluation of the direction in which we are headed before we as a field lose our way.

Public health science has become politicized

Public health has arguably long had a bias towards progressive politics. This bias reflects the reality that, while nonpartisanship may be an ideal worth striving for, certain policies are better for health than others and certain political parties can at times be more in favor of these policies than their counterparts across the aisle. In recent years, however, public health’s partisan bias has become increasingly explicit and entrenched in our institutions. In some ways this has been understandable, as a response to an empowered right-wing and the Trump administration’s frequent hostility to public health. In other ways, it has echoed the influence trading engaged in by political advocacy organizations—as, for example, in the CDC working with teachers’ unions and the Biden administration to shape pandemic policies for schools. This politicization has implications for our capacity to do our work. Public health is in the midst of a crisis of trust, with large percentages of Americans saying they do not trust public health institutions. Rebuilding this trust means, among other steps, doing all we can to avoid political bias. This does not mean embracing a false equivalence between political options when some are clearly bad for health and some are clearly not. But it does mean aspiring to an ideal of nonpartisanship whenever possible and remaining open to hearing views from all sides of the political spectrum even as we reserve the right to disagree.

We have disengaged from weighing tradeoffs

During COVID-19, there was a good-faith conversation to be had about whether to encourage continued vaccination for certain lower risk populations or to focus on populations we know are more vulnerable to the disease, given the unknowns of a novel vaccine and the rare but real risks associated with vaccination. Public health has, by and large, not engaged in this conversation. Instead, we have let those who express legitimate concerns about these tradeoffs be painted as “anti-vaxxers” while we have pushed for vaccine policies which do not always take nuance into account. This reflects public health’s broader unwillingness to fully address the tradeoffs involved in decisions about health. We also saw this in the conversation about lockdowns, when support for anything less than indefinite, society-wide closures was characterized by some in public health as a betrayal of our core mission. In a historical moment characterized by increasing complexity, such zero-sum thinking will not serve us well in the long-term.

We have let social media become the new peer review

In public health, the integrity of our data depends on a rigorous process of peer review. This process helps us test our conclusions, to ensure the data that support our work are sound. However, new forms of feedback have begun to emerge as key influences on what we do. Social media platforms have created incentives for expressing our views in ways which drive online engagement, often at the expense of nuance and the generative debates that sharpen thinking. It is significant, for example, that criticism of the Great Barrington Declaration was overwhelmingly amplified by social media rather than by the empirically informed consensus that emerges from a process of peer review. This generated much heat but little light towards understanding which approaches would indeed best serve the public’s health during the pandemic, a dynamic which we would do well to avoid repeating in future debates about issues of consequence for health.

We risk valuing the pursuit of influence over the pursuit of truth

The pandemic years saw public health amass an unprecedented level of global influence. Working with political leaders, we played a key role in creating and implementing policies that affected the lives of much of the world’s population. Social media gave us a megaphone to amplify our voices, and our association with progressive political movements gave us a party apparatus though which to translate our thinking into policy. The latter association became particularly significant as the 2020 election unfolded and the preferred candidate of many in public health won, creating new opportunities for public health to wield political power. During the Biden administration many public health officials who came to greater prominence during the pandemic, often in part through their social media engagement, were appointed to key positions. Such influence creates many opportunities to do good, but it also necessitates a level of deference to a party line. This can generate challenges when our science tells us something that is at odds with the views of our political allies. Public health must walk a fine line in these moments, and we have not always done well in doing so.  

Public health has forgotten its philosophical roots

Public health emerged from a tradition of free inquiry and scientific reasoning that dates to the European Enlightenment. During the pandemic, we strayed from these values, turning away from the open-minded pursuit of truth which has long supported our work. Rather than fully engage with the substance of arguments that did not fit neatly in the mainstream of public health opinion, some in public health have attacked the motives of those making such arguments, shutting down debate. This is not consistent with the philosophical tradition that has until now served as the basis of our efforts. For public health to be at its best, it must remain open to good faith, data-informed debate. Shutting down such debate is not consistent with our core values, nor does it help us support the health of the public.

When I wrote this book, I could well imagine some, though I am sure not all, of the disagreements that might accompany the book’s release. I address two principal critiques here. 

First, that somehow my challenges to public health mean that I have moved away from my core values and roots. I think nothing could be further from the truth. I continue to see myself as largely on the political left, deeply committed to social equity, social policies that can get us there, and economic structures that elevate all of us. However, those positions come from a place of deep commitment to the liberal ideal, one where we build a better world based on reason, not ideology, and commit to rational reforms towards a such a world. That informs my thinking, and the motivation behind the book.

The second critique is reflected in the question that given the number of challenges to public health from the outside—and indeed there are many—should we not batten down the hatches and make sure that we do not add to the critiques with “friendly fire”? I agree that there are times when it is necessary that a field as critical as public health is as cohesive as possible, and so it is not always appropriate to have conversations that challenge us to consider how we do what we do. I have recently written about when might, or might not, be the time to have such conversations. But there are also times when it is important to do just that, to launch the self-reflection that can make us better. I considered carefully when to write this book, when to release it, and I am doing so at a time when I think we can have the clarity of thought, in a post-war moment, to engage in honest self-reflection towards getting better. And it is a sign of strength—not weakness—that those of us who are concerned with the health of the public can take a close look at how we do what we do and think about how we can be better. That should not shake our core, but rather it should move us to becoming stronger.

In the past few weeks, I have had the privilege of presenting these ideas to several groups in my public speaking. I have enjoyed the exchanges and learned from them immensely. These conversations have reinforced in my mind that while public health needs to engage with the many external challenges that defined the pandemic moment, it is also time for us to look inward, to see where we have gone wrong and to change course. The time for doing so is now, before the next pandemic. My hope with this book is that it lays out a particular perspective, to give us ideas on which we can reflect, motivating each of us to form our own opinions about them, towards generating conversations about how we can move forward as a field. Our work is too important for us not to do so. Thank you to everyone who has engaged in these ideas through these Goldfish essays, and who will do so through the book.

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Also this week.

Thank you Dr. Irene Torres for guiding our thoughts in our new study in The Lancet Regional Health – Americas, “Governmental institutionalization of corporate influence on national nutrition policy and health: a case study of Ecuador.” We found deep levels of corporate influence on the country’s nutrition policy, reflecting the need for more robust regulation of the food and beverage industry. Thanks, too, to José Julio Villalba and Daniel López-Cevallos for your partnership on this research.

And, thank you to the many who contributed to our new study in Social Science & Medicine, “Does biological age mediate the relationship between childhood adversity and depression? Insights from the Detroit Neighborhood Health Study.”