Introducing the Purple Public Health Project

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

America needs public health. It needs public health to address urgent challenges—from obesity and cardiovascular diseases, to gun violence, to mental health and addiction, to persistent health inequities shaped by factors like economic status, race, and geography. It needs public health because we have already seen one global pandemic in the 21st century and will likely see more. It needs public health because climate change is real and poses significant risks for health, including for the health of the growing population of migrants forcibly displaced due to climate-driven shocks. It needs public health because the world needs public health, and America, for all the ruptures of recent years, still has the capacity to underwrite much that is good for the world.

America needs public health. Unfortunately, American public health is facing some daunting challenges.

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The art of being ourselves

Balancing pragmatic engagement with maintaining our identity and values.

We are in a moment that is marked by political upheaval, social division, and urgent challenges that demand engagement. The turbulent national and global moment has made it increasingly clear that if there ever was a post-Cold War “holiday from history”, it is certainly over. We may not yet be sure of exactly what the moment demands of us, but we sense it demands something, that passivity in the face of this new era is not an option. History moves, and we must move with it.

And the moment calls us to do, to take constructive steps towards a better future. We have a vision of where we want to go, a vision informed by our deepest values. We are moved to build a world where no one is excluded from health, where injustice and inequity no longer exist. This is a radical vision, and it is central to who we are in public health. The values that inform this vision give public health its meaning. Without our vision of better health for all, we would not be able to be who we are, do what we do.

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The time to build is always

Meeting the moment in the new year.

As we all return from hopefully a restful holiday season, I start 2026 with a nod to the seasonal. In A Christmas Carol, three spirits visit Ebeneezer Scrooge. The Ghosts of Christmas Past and Present are quite loquacious. But the third spirit—the Ghost of Christmas Future—says nothing. It shows Scrooge possibilities, a vision of his fate if he does not change his miserly ways, but it keeps its own counsel about what will ultimately be. Scrooge asks, “Are these the shadows of the things that Will be, or are they shadows of things that May be, only?” The ghost says nothing.

It is the start of a new year, and we face the same unknowability. We look to the future, wondering what 2026 holds. We try making predictions, as some years seems possible. In January 2024, for example, we could reasonably expect the year to be dominated by the American presidential election, and it was. Other years, however, events are a right hook coming out of nowhere. We thought we had some sense of the future in January 2020, then a pandemic came and knocked us off our feet. We spent the years since getting, sometimes unsteadily, back up. We learned much from the COVID moment; nothing more so, perhaps, than that the future always reserves the right to defy augury. We might do well to remember this.

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Looking back on 2025

Reflections on the challenging year that was.

As the calendar year wraps up, I would like to use this last essay of 2025 to reflect on the year we have just experienced. I would like to do this less to catalogue the year’s events and more to use this space, as I often try to do, to think in a systematic way about the world around us and what it means for how, and why, we do what we do. Events move quickly; the public debate often moves quicker still. Understanding what happens and why can be a challenge, one that calls for time and space to reflect, to think through the moment and its implications. The end of the year is such a time, and The Healthiest Goldfish aspires to be such a space, where we make an effort, together, to understand what is happening and the ideas that are driving the present moment.

So, what happened in 2025?

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On connecting too many dots

Ensuring the integrity of the associations that support our conclusions.

In 2020, a number of 5G masts were set on fire in the UK because of a belief that gained traction online linking 5G to the spread of COVID-19. Whoever committed this arson seems to have been motivated by the connecting of a series of “dots.” First (dot one), that 5G towers may weaken the immune system; second (dot two), that this made people more vulnerable to COVID; third (dot three), that 5G therefore, in a way, “caused” the pandemic.

It is easy to connect dots in ways that seem logical to us but do not withstand scrutiny. Sometimes these connections start with a fundamental misconception (such as that 5G weakens the immune system, which it does not), sometimes they start with correct, or at least plausible, information but go astray somewhere along the way. This was arguably the case with hydroxychloroquine during the COVID-19 pandemic. Early observational studies suggested there might be some benefit to its use. This was amplified rapidly through media and politics. But large RCTs, such as the RECOVERY trial, found no benefit. Nevertheless, hydroxychloroquine was touted for its supposed effectiveness, even as the data did not support this hype. The initial, plausible data point suggesting hydroxychloroquine may have some utility was quickly connected to other dots that had no bearing on its actual effectiveness, leading many to draw the wrong conclusions about the drug.

Closer to home, there has been much critique leveled at social science, in particular, for perhaps connecting too many dots, for making causal inferences too glibly. Are we maybe too quick to assert that a particular upstream neighborhood condition causes an individual health indicator? Are we connecting too many dots there? Is this, in part, why we have a replication crisis? We cannot avoid these questions if we are to shape a science worthy of the work we are trying to do, the world we are trying to create.

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Thinking outside the algorithm

On creating a better climate of ideas

Thinking back to when the internet was new is to remember a time when the world was promised an era of radical openness. The World Wide Web, we were told, would connect us and, in doing so, help us to better think, understand, and imagine. In some ways, the internet has delivered on this promise. It has linked anyone with web access to a flow of information that—in its speed, dynamism, and sheer complexity—resembles thought itself, a kind of global hive mind augmenting our ability to engage with everything, everywhere, all at once.

This Substack is, perhaps, a case in point, a small part of the great river of words and data that is the internet in 2025. The conversations, ideas, and connections that are the heart of The Healthiest Goldfish are enabled and deepened by the online world we have created, a world that has indeed opened new opportunities for how we communicate.

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Toward a more inclusive public health rhetoric

On embracing language that unifies in pursuit of health

In recent years, public health has engaged in a process of self-reflection about the language with which we communicate our ideas and engage with the public. This has involved asking at times uncomfortable questions, including whether efforts toward inclusive rhetoric in public health have had the effect of, in some cases, being exclusionary by acting more as progressive signifiers than as words and phrases that expand public health’s tent. This conversation has been informed, in part, by the 2024 election, in which the language of progressivism came under scrutiny for its role in possibly alienating elements of the public who might otherwise have been receptive to a message that aligns with many of public health’s preferred policies. In my role as dean of the School of Public Health at Washington University in St. Louis, I have had the privilege of being part of conversations with the school community about the signs and statements we embrace in our pursuit of health and how we can shape a style of communication that helps build a big-tent movement for health. Informed by these conversations, I wanted to revisit some ideas about how we can shape a rhetoric of trust and inclusion in public health, to build a movement that can create a better, healthier world.

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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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