A purple public health: Incentives and the research we don’t do

Why what we study is shaped by our motivations, and what this means for what we know

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

We all create our stories. Who we are and what we do are grounded in the foundational narratives that bring coherence to our day to day. Our work in public health is no exception. The foundational story of population health science and scholarship is that we work to advance health through the force of good ideas: the right questions rise, evidence accumulates, truth wins out. It is a flattering self-image. It is not, however, entirely accurate. Yes, there is much that we do that emerges as we follow the idea-trail, informed by our best thinking about how we generate health. But there is also much that we do that is determined by far more prosaic motivations: by what is funded, fundable, publishable, and institutionally rewarded. The “marketplace of ideas” is, in practice, a market, with budgets, buyers, and incentives. This is not a story of bad actors, but of structures. It is important to understand those structures in order to see where there are gaps in our thinking, and why it is that particular populations may be left behind in having questions that matter to them answered.

It is abundantly well-established that what is studied, and what is funded, are only weakly related to what the actual population burden of disease is. Gross, Anderson, and Powe found NIH funding tracked some measures of disease burden but diverged sharply for many conditions, with clear over- and under-funded outliers relative to need. Replications across decades have shown similar findings; Gillum and colleaguesfound funding poorly predicted disease burden, and a more recent analysis found very limited correlations between NIH funding and five measures of disease burden across 27 conditions.

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Thinking and writing in the age of AI

A two-part reflection on knowledge generation and our technological future.

Before getting into today’s essay, a brief note about some events I will be doing related to the launch of my new book, Why Health? What We Need to Think About When We Think About Health. On September 24, I will join Jessica Steier, of Unbiased Science, for a Substack live conversation about the book. On October 5, I will join Katelyn Jetelina, of Your Local Epidemiologist, for a conversation in Washington, DC, at Busboys and Poets. On October 22, I will be at The Novel Neighbor in St. Louis, MO, for a reading and Q and A. I look forward to these events, to continuing the conversations that shaped the ideas in Why Health?

Now, on to today’s topic.

This is the second part of a two-part series on AI and the future of knowledge generation. Last week’s essay addressed the intersection of AI and universities, touching on how higher education can survive and thrive in the AI era. Today, I would like to move from what AI means for knowledge generation at the institutional level to what it means for individuals. How should those of us who spend our careers in the idea space approach AI in our own lives and work? What does a healthy engagement with AI look like? What standards and best practices should facilitate this engagement in academia and beyond? These are difficult questions, not to be answered lightly, but rather through a process of conversation, of trial and error, of a collective working out of how to best navigate this technological moment. In the spirit of contributing to this conversation, some thoughts on thinking and writing in the AI era, and what this new technology may mean for those who work in the academic space.

Over the last few years, AI has increasingly dominated the conversation about writing and ideas (as well as conversations about much else). Within academia, AI is the elephant in many rooms, raising questions about what this new technology means for the fundamentals of how we do what we do. Questions like: what does AI mean for the practice of research, peer review, and other core academic tasks? Should AI be used exclusively for technical work, or does it have a role to play in the actual generation of ideas? Perhaps at the more existential level, should we be afraid AI might replace us—replace the individuals and institutions whose job is to think, teach, and engage in the idea space? Is AI a tool, even a partner, to be welcomed, or a rival to be warily regarded?

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Thinking about, and with, AI

A two-part reflection on knowledge generation and our technological future.

Before jumping into the theme of today’s essay, I would like to take a moment to acknowledge, with appreciation, the reaction to last week’s announcement of the launch of my new book, Why Health? What We Need to Think About When We Think About Health. It has been a joy to encounter such enthusiasm for the book’s ideas and for having the conversation I long hoped it would help spark about shaping a new practical philosophy for public health. I am excited to continue this conversation in the weeks and months to come.

Now, on to today’s subject.

Last month, The Healthiest Goldfish featured a three-part series about the intellectual foundations of public health including essays on the role of universities, science, and how both contribute to a healthier world. It seemed a ripe moment for such a series, coming as it did at the start of a new academic year, and at a time when the intellectual scaffolding of public health is shifting. The pieces seemed to resonate, with many readers reaching out to say the essays’ themes align with their own thinking about, well, thinking—about the ideas that shape the health endeavor and the institutions that shape these ideas.

Yet, as I have had conversations about these topics, a question keeps emerging: what about AI?

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Introducing Why Health?

A practical philosophy of public health for a new global moment

Why do we wish to be healthy? What is health for? What does it mean to pursue health in this moment, with the memory of COVID still fresh and public health facing political headwinds and a collapse in public trust?

These questions have been central to my thinking over the past few years, as I have tried to reckon with this unstable time for public health. This post-pandemic moment—which I and others have characterized as a “post-war” moment—is a chance for reflection, for evaluating what is fundamental about our field, the philosophy that animates our work at the deepest level.

When we look at the sweep of public health’s history, we see a field that has had remarkable successes. The treatment, even eradication, of deadly diseases. The doubling of global life expectancy. The development, and widespread dissemination, of vaccines. These successes rank among humankind’s greatest achievements. They were won by a combination of knowledge, values, and approaches which have long served public health well.

But we are in a new era. We can no longer assume the thinking that sustained us in the past can reliably do so in the present and future. Proof of this is in the challenges public health faces, its ongoing identity crisis in which our field remains a shadow of the confident, trusted, outwardly engaged movement it once was.

This is fixable. We can not only regain our footing, we can also build new foundations on which to stand. I serve as dean of the Andrew M. and Jane M. Bursky School of Public Health at Washington University in St Louis. Each day, I have the privelege of seeing our students grow into the public health leaders this moment needs. Their talent, their comittment to the work of public health, their keen understanding of this moment give me confidence that public health will find itself again.

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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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