A call for structured heterodoxy in medicine and public health

On doing the difficult work of engaging in conversation

The past few years have underscored the consequences of rigid orthodoxies in medicine and public health. The COVID-19 pandemic was followed by a deep erosion of trust in medicine and public health, fueled in part by shifting guidance during the pandemic and the enforcement of policies (e.g., lockdowns) that were seen in retrospect as heavy-handed.

Vaccination, one of the sentinel achievements of public health, has become a flashpoint, with hesitancy growing in part because community concerns about ever-growing vaccine schedules and about potential (even if unfounded) side effects, seemed to be unheard. Dietary guidelines, long promoted as settled science, later proved partly misguided, helping to energize movements like “Make America Healthy Again” that thrive on challenging expert authority. And in areas such as addiction, where abstinence-only orthodoxy dominated for decades, people were pushed away from services that could have saved lives until harm-reduction strategies forced a course correction. Taken together, these experiences have fueled challenges of orthodoxy in medicine and public health and have led to alienation from the very people we aim to serve. This should make us pause and ask: How can medicine and public health preserve the value of consensus while creating space for dissent that builds trust and advances knowledge?

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Idea Factories

How understanding where “our” ideas come from can help us have better ideas

This piece was co-authored by Dr Nason Maani, and is cross-posted here.

The very business of writing a Substack blog is to generate ideas, to hope that some people read them, that they provoke reflection, and generate even other ideas. Because fundamentally ideas are the raw material of progress, the foundation that then can become action. In the spirit of being self-reflective about this idea generation, we launched a series we have been calling Ideas about Ideas, reflections about where these very ideas come from. In our last Ideas about Ideas post, we talked about the social life of ideas. Today, some reflections on the structures that give rise to ideas, that perpetuate ideas.

It can be tempting to think of ideas as if they arrive to us, as individuals, in flashes of insight or inspiration. But most ideas are not born that way. Instead, they are products that have been made. Ideas have funders, deadlines, and production targets. They are the output of networks, incentives, and institutions within which we all live. And that has implications for how we understand the ideas that we ourselves have, and how we engage with, absorb, agree or disagree with the ideas of others.

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We should talk

On doing the difficult work of engaging in conversation

We live in bubbles. And our bubbles think and speak in similar ways. We spend most of our time talking with people who think like we do, who see the world through lenses not unlike our own. This is true across our professions, our social circles, and our political affiliations.

A recent study found that, “A large proportion of voters live with virtually no exposure to voters from the other party in their residential environment,” communities where nearly everyone they interact with votes and thinks the same way. While more and more attention is being paid to these “partisan echo chambers,” the pattern extends beyond politics. We see it in how we socialize, the workplaces we choose, the schools where we send our children, the churches we go to — or do not. There are many consequences of this siloing of our daily lives, but perhaps none is more consequential than the fact that our conversations tend to reinforce what we already believe.

I have written before about the importance of understanding people with whom we disagree. It is tempting to treat “understanding” as a purely intellectual exercise — something that happens at a comfortable distance. But understanding demands more than the dispassion of so stating it. It requires conversation.

Talking with people whose worldviews diverge sharply from our own is hard work. It makes us uncomfortable. It demands restraint, humility, and a willingness to listen without rushing to correct. It can feel safer to avoid the exchange altogether. Yet without conversation, we never truly experience the pluralism that we may claim to value as a core of our open-minded approach to understanding all people. Absent conversion we run the risk of remaining ensconced in our own bubble, mistaking comfort for clarity.

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On finding courage to stay the course

Part 2 of 2. The importance of doing what we do, even in difficult times

Last week I wrote about this moment of challenge. I suggested that in such a moment there are in some ways two competing impulses. The first: Should we rethink what we do, how we do it? Are there things we should do differently, and why? The other side of that is courage. What about all the things that we do, have done very well, that also may be under pressure? How can we have the courage to stand for things that matter to us? How do we find that courage? So, building on last week, this is about the second part of this formulation: courage.

Most of us admire courage. We admire it in others and aspire to it in ourselves. When faced with setback or danger, everybody wants to rise to the occasion. Nobody wants to feel like they have fallen short.

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On changing when we should change

Part 1 of 2. The importance of reimagining public health in an uneasy time

This piece was co-authored by Dr Nason Maani

Public health is at an uneasy juncture. Its central institutions face diminished public trust. The CDC has faced unprecedented cuts and challenges to its remit and organization. Funding for public health research has been under strain. Presidential declarations on diseases and vaccines have, at times, run directly counter to expert consensus. While understandably dominating the headlines, this is by no means a US-only trend. In more subtle ways, public health is being undermined in the UK too. Public Health England was disbanded, presented as a technical re-organization to strengthen pandemic preparedness, but also serving as a way of deflect criticism over COVID-19. This change replaced an arms-length organization that led campaigns and produced authoritative reviews with one embedded within health and social care, without budgetary independence or the ability to act autonomously. Two years later, a long-planned white paper on health disparities was scrapped. At the global level, health funding has been dramatically curtailed since January 2025. The immediate consequences of all this are increasingly visible: declining confidence in science and government institutions, resignations, confusion, policy vacuums, and a heightened vulnerability to mis- and disinformation

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How data can support a values-based argument for health

On the consequential, rigorous, and inquisitive science that should support a vision of a healthier world.

I recently contemplated how we might do a better job of engaging with the complexity of moral argument on issues of consequence for health. Today, I would like to continue this theme by revisiting an essay about the role of data in shaping and communicating our moral vision. While I have written about the importance of a values-based case for health, I balance that with the contention that such a case should rest on the best possible data, informed by science that is rigorous, consequential, and engaged with questions of central concern for health. It is science that helps us to engage in conversations that inform and persuade, to shape a movement for health. At the same time, data have a persuasive power all their own, even when they are not presented as part of a broader moral vision. Sometimes, clearly presenting the facts about a given issue can be enough to change minds. For these reasons, we should be centrally concerned with the integrity of the science that generates our data as a prerequisite to making the moral case for healthier populations.

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The Social Life of Ideas

Ideas about ideas, at a time when ideas feel endangered

This piece is co-written with Dr Nason Maani and cross-posted here.

Let us start with the present.

We are living in an unusual time. After many years of gains for more open liberal societies, populist forces are in ascendance. Several countries that nominally are open, democratic, and have freedoms of expressions are actively working to suppress media, universities, and other outlets that generally have been engaged in developing and disseminating ideas. Other countries, including some of the largest in the world, have long been operating in a sort-of unsteady social compact, where the population benefits from increasing prosperity, as long as it does not raise too many ideas that may threaten a status quo.

Whither then ideas?

We think ideas matter and are the core of liberal societies. We are interested in the enormous progress afforded by liberalism through core values of pluralism, diversity of perspectives, reasoned and rigorous debate, and gradual improvement of the world we live in, not as a partisan project, but as an intellectual foundation to a better world. And that matters to all we do in health as an aspirational foundation to that very world.

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On the complexity of moral argument

Understanding that good people, for good reasons, hold on to ideas we strongly disagree with

Your neighbors voted for the candidate you cannot stand. They are also friendly, congenial neighbors and regularly bring you baked goods.

Your cousin works in marketing at a tobacco company. They are also a wonderful parent, and you enjoy spending every Thanksgiving together.

Your friend since childhood is avowedly against any form of regulation to industry, convinced that those who cannot make it in a completely free market are simply not trying hard enough. You have enjoyed going on vacation with them every year since you were young.

In a time of partisan rancor, it is becoming — at least in the public narrative — almost impossible to engage with those whose perspectives might differ markedly from ours. For anyone who is engaged in the business of population health, political choices, and the candidates who espouse them, matter, as does caution to create the right framework for corporate incentives and disincentives, and minimizing the impact of harmful products.

How could rational, good people, feel so strongly, so differently than we do?

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