I have written previously about the aspirations of public health, seeing public health more as a journey, a path on which we should always be traveling, towards creating a better and healthier world, rather than as any specific set of actions, prescribed by narrow strategies. The challenge in that vision is that it risks being too broad, too all-encompassing. It then often falls on us to ask: what matters most? What should we be acting on to best advance our aspirations?
These questions can seem abstract. But the COVID-19 era has made them perhaps sharper in our minds than ever, providing urgent, real-world examples of their relevance. Addressing these questions is an animating force behind why I am writing The Healthiest Goldfish. Chiefly, I am trying to understand, through writing, what matters most to those of us who care about the aspirations of public health. I have, with colleagues, written previously about what matters most from a technical perspective, but in a year when we are (hopefully) emerging from COVID, I find myself asking—what values and aspirations should we be foregrounding, as we look towards creating a healthy future?
I was recently reflecting on this question by thinking about parallel universes, which, in my disciplinary home, epidemiology, we call counterfactuals. These counterfactuals allow us to model how the introduction of a given variable might shape health. We do so by comparing a real world where someone may, say, smoke, with a counterfactual universe where that same person, with everything else held exactly the same, does not smoke. This allows us to compare counterfactual universes where all is the same except for that one variable, whereupon we can then conclude that if the person we are observing gets lung cancer in the universe where she smokes—and avoids it in the universe where she does not—we might say with some confidence that smoking causes lung cancer.
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