A purple public health: Disagreement as a starting point

This piece was co-written by Dr Salma Abdalla and is also cross-posted here.

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