These questions have been central to my thinking over the past few years, as I have tried to reckon with this unstable time for public health. This post-pandemic moment—which I and others have characterized as a “post-war” moment—is a chance for reflection, for evaluating what is fundamental about our field, the philosophy that animates our work at the deepest level.

When we look at the sweep of public health’s history, we see a field that has had remarkable successes. The treatment, even eradication, of deadly diseases. The doubling of global life expectancy. The development, and widespread dissemination, of vaccines. These successes rank among humankind’s greatest achievements. They were won by a combination of knowledge, values, and approaches which have long served public health well.

But we are in a new era. We can no longer assume the thinking that sustained us in the past can reliably do so in the present and future. Proof of this is in the challenges public health faces, its ongoing identity crisis in which our field remains a shadow of the confident, trusted, outwardly engaged movement it once was.

This is fixable. We can not only regain our footing, we can also build new foundations on which to stand. I serve as dean of the Andrew M. and Jane M. Bursky School of Public Health at Washington University in St Louis. Each day, I have the privelege of seeing our students grow into the public health leaders this moment needs. Their talent, their comittment to the work of public health, their keen understanding of this moment give me confidence that public health will find itself again.

These rising leaders deserve a field that is worthy of them. A field that draws from the best of its past, that learns from both its successes and its shortcomings, that is fully engaged with this moment in all its complexity.

Public health can do better. But for public health to change what it does, it must first change how it thinks. We need a new philosophy of public health.

That is why I wrote my upcoming book, Why Health? What We Need to Think About When We Think About Health.

The book, which launches on September 1, makes the case for a practical philosophy of public health that is informed by the lessons of the moment, that engages with complexity, that is confident in its convictions even as it considers different points of view, and that can build a big tent movement for creating a healthier world in the 21^st century. The book works to define and develop this thinking through a series of essays adapted from writing that first appeared here in The Healthiest Goldfish.

At the heart of these essays is the question: why health? Why does health matter and what steps should we take, and not take, in our pursuit of it? Had we more deeply thought through these questions before the pandemic, it is possible we might have avoided some of our missteps during that period and the subsequent public backlash we have faced. But it is not too late for this process of reevaluation, for working through what we should think about when we think about health. As I tried to do so in the book, six themes emerged which can, I think, serve as a philosophical framework for a new public health.

Why Health?

The pursuit of health, I have long argued, is not an end in itself. It is a means to an end. That end is the living of a rich, full life. Public health should aspire, always, to strike a balance between protecting health and enabling what health is fundamentally for. When the pursuit of health interferes with the pursuit of happiness—the capacity of many to do as they wish, to make choices, even when these choices are not in the best interest of their health—then we should pause to recalibrate our actions. We are in the business of promoting health, and health is in the business of promoting living. We should not forget this.

Foundational values

Public health aims to create a healthier world for all by creating the conditions for better health and by working to eliminate health gaps. This focus has guided public health throughout its history, and we should stay grounded in this central aspiration going forward. Public health can and should change to meet the needs of the moment, but it should not deviate from the core values that constitute the field’s essential identity, and our values do not get more fundamental than our mission to build a healthier world for all.

Health at all costs?

I have argued for a muscular public health, and I continue to think the world is best served by a public health that is bold, ambitious, and radical in its aspirations. Yet it is important to temper this with moderation, with a willingness to act pragmatically and take a measured approach. If we neglect moderation, we risk advocating for steps which may go too far, sacrificing in the name of health much that makes life worth living.

The potential, and limits, of science

Science—the pursuit of truth through reason—is the bedrock of public health. Everything we do depends on generating data that reflect the truth about the world. We need to continue leading with our science, while being honest about what we know and what we do not. A trustworthy public health is one that follows the data wherever they lead, and, when data are lacking, admits this limitation.

The actions that generate health

Public health is mission-driven and our mission is the creation of a healthier world. Everything we do should point towards this goal. This means aligning our research priorities with what can do the most good on issues of consequence for health and aligning our practice with the pragmatism necessary to create tangible, real-world change. We can build a healthier world through a strategy of radical incrementalism, taking practical steps toward our goal, compromising where we must, without sacrificing our radical vision of better health for all.

Uncomfortable ideas for health

Public health evolves and improves through its engagement with data and ideas. But data and ideas do not always align with our preferred narratives about the world. For public health to progress, it must be willing to pursue the truth, and to have the hard conversations that sometimes come with this pursuit. We should remember that engaging with ideas does not mean embracing them and that an intellectually robust movement for health can, and should, take on this engagement.

I realize that these points pose challenges for public health. They are, fundamentally, a call to update how we think about what we do and, in some cases, to change the actions that are downstream of this thinking. But, as we have learned, change can come to us regardless of whether or not we choose to embrace it. The changes imposed on the field in recent years should move us to lean into this moment, in the spirit of revival, to shape a better, more resilient public health. This means taking an honest look at ourselves, fixing what is broken about our field, shoring up what works, and moving forward, boldly, towards the better world it is our mission to build. I wrote Why Health? to help start a conversation that might inform this process.

I look forward to continuing this conversation in the coming months, both here in The Healthiest Goldfish, and at a series of virtual and in-person book talks. Dates and times for future talks will be available here. Thank you to everyone who helped sharpen my thinking about these ideas over the past few years. I have found that the most constructive ideas are often those which emerge from a process of conversation and debate, and that when these conversations are uncomfortable, even slightly contentious, this can be a sign that they are generating the light we need rather than the heat we so often get. The extent to which we can have these conversations within public health is the extent to which we can start to emerge from the shadow of our shortcomings and build a new, better public health.

My hope is that Why Health? can help to catalyze these conversations, to help us navigate the challenges of this moment and seize its opportunities, to build a brighter future for our field and a healthier world for all.

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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.

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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.

I have been mulling this piece ever since a fireside chat-style conversation I facilitated with John Ioannidis at the 2026 Society for Epidemiologic Research meeting. After a lengthy discussion about the shortcomings of science, I asked him why—given the severity and persistence of some of these shortcomings—bother with science at all? His answer: because it is the best thing that we can do for homo sapiens sapiens. The answer has stayed with me ever since, and this essay is, in part, an attempt to think it through. Ioannidis is the author of what may be the most-read methods paper of this century, “Why Most Published Research Findings Are False,” and he is perhaps the field’s most famous (and at times controversial) internal critic. That the person who has done as much as anyone to expose science’s fallibility still calls it our species’ best endeavor is not a contradiction; it is, to my mind, an essential point about why science is indeed indispensable. The willingness of science to interrogate itself, to take a reasoned look at its own strengths and weaknesses, is precisely what makes it worth pursuing and defending.

So, in the spirit of this interrogation, “why science?” Why does it matter that we do it, fund it, teach it, trust it? And why science now, at a moment when science’s funding, standing, and store of the public’s trust are all contested?

A point of clarification before I tackle this. I do not address here the related, but different question of “what” is science? There is a long intellectual tradition of thinkers from Bacon to Karl Popper to Richard Feynman to Robert K. Merton and even to Vannevar Bush’s Science, the Endless Frontier who have discussed this. Fundamentally, my take is science is not a set of answers, but a discipline committed to uncovering, and communicating, truth.

How does such a discipline then go about elevating our species? I would suggest it does so in two ways.

First, science improves health by helping create the material conditions in which all can live better, healthier lives. At the most intuitive level, where health is concerned, this refers to the many treatments for which science is responsible, treatments which have made a world-changing difference in the health of populations. We saw a dramatic example of this during COVID, when science helped to quickly deliver a vaccine, shortening the acute phase of the pandemic and saving countless lives. That was just one chapter of the broader story of vaccines, a story in which science has created the lifesaving medications which have transformed our species’ relationship with disease, making contagions far less deadly, and even eradicating smallpox, a disease which killed 300 million people in the 20^th century alone.

Science has also improved health at the material level by helping to create the modern world—a world in which feats of progress like the harnessing of electricity, improvements in sanitary infrastructure, the application of scientific techniques to agriculture, and the still-unfolding digital revolution have made life longer and better for nearly every human being on earth. Science, whether directly or indirectly, has underwritten just about all of the material progress that has characterized the 20^th century, a century which saw the doubling of global life expectancy—a core metric (perhaps the core metric) of progress on health.

Science has not just made human life better, it has, arguably, helped make human beings themselves better. This is in part because of the values of science, the core principles that allow for the reasoned pursuit of truth. They include honesty (because the data are what they are), patience (because science is a long game, sometimes taking generations to yield a breakthrough), and humility (because the findings of even the most accomplished scientist may turn out to be false). These values help advance a scientific endeavor which can then present a picture of the world that is evocative of those very values. It is difficult, for example, to view the images of outer space science has allowed us to access without a sense of humility and a longer-term outlook on human life that lends itself to greater patience. And the essential role of truth in science is a reminder of the power of truth generally, of the necessity of keeping it always at the heart of all we do.

There are, of course, limits to science’s capacity to uplift humanity at the level of values. Science can also create the conditions for great harm. One of the central scientific developments of the past century, for example, is the atomic bomb, which has the power to end life on earth. It is for this reason that I have long argued, echoing the work of moral traditions, of philosophy, and of the humanities, that a moral case for health should exist alongside an empirical one. The work of science should be pursued in tandem with the work of building a philosophical framework for science to do the most good and to avoid where it can go wrong. This is, in part, the aim of these essays—to help shape a way of thinking about science that enables it to be at its best, to continue yielding the fruits that have done so much to improve life for us all.

Even as I, admittedly, elevate science, it is important to acknowledge that science cannot solve all the world’s problems. Nor is the work of science the end-all-be-all of human endeavor. Humans also love, make community, worship in their different ways. Such pursuits are as old as they are core to the human experience, and we should not think of science as somehow a candidate to replace any or all of them. Yet science remains one of the best things that we as humans do and, in doing science, we make a unique contribution which makes the world a better place in ways we would not want to live without. This is why I return to the question of why science and to the answer, in compressed form, of: science is the best thing we can do for homo sapiens sapiens because it is also something that only homo sapiens sapiens can do.

For these reasons, science is bigger than any one person or institution, and when we occasionally see the fallibility of the people and organizations tasked with the work of science, this should not be cause to doubt (or defund) science itself. Rather, such times are moments to return to what science really is, what it has given our species. When we do this, we can see the value of science as very nearly self-evident. Science is worthwhile because a better world is worthwhile and we cannot get to such a world without the work of science— nor should we try to.

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Also this week

In The Lancet Regional Health – Americas:

Pre-existing financial circumstance, job loss, and probable depression among U.S. adults: a prospective population-based cohort study – with Leila Mady, Grace Ringlein, Rajesh Satpathy-Horton, Elizabeth Stuart, and Catherine Ettman

Thank you, Leila, Grace, Rajesh, and Elizabeth, for your partnership on this work, and thank you, Catherine, for leading it.

I will start with a reflection on the institutions where I have worked for the past 25 years—universities. For thousands of years, universities have served as centers of thought around the world. Clark Kerr memorably noted that roughly eighty-five institutions in the Western world have existed in recognizable form since 1520. They include the Catholic Church, a few parliaments, some Swiss cantons, and some seventy universities. Some universities go even further back. The University of Bologna, for example, was founded in 1088 and is now the oldest university in continuous operation in the world.

Institutions do not survive five centuries and beyond by accident; they survive because they do something civilizations cannot do without. Through social and technological change, universities have remained hubs for the creation and dissemination of knowledge, for the intellectual formation of the next generation. There are many reasons for this—perhaps the key reason is that universities have always been physical spaces where smart, committed people have come together to discuss ideas, work out problems, and cultivate a life of the mind. This will remain true even in the AI era, with its potential to change so much about how we create and engage with knowledge. No matter what AI can do, it cannot be a physical campus where students and teachers come together for the shared pursuit of knowledge. This simple, powerful feature of universities have kept these institutions robust through the ages and will likely continue to do so.

However, this does not mean that universities do not sometimes find themselves faced with moments of challenge—moments like right now. The university, this most durable of institutions, now finds itself, in the United States, under a level of attack unmatched in living memory. Universities are being challenged politically, financially, and culturally—through federal actions against research funding and international scholars, congressional scrutiny, state-level interventions, and a broader collapse of public trust. The share of Americans expressing high confidence in higher education fell from 57 percent in 2015 to 36 percent in 2023 and 2024, recovering only partially to 42 percent in 2025, with confidence sharply divided by party.

Driving these challenges is a central question: what exactly are universities good for? While this question has often been posed somewhat antagonistically, it is actually a good question, one that is worth engaging with. We should not assume the worth of anything, even of what we value most, is self-evident to all. Universities depend on a level of public support (which includes public funding), and it is perfectly reasonable in this context that universities should be asked, from time to time, whether they still justify their privileged place in society. This moment should then push us to be clear about our purpose. If we cannot answer in language a skeptical fellow citizen would accept, we should not be surprised that the skeptics are winning.

Answering the skeptics, and making the case for universities’ worth, means first acknowledging where those who are critical of universities have a point. It so happens, in my estimation, that much of the critique that has brought us to this moment is not incorrect. There is, for example, the critique that the academy is ideologically orthodox, that universities lean overwhelmingly to the left, that this has limited their capacity to be spaces for free and open debate and that this leaves open the possibility of bias in the scholarship they generate. It is true that the academy does lean heavily left and, ideologically speaking, does not look like the country it serves. Democrat-to-Republican faculty registration ratios exceed 10 to 1 at elite liberal arts colleges, and there are ratios of over 17 to 1 in philosophy departments, more than 40 to 1 in English and sociology departments, and large shares of departments with no registered Republicans at all. Then there is the criticism that universities have become too insular, too self-referential. This, also, has some truth to it. We too often talk to ourselves, publish for ourselves, and mistake consensus within our walls for truth beyond them. Public health has its own version of this, which prior essays have addressed at length.

These criticisms have, correctly, produced calls for reform, and arguments in favor of institutional neutrality policies in the spirit of the Kalven Report by a growing number of universities. It has also prompted viewpoint-diversity and civil-discourse initiatives, renewed debates about admissions, governance, and the institutional voice, and a fair bit of genuine self-reflection. One need not agree with all of the criticisms prompting these developments to feel like this is to the good, acknowledging that institutions tend to improve when challenged.

From this context of self-reflection has emerged a subtler pressure on universities worth examining, the pressure to act, to take positions, to be ideological combatants, to deliver visible change. This pressure comes from both directions—from critics demanding universities doing a better job of fulfilling their historical roles and from allies demanding activism. And it is particularly relevant to academic public health, a field that is repeatedly asked, and asks itself, to change the world, a demand heard in every crisis from HIV/AIDS to COVID-19 to the present moment.

The temptation is to accept the framing, to justify the university by its activity, or lack thereof, in pursuit of a better world. But this framing, however well-intentioned, mistakes what a university is. Universities do act in the world, but what they do is different in kind from what governments, companies, movements, and service agencies do, and the difference is precisely what makes them valuable.

So, what, then, are universities for? Fundamentally, universities generate ideas, teach students, and translate ideas toward a better world.

The generation of ideas is the core of what universities are for, from which flows everything else these institutions do. The generation of ideas is the university’s irreplaceable contribution. More than that, it is perhaps the best action we can take for ourselves as a species, because it is difficult to see how else we could elevate ourselves collectively without engaging with old ideas and generating new ones. This has been said and said again. For example, Neuman in The Idea of a University reflects on knowledge as an end in itself; Flexner, in The Usefulness of Useless Knowledge, well summarizes world-changing discoveries that began as idle curiosity and Whitehead in Universities and Their Function makes a compelling argument about the university’s ability to weld imagination to experience. All of these works argue for the importance of idea generation as a fundamental human endeavor, central for human health and well-being.

Next, and following closely from universities’ role as knowledge-generating institutions, is their function of transferring this knowledge to the next generation through teaching. Universities are where each generation is equipped to think—not told what to think but taught how—and where the thinkers and doers of the next fifty years are formed. In a school of public health, this means training students who will staff health departments, run health systems, and shape the next generation of ideas. This process of teaching is not just about supporting students; it is also about supporting ideas themselves. We teach because ideas without inheritors die. Teaching is the university’s most democratic function, providing a route of access to intellectual and social mobility and sustaining a climate of ideas from which progress towards the common good may continually emerge.

Finally, universities are essential engines of translation—the process through which ideas are put to practical use in the “real world.” Translation matters; this is a longstanding personal commitment, expressed over a decade of writing on a public health of consequence, and The Healthiest Goldfish has consistently argued that our science must matter beyond our journals. But translation is not service provision. With the exception of clinical care in relevant settings, universities are not, and should not become, delivery organizations; when they try to be, they do badly what others do well, and they compromise the independence that makes their ideas credible in the first place. Translation, as I have written before, means partnership: working with health departments, communities, governments, and practitioners who own the doing. Universities have long been critical partners to a range of organizations and sectors, and they are poised expand these partnerships in the coming years as social, political, and technological change creates new openings for our data to drive progress.

So, what are universities good for? Universities are good for being the places where ideas emerge, where people are trained to carry them forward, and where, through partnership, ideas are bridged to a better world. Some institutions do some of this work, but no other institution does all three; that is why seventy universities have outlasted almost everything else built since 1520. The contemporary criticisms of universities are real, the reforms are needed, and we should pursue them with humility and without flinching. But reform is renovation, not demolition, and as we improve what we do, challenge what we do, and open our doors and our minds wider, it would serve us, and the health of the public, not to lose sight of what universities are truly for—the work they do that cannot be replaced.

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Also this week

In Health Affairs Scholar:

Medical debt and subsequent use of alternative financial services among US adults – with Hridika Shah, Kyle Moon, Katherine Miller, and Catherine Ettman

In Journal of Traumatic Stress:

The prevalence and distribution of traumatic events and stressors: Insights from eight countries – with Salma Abdalla, Madison Pickerel, Samuel Rosenberg, Bernard Banda, and Catherine Ettman

In the BMJ:

Artificial intelligence as a new commercial determinant of health – with Itai Bavli, Joel Lexchin, Nicholas King, and Nadav Davidovitc

In JAMA Health Forum:

Policy Approaches to Ensuring an Adequate Nursing Workforce in Coming Decades – with Angela Clark

Thank you to the colleagues who guided our thoughts on this work.

I have quite been enjoying watching the men’s soccer world cup the past few weeks. The FIFA World Cup, perhaps the most prominent worldwide sporting event has not disappointed—it has had great games, some sublime individual performances, and more impressively excellent teams. One of the central stories of this World Cup has been, of course, the USMNT crashing out to Belgium in a performance as uninspired as the start to their campaign was inspired. This has occasioned substantial reflection, with blame apportioned—depending in my estimation on the apportioner’s biases—on the coach, the federation, the players, the referee. Just about anyone but the structural forces that really bring about such outcomes.

I have previously written on the history of the game and the way small perturbations shape complex systems. I return to it now because it has been hard to avoid as one has watched and reflected on this year’s World Cup. In the US context, how could a country as large, wealthy, and athletically engaged underperform as it does in soccer? American athletes lead the world in basketball, in track and field, in swimming, in gymnastics. But not in soccer, the most widely played game on earth. In this sport, the US remains an also-ran, as we were painfully reminded during this World Cup.

The explanation that usually follows is that soccer arrived late here and that the game needs another generation or two to bear fruit. While this explanation is comforting and assuring, it is only partly true. Consider for example, Japan, a country that did not professionalize its domestic league until 1993. Japan now qualifies for every World Cup and regularly advances. Or Croatia, a nation of under four million people, which reached a final and a semifinal in successive tournaments. Or Morocco with a fraction of America’s resources, which reached the quarter finals of the World Cup and the semifinal in 2022 (and played impressively at this World Cup). Clearly a country’s wealth, its footballing heritage, and its population size matter. But neither are enough to explain its success or failure in soccer. So, what, then, is at work in ours?

The fundamental explanation that I have found most compelling is this. The US, while a large country, is drawing on soccer talent in its formative youth leagues, in what is often referred to as a pay-to-play model. These youth leagues are accessible and affordable to only a small proportion of the US population. Youth, particularly from lower income households find it difficult to engage in the sport at a meaningful level at a young age. Parent surveys show that families earning under $50,000 spend about $890 a year on a child’s primary sport. Families earning over $150,000 spend more than twice that amount—$2,361. Similarly, the elite youth soccer pathways, the leagues from which national team players are drawn, cost far more. This could run anywhere between $8,000 to $15,000 per child per year once travel, coaching, and club fees are counted. Further compounding this gap is the accessibility to such resources. ZIP codes that host America’s elite development clubs have median household incomes more than $30,000 above the national median.

There is no reason to believe that rare ability (or, if we prefer, “talent”) is not distributed across a population. And through a system that restricts who may participate, the US is losing a substantial proportion of its population where talent be found. The sports America dominates recruit through public schools, which cost families little and therefore sample the entire population. A gifted athlete in any county in the US will, sooner or later, run in front of a coach. This was how one of the most accomplished Olympians of this generation, Simone Biles, was discovered during a local daycare field trip to a gymnasium. Soccer, recruiting through private clubs, prices out most of the population before any coach has a chance to look. A country selecting its players from the top income quintile will lose to countries selecting from everyone, however large or rich it may be. The results of the past week are what sampling bias looks like on a scoreboard.

A counterexample for this can be found in how France has instituted systems that facilitate access to infrastructure and participation regardless of a child’s household income. The resulting abundance of soccer talent in France is such that 99 players in this World Cup were born and trained in France. Of these, 23 play for the French team; the remaining 76 play for other countries.

What relevance then if any does this bear to health? The mechanisms on display in the soccer pipeline, opportunity tied to the ability to pay, bear a striking resemblance to the mechanisms that produces health differences across the population. A young soccer player who, because of the resources available to them will have the opportunity to be seen by a top scout who is seeking talent across the country can get to tryouts and eventually play with a professional team, maybe even make it to the World Cup. Similarly, is the resources that shape the world around us—stable housing, sustainable income, safe neighborhoods, supportive social networks—create the opportunities for us to be healthy, or not. A child whose asthma or failing eyesight is caught early because a school nurse of a well-resourced clinic was there to catch it stands a chance to grow up healthy and live to meet their potential. Potential—be it in soccer ability, or in health that precedes everything else—is developed only where opportunity reaches.

In health as in soccer, opportunity is closely tied to resources. The inputs that generate health along the life course, nutritious food, safe neighborhoods, stable housing, good schools, timely medical care, are allocated in this country substantially by ability to pay. There is therefore no mystery as to why health tracks income and wealth with such remarkable fidelity. We price the conditions of flourishing, and the outcomes follow the prices.

And it is then not surprising that as resource inequality in the US has climbed over the past four decades, the participation gap in youth sports has widened, as has the gap in health indicators between haves and have nots. Since, 2012 the participation gap between children from the poorest and wealthiest households has widened from 13.6 to 20.2 percentage points. Similarly, the richest 1 percent of Americans now live 10 to 15 years longer than the poorest 1 percent. These both reflect the same phenomenon, an uncomfortable reminder that a child priced out of play at eight is measurably more likely to be priced out of health at fifty.

In my 2021 Goldfish post on soccer I talked about another theme that influences both soccer and health that stands true to this day. Complex systems amplify small structural choices into large divergent outcomes. American youth soccer was organized, decades ago, around a private club as opposed to the public school system. This design choice has compounded through every generation of children since. This shapes who plays, who is seen, who develops, and who stands on the field in a World Cup. Similar design choices are embedded in our health systems, in how we finance care, zone neighborhoods, fund schools, and price food—the fundamental work of public health. The impact of these design choices compounds the same way, through generations. Only in this case, quietly, until they surface as a life expectancy gap.

Health has no quadrennial global reckoning. Its results accumulate slowly and privately, in clinics, streets, homes, and schools making them easy to attribute to chance or choice. And so, the conditions producing health continue to go unremarked for generations. Perhaps, while the sporting version of the lesson is fresh in our minds, the question the opportunity gap poses, “who never gets the chance to thrive and flourish?” is worth re-asking and resurfacing. This is the same question our health data have been asking for decades. Who never got the opportunity to engage the conditions that produce long, healthy lives? A country this wealthy can choose systems that engage everyone, in play and in health alike. The return on that choice would appear where it matters more, in years of healthy life, distributed as talent always was, everywhere.

Thinking about America, celebrating America, then, means engaging with the ideas that is has introduced into the world over its 250 years of existence, starting with its founding idea of fundamental equality. We should engage with these ideas not uncritically—just as we should not think about the US, or any country, uncritically—but with a realistic appreciation for the good they have brought into the world. This is particularly true this July 4, when we reflect on America’s past and present, and all that it offers the world that is worth celebrating and preserving.

In the spirit of this, I would like to take the occasion of this milestone in America’s history to reflect on one specific subset of its global influence—how America has advanced science, health, and human flourishing. In doing so, I will start—as America started—with ideas. Many of the conditions that shape health are not medical at all, but ideational: self-government, individual liberty, pluralism, the rule of law, free inquiry. America did not invent these ideas, but it staked a national experiment on them at scale, and the world’s health has been shaped by that political and intellectual choice.

How has this influence unfolded over the last 250 years? I will answer by addressing four of America’s core ideas—the principle of liberty and self-determination, the principle of free inquiry, the principle of material prosperity as a central good, and the principle of openness and personal mobility.

First is the principle of liberty and self-determination. This principle is encoded in the American founding through the Declaration of Independence (which asserts the inalienability of this principle and the British Crown’s traducement of it as a key reason for the colonies’ political separation from England). It has been exported throughout the world by both America’s example—a stable and prosperous system other countries have chosen to imitate—and, at times, by force (as in Iraq, for example, and America’s imposition of democracy on occupied Japan after World War II). Even acknowledging the harms at times associated with the latter, there is little question that the stability and prosperity that often emerge from systems based on the principles of liberty and self-determination make the ideas potent influences for good health.

Amartya Sen’s observation, “Famines are easy to prevent if there is a serious effort to do so, and a democratic government, facing elections and criticisms from opposition parties and independent newspapers, cannot help but make such an effort” makes the point and the facts bear this out. If we look at the world today, we will find most, if not all, famines are occurring in war zones, autocracies, or otherwise closed systems. The reasons for this align with Sen’s point: when people have liberty and political self-determination, they can hold governments accountable for the policies which lead to preventable tragedy at scale. To the extent that the US has played a role in the proliferation of these political conditions, it has done a great service for health around the world.

Second is the principle of free inquiry as the essential engine of discovery. Free inquiry is, of course, an idea that long predates the American republic. Its roots go back to the Scientific Revolution and the Enlightenment. But the US placed the principle of free inquiry at the heart of much of its investment and infrastructure. This arguably began when Thomas Jefferson, as president, commissioned the Lewis and Clark Expedition as, in part, a journey of scientific discovery. It was notably carried on by the 1863 creation of the National Academy of Sciences and has continued in America’s funding of open science—nationally and globally—in the 20^th and 21^st centuries. This has yielded world-changing dividends, including the space program, the development of essential vaccines, the eradication of diseases, and the scaffolding of basic scientific research that others have built on all over the world.

Third is the principle of material prosperity as a central good worth pursuing. I realize this principle may strike some as controversial, given this pursuit’s capacity to underwrite unchecked materialism and inequality. This critique is correct, and always worth bearing in mind. However, it is also true that expanded access to relative prosperity that came first with the advent of industrial capitalism and, later, with America’s embrace of this economic model, has created the conditions for better health for many. Economic dynamism and the flow of productive forces have, for all their unevenness, created the material conditions that underwrite health. These conditions include greater access to the basic necessities of life—climate-controlled homes, nutritious food, technological conveniences—as well as the prosperity that underwrites greater access to education, employment, and civic participation.

Fourth is a principle which has been stress-tested in recent years, but which is nevertheless fundamental to the American project—the principle of openness and personal mobility, particularly with respect to immigration. America is a nation premised, however imperfectly, on the proposition that where you are born need not determine your fate—that you can come to America and create a better life for yourself and your family. It was this ideal that brought me as an immigrant to the US and this idea continues to have unique power in the world. It is worth noting, for example, that America’s chief rival, China, which is neck and neck with the US in so many domains of global competition, has nowhere near the influx of immigrants enjoyed by the US. The immigrant dream, in some ways, also extends to American citizens who, while Americans by birth, may feel far removed from the prosperity and success so many seem to achieve in the US. To those people, America at its best says “You need not be alienated from the fruits of this land. Work hard, seek opportunities, and you too can build a better life. It may not be one of fabulous wealth and professional success, but it might be, and even if it is not, it will very likely be a better life than the one you leave behind in order to pursue it.” This promise, this American Dream, imperfectly realized as it often is, has nevertheless been, as an idea, a powerful engine driving individuals to improve their lives and driving political movements to shape policies that make this pursuit easier and accessible to all.

All of these ideas have a complicated legacy. This is evident, for example, in the country’s dramatic swings between moments when it has opened its arms to immigrants and moments when it has all but sealed its borders. It is also evident in how America’s promise has been withheld from many over the course of its history—for many of the 250 years we now celebrate, African Americans, women, LGBTQ+ communities and other marginalized groups were denied their full rights to life, liberty, and the pursuit of happiness. This legacy has shaped present-day inequities, including health gaps and the democratic strain that has roiled our politics. Just as we should be honest about the country’s virtues on its 250^th birthday, we should be honest about the ways it has fallen short, in both the past and the present. One is honest with those that one loves; to love America, then, it to be honest about it, both its good and bad.

But historical context should also be part of any conversation that critiques this country’s contributions. Birthed in an era when exclusion was common and widely accepted (though not by all), America has consistently been a force for deepening the definition, and expanding the reach, of human freedom. A significant reason we now have the modern mindsets that lead us to, at times, critique the past is because of the slow, imperfect, but nevertheless revolutionary American project shaping the consciousness not just of Americans, but of the world, broadening our moral imagination of what freedom can mean.

I realize that celebrating the ideas that have shaped America and their influence on health can sound like self-congratulation. But this is not the case. It is important to note that while the ideas I have mentioned here are integral to America’s formation, they are not America’s property, nor are they the property of any movement or political party. They are, fundamentally, small-l liberal ideas. Human liberty, free inquiry based on reason, rejection of the belief that there are preexisting hierarchies into which we are born—these ideas are our common inheritance. They have flourished in America, but they remain on the move, shaping a better world by their influence.

Naming these ideas on July 4 is a way of reclaiming a less sectarian and less partisan account of how these concepts have helped make this country great and the world healthier. Even recognizing that we still have to do much better, if health is one measure of whether a set of founding propositions have proved their worth over time, then America’s founding ideas have been successful indeed. This 250th anniversary is an opportunity to recommit to these ideas, to continue the unfinished work of building a more perfect, healthier union—and world.

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Also this week

With Debbie Cheng and Madhu Mazumdar in American Journal of Public Health (AJPH) Trustworthy Artificial Intelligence in Health Requires Public Health Leadership

New on Ideas Matter, a conversation with Stanford University’s Lukas Althoff about inequality and opportunity in America.

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Goldfish takes a break

As we enter the slower part of the academic calendar we shall stop publishing The Healthiest Goldfish for a few weeks. We shall return in early August. I hope that everyone has a good, restful few summer weeks.

Ideas, and the institutions that house them, are under pressure of a kind few of us anticipated a generation ago. Universities are being challenged, research funding is being constrained, and the very legitimacy of expert knowledge is being contested in ways that feel (and perhaps are) particularly acute and raw. In such a moment, it is tempting to reach for the language of defense, of protecting ideas, of shielding institutions. But that approach may not always be right for the moment. And it is particularly not right when we think carefully about our role in the world of ideas. Those of us who work in these settings could call ourselves producers of ideas, or thinkers, or scholars, or, as we suggested earlier in this series of essays, workers in idea factories. But perhaps more than anything else, we are stewards of ideas, both holding ideas in trust and improving them for the next generation. That shift in framing is central to the point of this essay, part of our Ideas about Ideas series. When we think of those who generate ideas as stewards, it pushes us to ask what such stewardship demands of those of us fortunate enough to find ourselves in the business of ideas, particularly now when the task may be as much to reinvent our ideas as it is to preserve them.

What then might be the responsibilities of stewards of ideas? We organize our thinking here along three lines. First, we talk about foundational moral, intellectual, and aesthetic responsibilities. Second, we dwell on instrumental responsibilities that have been implicit in our writing on these topics but that we feel here deserve to be underlined: the responsibility to widen the door for many, to speak when silence is easier, and to the institutions where ideas are generated that shall outlast us. Thinking of these responsibilities finds us following a single thread through this essay, that stewardship is not only about conservation, but it is as much about the willingness to build anew when the forms that are inherited are no longer fit for the purpose of the moment. Let us start with our foundational responsibilities.

In Science as Vocation, Max Weber argues that scholars cannot hide behind their methods; the choice of what to study itself is a moral choice. To have the privilege of time to think incurs an obligation about what one thinks about. This does not mean that science and scholarship need to always have a clear and direct application; it does mean however that stewards of ideas have to ask whether their work serves larger societal goals, a centering of consequentialism that we have previously argued for in health. All too often, we assume that what is ultimately consequential or most important is that work that was funded before, or work that aligns to the goals of the current dominant funder of science. But our responsibility transcends these imperfect criteria, which can and do change over time. Hans Jonas’s The Imperative of Responsibility sharpens the point further. In a world where ideas have consequences at scale, our responsibility extends forward in time, to those who will live with the real-world expressions of what we thought. This obligation feels particularly pressing now, as we live with the real-world expressions of once-fringe ideas. When the public is increasingly skeptical of what we produce, the answer cannot be retreat into technical narrowness, or necessarily to retreat to what we did before, but rather to lean into work of visible consequence, done in the open, with a clear commitment to our larger social purpose.

Adding to our responsibility to produce work that matters is an intellectual responsibility of doing the work right. Bernard Williams, in Truth and Truthfulness, identifies two relevant virtues here, accuracy (i.e., doing the hard work of getting it right) and sincerity (i.e., saying what one actually believes). Currently, it feels as if both are under pressure. Accuracy requires slowness, reading widely, engaging with inconvenient evidence, being willing to update and change. After all, a certain mind is also a closed mind. Sincerity requires refusal of the performative positions that professional incentives, and, increasingly, political pressures reward. Both of these virtues feel under some challenge at the moment making them, of course ever more important. And it is through accuracy and sincerity that we can advance ideas that challenge what we know, to the end of being better at the very ideas that we generate. And, doing so is hard. Kuhn reminds us that paradigms resist revision; part of intellectual responsibility is being honest about when the frame no longer fits, including frames within which we have built our own careers.

Adding to our moral and intellectual responsibility is our aesthetic responsibility to ideas. This calls on us to be clear in our ideas, with clarity serving as an act of generosity towards the others who will pick up, advance, and improve upon our ideas. George Orwell, in Politics and the English Language, argues that clear writing is not decoration but a moral act, because obscurity protects bad thinking. To write clearly is to attend carefully to the reader, to offer an idea in a form that can actually be received. The aesthetic responsibility then, correctly understood, is craft, the discipline of saying precisely what one means and not more. In a noisy information environment, where attention is scarce and skepticism is high, this craft is central to how ideas earn their keep.

Let us now move to the instrumental, but no less important, responsibilities of idea stewards.

We have written previously about the politics of recognition, about who gets to participate in generating ideas, who is seen as doing so. If such recognition is unevenly distributed, and we argued that it is, the stewards of ideas have a particular obligation to mentor, to amplify, to cite, and to open the spaces they occupy. This responsibility is both individual and institutional, it extends to who we read, who we invite to speak, whose early work we champion, and how we structure the rooms (sometimes literally) in which ideas are shaped. This is one of the most tangible forms idea stewardship takes, and it is a practical antidote to the challenges of closed loops that Bourdieu discussed in his account of intellectual fields. Separate and apart from being the right thing to do by our responsibilities, widening the door to other and newer ideas stands to practicably help us rebuild the trust that we have lost in recent years, to move us back to the center of the public conversation where a plurality of ideas shape how we, as a society, think.

Beyond accuracy and craft, idea stewards have a further obligation. There is a long and clear tradition that articulates the responsibility of idea stewards to engage with inconvenient truths. We have long admired Edward Said’s Reith Lectures where he argued that the intellectual should refuse expertise as isolation. Indeed, he pointed to the example of the Vietnam war as one in which, if debate regarding its merit were restricted only to those “certified experts” in foreign policy, much of the scope and accuracy of public discourse regarding the war would have been lost. There is clearly a large difference between expertise, and knowledge. Noam Chomsky’s The responsibility of intellectuals put it bluntly: intellectuals should tell the truth and expose lies. As part of this, intellectuals should fight to maintain the space for subjective representation, for asking important questions, and challenging assumed wisdom. This is particularly resonant when a field, as public health is now, is under threat. Idea stewardship then becomes inseparable from a willingness to stand up for the ideas, publicly, even if uncomfortably.

And finally, stewards of ideas have a responsibility to institutions within which we build. Michael Polanyi and Alasdair MacIntyre both have made this point eloquently in their writing. Stewardship of institutions needs to accept that the structures that support idea creation, journals, societies, departments, schools, are built by many and should transcend any one of us. To be a steward of these institutions means to accept that one is a temporary caretaker. But caretaking is not passive. There is a strong argument to be made that several of our institutions were built for a different world, one with slower information, narrower participation, different kinds of legitimacy. If we were merely to preserve these forms, we would be doing our responsibility a disservice. The modern research university was itself an act of reinvention and the moment calls for more of the same.

Idea stewardship is demanding work, and in difficult times, more demanding still. It is also a privilege. The work of ideas is one of the few vocations in which the work itself, if done right, is indistinguishable from its purpose. The ideas we inherit are not fully ours, and neither are the institutions that house them. They are, transiently, in our keeping. What we do with them, and whether we have the courage to reshape them when the moment requires, is what this generation of stewards will be remembered for.

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The Ideas about Ideas project

The Ideas about Ideas project, co-written with Dr Nason Maani, and cross-posted on the Money, Power, Health substack is a series of reflections of how thought lives in the world. It follows ideas as they emerge in institutions and everyday life, as they move across borders, as they harden into orthodoxy or fade into silence. It argues that ideas are not possessions but shared conditions of living, and that to see them clearly is to recognize both their power and the obligations they impose. Fundamentally, this project is built on the notion that without ideas we have nothing, and that the business of creating a healthier, better world rests on ideas.

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Also this week

In The Milbank Quarterly:

Firearms as a Market-Driven Epidemic: Potential Pathways to Reduce Preventable Firearm-Related Harm in the United States – with Eszter Rimányi, Jonathan Quick , Stephen Hargarten, Charles Branas, Nason Maani, Jonathan Lowy, Zain Hussain, and Nicholas Hoffmann

In PLOS Mental Health:

Understanding the impact of natural disasters on post-traumatic stress disorder and depression symptoms: An examination of counterfactual displacement scenarios - with Mohammed Abba-Aji , Gregory Cohen, Salma Abdalla, Ruochen Wang, and Jaimie Gradus.

How do we advance a practical philosophy of health so that we can lean into the goals and aspirations of public health? At a foundational level, that is the central goal of the Purple Public Health Project. We have written on the values that may animate us, and the importance of trust necessary to engage populations to be able to do the work we need to do. All those are building blocks of the context on which we can build the work of public health. We worry, however, that thinking of shared values and trust as foundational scaffold might suggest that our aspiration is to get to a place where everyone agrees with the work and goals of public health. We suggest, rather, that we are doing the work of public health not when there is such agreement, but when there is disagreement that is clearly visible and discussed. To our mind the aspirations of public health—that all can live healthy, fulfilling lives—are so radical, that we cannot truly expect to make progress towards them without an underlying level of disagreement both about the shades of the aspirations, but also how we may get there. Seen this way, disagreement, about the goals and methods of public health, is a feature, not a bug. Stated more eloquently, Hannah Arendt wrote that plurality, i.e., the fact that each of us brings a distinct perspective on a shared world, is a condition of human action, not an obstacle to it. Unfortunately, public health has sometimes (often?) treated plurality as a problem to be managed on the way to consensus. We would like to suggest in this piece that disagreement is a condition we need to learn to work with and within, and even to welcome.

Our dominant orientation in the field, perhaps more so in recent years, has long been that disagreement is best met with more persuasive evidence, and more compelling argumentation to “bring more people around”. If only people understood the data, surely they will side with the goals of public health? However, most of the disagreements that actually matter in public health are not arguments over what the evidence shows. They are in fact disputes about what, in light of the evidence, we should do. They are arguments about cases of values. We made the case in February that data and values belong to different domains and should be kept conceptually separate. This argument extends that one by focusing on the values, recognizing that values differ, and that those differences in values between people seldom narrow through closer contact with better data.

Moving beyond abstraction, it is worth talking, plainly, about the dominant value disagreements that genuinely challenge the work of public health. Thinking through these areas of such disagreement highlights that these issues are not isolated points of contention but features of a challenging moral terrain.

Why do we care about health? For some, health is instrumental—a condition for productive work, strong families, a citizenry that is engaged and capable. For some, health is intrinsic to human dignity, worth pursuing for its own sake. Both are legitimate perspectives, and depending on one’s perspective on this issue, they have implications for how we aim to persuade on issues that matter to the public’s health. For example, should we dedicate resources to tackle childhood obesity because of all children’s right to flourish, or because we want to make sure we have a military or economy-ready citizenry? These approaches can both be true but choosing where to engage commits us to different partners and suggests different compromises. Reasonable people can find themselves in very different places on the question, and its consequences.

What values should guide our work? Let us take the examples of equity and efficiency, or of autonomy and solidarity. The allocation of scarce COVID vaccines in early 2021 made the potential value tradeoffs on these axes vivid. Should vaccines go to those most likely to transmit the virus, those most likely to die from it, or to those most structurally disadvantaged by prior health crises? Each answer can be defensible and grounded in a coherent moral viewpoint. None of these answers are predicated on mistakes that are corrected by better evidence. This brings to mind Isaiah Berlin’s observation that there is no single harmony of human goods, and that real goods can be genuinely incompatible with one another. These approaches, of central import to the field, are not choices between right and wrong, but between goods that each have different costs which we should be honest about.

How much are we willing to invest? We often approach questions of investment through the cost-effectiveness lens. That has merit indeed. But fundamentally, when we are dealing with a field, public health, that is concerned with changes to social structures that transcend any one sector, we are choosing to make tradeoffs about what we owe one another, and to continue Berlin’s analogy, a tradeoff between health and other goods, like security, economic dynamism, some parameters of individual liberty. Climate policy and health make this point particularly sharp. Many climate policy proposals often rest on investments required to protect the health of future generations and impose real costs on present ones, particularly in low resource settings. The ethical weighting of lives not yet lived against lives being lived now is a matter for debate, around which we may well disagree.

How do we improve health for as many as possible? There are dramatically different approaches to how we may achieve health for all. We could focus on aggregate well-being, prioritize attention on those who are worst off, or center our thinking on rights-based floors beneath which no one should fall. These are all different moral frameworks and can recommend different policies in the same situation. For example, the debate between Housing First approaches to homelessness and treatment-first approaches is, at root, a disagreement about whether autonomy is a precondition for recovery or a reward for it. While there is good evidence in favor of Housing First approaches in most instances, the objection to these approaches can be one of values, not simply a refusal to consider data.

What does it mean to articulate a radical vision when it leads to impracticable places? Public health rests on a radical vision of a better world. We contend that such a vision is not the opposite of reasonable policy but rather a horizon to which we aspire, as articulated previously in the notion of radical incrementalism. However, radical visions can also point to where we cannot go, and the work of balancing vision with feasibility and practicality is itself a question of value. Keats’ concept of negative capability, the capacity to dwell in uncertainty and doubt, seems apposite here. Public health, in its most honest moments, requires something like this: the ability to hold a radical vision for a healthier world alongside the stubborn constraints of the world we have, without collapsing either into the other.

Why does articulating these questions matter? It does, we argue, because pretending that these questions are not there creates a manufactured consensus that itself breeds mistrust. When we smooth over genuine disagreement, amongst ourselves or between us and the public we serve, people notice and calibrate their trust accordingly. In the long turn, the illusion of agreement is more damaging that acknowledging disagreement that “reasonable people can differ”. We wrote in April about transparency and its centrality to trust. To be transparent is in part to be transparent about what we do not agree on, and about which of our disagreements are moral rather than empirical.

Perhaps the hardest balance for us in public health is to find a way to hold true to a radical vision of a better world as an animating horizon and doing so while being capacious in our tolerance for who belong in the conversation. We can believe deeply in a healthier world, a more just distribution of the determinants of health, a commitment to the improving the social conditions that shape life and death, and still welcome into the conversation those whose instinct is to get there by different means, and who disagree about how far we can go. The test of a radical vision should be whether it enlarges our moral imagination or contracts it. To that end, the more people we are willing to embrace as we find our way towards our vision, the more expansive our vision is. If we speak only to those who already share the vision, we end with, inevitably, a smaller vision.

This leads us then to the way forward, an approach that does not rest on lowest common denominator compromise but rather builds procedures and norms robust enough to hold genuine disagreement without collapsing under its own weight. We argued in March that small-l liberalism provides the framework for this: the commitment to discussion over power, to procedural integrity even when it slows us down, to the recognition that a community that can disagree without dissolving is a community capable of correcting its own mistakes over time. Reinhold Niebuhr wrote of The Irony of American History, that the pursuit of justice requires the humility to recognize that our own virtue is never as pure as we imagine. That applies equally well to public health.

We close where we started, with a call for public health to find comfort with disagreement, to celebrate open, generous, non-disagreeable disagreement, in the expectation that disagreement itself is where the best thinking happens. This positions public health as a conversation rather than as a consensus. Our work should be to keep that conversation honest, inclusive, and oriented to a healthier world. The true measure of our success becomes then not whether we disagree along the way, but whether the healthier world we build can withstand the disagreement.

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The Purple Public Health Project

This piece is part of the Purple Public Health Project. The Purple Public Health project is a multiyear, multimedia effort to re-establish public health’s legitimacy, broaden its reach, and shore up its foundations in this moment and beyond. The project engages with topics that are core to shaping a more heterodox public health. Previous essays and other material related to the project are available on the Healthier Futures Lab webpage.

One of our Purple Public Health products is an ongoing podcast. This month, Salma’s guest is Brinda Adhikari, Co-Host, Co-Creator and Executive Producer of the “Why Should I Trust You?” podcast which explores the erosion of trust in science and public health. Brinda and Salma explore the importance of healthy disagreement and what it takes to have meaningful conversations across differences. Drawing on Brinda’s experience bringing together public health experts, physicians, and people skeptical of both, they discuss how to facilitate difficult conversations, why understanding is more important than persuasion, and how connection can serve as a measure of success. The conversation highlights the value of engaging with opposing viewpoints and offers insights into building trust in a time of increasing mistrust and polarization.

Listen to this episode on Apple Podcasts, Spotify, Amazon Music, Podbean or wherever you get your podcast. You can also watch the episode on Youtube.

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Also this week

In this episode of Ideas Matter, I spoke with the University of Pennsylvania’s Suraj Yengde about the historical foundation of the caste system and how it shapes the social dynamics of our world today.

In JAMA Health Forum:

The Implications of Population Aging for Health Policy and Health Services Research

We tend to treat health like something to be fixed when it breaks. Under this paradigm, we are healthy until we are not, and it is then that we should apply the best possible healthcare solutions to return us to the world of the well. Our investment in health largely follows this lead, with vast sums going to the development of the drugs and treatments that do this work of fixing. To be clear: there is nothing wrong with having the best possible healthcare at our disposal when we are sick—there is nothing wrong with fixing. Indeed, my early training is as a doctor, and I spent the first part of my career engaging in the work of repairing health when it “breaks.”

Yet, as an overarching framework for how we think about, and invest in, health, this model can fall short. It is not enough to have the best possible fixes if this comes at the expense of addressing the root causes of health and disease in society. Just as, in individuals, we would not be content just to treat the symptoms of disease and leave the underlying problem unaddressed, in societies, we should not put all our eggs in the curative basket without investing in the prevention that makes cure less necessary, populations healthier.

This suggests the need for a new paradigm around health. Rather than treat health as something to be fixed when it is broken, we should treat it as we treat the roads, the water system, and the electrical grid: as a public scaffolding that decays without continuous investment, that requires vigilance long before failure, and that is the necessary, if quiet, condition of everything else that we want to do. On the most basic level, this means bearing in mind, collectively, something I have long argued—something which is, indeed, in the mission statement of The Healthiest Goldfish: the reality that health is not healthcare, but, rather, a product of foundational forces, the social, economic, and political conditions in which we live. However, for the purposes of this essay, I would like to push past this familiar, though still necessary, framing, to engage with the more concrete question of: what it would actually mean to fund, govern, and live as if health were infrastructure rather than healthcare alone?

We can answer this question, first, by defining and understanding the role of infrastructure. This is, in some ways, most clearly done when infrastructure breaks: in the bridge that collapses, the water main that breaks in the cold, the power grid that goes down in a storm. Infrastructure is something we often notice only in its absence. We tend to treat our own health and the health of our communities the same way. We only fully see it when it fails—in the heart attack, the overdose, the outbreak—and we mostly do not see the long, slow, public work that kept the failure from happening sooner, or the lack of investment that allowed it to happen at all. This suggests that the central reframe we want to make in the conversation about health may be this: to insist that health belongs in the infrastructure conversation, not only in the conversation about intervention, rescue.

This is a big ask, for us and for others outside the health field. We are deeply invested in the intervention paradigm. Most of what we call a health system is actually an intervention system, built around acute care, organized around episodes of poor health, paid for through reimbursement, justified through downstream outcomes. The intervention frame has accomplished much and should not be dismissed; modern medicine is a profound achievement, practically and morally. But the intervention frame quietly determines what we perceive—what we think about when we think about health. It makes the cardiologist visible and the housing inspector invisible. It makes the new drug a breakthrough and the bus route a footnote. The intervention framing teaches us that health is what happens after something goes wrong, which is precisely the wrong place to direct our energies if we want a healthier population.

We can see this clearly by way of a conceptual detour into the world of physical infrastructure. Infrastructure, in its ordinary sense, is the layered and largely invisible scaffolding—roads, sewers, water, electricity, broadband, public transit—that supports the activities we can more readily understand that the often-hidden mechanics that underlie them. It is public or quasi-public, durable, long-horizon, expensive to build and more expensive to neglect. Eric Klinenberg’s work on social infrastructure (libraries, parks, schools, community centers) extends the concept in exactly the direction we need: the scaffolding that supports human connection is no less real, and no less consequential, than the scaffolding that supports human movement. Health belongs on the same conceptual map.

This idea may seem like an expression of futurism, but it is actually a lesson of history. The great population health gains of the nineteenth century did not come from clinical breakthroughs; they came from infrastructure. Edwin Chadwick on sanitary conditions, Lemuel Shattuck on the Massachusetts Sanitary Commission, John Snow on the Broad Street pump—these were conversations about pipes, drains, ventilation, housing, and the public works that made disease less likely. Thomas McKeown later sharpened the case that the modern rise of populations owed more to social and environmental conditions than to medicine. Geoffrey Rose’s distinction between sick individuals and sick populations belongs in this lineage. The twentieth century’s pivot toward medicalized health was, among other things, a forgetting, a reframing that obscured what the sanitarians had always known. We are now in a moment that requires remembering.

What does this frame shift imply? Time horizons that stretch from budget cycles to generations, where we plan for what a community will need in forty years, not what an insurer will reimburse next quarter. Maintenance that becomes a central activity rather than an unsexy afterthought—the steady work of sustaining clean air, walkable streets, mental health services, food systems—and trust being recognized as the core work of health, not incidental to it. Public investment in infrastructure that becomes the natural mode for policymaking rather than an exceptional ask. Decay becoming a threat we are organized to watch for, with surveillance that is anticipatory rather than reactive. A professional class that expands to include engineers, planners, urbanists, social workers, teachers, and community organizers working inside the health enterprise, not adjacent to it. Accountability that shifts from outcomes in individuals to conditions in communities.

This change in investment starts with a change in thinking, in culture. A culture that overvalues innovation will underinvest in maintenance, and a culture that underinvests in maintenance will keep being surprised by collapse. Andrew Russell and Lee Vinsel, in their work on The Maintainers and in The Innovation Delusion, have made this case directly for infrastructure; Steven Jackson’s thoughts on rethinking repair make the deeper philosophical version, arguing that maintenance and repair are not secondary activities but constitutive ones. It is not just the wider culture that needs to change how it thinks about health and infrastructure. Public health can fall into the same pathology of thinking about health as the bright shiny thing we see rather than the more understated necessity we do not. We celebrate the breakthrough drug, the new program, the bold initiative; we underfund the bus route, the housing inspector, the school nurse, the public health workforce, the libraries and parks and clinics that constitute the actual scaffolding of community health. The frame shift we need, then, is, in part, a cultural one—learning to honor the steady, undramatic work that holds the world up.

I realize there are strong counterarguments to this. One is that the infrastructure metaphor risks flattening health into something purely physical or technical, when health is also relational, cultural, and contested. But infrastructure has never only been physical. Also, the state cannot or should not carry so much of the burden—or accrue so much of the power—that comes with running this kind of massive, comprehensive investment (or what critics might call “social engineering”), especially in a political moment skeptical of public investment. But infrastructure is one of the few domains in which the case for public investment has held across political traditions—conservatives and liberals have both built bridges—and a health-as-infrastructure framing may travel more easily across the political spectrum than the partisan public health framings that have eroded trust. When we see health in these terms, we can then build a world that better supports health at every level of experience, and invest accordingly, so that our collective health rests on the strongest possible foundation.

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Also this week

Enjoyed speaking with Tom Frieden on his podcast, The Formula, about the forces shaping public health in this moment and pragmatic steps we can take towards a healthier world.

The Formula

Public Health Progress and Pragmatism

I sat down with Dr. Sandro Galea—founding dean of the new School of Public Health at Washington University in St. Louis, physician, epidemiologist, and editor-in-chief of JAMA Health Forum—to explore the forces shaping health in a turbulent moment and discuss how pragmatism can lead to public health progress…

Listen now

3 months ago · 6 likes · Tom Frieden and Sandro Galea

We have written here often about the challenges facing public health, and about the slow erosion of public trust in the field. Those challenges have many roots — partisanship, the inconsistencies of pandemic-era communication, the perception that public health speaks more in the language of values than in the language of evidence. We have taken up several of these elsewhere. There is, however, one further piece that deserves more attention than it tends to get, and it has to do with the story we tell about ourselves.

The dominant national narrative about health is, on most days, a narrative of foreboding. Things are bad and getting worse. Every week brings another headline of imminent risk. That story is not entirely false. Many of our health indicators are indeed troubling, and public health draws much of its public license from sounding the alarm when the alarm is warranted. But foreboding is not the whole picture. Some health problems are getting worse. Others, quietly and with very little fanfare, are getting better. When the public hears only the first half of that story, it shapes how people understand what we do and whether the work is worth supporting.

This matters because public health, more than most fields, depends on a citizenry that believes the work we are doing is effective, is worth investing in. Belief in that proposition is not automatic. It has to be cultivated, and it can be lost. A poll out of St. Louis, recently fielded, captures the problem with unusual clarity.

In an analysis of the iHeard regular survey, adult community members in St. Louis, MO were asked whether they thought the rates of six different health issues were currently rising, falling, or staying in the same in the U.S., or if they didn’t know. In other words, were these problems getting better or getting worse?

The good news: the public was widely aware that rates of measles and depression had been rising in the U.S. The bad news? People overwhelmingly had the same reaction to health issues that were actually improving. By margins as high as 10-to-1, the public thought that rates of drug overdose deaths and gun homicides were getting worse. They are not. They are improving.

There is, in other words, a gap between what is actually happening to some of our most pressing health problems and what the public believes is happening. These data suggest that people are walking around convinced we are losing ground on overdose deaths and gun homicides when the data show that we are not. Taken at a higher level, these data suggest that the public believes public health is failing on problems where it is in fact succeeding, and that this gap between reality and perception runs in only one direction. The public has correctly registered that measles is back and that depression rates are rising. What it has missed is the slow, hard-won improvements that have come from years of coordinated effort, often led by the very public health institutions whose competence is now in question.

Does it matter if people do not recognize when public health efforts are making a positive difference? We think so. Why?

First, there is a clear link between demonstrating competence and earning trust. Public agencies and public leaders build trust by committing to and delivering on promises. Over time, when organizations establish a record of delivering on promises, people trust them. Perhaps obviously, if the public does not know that we are succeeding, it is at the very least a missed opportunity to build trust.

Second, ask yourself, what do we want people’s mental model of public health to be? Do we want public health to be primarily associated with problems and threats? Crises? Pandemics? Do we want people to think “They’re the ones (not) dealing with the problem” or “They’re the people solving the problem?” Imagine if a local sports team only televised the games it lost, never the wins. Casual observers might reasonably assume the team wasn’t very good.

Claiming progress when it has been earned would be a step forward for PH. For many people and organizations in the field, humility is a badge of honor. It is on-brand for public health. But untoward humility can also work against the best interests of the field. Consider how different this is from other government entities. Think of how military successes are shared and celebrated, or the attention paid to positive reports on job creation or other economic indicators.

Taking credit for earned successes is just the first step. A bigger prize is helping the public understand how success was achieved. That requires explanation. In the case of reducing fatal opioid overdoses, making naloxone and Narcan readily available helped. Reducing the flow of fentanyl into the U.S. helped. Testing street drugs and expanding treatment helped. Perhaps most importantly, all these efforts had to be coordinated and depended on mobilizing thousands of communities and organizations across the U.S.

Successes afford public health the opportunity to explain how policies make a difference, how coordination across government agencies magnifies impact, and to recognize and thank the myriad community partners that execute plans on the ground. If we do this consistently, the public should grow to better understand the public health playbook, and trust and support its use.

The harder work, though, is structural. It means building, into the everyday practice of public health, the habit of telling our successes alongside our concerns. It means dedicating real communications resources, in agencies and in schools of public health, to explaining what is improving and why. It means leaning into optimism when it is warranted. It means training the next generation of public health professionals to feel as comfortable narrating a win as raising an alarm. None of this displaces the field’s responsibility to be honest about what is going badly. It simply widens the field’s responsibility to also be honest about what is going well. The public, and the work of public health, deserve both halves of the story.

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Also this week

In this episode of Ideas Matter, I spoke with Lisa Gibbs, president and CEO of the Pulitzer Center, about the future of journalism.

In JAMA: Trials That Inform Health Policy: A Bridge Too Far? – with Alison Huang

Public health is concerned with health at the population level. Most of the time our work as public health scientists and practitioners, expands rather than restricts what people can do with their lives. Clean water, safe food, and the countless quieter interventions that constitute public health have given people more years, more options, and more freedom to live the lives they wish to live. But sometimes, the pursuit of public health requires that individuals accept constraints on their choices for the sake of the population’s health.

There is nothing particularly new about this restricting feature of public health. But this feature was brought to the fore in an unprecedently visible way during the Covid-19 pandemic. Vaccine mandates, mask requirements, and restrictions on movement and gathering all surfaced a national conversation about the role of public health: when is it right for the field to infringe on an individual’s autonomy in the name of the population’s health, and when is it not? The debate has not settled since. If anything, it has widened, as the field faces questions about harm reduction, policies to tackle obesity, and many other issues where the line between protecting populations and respecting individuals is less clear than we sometimes think.

This month, we want to take the question of where autonomy sits when we develop public health policies seriously. By autonomy, we mean the ability to govern oneself, to make one’s own choices, and to act according to one’s own reasons rather than external coercion. We recognize that autonomy claims are more complicated in particular cases, including for example where children, acute crisis, or compromised capacity are involved. But for what follows, we have in mind the ordinary case: an adult going about their life, making choices about what to eat, what to buy, where to live, how to move through the world.

When we argue about autonomy and freedom, we are often not actually disagreeing about the same thing. Some of us might be talking about freedom understood as the absence of interference, such as the freedom to choose what to eat, what to drink, what risks to take with one’s own body. Some of us may be talking about freedom understood as the conditions under which meaningful choice is possible. This includes the freedom from disease, from injury, from the circumstances that make healthy choices hard or impossible to sustain. Both freedoms matter. Yet public debates routinely collapse them into a single contest in which one must win and the other must lose. This is familiar terrain in the liberal tradition; the philosopher Isaiah Berlin distinguished between freedom from external interference and the freedom to pursue what one has reason to value and argued that both are important in a free society.

We have written before about how this tension appears in public health, using the more accessible language of freedom “to” and freedom “from.” Many of the rights we celebrate most in the American tradition are rights to do something, including the right to speak, vote, assemble, etc. Much of the work of public health, by contrast, is about freedom from something: freedom from preventable illness, from unsafe food, from the environmental and economic conditions that shorten lives. Neither kind of freedom is more important than the other. Neither is more American than the other. But because one has tended to dominate our national conversation, the work of public health has sometimes appeared to be operating against the grain of freedom, when in fact it is often operating in service of a version of freedom that is simply less often named. And we think it is worth remembering that this is not only a progressive position. Edmund Burke described liberty as “secured by the equality of restraint.” Burke’s point is that institutions and rules are not the enemies of liberty; they are what make liberty possible for everyone rather than for only the strongest.

Consider the Bloomberg-era New York City effort to limit the size of sugary drinks offered in restaurants and other venues. The policy was widely described as a question of whether the city could tell people what size soda they were allowed to buy. Framed this way, the answer was obvious to most voters: of course not. Yet framed differently—as a question about whether a person should be free from a food environment engineered, at every turn, to encourage overconsumption of products known to cause chronic disease—the debate might have looked quite different. The same pattern has played out across other public health interventions. The debate over indoor smoking bans was, for decades, framed as a question about the freedom to smoke in the places one chose to smoke, rather than as a question about the freedom from breathing other people’s smoke while trying to eat, work, or travel.

All of this is to say that the freedom-to/freedom-from reframing is an important insight, rooted in a long liberal tradition, and public health has every right to claim it. But we would caution against letting the reframing do too much work on our behalf. Not every public health intervention is clearly an exercise in freedom from something. The harder cases are where the rest of this essay turns.

The starting point, we think, is that the strength of public health’s claim on an individual’s autonomy depends heavily on the directness of the harm at stake to the population. A person carrying a highly contagious and dangerous disease, Ebola is an example often invoked, poses a direct and identifiable risk to others and will be quarantined. In such cases, public health has both the authority and the obligation to act, and the field has long developed standards for when that threshold is reached. Such measures are reserved for circumstances in which the evidence of transmissibility and severity is strong, the intervention is proportionate, and the alternatives are inadequate. When the field does conclude that intervention is justified, it is obliged to choose the version of that intervention that achieves its aim with the least intrusion on individual liberty. This is not a new idea. It has been articulated in various forms in public health ethics for decades, under headings like the least restrictive means or the ladder of intervention. But it has not always been applied with the discipline it deserves. When a mandate will do, a mandate is chosen. When a ban will do, a ban is enacted. Less restrictive alternatives such as incentives and structural changes to the choice environment sometimes receive less attention than they should, particularly when the field is under pressure to demonstrate decisive action.

The case becomes more difficult when the harm is largely to the individual themselves. Here, the argument that autonomy must yield becomes much harder to sustain, and the field’s authority to act becomes much more contested. It is tempting, in these cases, to reach for arguments about indirect harms to others such as the costs borne by the healthcare system or the drag on economic productivity. While these arguments are not wrong, they are not the same as direct harm and treating them as though they were risks extending public health’s authority into territory where it does not belong. A society that accepts the premise that any individual choice with downstream costs to others justifies public health intervention has accepted a premise that leaves very little of private life untouched.

The hardest cases, thus, are the ones where the science supports the intervention, the intent is good, and yet the intervention still asks something of individual autonomy that may be difficult to justify on public health grounds alone. There are cases where the science alone that cannot provide a single correct answer and where societal values should play a role. Before turning to these cases, is one observation worth making upfront. Public health interventions that restrict individual choice in the name of health tend to fall, disproportionately, on people with less economic and political power. We do not think this makes such interventions categorically wrong. But we do think it imposes a heightened obligation on the field to be especially careful, especially transparent, and especially honest about what we are asking of people who already have fewer choices than most.

With that in mind, three case examples.

Motorcycle helmet laws. The evidence shows that helmets reduce the risk of fatal head injury substantially, and universal helmet laws increase helmet use to near-universal levels in the states that have them. This is a clear public health gain. However, a rider who is wearing a helmet poses essentially no additional risk to anyone else; the risk being managed is largely to the rider themselves, which makes this also an autonomy question. The harm to others arguments, such as costs to emergency rooms, are sometimes invoked to justify these laws. At the same time, we rarely advocate for universal helmet laws for anyone in a moving car despite the potential benefits. Reasonable people largely agree that the helmet law is the right call for a motorcycle but not for a car. But that would be an argument about tradeoffs, not autonomy. Making a harm to others argument to justify a motorcycle mandate, if accepted as sufficient, would justify intervention in nearly any risky activity an adult might choose and would create a public health that is heavily paternalistic.

Smoking restrictions in public housing. Banning smoking in public housing units is a policy that has expanded in recent years and that has a public health rationale. Where secondhand smoke moves through shared ventilation, the harm-to-others argument applies, and the field’s authority rests on familiar ground. But the policy is sometimes defended, and applied, even where the secondhand exposure risk is minimal. If the harm is almost entirely to the smoker themselves, the question is whether public health has the authority to restrict an adult’s behavior in their own home for their own good. This is, by most accounts, a question about paternalism. A restriction that would be politically unthinkable if applied to homeowners is applied, here, to people whose housing depends on accepting it. This is not itself a reason to abandon the policy, but it is a reason to hold it to a higher standard of justification than we sometimes have.

Restrictions on what food assistance can buy. The question of whether food assistance benefits should be usable for sugary drinks, snack foods, or other products associated with poor dietary outcomes is among the most politically scrambled in contemporary public health. It is supported by some on the right, who see it as a reasonable condition on public spending, and by some on the left, who see it as a way of improving nutrition among low-income populations. We think the strongest argument in its favor is that the government has a legitimate interest in the health outcomes of the programs it funds. We also think the strongest argument against it is that a restriction of this kind, applied only to people using food assistance, singles out low-income Americans for a form of supervision that no one else is asked to accept. If the concern is really about the health effects of these products, the more consistent response would be to tax them broadly, or to regulate their marketing, or to restrict their sale in ways that apply to everyone. The case to restrict food benefits may still be defensible. But it deserves to be defended on its actual merits, rather than under cover of a generalized claim on improving nutrition policy in the US.

Autonomy should be one of the goods public health exists to protect as much as possible. When we forget this, we do harm to the people we serve and to the field itself. A purple public health does not pretend the tension between autonomy and the population can be resolved once and for all. It takes the tension as a permanent feature of the field’s work and asks us to engage with it honestly rather than to paper it over. Much of the time, we are not asking anything of individuals that they would not, on reflection, choose for themselves. When we are asking something of individuals, we should be honest that we are asking, and we should be disciplined about how much we ask. Most importantly, we should be particularly careful, and particularly transparent, when the interventions we reach for fall hardest on those with the fewest resources and the least political power to push back.

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The Purple Public Health Project

This piece is part of the Purple Public Health Project. The Purple Public Health project is a multiyear, multimedia effort to re-establish public health’s legitimacy, broaden its reach, and shore up its foundations in this moment and beyond. The project engages with topics that are core to shaping a more heterodox public health. Previous essays and other material related to the project are available on the Healthier Futures Lab webpage.

One of our Purple Public Health products is an ongoing podcast. This month, Salma’s guest is Justin Bernstein, Assistant Professor in the Department of Philosophy at the University of Virginia. Justin and Salma examine when, if ever, public health can justify limiting individual autonomy in the interest of population health. The conversation works through different ways of understanding freedom and several recent debates — Covid-19 lockdowns, vaccine mandates, soda taxes, food assistance restrictions, and smoking bans in public housing — and asks whether public health risks imposing its own view of the “good life” when it prioritizes health above other values people may hold.

Listen to this episode on Apple Podcasts, Spotify, Amazon Music, Podbean or wherever you get your podcast. You can also watch the episode on YouTube.

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Also this week

In Journal of Clinical Psychiatry:

A Longitudinal Analysis of Self-Rated Health Correlates and Predictors in Hurricane Survivors – with Jeffrey Pavlacic, Jesse Walker, Arthur Andrews III, and Kenneth Ruggiero

In this episode of Ideas Matter, I spoke with Stanford Medicine’s John Ioannidis about the replication crisis and the future of science.

Today’s essay is part of our Ideas about Ideas series, a running theme of which is the notion that ideas have social lives. This may seem strange. How can ideas have social lives? It is not as if they are alive, with personalities and independent agency. This may be so. Yet, like living things, like people, ideas have origins and conditions that shape them. Ideas can grow their influence in a variety of ways. They can spread slowly and steadily simply by being good, workable notions that many are happy to adopt. They can advance through patronage, their wagon hitched to powerful people or social movements who use this power to encourage, even force, the adoption of favored ideas (and discourage disfavored ones through censorship and suppression). Or they can catch on through sheer prevalence and dominance in the public conversation and influential institutions, crowding out alternatives to become the only lens through which a problem or issue is viewed.

It is this form of influence that we would like to discuss today—ideas crowding out alternatives. It is a phenomenon that is of central importance to the work of science and public health, characterizing how many ideas gain traction and stay ubiquitous in our field. The better we understand this tendency, the more we can contribute to an intellectual ecosystem where ideas rise to the top because they are genuinely the best ideas, rather than simply the most widespread or intractable (it is not always the case, of course, that ideas which are ubiquitous are necessarily bad or mediocre, but when such ideas rise for reasons other than pure meritocracy, even when they are good, it is always worth asking why).

How, then, do ideas crowd out alternatives to become the dominant paradigm within science? At the core of this tendency is a self-reinforcing cycle. An idea attracts funding, institutional support, or perhaps media coverage, which in turn leads to…more funding, support, and coverage. It is tempting to look at this process and feel it represents a rigging of the system in favor of some ideas at the expense of others. Yet far from being conspiratorial, this dynamic is structural, reflecting the natural processes by which attention and resources tend to accumulate. This recalls the “Matthew Effect” mentioned in a prior Ideas about Ideas piece, in which those with much tend to acquire more and those with little can lose even that.

This begs the question: why does this dynamic emerge? Why should it be that, in what we might call the intellectual state of nature, the flow of attention and resources tends to favor ideas that already have much going for them? Thomas Kuhn theorized that much of our work happens under what he called “normal science,” in which the daily business of science happens in a context of an accepted paradigm. By paradigm broadly we mean a mental blueprint, a framework of concepts or thought patterns that define what a legitimate perspective is in a given field. This kind of framework rests on shared assumptions that created a generally conservative scientific culture which supports incremental progress, even as it is not always hospitable to novelty or the major discoveries that can come from challenging the paradigm. This can seem, perhaps, like a rather uninspiring vision of science, yet it is worth remembering that much good might come from this small-c conservative framework. Major discoveries are vital, exciting, and rare—we cannot depend on them to sustain the daily work of science, as they do not happen often enough. We need stable paradigms, based on data-informed consensus, to shape a status quo which enables the regular production of good work. That is what normal science provides.

Yet this can also create a context where ideas that align with the dominant paradigm enjoy an immediate qualitative advantage over ideas that do not. Because they “go with the flow,” because they are oriented towards where the dominant paradigm already points, they can quickly accumulate the funding, attention, and institutional support that lets them crowd out other ideas and become, and remain, prominent. When ideas are not oriented this way, they can suffer in the intellectual marketplace. Once a community invests in a framework, it becomes professionally and cognitively costly to deviate. Funding bodies, journals, and career structures reward work within the dominant paradigm and penalize departures. Repetition in media and culture compounds this through sheer familiarity—the most visible ideas continue to gain visibility, while ideas which never gained much traction continue to lose ground.

History provides many examples of this dynamic, a central one being the story of miasma and germ theory. For hundreds of years, the mainstream scientific view was that disease was caused by miasma, or “bad air.” We now know, of course, that disease is caused by germs. It took a long time, however, for this idea to become the dominant paradigm. Miasma theory had institutional backing, apparent practical successes (as trying to get rid of bad air can motivate the creation of better-ventilated spaces, which can indeed help slow the spread of airborne disease), and prestigious champions. Germ theory was simply crowded out by the weight of the established framework, until anomalies became undeniable and scientific consensus changed. Another often discussed paradigm from history was geocentrism, a once predominant description of the universe in which the earth was at the center and other heavenly objects revolved around it. When the idea Copernicus proposed and Galileo championed at great personal cost, that the solar system was heliocentric, revolving around the sun rather than the earth, became widely accepted, the paradigm shifted.

For a more contemporary example, we might look to the dominance of biomedicine in the response to the COVID-19 pandemic. During COVID-19, the biomedical approach to the virus—a focus on drugs and treatments—so monopolized attention that the role of social determinants of health such as poverty, housing, and racial inequity was acknowledged only belatedly. This is not to say that biomedicine was not important during the pandemic—vaccines played a decisive role in ending the COVID era’s acute phase. But the social determinants of health also played a central role in shaping who got sick and who did not during that time. Why did they not get as much attention as biomedicine? It was not because anyone banned discussion of these factors; the biomedical approach simply absorbed all the oxygen, it was the dominant paradigm of the moment, and in our preoccupation with that, there was little room for others. It has long been the case that, when we think of the opposite of disease, we think of cure rather than prevention. This is why there is constant media interest in the latest drugs, treatments, and technological “fixes” to physiological inevitabilities like aging and death. Given this paradigm’s power, it is no surprise that the pandemic only strengthened its hold on the public’s imagination—and, through this, increased the resources that were brought to bear on developing better drugs and medical technologies.

The biomedical model has, of course, yielded much of value. Better drugs and medical technologies do indeed save lives. Yet there has also been a cost. Creating a world where such treatments are not necessary—where no one gets sick in the first place—means addressing the social determinants of health by investing in our engagement with these factors. That we have not fully done so is a reason why we were so vulnerable to COVID-19 when it struck. It also explains while we are willing to expend enormous resources to advance research and spend on new medications along the lines of the biomedical paradigm, but relatively low-cost, yet highly effective preventive measures, like reducing lead exposure, or improving food fortification, that are less biomedical, receive far less attention.

This reflects the costs of what can happen when we leave in place the structures that allow some ideas to crowd out others: partial truths are overemphasized, at the expense of the full truth that should be the central aim of the scientific endeavor. The danger is not always that the dominant idea is wrong, but that it is incomplete. It is partial blueprint of a bigger and much more complex reality. Drugs and treatments do manage disease. But unless we balance our investment in drugs and treatments with an investment in the social determinants of health, we will not be as healthy as we could be—far from it.

Other examples of incomplete truths that loom large, crowding out a fuller picture of reality, include BMI and GDP as proxies for physical and economic health, respectively. Each capture something real but, through their dominance in the intellectual and media ecosystem, they have become stand-ins for far more complex realities (in health and national economic progress). This can lead to distorted policymaking and missed opportunities to shape a better status quo.

What is the answer to this? It seems to us that we need a more pluralist intellectual ecosystem, where all ideas can get a fair hearing, with the best rising to prominence regardless of their alignment or lack thereof with mainstream opinion. We should be arguing for intellectual self-awareness, routinely asking why an idea is dominant and whether alternatives have been seriously tested. We should also remember that the driving forces behind ideas crowding out ideas are structural, and work to address these structures to create a better climate of ideas. This means prioritizing viewpoint diversity at the level of institutional policymaking, funding heterodox work, and asking, always, whose ideas are not being heard and why.

Such engagement reflects the central aim of the Ideas about Ideas series, in which we are continually thinking about not just ideas themselves, but about the context, values, and structures that shape them. If we can do this, we can create the conditions for better ideas to be built and maintained. The goal is not contrarianism—elevating overlooked ideas simply because they are not mainstream—but rather ensuring that even our best ideas must continually earn their place, and that our intellectual ecosystems remain open enough for the next necessary insights to break through.

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The Ideas about Ideas project

The Ideas about Ideas project, co-written with Dr Nason Maani, and cross-posted on the Money, Power, Health substack is a series of reflections of how thought lives in the world. It follows ideas as they emerge in institutions and everyday life, as they move across borders, as they harden into orthodoxy or fade into silence. It argues that ideas are not possessions but shared conditions of living, and that to see them clearly is to recognize both their power and the obligations they impose. Fundamentally, this project is built on the notion that without ideas we have nothing, and that the business of creating a healthier, better world rests on ideas.

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Also this week

For Ideas Matter, I spoke with Professor Lilliana Mason of Johns Hopkins University about why politics have become so polarized in this moment and what this might mean for the future.

Graduation season is also a time when I find myself reflecting on the first principles, the aspirations that guide our mission, a mission this year’s public health graduates have now made their own. It is worth reflecting on these aspirations as a reminder of why we do what we do, and, on a perhaps deeper level, of the power of aspirations to endure through a range of historical moments, outlasting, and even changing for the better, times of challenge. It is important to recognize that public health, at its most essential, is a series of aspirations. An aspiration is simply something we are reaching towards, whether that is an idea, a manner of conducting ourselves, or a set of policies. This reaching is what helps us clear the distance between the world as it is and the world as it should be. Sometimes, the simple act of expressing our aspirations can help lay the groundwork for a better world, by setting a marker for future progress. This is perhaps most true in difficult moments, like the one public health is arguably now in, when it can be easier to see challenges than opportunities and when the distance between the world as it is and the world as it should be seems far indeed.

So, I would like to share some thoughts about the aspirations of public health in this moment. In keeping with the season, I will address these remarks to the public health graduates of 2026, with excitement for all they have achieved and for all they will do next.

I will start with a story.

It is a story drawn from the history of the United States. I tell it not as a celebration of one nation over others, but because this particular moment in this particular history teaches a lesson that belongs to all of us. The lesson I want to draw out is one that travels. It is about what it means to hold fast to an ideal, even—and especially—when the country which has committed to that ideal is going through a hard time. Every country worth caring about has such moments. And every country worth caring about is, in the end, defined less by those moments than by what its people continue to aspire to through them.

With that in mind, here is the story.

This July 4th, the United States will celebrate its 250th birthday. It is significant that we date the country’s birth not from the British surrender at Yorktown, not from the ratification of the Constitution, not from the convening of the first Congress, nor from the swearing-in of the first president, but from the adoption of the Declaration of Independence. We do this because America is an idea—an idea first expressed through the eloquence of Thomas Jefferson (with a famous edit from Benjamin Franklin):

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

On the eve of war with Britain, a single sentence affirming the self-evident equality of all may have seemed like a minor detail—a throwaway in what was fundamentally an airing of grievances against King George III, and the likely death warrant of all who signed it. Yet these words, more than any others, have shaped what America became, and what it is still becoming.

This was recognized by no less than Abraham Lincoln, who wrote:

“All honor to Jefferson—to the man who, in the concrete pressure of a struggle for national independence by a single people, had the coolness, forecast, and capacity to introduce into a merely revolutionary document, an abstract truth, applicable to all men and all times, and so to embalm it there, that to-day, and in all coming days, it shall be a rebuke and a stumbling-block to the very harbingers of re-appearing tyranny and oppression.”

This is one of my favorite quotations. And what makes it travel—what makes it a quotation for all of us, wherever we are from—is what Lincoln saw in Jefferson’s words, and what he wanted us to see. Even in the concrete pressure of difficult moments, what endures is what we aspire to. The aspiration is the thing. It is the abstract truth, embalmed in the document, that becomes the rebuke and the stumbling-block to whatever forces would diminish us. And this is truer when times are hard. When the world feels turbulent—when there is much, in any country, that we would wish were otherwise—it becomes more important, not less, to be clear about what we aspire to. The aspiration is what carries us through. It is what makes a country, and a profession, worth committing a life to.

What we aspire to in public health

Which brings me to what we aspire to in public health, in this moment. I would suggest we lean into four aspirations.

First, we aspire to be a community of excellent scholars dedicated to the science. This is our foundation. It means working out the first principles of what we believe and then gathering around us people who are animated by the call of science and scholarship—people willing to follow the facts wherever they lead, grounded in humility, in reason, and in a steadfast commitment to truth. This means ensuring that public health is, and remains, a community of innovative, intellectually curious, heterodox thinkers who take the science seriously because the stakes—people’s lives, people’s health—are serious.

Second, we aspire to train the next generation, so that the work continues always. No single individual finishes this work. None of us, however gifted, however hardworking, gets to see all of it through to its end. The only way the work endures is by being handed on—from teachers to students, from one generation to the next, with care, with rigor, with the conviction that those who come after will go further than we ever could. That is, in a real sense, is what graduation is about. You, the graduating class of 2026, are the handing on. You are the proof that the work continues. And one day, sooner than you think, you will be the ones doing the handing on yourselves.

Third, we aspire to elevate, encourage, and lean into science across disciplines and sectors. Public health is not, and has never been, a solitary discipline. The questions we care about—why people live the lives they live, why some are healthy and others are not, what it would take to change that—do not respect the boundaries of any single field. They sit at the intersections: of biology and economics, of medicine and policy, of climate and food and housing and law. This calls for the building of partnerships. The Beatles had it right: we get by with a little help from our friends. Public health has many friends, and it can have more—across disciplines, across sectors, across the lines that too often keep good ideas from finding each other. There is a saying: if you want to go fast, go alone, but if you want to go far, go together. When we lean into science wherever it lives, and forge partnerships wherever they are useful, we can go far indeed.

And fourth, we aspire to do all of this with an unwavering eye to impact and consequence. The science matters because it changes things. The teaching matters because it changes people. The collaborations matter because they change what is possible. We are in public health because we are idealists—motivated by a radical vision of a healthier world. But getting to that world takes pragmatic, incremental steps. Sometimes it takes a step back for every two steps forward. Sometimes it takes choices that seem, in the moment, frustratingly minor. It is in such moments that we might recall the Butterfly Effect—the idea that small events can ripple across time and space to shape large outcomes. The butterfly flapped its wings in 1776 and blew into being a national story with global implications. Everything we do has the potential to matter. So, we should act as if everything we do does matter—because, in the end, the only public health worth doing is one that bends, however slightly, the arc of history toward health.

These are our aspirations. This is why we do what we do. Because the world is not yet as healthy as it could be, because it is on us to help make it so. Thank you to all who are engaged in this work, particularly the public health class of 2026. You are graduating in an uncertain moment, but there is no uncertainty about your capacity to meet challenges and make a difference. Thank you for all you have done, all you will do, for our collective health.

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Also this week

We are delighted to announce a transformative partnership between the Bursky family and WashU, to create the Andrew M. and Jane M. Bursky School of Public Health. This investment will help shape a new public health for this dynamic global moment. We are deeply grateful to Andy and Jane Bursky for their vote of confidence in the future of public health at WashU.

For the Ideas Matter podcast, I spoke with Professor Lizhi (Liz) Liu, of Georgetown University about the booming political economy surrounding e-commerce in China.

The Artemis II mission was a unique moment in the history of science and exploration. Yet, in many ways, it was reflective of work that is happening all the time, here on earth. The work of science, the building of social movements, the pursuit of knowledge, the shaping of policies that promote better lives, better health—these are all, in a sense, moonshots. They all represent aiming upward, marshaling time, data, and resources in pursuit of progress, of a better world for all. They are not solitary efforts. They involve working in teams, in communities, across disciplines and sectors. They can be deeply rewarding, helping to bring about much improvement, providing a glimpse—like earth seen from a spaceship window—of a brighter future we can all play a part in helping to build.

But these efforts can also include times when we feel isolated, when the way forward is obscured, when we are cut off from sources of support on which we have long relied, when we even feel, perhaps, a bit of existential anxiety about the future of our work and world.

Public health is arguably in such a moment now. Since the pandemic, we have faced declines in the public’s trust in us, and, to date, we are far from reestablishing the credibility we once enjoyed. Over the past year, this collapse in trust has left us vulnerable to political attacks that have seen public health institutions defunded and dismantled. We have also seen a broader disinvestment, at the federal level, in the work of science.

This is all the more jarring for happening after many generations of public health, and science more generally, achieved great success in improving living standards, preventing injury and disease, and working both within the US and across national borders to build a healthier world. We have traveled far as a field, yet we now find ourselves feeling, at times, like we are far from the sources of our initial momentum—public support, federal investment, and a clear understanding, and ability to articulate, the guiding values of our work.

Such times recall the roughly 40 minutes of the Artemis II mission’s lunar flyby when the astronauts found themselves on the far side of the moon—sometimes known as the dark side of the moon—cut off from earth in a planned communications blackout. During that time, they were the farthest from earth any human beings have ever been, surpassing the distance records set by prior moon missions. A lonely place to be, yet those 40 minutes were essential to the completion of the Artemis II mission. Had Artemis II not spent time on the dark side of the moon, its lunar view would not have been complete, nor would it have gathered as much data as the mission ultimately yielded.

Perhaps the most essential fact of Artemis II’s time on the dark side of the moon was that it was, ultimately, just a moment in time, from which the astronauts emerged, returning to light, to human connection, to a warm welcome back on earth. This is the case with most dark moments—that they are just that, moments, which yield sooner or later to a return to light. This is important for us to remember, as public health undergoes its own darker moments. In such times, it is worth reflecting on how far we have come, how much distance we have traveled towards building a healthier world for all. This is the healthiest time in human history—due, in large part, to the successes of public health. Just as the astronauts traveled far before rounding the moon, we have come far to reach this moment. The fact that we have come so far reflects the fundamental resilience of the work of public health, a resilience supported by our collective desire—shared by all—to be healthy. This wish for health has supported public health’s work through generations, in the face of epidemics, political pushback, and moments when public health itself has gone astray, deviating from its core values.

It is also important for us to remember that public health’s successes continue, even in this challenging moment, as green shoots in public health spring up across the US and around the world. These efforts are helping to renew public health in this moment. History has long shown how moments of adversity can yield much of value; can even be essential catalysts for the ideas and movements that help build a better future, and this remains true today. This is not to say, of course, that we should celebrate when our work comes under attack or embrace as a virtue alienation from communities and the public’s trust. Only that, when we find ourselves in such positions, we can use these moments to reflect on where we are, how we got here, and emerge better for having spent time on “the dark side of the moon.”

This means, centrally, using such times to reflect on our values, on the core principles that guide our work. The Healthiest Goldfish has long aimed to be a place for such reflection, for thinking about the values that guide public health. These values include scientific rigor, a commitment to improving the health of all, not just some, an embrace of reason and conversation in a context of free speech and open debate, and a pursuit of partnerships towards building a big tent movement for health. Guided by these values, we can navigate this moment, emerging from the dark into a brighter day for public health and for the world.

There are reasons to hope we are already starting to see this brighter day. There is hope in the many who are showing up each day to do the work of public health—in government, in universities, in the private sector, and in communities. There is hope in public health’s continued commitment to its core values and its vision of a healthier world for all. And there is hope in the willingness of many in our field to engage honestly with our strengths and our shortcomings, to shape a new public health for a new global era, informed by the lessons of the recent past and present.

Most of all, perhaps, during this graduation season, there is hope in the public health graduates—at the WashU School of Public Health, where I am dean, as well as around the country and world—who are about to launch into the next phase of their careers as public health professionals. Their talent, their commitment to building a healthier world, is reminiscent of all who have dared greatly in pursuit of a vision of a better future. Each day, at WashU, I am privileged to see how our new graduates are working towards this future. Today’s graduates have been through much, navigating a once-in-a-generation pandemic before some of them had even graduated high school. Yet rather than grow demoralized by this experience, our graduates have chosen to become active, engaged participants in history, determined to bend the arc of the universe towards better health for all. They make it possible—indeed, easy—to imagine public health emerging from this moment into a brighter, better day.

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Also this week

For our Ideas Matter podcast, I spoke with Alex Broadbent of Durham University and Pieter Streicher of the University of Johannesburg—authors of a new book on science during the COVID moment.

And yet, the notion of just being “useful,” in a rancorous public moment, feels somehow…small. I argue, though, that far from being small, it is exactly what we should aspire to - individually and collectively - and that if more of us did so, the world would be a better place indeed.

How might we define usefulness? Broadly, we can think of usefulness as a good, one which helps to make other goods possible. In this sense, it is what philosophers define as an instrumental good—a good that is valuable as a means to an end (as opposed intrinsic goods, which are goods that are valuable for their own sake, such as love or happiness.) It is a kind of tool, which allows us to access higher goods until we reach eudaimonia, or human flourishing, which Aristotle saw as the highest possible good and which readers of The Healthiest Goldfish might recognize as what I have long thought health is fundamentally for: to enable human flourishing, the living of a rich, full life. This aligns well with the fundamental goal of public health, an aspiration to create a world where all can live, all can thrive. It also aligns with the notion of radical incrementalism, where we pursue a vision of a healthier world by taking daily steps, sometimes small ones, even when this contribution is “modest.” The Healthiest Goldfish is itself, at core, an exercise in trying to be useful, to help inform a conversation that does right by the world and by the public health community, towards a pragmatic pursuit of healthier populations.

It is worth noting that the moral characteristics of usefulness, in this philosophical conception, are somewhat ambiguous. An instrumental good is a means to an end and that end might be good or it might not (something can be useful in pursuit of a bad goal). This is addressed in John Stuart Mill’s concept of utilitarianism, in which actions are evaluated by their consequences for collective welfare. Thus, the morality of a useful action is determined by whether or not it supports the greatest good for the greatest number of people. This aligns with a consequentialist vision of public health, in which we choose what we do, say, and study conscious of the degree to which these actions will help advance our mission of health. Usefulness, then, is fundamentally about pragmatism. It is about what helps, what makes a difference. It does not matter whether these steps are big or small, only that they are pointed in the right direction: towards better health for all. In this sense, signing legislation that strengthens the social safety net for millions, completing a PhD in public health, or donating $5 to an organization that supports global vaccination are all the same category of action. They are all useful in pursuit of a healthier world.

When we understand usefulness in this way, we realize that there are many varieties of usefulness, all of which can play a role in the work of health.

There is practical usefulness. It is the usefulness that delivers goods, services, and policies that reduce harm and improve wellbeing. For example, global measles vaccination is estimated to have helped reduce measles mortality by 74% between 2000 and 2007. Practical usefulness is essential for the pragmatic work of implementation. It helps ideas become concrete actions that make a tangible difference in the world. The introduction of handwashing in hospital settings as a means of preventing maternal mortality is an example of this form of usefulness. Ignaz Semmelweis first argued for the practice in 1847. Despite resistance to the idea, handwashing dramatically reduced puerperal fever rates in hospitals. John Snow’s cholera investigation—in which he linked contaminated water to the emergence of the disease in London—is another such example, a canonical one for the field of epidemiology which served as a template for other approaches to infectious disease prevention in the generations to follow.

Then there is intellectual usefulness. This is the kind of usefulness that helps to develop the ideas that support sound action in pursuit of health. Intellectual usefulness includes the development of study design, causal inference, and standards for transparent reporting. Such usefulness is apparent in resources like textbooks, the STROBE reporting standards for observational studies, academic journals, all dedicated to doing something, even if small, in pursuit of our larger aspiration. Intellectual usefulness is also in play whenever we engage with the world of ideas to help build the architecture of public health thinking. Less immediately tangible than practical usefulness, intellectual usefulness is nevertheless foundational to all we do, upstream of the policies and approaches that support the health of the public.

Finally, there is moral/social usefulness. This is the work of sustaining the trust, participation, and social infrastructure that make population health possible (e.g., the work of community health workers, or the cultivation of trust in health systems and vaccination). This form of usefulness is essential because it concerns what is possible in public health. We can do all the thinking, all the practical legwork we want, but if our efforts face intractable social norms or a political status quo that is inhospitable to our vision, we cannot get far. When we take steps that help to broaden our collective moral imagination, that rebuild trust in public health or pave the way for new systems that generate health, we are creating fresh pathways to a healthier world. Doing our part in public health means doing all we can to build these pathways even as we also navigate existing routes, balancing pragmatic actions with a vision of a world transformed, each day doing our part, whatever that may be, to move our field forward.

As I noted at the outset, even if we aspire to be useful, we often do so a bit abashedly. It somehow does not feel “enough” to be useful. We prefer to talk about, and mythologize, grander-seeming virtues like, say, courage and brilliance. Such virtues have their place. But that place is not always in the average day, in which simple usefulness is what is often called for. Recognizing this takes humility. Usefulness reflects a posture of service. We are most useful when we are in a position to be useful to others, when collective endeavor calls for us to make a contribution, however big or small.

Usefulness is particularly, well, useful in times of challenge and disruption like the one we are in. When we face shocks to the system, when we see institutions dismantled and good work targeted and defunded, when political winds blow and much about which we care falls down, it is hard to know what to do. It is in such moments, we might ask not “What can I do?” but “How can I be most useful?” The answer, more often than not, is right in front of us. There is always something useful, constructive, to do. Whether practical, intellectual, or engaged with the moral/social foundations of the moment, there are many ways we can do our bit. In practice, usefulness asks us to contribute something that actually helps - reducing harm in the near term, clarifying knowledge for the medium term, and strengthening the social conditions that make health achievable over the long term. Naming usefulness as a virtue orients us toward contribution, toward effects, toward a helpful standard against which we can measure our work in population health.

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Also this week

For our Ideas Matter podcast, I spoke with Janet Rafner, an expert in hybrid intelligence and human–AI co-creativity, on AI’s role in the creative space.

It seems particularly troublesome that this language of exclusion appears to becoming common in the very professional and intellectual contexts that are committed, at least nominally, to a free exchange of ideas. There was a time when phrases like “I won’t share a stage with…” and “We shouldn’t platform…” were reserved for the most extreme forms of speech, the most obviously objectionable voices. And even then, efforts were often made to give such voices a hearing, with the understanding that when the objectionable are nevertheless allowed to speak, it sends a signal that free speech remains of utmost importance, a value worth even the discomfort that can come when the right to speak is exercised by those whose ideas we dislike.

This understanding used to be a central value of our society and, in particular, of the people and institutions privileged to engage with ideas for a living. Is this still so? There is a case to be made that it is not. And I think this is a problem, that our collective retreat from engagement is a mistake. I have written about why I think it is a problem, how it reflects a backsliding of the intellectual traditions that support a healthy exchange of ideas. Core to this backsliding is confusion over a reality that often gets lost in conversations about platforming and speech, one that it is important, always, to remember: inclusion is not endorsement. We can create space for the hearing of views with which we disagree without embracing these views—and we can insist to those who accuse us of just such an endorsement that a society that does not understand this distinction cannot long function as a space where genuine intellectual engagement can occur.

To give these objections their due, it is true that conversation is the precondition for persuasion, for learning, for the kind of friction that sharpens our thinking. When a view is expressed, even a view we strongly disagree with, there is, yes, a chance that someone might agree with it and disagree with a position we may hold in opposition to this view. But why should we be afraid of this? If our ideas are sound, they will hold their own in a context of free speech and open debate. If they cannot do so, they are weaker than they should be, and we should do something about that.

That is why, in part, I have argued for a big-tent movement for health, one that makes room for many ideas and perspectives, some of which may be in opposition to each other, perhaps even deeply so. Such a movement lets us stress test our ideas, to ensure they are strong. There is another practical reason for building and maintaining such a movement. The more people who are part of a movement, the more powerful it will be, the greater its capacity to create change. Some would disagree with this, arguing that it is more important to have a deeply committed minority, as such a group will be more focused and energized in pursuit of its goals. I would answer this with the example of the past ten years in American politics, as extremes on both sides of the political spectrum have, at various moments, sat in the driver’s seat of key movements and institutions. What has this produced? Gridlock. Hostility. Small gains quickly rolled back the moment the other side regains power. The past decade has been an experiment in letting the extremes lead. We should try something new.

When we have done so in the past—when movements have embraced a big tent approach, when they have engaged with a range of people and perspectives—the results have been a marked contrast to the dysfunction of this moment.

The key 20^th century example of this is likely the American civil rights movement. It is important to remember that there were many voices within the civil rights movement with different ideas about how the movement should conduct itself, including some who called for a separation between the races and a cutting of ties with white America. Yet the voice which rose to the top to lead the movement was that of Martin Luther King Jr., and his message was emphatically one of engagement and persuasion, of growing the movement by bringing more and more people on board. King understood that civil rights would become a reality when large numbers of Americans, include white moderates, became aware of the injustice of racism and Jim Crow and supported legislation to dismantle the legal basis of segregation. This could only come about through engagement, persuasion, even when that meant dealing with people—on both sides of the issue—who deeply disagreed with King’s goals and methods. So, he dealt with everyone, towards building a big tent and an ultimately successful movement.

What does this kind of engagement require today? Danielle Allen, in Talking to Strangers: Anxieties of Citizenship since Brown v. Board of Education, addresses the concept of “political friendship,” in which citizens engage across deep difference not with the goal, necessarily, of the intimacy or deeper understanding that comes with true friendship, but with the aim of communication, of the resolving of disputes and the establishment of policies and practices that support the common good. Citizens commit to hearing each other out and, through this engagement, may or may not become genuine friends, but they are able to work together to distinguish good ideas from bad, to come to a rough consensus on key issues, and to move forward as a society, however haltingly.

Such engagement is not easy. Like most hard things, it takes discipline, practice, and no small measure of courage. Courage is necessary because this engagement has real costs. Sitting across from someone whose views seem antithetical to ours can feel like complicity, like a tacit endorsement of these views—a feeling which can persist even when we know, intellectually, it does not reflect reality. We should take this feeling seriously and recognize that the burden it represents falls unevenly, that engagement can be painful, and for some people more than others.

It is also important to stress that there is a limit to our engagement, lines we should not cross. Some conduct—incitement to violence, name-calling, outright falsehoods, the willful destruction of others’ dignity—does warrant exclusion. The argument here is not for engagement without limit; it is that the line should be drawn much further out than we currently trace it. This builds on Karl Popper’s “paradox of tolerance,” in which unlimited tolerance ultimately destroys our collective capacity for tolerance by undermining the social structures that allow for reasoned decision-making about what speech we will allow. But Popper actually defined a threshold: he was talking about those who “are not prepared to meet us on the level of rational argument” and who “answer arguments by the use of their fists or pistols.” That threshold is far from most contemporary disagreements. This aligns with the thinking of Hannah Arendt, who, in both The Origins of Totalitarianism and The Human Condition, notes that the public realm depends on the presence of others who are irreducibly different from us. When we narrow the circle of who belongs in public discourse, we erode the conditions for political life itself.

Doing the hard work of maintaining engagement with a wide range of people and perspectives—of building a big tent movement for health—means remembering that we can hold firm to our values even as we sit down with those whose values may be the opposite of our own, as long as their expression of these values does not dehumanize, incite violence, or tear down the dignity of others. Such engagement is not incidental to the work of health—which is, at core, the work of developing and then putting into practice ideas about health. It is, in fact, central to this work. Ideas that have never been tested in the presence of disagreement are brittle. And public health cannot afford to rest on brittle ideas. Nor should we let our public life, which we collectively share, become a mere echo chamber, in which we are exposed to nothing challenging, nothing that really makes us think. We owe ourselves better than that.

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Also this week

In Annals of Epidemiology:

Advancing Systems Thinking in Implementation Science: An Epidemiologic Perspective – with Danielle Giovenco, Lindsey Filiatreau, Justin Knox, Aaloke Mody, Brandon Marshall, Kristin Wall, and Patrick Sullivan

For our Ideas Matter podcast, I spoke with the University of Chicago’s Robert Gulotty, an expert in international relations and political economy, on how systems of trade could contribute to global cooperation in the 21st century.

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It is in relationships where trust is strongest that it is often most unspoken. We generally do not spend our days saying “trust me” to our spouse, to our children, to friends who have known us for a long time. Trust is implicit, understood, tested over years of relying, and being relied on. It is simply a fact of these relationships, something we take for granted. If we find ourselves having to say, “trust me,” it is likely something has gone wrong.

For a long time, public health enjoyed the kind of trust that does not have to say, “trust me,” in which the public understood it could trust what we say and do without having to be reassured of our honesty. Public health institutions had credibility because they were seen as broadly nonpartisan, guided by scientific rigor, towards the goal of keeping populations safe.

Just think back to movies, like 1995’s Outbreak or the 2011 film Contagion, in which public health officials are portrayed as competent, data-driven professionals, the heroes of the story. What is striking about these portrayals is how unmarkable they seem. There is a sense in these films that of course public health officials would be portrayed this way because of course this is how they conduct themselves—as sober professionals, trustworthy in pursuit of their mission.

But while fictional virus outbreaks can see public health’s reputation burnished, the recent real one opened a gap between what we say and the public’s willingness to trust us—a gap which has arguably widened in the years since the pandemic.

Survey data have shown significant declines in trust in public health since 2020. One study, for example, found “Between February and May 2020, the percentage of respondents reporting high confidence in the CDC decreased from 82% to 68%, before dropping to 56% in 2022.” This has happened in a context of declining trust in science generally, with the share of US adults with a “great deal” of confidence in scientists falling from 39% in 2020 to about 23% in 2023. But these declines in trust are only part of the story. Perhaps equally, if not more, significant is the sharp polarization of Americans’ trust in science, with just 52% of Republicans viewing research scientists as honest, compared with 80% of Democrats. More recently, however, that pattern has begun to invert and trust among Democrats has declined sharply after the change in federal administration and the accompanying shifts in health policy.

All this has meant that public health is, increasingly, in the position of having to say, “trust me,”. This is not sustainable. Trust is essential to the work of public health. Without it, we cannot do what we do. It is not enough for half the country to trust us while the other half doubts our honesty. Building a Purple Public Health means ensuring that this trust is shared across both red and blue America. The first step to rebuilding trust is to ask ourselves honestly why we may have lost it, owning up to our shortcomings. We recognize that trust in public health is also shaped by forces beyond our control like deliberate disinformation campaigns, changes in media ecosystems that reward polarization, and a broader erosion of trust in all kinds of institutions. These factors matter, and we do not mean to minimize them. But they are not the part of the picture we can change from within the field. Our focus here is on what we can change: the choices, habits, and practices that are ours to reckon with. With this in mind, we suggest the following three reasons why we have lost much of the public’s trust and why this loss has so strongly intersected with the country’s political divide. We do not think, in any way, that these are the only reasons, but rather they are three reasons that we think matter and that are important to discuss within the public health community, to think of ways in which we can address them, simply to do better.

Partisanship

Public health has long been perceived to lean to the progressive left. However, during the pandemic years, and as part of the broader polarization of the current era of US politics, this bias became more explicit in our words and actions. Such bias can be seen, for example, in the CDC shaping guidance about school reopening with significant input from teachers unions—arguably placing the priorities of a political interest group over what the data said about the complexities of reopening schools during COVID. It can also be seen in public health’s widespread comfort with the language, attitudes, and priorities of the political left, and its discomfort with the signs and symbols of the political right—or, at times, of even the moderate left.

None of this is necessarily bad. We are not saying public health should not have a political perspective. It should—and this will not make it unusual. Institutions and individuals have personal beliefs about issues and there is nothing wrong with that. We may know, for example, that a teacher or a newscaster feels a certain way about politics. We can still trust them, however, when we can feel secure that their personal beliefs do not unduly influence their work. A history teacher may feel like the New Deal was a failure, but she can still expose her class to a range of views about it, keeping her personal perspective to herself. A newscaster may feel the US should rarely, if ever, get involved militarily in other countries, while giving airtime to those feel differently. Personal belief only becomes problematic when it seems to be shaping what we do in the course of our work. It is when perspective becomes outright partisanship that we risk the integrity of our efforts and the public’s trust in what we do. To the extent that we have run this risk in recent years, we need to rethink our engagement with politics to ensure we can still lay claim to a level of neutrality in our work, even as we stay true to our values and their policy implications.

Inconsistency

Consistency is a companion of truth, and trust. We trust people in the moment because they have demonstrated trustworthiness over the long term. Rare is the person we meet and immediately feel like we can trust with what is most precious to us—and that, we should remember, is what we are asking the public to do, to trust us with what is most precious to them, their health. Earning this kind of trust means behaving consistently, over time, in a trustworthy way. It means that whenever we make recommendations based on incomplete information, we are up-front about what we know and what we do not know. It means always following the data, even when the data lead us to places that challenge our ideological priors. It means, when we fall short of the highest standards of trust, when we do something partisan, or shortsighted, or just plain wrong, we are quick to own our mistake, to explain why we made it, to commit to doing better, and then to actually do better—consistently, over time. Have we always conducted ourselves this way? An honest reckoning with recent years suggests we have not. Perhaps the central example of this during the pandemic was our attitude towards public gatherings. In the early days of COVID, public health was very critical of groups of people who congregated in defiance of advice about the dangers of doing so. Particular criticism was directed at those who attended the Sturgis Motorcycle Rally in South Dakota. However, after George Floyd’s murder in May of 2020, public health was broadly supportive of mass rallies across the country. It is hard to overstate how much this inconsistency eroded the public’s trust in us by contributing to the view that we place activism above science and that our activism skews one way—to the left. Many in public health argued that the imperative of addressing systemic racism, and the fact that the protests were outdoors, made gathering in protest worth it, despite the risks. Nevertheless, this seeming inconsistency that has had consequences for how half the country hears us, and we must reckon with this if we are to earn back the trust we have lost.

Lack of transparency

A hallmark of trustworthy action is transparency. Research has shown, for example, that managers who are maximally transparent are more trusted by their employees. We build trust when we are willing to share data, share the reasons why we do what we do, and act in ways that subject us to the accountability that comes with working out in the open. However, we have not always embraced transparency. Rather than share our data and reasoning, we have been quick to claim that we speak for “the science” and that this should be enough of a justification for what we wish to do. Rather than work in the open, where the public can fairly judge what we do, we have embraced a bureaucratic vision of power, pursuing our interests through institutions and funding structures whose workings have not always been easily viewable or understandable by the public. An example of this has been the public conversation, which has widely occurred outside the public health “bubble,” about the origins of COVID-19 and whether US public health agencies may have leveraged the opacity of the funding process to support research that was not being conducted safely and which may have led to the inadvertent leak of the virus from a Chinese lab. This may be an uncomfortable topic to raise within institutional public health, but, outside our spaces, it is very much a live issue, with genuine political force, fueling the view that public health is not transparent and that this lack of transparency can, and did, place the public at risk. We cannot pretend that this conversation is not happening if we are to build back the trust we have lost. Rather, we should engage with it (even as we acknowledge its potential to be weaponized by bad faith actors), embrace accountability, and learn the lessons of the last seven years, to ensure the COVID moment represents the nadir of the public’s trust in us, rather than the edge of a cliff off of which we continue to freefall.

Trust is built slowly, but it can be lost quickly. Rebuilding trust is a painstaking process. It will not be easy to reclaim the credibility we have lost. But the path is there for us if we wish to walk it. It entails taking an honest look at ourselves and then being honest with the public about what we see. It means having uncomfortable conversations which some in our field—in our organizations, our offices, even our friend circles—may not want to have. And it means, having identified where we have fallen short of full honesty, taking pains to not fall short again. If we can do this, we can rebuild the public’s trust in us and remain worthy of it in the years ahead. That will have been worthwhile work indeed.

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The Purple Public Health Project

This piece is part of the Purple Public Health Project. The Purple Public Health project is a multiyear, multimedia effort to re-establish public health’s legitimacy, broaden its reach, and shore up its foundations in this moment and beyond. The project engages with topics that are core to shaping a more heterodox public health. Previous essays and other material related to the project are available on the Healthier Futures Lab webpage.

One of our Purple Public Health products is an ongoing podcast. This month, Salma’s guest is Erin O’Malley, executive director of the Coalition for Trust in Health and Science, a coalition of more than ninety organizations working to enhance public trust in health and science. Erin brings nearly two decades of experience in health policy, advocacy, and cross-sector partnership, and she leads an organization that is grappling daily with the question at the heart of this month’s work: how do institutions that have lost public confidence go about becoming trustworthy again? The conversation explores what the coalition does, what Erin has learned about the mechanics of trust-building, and what she thinks the path forward looks like, including the practical question of how any of us can navigate an increasingly complex information environment.

Listen to this episode on Apple Podcasts, Spotify, Amazon Music, Podbean or wherever you get your podcast. You can also watch the episode on YouTube.

Each month, we will also highlight perspectives that inform or complicate the month’s theme. These are meant as starting points for deeper engagement with the ideas the project is exploring. This month’s perspective is from Dr Matthew Motta, Associate Professor at Boston University’s School of Public Health, about communication across values and trust in public health.

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Also this week

Delighted to announce the launch of Ideas Matter, a new podcast I am hosting at WashU. The podcast features conversations with experts about the ideas and forces shaping this moment. The first episode is a conversation with Alexander Kustov, an expert in public opinion and democratic governance and a professor of global affairs at the University of Notre Dame, about immigration in a changing world.

Also, in JAMA Health Forum: The Year We Lost Medicaid

Spoke with Bryant Furlow in The Lancet Child & Adolescent Health about social media use and youth mental health.

What gives you hope? Over the past year, I have had the privilege of speaking with colleagues about the work they are doing at the WashU School of Public Health. I always end these conversations by asking what gives them hope in this moment. Here are their replies

There is a story David Foster Wallace told in a commencement address in 2005, that in part inspired the name of The Healthiest Goldfish substack. Two young fish are swimming along when an older fish passes them going the other way and says: “Morning, boys. How’s the water?” The two young fish swim on for a while, and eventually one of them looks at the other and says: “What is water?” Some of the most profound forces shaping us are also invisible due to their near ubiquitous nature. This is certainly true of health at the population level.

One of the most consequential, yet often invisible forces shaping our health, one that we swim through every single day without noticing, is commercial activity, the activities of the private sector. That set of forces, and their implications, is what A Healthier Profit, published by Oxford University Press early next year, is about.

The case is this: globally, when one looks at the main current and future drivers of preventable death and disease, these are no longer in the main due to infectious disease, but rather, are commercial in origin, such as the consequences of food systems, pollution or climate change. They are not primarily the result of individual failings, bad luck, or the inevitable march of biology. They are, in meaningful and traceable ways, the downstream consequences of how businesses operate, what they produce, how they market it, what they lobby for, and how they shape the environments, physical, informational, social, in which the rest of us make decisions about our lives. This is the conclusion of a growing body of rigorous research, documented in academic journals and global health reports, but also by investigative journalism and growing coalitions of civil society groups.

Now, to be clear: business is not inherently harmful, and profit is not the enemy of health. Economic activity has lifted billions of people out of poverty. Markets have generated essential medicines, vaccines, built hospitals, developed treatments and funded government spending through taxation. The private sector is enormously diverse. Commerce and health are not, in any simple sense, opposites. Our point is that the world has passed an inflection point. That the primary causes of preventable ill-health now and increasingly in the future will have structural, commercial roots, and yet our definitions of economic success, priorities in regulation, subsidy or partnership largely avoid this fact.

This dynamic will only cause more health harms as we move forward. It cannot be addressed by telling individuals to make better choices, or by waiting for corporations to voluntarily do better, or by treating the problem as primarily a matter of healthcare spending, as governments around the world are finding. The tools and the framing we have been using are not matched to the scale of the problem. This book seeks to bring and present that story to a much wider audience, to employees, business leaders, investors, policymakers, and citizens who are, knowingly or not, both subject to these forces and participants in them. The fact is that a much greater body of the world’s population than previously thought is involved, directly or indirectly, in shaping the health of those others than themselves, directly or indirectly.

One of the things that strikes us most, looking at this evidence, is not the existence of harm, for harm has always existed. It is the gap between what we now know and what we are actually doing about it. We know that the food environment drives obesity and metabolic disease at a population level. We also know that fossil fuel companies understood the health and climate consequences of their products long before the public did and sought to obscure and diminish public understanding of this fact. We know that social media platforms are designed in ways that seek to exploit psychological vulnerabilities for profit. The gap between knowledge and action remains large. And that gap exists, in large part, because of the power, financial, political, discursive, that commercial actors who benefit from inaction are able to bring to bear on the systems that might otherwise act. Part of that reason, we feel, is not so much to do with evidence, but with wider public discourse on these themes, on what stories are told to whom, and for what reason.

That is why wrote this book for a broad audience, with a particular interest in our colleagues whose primary work is in, or relates to, the private sector. We believe the conversation about commercial forces and health remains too confined to those with a special interest in population health or wellbeing, or conversely, are occupied by those with a conflict of interest in bending such stories away from the root causes of health harms. Meanwhile, members of the public, students who populate business schools, or those who write legislation concerning transparency, monitoring or accountability, or rate company risk profiles have, by and large, remained outside. We are not naive about why. These are not comfortable conversations for those with a stake in the status quo, and there are legitimate conflicts of interest in a range of areas. But we are also not willing to assume bad faith as the default explanation. Most people, we believe, if given the full picture and sufficient agency, would rather not harm others, and would welcome the knowledge that their actions might indirectly help them instead. Indeed, this is the flipside, the reason, why so much corporate money is spent on public relations, on politics, on greenwashing, on managing employee organizational loyalty and moral. It is because people care about these issues, and because a fuller knowledge would influence their decisions and actions. So, we seek to speak to this wider audience.

The book is also an argument, we hope, that the current trajectory is not sustainable. Not morally, not economically, and not in terms of the reputational, regulatory, and legal risks that are beginning to materialize for industries whose harms are becoming harder to obscure. The same accountability arc that transformed how we think about climate risk is now curving toward population health and its many drivers, positive and negative. The funding of increasingly extreme political views is in itself a reminder that now, only in the extremes can one avoid facing these growing realities, and only for so long. The choice is whether to get ahead of that arc or be caught beneath it.

What comes next

A Healthier Profit is structured in two parts. The first maps the territory, how commercial forces shape health through products, power, discourse, and the shaping of responsibility. The second asks this means for what we do next, what would it mean for how we define success, legacy and where the boundaries of legitimate commercial influence should lie. What is a healthier profit? We do not pretend these are easy questions or that all the answers will come from the field of health, or indeed that we are experts in economics, ethics, finance or law. We do think they are unavoidable questions that will be increasingly grappled at local, national and supranational levels.

We will elaborate on this conversation through various other media throughout the coming year, including substack, podcasts, and LinkedIn, drawing on the book’s arguments, engaging with new evidence, and trying to extend the reach of a set of ideas that we think matter across sectors.

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Also this week

Coming soon:

On April 14, the WashU School of Public Health will host “Building for a New Era of Global Health,” the inaugural convening of WashU Public Health’s Global Health Futures research network. Learn more and register here.

And ICYMI a JAMA Health Forum Conversation with Kevin Johnson, of the University of Pennsylvania, on keeping health equity at the forefront of the AI revolution.

None of these moments register as noteworthy. That is precisely the point.

Behind the meal that was picked up was a sanitarian who had inspected that kitchen, checked its refrigeration temperatures, reviewed its food handling practices, and certified it safe to serve the public. Behind the glass of water was a monitoring system that tests for contaminants, enforces safety standards, and ensures that what comes out of the tap will not make anyone sick. Behind the prescription was a regulatory apparatus that had reviewed that drug for safety and efficacy before it ever reached the pharmacy shelf. Behind the toddler’s vaccination was an immunization program run by a local health department, staffed by nurses who track coverage rates and follow up with families. And behind the stomach bug that did not become an outbreak was an epidemiologist — probably in a small office somewhere, probably underpaid — who noticed the cluster, investigated it, and made sure it stayed contained.

All of this happened in the background. None of it happened by accident.

Every one of these quiet interventions is the work of public health practice. The challenge in the moment that many recent cuts to public health threaten these fundamental core actions of public health.

I have not been able to stop thinking about this since a conversation I had earlier this week. We convened, at Washington University, the leaders of four organizations that collectively represent essentially all public health professional in this country: the American Public Health Association, the National Association of County and City Health Officials, the Association of State and Territorial Health Officials, and the Association of Schools and Programs of Public Health. What emerged was not a policy seminar. It was something closer to a reckoning—an honest accounting of what is being lost, and of how little the public understands about what it stands to lose.

The proposed federal budget for fiscal year 2026 would cut CDC funding by more than half. Over one hundred public health programs would be eliminated. Twelve billion dollars in previously approved grants have already been clawed back. And about half of local health department budgets come from federal sources. So, when federal spending on public health is cut, the implications of these cuts are largely felt throughout the country, not in the capital itself. It is the county health department in rural Alabama. The immunization clinic in Kansas City. The epidemiologist—the one tracking the stomach bug, the one ensuring it does not become something worse—in Milwaukee.

Georges Benjamin, who has led the American Public Health Association for more than two decades, drew a distinction that I found clarifying. He described the historical pattern of public health funding as “yo-yo funding”— crises arrive, money follows late, then vanishes too soon. That pattern, frustrating as it is, has at least had a rhythm to it. What is happening now, he argued, is different in kind. The word he used was indiscriminate. CDC is issuing funding allocations in fifteen-day increments. Organizations cannot plan. Staff do not know, from one Monday to the next, whether they will have jobs. That is not a funding cycle. That is institutional dissolution.

And here is where I think the conversation cut deepest. Because the case for public health funding assumes that the public values public health. And we have evidence that many people do not, or, more precisely, that they do not understand the work of public health enough, or the institutions behind it. I find it alarming that nearly sixty percent of Americans express some form of mistrust towards the CDC and the FDA. That number should trouble all of us. Importantly, that number predates the current political moment. There is no doubt that it is a challenge that was deepened by the pandemic; but it also is clear that it was not created by the pandemic. The pandemic sharpened underlying challenges that have led to a moment of public skepticism that has created space for the current cuts to public health practice to go largely unchallenged in the public space.

Scott Harris, the State Health Officer for Alabama, offered what I thought was the most honest observation of the afternoon. He admitted that when the pandemic arrived, he had been naive—he had assumed the science would speak for itself. It did not. “The messenger,” he said, “was more important than the message.” And then he said something that has stayed with me: people may not trust capital-P, capital-H Public Health as an abstraction. But in his state, people do trust the county health department nurse they have known since their children were small. Trust, in other words, is not a communications strategy. It is a relationship. It is local, personal, and accumulated over years of showing up. It is precisely the kind of thing that cannot be rebuilt quickly once it is lost. And it is being lost—not through some gradual drift, but through decisions made far from the communities that will bear the consequences.

I have written in this space about the perception, held by a significant portion of the public, that public health has become a partisan enterprise. I will not rehearse the full argument here, except to say that the implications are worth restating. If public health is seen as belonging to one side of a political divide, then defending it becomes a partisan act, and defunding it becomes a partisan act, and neither framing serves the actual purpose of the work. The way out—the only way out, I believe—is to return, relentlessly, to what public health actually does. Not what it says. Not what it believes. What it does. It creates a world where everyone has access to safe food, drinkable water, clean air. It ensures that we all have the opportunity to live a rich fulfilling life. Public health minimizes avoidable death and suffering. These are not ideological propositions. They are functions of a civilized society. And they are functions that indeed all of us—regardless of partisan stripe—can get behind.

Laura Magaña, who leads the Association of Schools and Programs of Public Health and who founded the Global Network for Academic Public Health, made a point that deserves more attention than it typically receives. She argued that public health literacy should begin not in graduate school but in primary school. If every citizen grew up understanding what public health is—understanding that it is the reason their drinking water is safe, the reason outbreaks are caught early—then the case for sustaining it would not need to be made in a crisis. It would already be understood. That is a long-term proposition, and we are in a short-term period of challenge. But the two are connected. The reason we find ourselves making the case for public health now, in a moment of acute strain, is precisely because we failed to make it in calmer times.

I want to close with something that happened at the end of our conversation. I asked each panelist what gives them hope. Laura said the young generation—their passion, their purpose. Lori Tremmel Freeman, who leads NACCHO, said she has unwavering faith in the people who run local health departments, who know what they have to do even in the hardest of times. Scott said that as long as people want things to be better, they are going to get better. And Georges said: “My grandkids. They are a pistol. And they do not let us get away with anything.” The room laughed. But I think he was making a serious point. The generation coming behind us is not sentimental about institutions that do not serve them. Their impatience is, in its own way, itself a form of hope.

During the conversation, someone called the people who do this work “the silent guardians of health.” I keep returning to that phrase. It captures something essential: public health works in the background so that the rest of us do not have to think about it. That is its great strength. It is also its great vulnerability. Because when something is silent, it is easy to forget it is there. And when it is forgotten, it is easy to cut.

Tonight, someone somewhere will pick up dinner on the way home without having to think about whether the kitchen was inspected. A mother will fill a glass of water from the tap and hand it to her child without thinking about whether it was tested. A toddler will receive a vaccination at a clinic that simply exists, as though it has always existed, as though it always will. That quiet confidence that manifests as not having to think about all these, and many others. The kind so deep we hardly even recognize it as trust, is to my mind one of the greatest achievements of public health. I would like us all to continue not having to think about these. That will require us to protect the system that makes such confidence possible, to insist that the health of the public is not a line item, not a partisan project, but a foundational obligation of a society that means what it says about caring for its people.

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Also this week

The conversation referenced above, “Public Health in Challenging Times: Finding a Way Forward,” took place on March 31, 2026, as part of the Assembly Series at Washington University in St. Louis. The panel featured Georges Benjamin (APHA), Lori Tremmel Freeman (NACCHO), Scott Harris (ASTHO), and Laura Magaña (ASPPH). Thank you to the panelists and to the many colleagues who made the event possible.

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Coming soon

On April 14, the WashU School of Public Health will host “Building for a New Era of Global Health,” the inaugural convening of WashU Public Health’s Global Health Futures research network. Learn more and register here.

And yet, this unsettled environment, there are signs of hope.

Green shoots are sprouting all around us. If we look carefully enough, we can see promising developments that hint at a renewal in public health. In my role as Dean of the Washington University School of Public Health, I am privileged to be able to see these signs of hope every day, in the good work of colleagues who are creating a brighter present and future for public health. I would like to take a moment today to highlight some of this work, to give a sense of the progress being made on health globally, nationally, and locally, even in this moment of disruption.

Global green shoots

There is much to worry about in global health. But there are also enormous positives happening all around us.

New medical tools are emerging all the time. For example, Brazil approved the first-ever single-dose dengue vaccine in 2025, a key step against one of the fastest-spreading mosquito-borne diseases.

The World Health Organization (WHO) recently issued guidelines endorsing long-acting antiretrovirals like lenacapavir for HIV prevention, a move hailed as a major stride toward ending AIDS by 2030. The WHO also prequalified the first triple test for HIV, hepatitis B, and syphilis, simplifying diagnosis for vulnerable populations.

While we are aware of, and suitably concerned about, disruptions to international cooperation around health, the global community has demonstrated fresh commitment to collective action on creating a healthier future. In 2025, world leaders came together to adopt a historic Pandemic Agreement at the World Health Assembly, learning COVID-19’s lessons to better prepare for future outbreaks. The United Nations also issued a high-level political declaration on non-communicable diseases (NCDs), setting ambitious targets (e.g. reducing global tobacco users by 150 million) and pledging stronger action on issues like hypertension and mental health.

On the ground, public health campaigns continue to score victories. Even in conflict settings, there has been progress; for example, a UN-led polio vaccination drive in Gaza achieved about 90% coverage of children under 10.

Long-term battles against ancient diseases are seeing success: Egypt and Cabo Verde were declared malaria-free, joining the ranks of countries eliminating the disease. In the Americas, measles was re-eliminated as Brazil’s concerted vaccination efforts helped make the Western Hemisphere once again free of endemic measles. And when a rare outbreak of Marburg virus emerged in Rwanda, the country’s health system was able to stop it.

The work of public health is the work of building a healthier world. And we have been building such a world, step by step, even in this time of global challenge.

Green shoots in the US

Equally encouraging has been the progress we have made domestically in the US.

After years of worrisome trends, some critical health indicators have started to move in the right direction. Opioid overdose deaths have declined for the first time in over a decade, thanks in part to widespread naloxone distribution and education efforts (such as door-to-door “knock-and-talk” programs in Laredo, TX, and free Narcan vending machines in Marin County, CA).

Rates of sexually transmitted infections like syphilis and gonorrhea fell by about 2%—a modest dip, but a hopeful sign of reversing the disease’s growth. Even chronic and long-term health metrics show promise: cervical cancer deaths are decreasing in the first generation of women who received the HPV vaccine, powerful evidence that prevention works.

US obesity rates actually dipped for the first time in a decade, potentially aided by new widely-used weight-loss medications.

Even amidst political divides, substantive public health policies have been enacted. For example, the EPA issued the first-ever drinking water standards for PFAS (“forever chemicals”) in 2024, targeting pervasive contaminants linked to disease.

Long-running programs continue to yield dividends: the federal Vaccines for Children (VFC) program celebrated 30 years of existence, having helped prevent an estimated 508 million illnesses and having saved $2.7 trillion in costs by providing free childhood vaccines.

Technological innovation is being harnessed like never before—wastewater surveillance networks monitor not only COVID-19 but also influenza, RSV, and even emerging threats like avian flu, giving communities early warning systems for outbreaks.

These developments point to a country in which the work of public health continues, despite political headwinds. The progress being made can be measured in lives saved—the most encouraging metric there is.

Green shoots locally

Throughout the US, public health has been making a difference in communities, building a healthier country one region at a time.

Across the US, more than 3,300 city, county, and tribal public health departments serve as the frontlines of health. Many of the most encouraging public health successes occur at this local level.

Public health teams have contained dangerous disease outbreaks. In 2024, for example, when a measles outbreak struck a migrant shelter in Chicago, public health officials limited the spread to just 64 cases by rapidly administering over 30,000 MMR vaccine doses and other measures.

In Oregon, public health workers implemented an innovative peer-support program for rural residents with hepatitis C, improving access to care for a vulnerable population that traditional services often miss.

In 2024, California adopted higher air-quality standards for classrooms, ensuring schools improve ventilation and filtration to reduce students’ exposure to respiratory viruses and wildfire smoke.

These green shoots in public health convey a larger message: even amid fractures in our systems, renewal is possible indeed. And, looking across these green shoots, some core themes emerge.

As long we care about living long, healthy lives, we shall need the work of public health. That makes public health resilient, with the capacity to rebuild and even be strengthened by crises. Indeed, it is often strain that exposes points of vulnerability and weakness in our efforts, allowing us to rebuild stronger than before. This echoes the practice of Kintsugi, about which I have previously written, in which cracked pottery is repaired with gold lacquer. Crisis has helped us to see where we must improve and the act of reckoning with our areas of vulnerability can contribute to the resilience that helps us to continue doing what we do, and to do it better.

It is also worth noting that many of these hopeful stories were made possible through the embrace of new science, technology, and ideas—such as vaccines, data systems, and community outreach methods. Public health is at its best when it combines tried and true approaches with new technologies and methods that allow us to scale up our efforts, reach new populations, and pursue multiple avenues to a healthier world—from AI-driven data science, to improving access to new vaccines, to mitigating the downsides of new technologies (e.g. the mental health consequences of widespread social media use) while leveraging the upsides (e.g. the connectivity of the digital age that lets us more effectively target our interventions).

And finally, none of the green shoots of which I write here would have been possible without partnerships across sectors and borders (through global treaties, federal-local cooperation, and public-private initiatives). Partnerships grow our reach and allow us to pool resources to tackle challenges no single entity can solve by itself. As the saying goes, “If you want to travel fast, go alone, but if you want to travel far, go together.” Through partnerships, public health has traveled far indeed. We can travel even farther by continuing to pursue these collaborations.

Green shoots start small, but they grow. Our task is to nurture these shoots, so they develop into more robust systems and enduring improvements. Even in a time of skepticism and uncertainty, these hopeful trends help us to see that opportunities continue to abound for public health make progress, that the time to build is always, and that it remains within our power to do much to shape a healthier world no matter what the world may look like in the present moment.

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Also this week

In JAMA Health Forum:

JAMA Health Forum—The Year in Review, 2025

Upcoming at the WashU School of Public Health:

On Tuesday, March 31, we will host a WashU Assembly Series event, “Public Health in Challenging Times: Finding a Way Forward.” The event will feature a conversation with Georges Benjamin, Lori Tremmel Freeman, Scott Harris, and Laura Magaña about how public health can navigate this uncertain moment. Learn more and register here.

On Friday, April 3, we will host “Race, Reason & Health,” a symposium hosted by the School of Public Health and the Center for the Study of Race, Ethnicity & Equity. Learn more and register here.