An argument for intentional moderation

Holding the center in an age of extremes.

I would like to talk about moderation. Most of us, if asked our view on moderation, would likely say it is something of which we could use more in our public life. Yet, when we look around, we often see this sentiment “more honored in the breach than the observance.” This is true in our political and cultural ecosystem, and it is true, perhaps particularly so, in our online spaces. If you have been on the internet long enough to find this blog, you have probably seen how extremism, in ideas and in their expression, is often the order of the day.

Yet it is not just at the political rally, on the social media site, on the tongues of bitter partisan foes that extremism poses a problem. It is also in the moments when a touch of immoderation, of overstatement, creates a kind of “cried wolf” paradigm in how the public is presented with key issues, complicating efforts to address them. The reasons for this presentation are often understandable, sympathetic. We may care deeply about an important issue and find ourselves frustrated with the lack of public action on it. So, when we talk about it, we may overstate the risks of inaction, presenting worst-case scenarios—which, while certainly live possibilities, are not the likeliest trajectory for the issue to take according to the data—as if they are open-and-shut representations of the future.

Read more here

Ideas about Ideas: The limits of technocratic thinking

What are the limits of expert evidence-based analysis?

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

We are largely rationalists. After all this essay—part of our ongoing Ideas about Ideas series—is being written from within universities where we spend our careers trying to understand data to identify fact. While we are both often working on social science contexts, our disciplinary training began in medicine and biomedical science, making us even more wedded to empirically grounded, expert-led, evidence-based analysis. There is no question that this approach has done enormous good and remains the foundation of science and what we do in universities. But are there limits to the insights that can emerge from such rationalism? What would a more honest public health look like if we acknowledged the limits of this approach?

If we look closely enough there are plenty of examples where public health hit a wall, not because the evidence was wrong, but because the question that dominated the questions of the moment was not one that any kind of study can settle. Think for example about the recent pandemic, where much animus and political division was cloaked in “what do the data say?” or “follow the science” when in fact what we should have been asking was “what should we do, balancing data and other things that we value as a society?”. Think of the opioid epidemic that was fueled in part by OxyContin marketing. It was in large part built on technocratic claims about addiction risk that turned out to be an ideology about pain medications masked as data. Or think about any number of academic debates where we preserve the peace by deferring to a methodological difference in perspective when in fact the foundational question was about what we were trying to understand in the first place. Technocratic thinking emerges when we treat the answer to societal questions as though they were merely technical questions. But so very few questions that matter to societies, certainly in health, are technical in nature.

Read more here

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.

Read more here

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?

Read more here

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?

Read more here

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.

Read more here

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.

Read more here

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.

Read more here