We may disagree

On ideas, criticism, and the generative debates that shape a healthier world.

In recent writing for The Healthiest Goldfish, I have argued that we are in a post-war moment for public health. By this I mean that the disruption of the pandemic created space for a reimagining of public health, a shoring up of its foundations by integrating the lessons of COVID into what we do, to shape a new practical philosophy for our work. This has meant asking questions about what is most fundamental about what we do. Questions like: What is health for? What are the limits of science? How can we better center proportionality in public health thinking? How do we reconcile the role of individual behavior in shaping health outcomes with the structural drivers of health? How should we think about the influence of context, effort, and ability in shaping these outcomes?  

These questions are consistent with writing I have done for many years in an effort to engage with the issues that matter for public health. I write because I have long believed that this is how ideas shift and change—through a process of thinking, writing, and debate. Participating in this process can, over time, help to change the paradigm around health, getting us closer to a healthier world. I encourage others to engage in this process, toward the goal of a more inclusive public conversation with many perspectives represented. Writing is at its best when it is a conversation, a debate. It is in the space between different views, in the generative conflict of ideas, that we sharpen our thinking and elevate the ideas that create a better world. As long as I have had a voice that people have listened to, I have seen it as part of my responsibility to engage in these conversations. This was the case at the beginning of my career, and it remains core to my current role as Dean of a school of public health. As such, I welcome views that are different from my own, I learn from them, and I would consider my time poorly spent if I did not, in the course of my daily reading, encounter one or two pieces of writing which challenge how I see the world.

It was in this spirit that I wrote the essays which became my upcoming book, Within Reason: A Liberal Public Health for an Illiberal Time. The book aims to hold a mirror up to the work of public health, to consider both our strengths and where we have stumbled, to challenge our field to be its best. Such conversations can be difficult, uncomfortable. Just as the process of exercise can result in sore muscles, self-reflective discussions can generate disagreement and criticism. To my thinking, this disagreement lets us know we are doing something right. It indicates that our conversations are addressing something real towards advancing progress that makes us better as a field. I can, for example, anticipate, and indeed welcome, several criticisms which may emerge in response to the ideas I have shared in these essays and which I develop at length in Within Reason. They reflect the start of a conversation that can, hopefully, help us move towards a new understanding of public health in this moment.  

The first criticism is that, in addressing areas where public health can potentially do better, I have forsaken the values that have long been the basis of public health, abandoning a radical vision of a healthier world for something more reactionary, even right wing. This is not the case. I have spent my career arguing for a range of progressive, even radical, policies in pursuit of a healthier world. They include Medicare for all, a more welcoming immigration policy, a world without guns, reparations for slavery, and a more robust social safety net. I still believe in these policies and support working towards them pragmatically, embracing a “radical incrementalism” that helps get us to a better world. Far from changing my philosophy, I see myself as being where I have always been, standing for a vision of a healthier future and the steps that can most effectively get us there. I was moved to write the essays that become Within Reason because it seems to me that, in recent years, public health has drifted from its core values of small-l liberalism. This strikes me as not just a deviation from what our field has long been about but, ultimately, as a less effective way of pursuing our goals, of making our radical vision of health a reality.

The second criticism is that, when an empowered right wing is pursuing policies which threaten the health of populations, it is dangerous to be pointing out the shortcomings of public health. In Within Reason, I address this with a passage from George Orwell:   

“A phrase much used in political circles in this country is ‘playing into the hands of’. It is a sort of charm or incantation to silence uncomfortable truths. When you are told that by saying this, that or the other you are ‘playing into the hands of’ some sinister enemy, you know that it is your duty to shut up immediately.

For example, if you say anything damaging about British imperialism, you are playing into the hands of Dr Goebbels. If you criticize Stalin you are playing into the hands of the Tablet and the Daily Telegraph. If you criticize Chiang Kai-Shek you are playing into the hands of Wang Ching-Wei—and so on, indefinitely.

Objectively this charge is often true. It is always difficult to attack one party to a dispute without temporarily helping the other. Some of Gandhi’s remarks have been very useful to the Japanese. The extreme Tories will seize on anything anti-Russian, and don’t necessarily mind if it comes from Trotskyist instead of right-wing sources. The American imperialists, advancing to the attack behind a smoke-screen of novelists, are always on the look-out for any disreputable detail about the British Empire. And if you write anything truthful about the London slums, you are liable to hear it repeated on the Nazi radio a week later. But what, then, are you expected to do? Pretend there are no slums?”

Public health is not perfect and to pretend otherwise is to leave its imperfections dangerously unaddressed in a moment when we need to be at our best. We are at our best when we are a discipline informed by a diverse range of perspectives, dedicated to a vision of a healthier world. We need to have the self-critical conversations that shape a better, more effective public health because this is our field—we are the ones who have its best interests at heart. If we do not engage in this criticism, we will leave it to those who criticize public health not to make it better but to make it go away. Certainly, our criticisms can, and sometimes will, be used by those who are not engaging with us in good faith, but that is not a reason not to make them. It is, instead, a reason to do so always with care, in a spirit of free and open debate, guided by the values of small-l liberalism. This is how I have always tried to engage with issues throughout my career.    

There is, of course, a case to be made that we need a more radical approach, that we are at a time when a liberal engagement with issues is unacceptably milquetoast, inadequate to the challenges of the moment, and that those who espouse a return to liberal principles are enabling a status quo that harms health. I respect this perspective, and have, at times, felt the frustration which underlies it. To argue for a liberal approach in a time of crisis can be to seem as, at best, out of touch with the moment, and as, at worst, a counterproductive influence. In this context, the case for pragmatism can appear tantamount to the case for inaction, for giving up on addressing the injustices that create poor health.

In response to this, I would cite an example from history. In his famous broadcast against Senator Joseph McCarthy, Edward R. Murrow said, “This is no time for men who oppose Senator McCarthy’s methods to keep silent, or for those who approve.” In speaking out about McCarthy, Murrow and his team took a risk. They were running afoul of a powerful politician who had destroyed the lives of many and who still had much support in the country. The US also faced a genuine threat from the Soviet Union and, in calling out McCarthy’s redbaiting, Murrow and his team risked the charge that they were giving aid and comfort to the enemy. Yet even at that fraught moment, Murrow still made a point of saying that the public conversation needed both sides of the argument—those who opposed the Senator and those who approved of him. This is the essence of small-l liberalism. It says that to surrender our principles in the face of challenge—to respond to the demagogue by becoming like him—is to lose ourselves and our cause. We need more debate, not less. It would be easy to spurn this engagement, to preach to the choir, embracing bumper sticker slogans over reasoned argument. There are personal and professional benefits to moral grandstanding, but they do not include the creation of a healthier world. For public health to build such a world, it needs to pitch a big tent, welcoming those from many social, political, and economic backgrounds. Insisting on ideological purity risks keeping us small, a clique rather than a movement, to the detriment of our work.

To those who read this and find themselves disagreeing with me I say, first and foremost: thank you for engaging in this space. I write essays, books, and articles because I believe that ideas are best presented in a context where they can be explored in all their nuance and complexity. In an age when so much is reduced to a tweet, it is a privilege to be able to discuss ideas at length and have a readership willing to engage with them. Within Reason (which can be preordered here) is an effort to continue to explore the issues I have raised in this newsletter, to get beyond the occasional distortions and misrepresentations of online media and present a nuanced case for a public health that balances principle and pragmatism. I much look forward to the conversations ahead.