Universities, social purpose, and the generation of health

Part three of a three-part series on universities, science, and the promotion of health as our social purpose.

This is the third and culminating essay of a series on the intellectual first principles of public health. The first essay concerned the role of universities, arguing that universities do three things no other institution does together: generate ideas, teach students, and translate ideas toward a better world. The second essay argued that science, the beating heart of the ideas enterprise, is the best thing we can do for homo sapiens sapiens, the one endeavor by which the species systematically elevates its own condition.

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.

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Why science?

Part two of a three-part series on universities, science, and the promotion of health as our social purpose.

Last week’s Healthiest Goldfish essay was the first in a series of three essays about the process of knowledge generation that is at the heart of all we do in public health. In that essay, I considered the role of universities in this process and how we can strengthen and sustain universities in a time when they are being challenged. Today, I would like to engage with another essential element of knowledge generation: science.

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.

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What are universities for?

Part one of a three-part series on universities, science, and the promotion of health as our social purpose.

Summer break offers a bit of an opportunity reflection about what one does, why one does it, and how to do it better. Over the past few weeks, I have found myself thinking about something at the heart of all we do in health—the process of knowledge generation. What we do is upstream of what, and how, we think. As we look ahead to the end of summer and a reengagement with a livelier pace of work, I would like to use this space for a three-part series of reflections on the thinking that drives all we do, the institutions that shape this thinking, and the social purposes that our knowledge helps to define and advance.

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.

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On soccer, the World Cup, and the water we swim in

A Goldfish extra, reflecting on the role of opportunity in soccer and health

This piece was co-authored by Mohammed Abba-Aji, and also appears here, on his new Substack.

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?

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How America’s founding ideas have made the world healthier

A reflection on the country’s 250th birthday

Today the US celebrates its 250th birthday. It is notable that the US marks as its founding not the anniversary of the victory of the continental army at Yorktown, nor the adoption of the Constitution, the seating of the first Congress or the inauguration of the first president, but, rather, the day when the delegates of the Second Continental Congress formally approved the Declaration of Independence. That moment marked the birth not just of a new country, but of a new idea—that an assumption of basic human equality could serve as the foundation for a state, and that the state should be a safeguard of the rights such equality demands—namely rights to “life, liberty, and the pursuit of happiness.”

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.

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The responsibility of idea stewards

What we owe the ideas we inherit

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

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.

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A purple public health: Disagreement as a starting point

Studying and practicing public health amid real values divides

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 Februarythat 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.

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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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