Health as infrastructure, not intervention

Ebola reminds us of the need for the scaffolding we often do not see until it fails.

As of now, over 1,400 suspected or confirmed cases of Ebola, and at least 200 deaths from the disease, have been reported in the area of Congo and Uganda. Outbreaks like this are challenging in the best of times, as communities and health workers do all they can to contain the spread. Such efforts helped to limit and ultimately end the 2013-2016 West African Ebola outbreak, which could have been far worse without the presence of global health infrastructure—the network of NGOs, government agencies, public and private investment, and international bodies dedicated to supporting health and preventing disease around the world. When such programs are well-funded and working, the world is a safer, healthier place. When they are not—when they are subject to firings and funding cuts and a collapse of political support, as they have been over the last year or so—this creates a difficult context for global health. That the present Ebola outbreak has emerged in such a context is cause for concern indeed. That we have entered a time of disinvestment in global health infrastructure reflects what could be fairly called a blind spot in how we in the US think about health and the infrastructure that supports it at home and abroad.

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.

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When public health succeeds and no one hears it, does it make a sound?

Thinking about how we communicate public health better

This piece was co-authored by Dr Matthew Kreuter and Dr Rachel Garg.

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.

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A Purple Public Health: The individual and the public

Rethinking autonomy in a field that serves populations

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

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.

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Ideas that crowd out alternatives

Why the most prominent ideas are not necessarily the best.

This piece was co-authored by Nason Maani, and his version is cross-posted here

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).

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To the public health class of 2026

As a new cohort of public health professionals start their careers, some thoughts on the aspirations that guide our work.

We are in the midst of graduation season, which I have long considered to be the happiest time of the year. It is a joy to gather with graduates, family, and friends and wish the next generation of public health professionals well—as I had the privilege of doing last week at the Andrew M. and Jane M. Bursky School of Public Health at Washington University in St. Louis, where I serve as dean. The commitment of these graduates to the work of public health, and to the values that support this work, is a source of hope indeed, as much a sign of renewal as the flowers that accompany this time of year.

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.

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Into the light

During commencement season, toward a brighter day for public health

Last month, the Artemis II mission successfully flew to the moon and back. Astronauts Victor Glover, Christina Koch, Jeremy Hansen, and Reid Wiseman crewed the Orion spacecraft, which they named Integrity, in the first human-led flight beyond low earth orbit since the Apollo 17 mission in 1972. The lunar flyby was conceived as a test flight in support of further Artemis missions, with the goal of returning humans to the moon’s surface.

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.

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On being useful

In a rancorous public moment, what could I possibly do?

More or less every day, I find myself engaging in conversations around some variant of this question: “in a world where so much seems awry, what could I possibly do?” My answer generally is that we should be leaning into what we do, doing it as well as we can, and that this, in and of itself, is useful for the world.

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.

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On finding the discipline to engage

A case for doing the uncomfortable, essential work of listening to ideas we dislike.

There seems to be a growing tendency, in public health, universities, and elsewhere, not to engage with anyone who holds views with which we may disagree. We can see this in a hesitance to invite speakers to events whose views fall outside the mainstream of accepted opinion (or our own opinion), in an unwillingness to appear in certain spaces where ideas we do not like have been aired, and in a general sense that the social distancing of the pandemic era seems to have extended into the realm of ideas, keeping us and our institutions from the perceived intellectual and moral dangers posed by contact with divergent points of view.

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.

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