Balancing Our Focus on Context, Ability, and Merit

In recent years, a highly polarized political discussion has emerged about meritocracy in the U.S. On one side of the debate is what might be called the classic view of American meritocracy, the Horatio Alger-esque story¹ of striving for one’s way to success through individual ability and effort. In this framework, all have more or less equal potential to rise, and only differences in individuals’ talent and effort shape differences in life outcomes. This has arguably long been the dominant narrative about meritocracy in the U.S.

More recently, however, a new narrative has emerged, one that, in many ways, aligns more closely with our public health paradigm. This narrative says that what has passed for merit (for example, doing well on exams, being promoted, or simply being healthy) is a product of engrained social systems. Structural forces–such as systems of historical injustice, present-day inequality, or marginalization due to identity status–have created a context² that advantages some and disadvantages others.

It makes sense that this perspective, aligned as it is with our goals in public health, has shaped our attitude toward achievement and merit. So deeply versed are we in the forces that shape health gaps, in their profound influence on the health of populations, in their persistence in our society, and in the urgent necessity of closing them that it can be difficult to see beyond this focus, to consider other factors that influence life outcomes at the level of individuals and populations. Indeed, it can be uncomfortable for us to engage in conversations about these factors because it can be uncomfortable for us to talk about the role of behavior and poor choices that can lead to disease and preventable harm.

Yet it is precisely now, in articulating a post-war, practical philosophy of health, that we have an obligation to tackle what is difficult and uncomfortable in shaping the intellectual foundations of the next phase of public health achievement. We need to talk about the subjects we do not talk about enough. This requires us to think critically about the intersection of context, effort, and ability and to acknowledge two truths. First, if all things are equal (thus, if the context is removed from the equation), people will have differing levels of effort and ability. Second, all things are not equal. Public health's role is to hold both truths and create conditions that work toward an “all things being equal” world and promote dignified life paths for people of all levels of effort and ability.

The role of effort in shaping the trajectory of our lives and health may be obvious to most but often neglected in the mainstream health conversation. This is, perhaps, understandable. To discuss the importance of effort is to run the risk of seeming to stigmatize those who may not apply the same level of effort as others. To speak of effort, after all, is to speak of something which is largely within our power to influence. Anyone who has lived a life knows the value of hard work, yet it can be difficult to acknowledge this collectively as a field.

This difficulty is, in part, due to concerns about harmful prejudice. It is also because of how "effort" has been weaponized in bad faith by political actors trying to justify disinvestment in the social safety net and other policies that support health, much like how concerns about “personal responsibility” in the area of health-related behavior have been used to attack the policies we favor. Justifiable concern for not fueling these attacks has informed a hesitance to discuss effort forthrightly.

Yet, as I wrote recently, just because something can be used in bad faith does not mean it is not true, and to refuse to engage with uncomfortable but empirically grounded topics gives opponents of public health the greatest possible gift: the ability to say that they are the ones engaging with truth while we are running from facts, from the science. When the truth is suppressed for ideological reasons, it does not eliminate inconvenient facts. It just drives them underground, where some truly unsavory actors lurk. We cannot afford to cede the territory of truth to such people. So, we must acknowledge that effort and hard work matter and make a difference, independent of context. That, all context being equal, some people choose to eat healthier, exercise more, and smoke less. And all of this seems worth acknowledging in our individual spaces, recognizing that what we understand and talk about shapes how we think and move the field forward.

Moving to the equally tricky concept of “ability," the idea of ability is simultaneously obvious and anathema to our foundational thinking about health. It is obvious, for example, that I can never achieve stardom in basketball, grazing 5’10’’ as I do on a good day. But it's also obvious in other ways. I grew up playing, loving, and trying my best to be great at soccer. From an early age, it was clear that, despite my effort, I did not have whatever ineffable inner geospatial awareness is required to touch a ball with your feet and have it go where you wish it to go to be successful as a player. Every kid who has ever played a sport knows this–ability is part of who we are, what makes us. We can work hard and improve, but some people are simply born with “it,” while others are not.

Should we have systems that reward effort? Absolutely. Is there such a thing as advancement based on merit, like effort? Absolutely. But all of that is superimposed over the unearned advantages of context and ability, and it is our job to structure the world such that the benefits that accrue to effort (the “meritocracy”) are not such that they obviate the benefits that should accrue to all. We can create opportunities and address the effects of societal and individual shortcomings without saying these shortcomings are bad. We can valorize ability and encourage effort without stigmatizing and abandoning those who stumble or lack an excess of inborn ability. A mature public health can hold all of these truths, and we need a mature public health to meet the moment's challenges.

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A version of this post also appears on Substack.