The Values That Guide Public Health

Throughout history, ideas have emerged, forming the basis for a better world. The ideas that form the intellectual grounding for public health are, in large part, a product of the European Enlightenment, although they are, of course, informed by other cultures and traditions.

It was the Enlightenment that originated what we now call small-l liberalism. Philosophers like John Locke and Thomas Hobbes expressed a view of society and politics based on reason, free speech, individual rights, and a government that derives its legitimacy from a social contract between rulers and ruled rather than from assertions of divine right.

Over time, this vision evolved into an understanding that societies should be organized in support of human rights, with a focus on creating the material and political conditions that sustain these rights. This perspective informs the core principles of public health, focused as we are on improving the health of populations by creating a context that supports health.

How do these values underlie the work of public health? It strikes me that public health in its current form most clearly intersects with the principles of small-l liberalism in our embrace of three key values: freedom, equity, and the pursuit of truth. These principles are foundational to public health—at the roots of our field—in addition to being core concerns of the philosophers whose ideas birthed Enlightenment liberalism.

We start with freedom—a word which can have different meanings for different people. For some, freedom is simply the capacity to do what we wish, unhindered by all but the most basic restrictions. For others, freedom means being able to live free from preventable hazard and disease, which can mean accepting certain necessary constraints.

I have long thought it best to pursue a balance between these two definitions of freedom, mindful that one does not overshadow the other. In the U.S., we have not always been effective at striking this balance. In our politics, we have often seen efforts which would undermine health attempted in the name of “freedom.”

These include opposition to commonsense gun control, attempts to dismantle the Affordable Care Act, and a general hostility to the social safety net. Because these efforts tend to come from those on the right, many on the progressive left—a group which is well-represented within the ranks of public health—have come to see freedom as, at least rhetorically, shorthand for a political outlook which is inimical to the policies which support a healthier world.

It is important to acknowledge this, and the conditions that have led many to, understandably, regard freedom skeptically. Yet it is also the case that freedom can mean much more—that it can, in fact, align with the mission of public health. A context of freedom allows us to live healthy, happy lives in which we are able to pursue what makes our time on earth meaningful.

We should not surrender the pursuit of freedom to those who define it differently than we do. Rather, we should embrace and promote an understanding of freedom that aligns with the mission of public health.

Next, we are committed to the value of equity. This reflects our understanding that, even in a context of liberalism which aspires to create equality of opportunity for all, there can still be much unfairness. This unfairness is often structural, emerging from a context of historic injustice which echoes in the present.

In the U.S., for example, the legacy of slavery and racism has created a context where many Black Americans are born into conditions of disadvantage not faced by their white counterparts. Creating equality of opportunity in the U.S. means addressing the structures that create this disadvantage, leveling the playing field for all. A concern for equity helps us to see how, sometimes, what looks like fairness can hide this structural disadvantage. It is up to us to advance opportunities for equal achievement and thriving by first addressing the injustices that can prevent everyone from having an equal start in life.

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Finally, we are called by our values to the pursuit of truth. Creating a better world means first clearly seeing the world as it is, through our pursuit of truth. This pursuit is not always easy. It means being open to facts that may complicate our preferred narratives. It also means subjecting our ideas to the rigorous debate, peer review, and good-faith critique that helps us to see when we are wrong, a necessary but sometimes uncomfortable process.

It has been disheartening to see how, in recent years, it has become more common to shy away from this process. It has been particularly unfortunate to see this happening in academia, where forthright engagement with difficult topics can at times be conflated with giving quarter to hate speech. This has arguably had a chilling effect on the public conversation, leading Nadine Strossen, a former president of the American Civil Liberties Union, to suggest that speech norms on college campuses are now reminiscent of the McCarthy era.

By serving as a unifying influence, these values are core to the work of creating a better world. They provide the cohesion necessary for the collective action that drives positive change. Public health has long emphasized the importance of a collective approach to health. This perspective helps provide a counterweight to the view that health is entirely a matter of individual choices and behaviors.

In public health, we engage with health from the perspective of populations, addressing the forces that shape health at the macro level. This task is too big for any one person; it takes the collective action of many, united around animating values. These values help us to imagine and articulate a vision of the world as we would like it to be–a healthier world characterized by freedom, equity, and the pursuit of truth. The better we understand these values, and the philosophical tradition from which they emerged, the better we can advance the mission of public health.

This piece also appears on Substack.