The political decision that health matters

On centering health as a value that informs politics, particularly in divided times.

The newly installed administration, like every new administration, inherits a country facing many challenges. These include challenges in our energy sector, at our border, in the emergence of natural disasters, and in the geopolitical tensions that threaten to destabilize our world. They also include, centrally, challenges in health. The U.S. faces a range of problems that have held our health back relative to peer countries, problems such as substance use, gun violence, chronic disease, mental illness, and deep inequities that have created pockets of persistent poor health among populations. For example, black Americans sicken and die at a much higher rate than white Americans from a host of health challenges, such as diabetes, heart disease, and asthma. Black maternal mortality is also higher, as is the likelihood of this population being injured or killed by gun violence. The scale of these problems echoes the scale of challenges to health we see at the global level, including under-five mortality, the threat of infectious disease, and global inequities in health that concentrate a disproportionate burden of poor health in certain regions.

These challenges raise the question: How do we create health? This question is core to the work of public health, and our efforts to answer it have yielded a great deal of data on how to go about building a healthier world. Fundamentally, we create a healthier world by creating the conditions that generate health. This is reflected in the animating metaphor of The Healthiest Goldfish — that of the goldfish who died for lack of clean water. When it comes to health, our “water” is a metaphor for the conditions in which we live. Building a healthier world takes creating healthy conditions, such as clean air and water, nutritious food, accessible education, livable wages, and an end to the misogyny and racism that deprive many of opportunities for health achievement. Ensuring these conditions are in place can play a decisive role in improving health locally, nationally, and globally.

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On cruelty, liberalism, and the moment

Finding the signal in the noise of recent days.

This is a time of change and turbulence in our national conversation. President Trump took office a week ago, and with this new administration has come a raft of changes. I have written over the past few months about the importance of those of us who work in health remaining nonpartisan, of making an effort to take a big-tent approach to health, of leaning into hope and optimism and of recognizing that there are reasons why President Trump was reelected and that we should try to understand and engage with them. We should be willing, always, to listen and learn, towards gaining back some of the trust we as a field have lost. We also owe any new administration a chance to act according to what it feels the American people have called on it to do. We have just had a free and fair election in which two competing visions for the country were defined and debated. One of those visions won, and Donald Trump, for all that is problematic about him, is a known quantity that Americans, of sound mind and body, decided they wanted to reelect. These are facts with which we should engage and which we should seek to understand, with an open heart and open mind.

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Bias

There is a bias against having biases. Our everyday use of the word bias is derogatory, suggesting a belief that is unfounded and unfair; a bias is a prejudice. In biomedical science, by the 1970s, bias had largely become a statistical, clinical trial term with a negative connotation associated with misclassification, error, a flaw in an experimental design or data collection, and lack of validity. The moral association of the term “bias” is still apparent as a disparagement, something to be avoided in our experiments. Pushing against this dominant conception of the notion, we suggest that bias, seen as a part of science that is unavoidable, may be getting a bad rap. Perhaps a more neutral understanding of what bias is could offer some insight into the process of science and a preferable approach to our thinking about scientific work.

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Challenging health in 2025, part 2 of 2

On seizing opportunities to shape a healthier world in the new year.

In last week’s essay, I suggested four trends that likely will play an outsized role in health in the coming year: the need for new ideas in health, the rise of new approaches in how we engage with health and the forces that shape it, the creation of new systems that generate health, and the work of improving public health’s relevance. In that essay, I stressed that these trends and ideas long predated this moment, representing major shifts in our engagement with health. They are structural factors in what we do, currents that already are playing a significant role in health and how we work, collectively, to support it. The essay was, in a sense, countercultural to this moment in that it did not engage with the upcoming presidential transition. Certainly, the incoming Trump administration matters for health, but had Vice President Harris won the election, I still likely would have written much the same essay, in an effort to address these longstanding trends and issues in health. This aligns with the aspiration of these essays to, at times, pull back from the daily developments of politics and culture, the current events that shape the news cycle, to engage with what is driving events at the most fundamental level.

Having identified trends in last week’s essay, I would like today to discuss how we can tackle these trends in 2025. How do we challenge ourselves to intersect with emerging trends in the pursuit of a healthier world? It can feel, at times, like large-scale trends just happen to us, with little we can do to meaningfully affect them. However, I would like to suggest that we challenge ourselves to do more, that we can engage with trends to build a healthier world in 2025 and beyond. Toward this aspiration, I would like to suggest four challenges to health in this moment, inspired by four strategies that have guided our efforts at WashU as we have begun the work of building a great school of public health in St. Louis.

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A Science of Values

In the public realm, our values are thought to reflect our personal tastes, arbitrary and unverifiable—a matter of will and subjectivity. This subjectivity may seem to put values at odds with science and claims that can be objectively verified. A strong strain in science argues that we should remain “value-free” and even “ethics-free.” This perspective argues that we value the appearance of not having values, or at least having them well-managed through the use of objective methods.

Yet this fact-value distinction ignores a cultural and political reality: policymakers create policy that may include evidence but always has value commitments in mind. And various efforts in science are catching on, attempting to study values as an intrinsic part of science.

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What is next for health in 2025, part 1 of 2

On the trends and ideas that will shape health in the coming year.

This is the first Healthiest Goldfish essay of 2025. I hope all the readers of this newsletter had a happy, restorative holiday season with family and friends. For my part, I spent much of the season moving with my family from Boston to St. Louis, to join the new School of Public Health at Washington University. It is an exciting time, one of transition, of engaging with the possibilities of the moment and looking ahead to the future. Thank you to the many who have participated in this process—those at WashU, those in the wider world of public health, and you, the reader of The Healthiest Goldfish. It takes the proverbial village to build a healthier world, and, in this time of change, it is just such a village that we are building around the ideas that generate better health for all.

The start of a new year is a time for looking ahead, for thinking about the challenges and opportunities of the moment and how they might shape the next twelve months and beyond. In today’s essay, I would like to reflect a bit on what is next for health in 2025. What are the key trends that will likely define the pursuit of healthier populations in the coming year? What should our priorities be as we aspire to do the most good in this moment? We are in a time of social and political churn, with a range of influential forces shaping the present and, potentially, the future. However, it seems to me that the following four trends will be of special salience to health in the coming year, reflecting the ongoing work of shaping a forward-looking vision for health and suggesting our engagement with these forces should be at the heart of our collective priorities.

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Censoring Ourselves

One of the central tenets of science is that its work be allowed to follow the data, to publish the facts wherever they lead us, to the end of advancing knowledge and understanding. Scientists bridle, correctly, at any efforts aimed at stifling or censoring science. For example, recent efforts to censor science around climate change have been met with widespread opprobrium in the scientific community. Similarly, a few years ago, there was substantial pushback against efforts by federal funding agencies to align with a more conservative agenda that was being promoted by the then-president. In the main, countries such as the U.S. with a robust tradition of research have been able to maintain the progress of science, pushing back occasional politically motivated efforts to impose ideological agendas that censor the work of science.

But what happens when science starts censoring itself? It is no secret that science, the bulk of which happens in universities, is predominantly being carried out by scientists who have a particular ideological bias themselves. Fewer than 10% of U.S. academics, in one study, identified as being on the “right” of the political spectrum. In and of itself, there is nothing wrong with scientists having perspectives on the world around them, nor that those may cluster similarly, as do perspectives in all workplaces. But in the context of science, where the purpose is to dispassionately evaluate data, does such homogeneity of perspective affect the work of science? 

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Health, not all about the molecules

How population health science and biomedical science together can create a healthier world.

I recently had the privilege of interviewing Dr. Arati Prabhakar, the current Director of the White House Office of Science and Technology Policy. Our conversation was wide-ranging and I much enjoyed it (it can be viewed here on the White House website). At one point in the discussion, Dr. Prabhakar said, “Health is not all about the molecules.” I thought this was a terrific encapsulation of much of what we do in our engagement with health, a succinct distillation from someone who serves as the chief science and technology advisor to the president. Because, fundamentally of course, when we think of science and technology and health, we do often think about the molecules, about the “hard” sciences and the technological developments they yield. We are accustomed to measuring scientific advances in health as the emergence of new pills, potential genetic modifications, and biological enhancements. This perspective is understandable. Such innovations are important, and we would likely all agree that, when we get sick, we want to do so in a world with the best drugs and treatments. Yet it is also true indeed that “Health is not all about the molecules.” Drugs and treatments can help us when we are ill, but they are far less decisive in shaping the health of populations. Health, at its core, is a product of the conditions in which we live. Do we have clean air and water? Can we access nutritious food? Can we get a good education? Do we face racism, misogyny, and xenophobia? Are we financially afloat or do we lack the material resources to live economically secure lives? Such questions are at the heart of population health. They determine whether we live healthy lives or remain vulnerable to disease and preventable harm.

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