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Let's define "radical" as "of change or action: going to the root or origin; touching upon or affecting what is essential and fundamental; thorough, far-reaching."
This definition aligns well with the work of public health. We are centrally concerned with "going to the root or origin" with "what is essential and fundamental." We pursue our work with the understanding that the creation of a healthier world is, by definition, engagement with the foundational drivers of health.
This is reflected in a metaphor I have long used to explain the work of public health. It is that of standing on the bank of a river, seeing people falling in, and pulling them out one by one before realizing that the more fruitful action is to address what is throwing them into the river in the first place. This metaphor explains what we do to those new to public health and has an important place in illustrating the philosophical underpinnings of our work.
For a long time, society's collective focus has been overwhelmingly on pulling people out of the river through medicines and treatments—through healthcare—rather than on creating a world where no one is thrown in the river in the first place (i.e., creating a world that is fundamentally healthy). In attempting to reorient the public conversation about health, we have, as a field, out of necessity, emphasized in recent years the structural drivers of health more than we have engaged with the means of pulling people out of the river—doctors and medicines. To this end, I have long tried to help support a public conversation that focuses more on the upstream drivers of health.
At the same time, it has always seemed right to me that we aspire to balance engaging with upstream forces and working in the here and now to help as many people as possible by pulling them out of the river. For a long time, this balance was lacking, and attention was disproportionately on pulling people out of the river at the expense of keeping them from falling in. This necessitated, in public health, an effort toward a course correction involving an emphasis on upstream factors as we tried to achieve balance.
As we pursue this emphasis, we should be careful in our approach, bringing nuance and balance, reconciling a focus on downstream factors (i.e., changing behavior and creating better treatments for disease) with a recognition that health is shaped by upstream factors by context. We cannot create a healthier world without addressing what is upstream.
Centrally, there are, I think, three reasons why we should aspire to a balance between the upstream and the downstream.
First, well, there are many people in the river already, and saying we are not going to get them so we can focus upstream eludes the fact that there are many to be helped in the short term, that upstream work alone is just not good enough, particularly for those who are actively drowning. We have a moral obligation to help all people as much as we can. Ignoring those who are drowning now abrogates that. Going beyond the river metaphor, regardless of how optimistic we are, it is going to take decades to achieve a world where no one is unstably housed, where everyone has a stable income, etc. because inequities are so entrenched. Even if we dropped everything else to focus on them, there is no reasonable universe where we can imagine they will change quickly. So, there are going to be people affected by them who we can help now, and we should do so.
Second, much of the work of public health depends on engaging people in what we do, and people are more readily engaged in the day-to-day business of helping those in the river. This is why service organizations thrive, why community members dedicate time and resources to them, and why we should engage with and support them. It builds our capital in public health to solve the immediate problems, capital we can then leverage towards persuading people to follow us as we move to our radical vision. Helping those drowning now builds trust and buy-in for our long-term efforts toward a healthier world.
We should also consider how seeming indifferent to those in the river now may look to the public we want to engage with. If we look like we are more concerned with abstract aspirational goals than we are with human suffering in the present, we run the risk of appearing callous. Such a perception does not serve our movement.
Third, the people who are downriver have their own ideas about how to get out of the water and their own ideas on how to keep out of the water once they get out. Indeed, there are whole industries dedicated to keeping people healthy. Capacious public health needs to recognize that people are going to engage in behaviors and pursue solutions that they see as good for their health, and it behooves us to, whenever possible, meet people where they are towards the goal of getting all of us where we hope to be.
It is possible, of course, that there may always be a degree of tension in the pursuit of health between upstream and downstream. Such tension is perhaps natural, even generative, helping us imagine and implement new approaches to pulling people out of the river and keeping them out of it. We can accept this while also aspiring to bridge gaps and ease some of the intensity of this tension. What matters most is our radical vision of a healthier world. There are many paths to this world. Some engage with upstream factors, some with downstream. It is truly radical to do both.
A version of this piece appeared in Substack.
