When Public Health Values Are Not Embraced by All

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From opposition to bans on harmful substances like cigarettes and sodas to widespread resistance to the COVID vaccine, the work of public health has long faced these moments of rejection. What can seem at first like run-of-the-mill political debates (about, say, taxation), are often fundamentally about values.

The fact is, many populations do not share the values of public health and this mismatch can create impasses that complicate our ability to be effective in our work. This leads to notions that populations are working against their own interests, that somehow populations misunderstand the values that they should hold to. That populations are thinking the “wrong way” and that our work rests on righting these misunderstandings.

Understanding Differing Values

But perhaps there is a different, more productive way, of understanding values that differ from ours. Cast in a different light, we can move beyond seeing value clashes as a conflict between good and bad (with public health on the side of good), and rather see these conflicts as being between two different understandings of what is right.

I have long been inspired by the story of British Prime Minister Clement Attlee as an example of how to strike this balance in the political space. Attlee was an unassuming man, with few of the charismatic gifts we associate with transformative leaders.

However, he had a talent for engaging with all sides of the political spectrum, working pragmatically to advance change without compromising his core progressive principles. As a result, his government passed much of what would become the basis for the U.K.’s robust social safety net, including the National Health Service. In his review of a biography of Attlee, Adam Gopnik wrote in The New Yorker:

[T]he true progressive giants are radicals of the real—those who accept that democracy implies pluralism, and that a plural society is self-evidently made up of many people and kinds, only a few of them truly exploitative and criminal, most just pursuing their own version of the good life as tradition and conviction has offered it to them. The oscillation of power among them is not a sign of failure; it is a sign of life. Attlee’s example reminds us that it is possible to hold to moral absolutes—there was no peace possible with Hitler, and it was better to go down fighting than to try to make one—alongside an appetite for conciliation so abundant as to be more prolific…than merely pragmatic.

This is, I think, a powerfully stated theory of the case for a constructive engagement with values. Some values are fundamental and inalienable. They include respect for personal autonomy, inclusion, kindness, and for reliance on data and facts.

These echo core Enlightenment values, including those reflected in our country’s aspirational promise of “life, liberty, and the pursuit of happiness.” At the same time, we should be animated, always, by an “appetite for conciliation” informed by a willingness to acknowledge the validity of different values, and different points of view, and to see how these values can inform a framework that may be no less ethically grounded than our own, even as it supports different conclusions about the right course to pursue.

Pursuing Public Health and Differing Values

How can we support health in a country, and a world, where populations can have such vastly different values?

First, we should not pretend that everyone shares the values of public health. This is important because if everyone did share our values—shared our understanding of what is in the best interest of the public good—it would mean that anyone expressing views contrary to these values could indeed be accused of working in bad faith, rather than simply acting in accordance with their own set of values.

For example, if we all agree that vaccines are good and that the data support their safety and efficacy, then someone who advocates against vaccines might well be accused of knowingly spreading disinformation, rather than expressing skepticism due to a genuinely different set of values. By rejecting the fiction that we all share the same values, we can avoid the waste of time and energy that comes with demonizing those with whom we disagree because we will be able to see where their disagreement is rooted in a difference in values and work to address it.

Second, we need to shape a public conversation that is capacious enough to acknowledge different sets of values with an eye toward understanding them better. At a practical level, this means public health cannot just “preach to the choir” if it is to build a movement that can truly shape a healthier world.

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Those of us in public health tend to run in circles with those who share our values; we need to open ourselves to other populations with all the humility—and courage—such outreach entails. The work of public health is not a theoretical exercise. It is the work of compassion and radical solidarity. It means putting ourselves at risk.

Not just the risk of far-flung travel or contact with disease, but the risk of having our assumptions challenged, and our convictions tested by those who do not share them. This reflects a process of outward-facing engagement that can help us stay oriented toward the core mission of public health—serving all populations, no matter who they are or what they think.

Finally, we need to work to shift hearts, to move the "Overton window" towards the widespread embrace of values that support healthy populations. This does not mean trying to impose our values on those who do not share them. It means engaging in dialogue and participating in a national debate in which we respect differences, prioritize empathy, and demonstrate that we see and understand the values of others, even as we advocate for our own values with conviction and clarity.

Progress comes from this process. An appreciation of the ideas that create a better world emerges as a result of patient work over time, and the most enduring wins for health are those which are rooted in changes in our collective values, not just in our laws.

Such progress depends on engagement, persuasion, a willingness to listen, and a commitment to understanding the values of those with whom we may disagree. It is only by understanding these perspectives that we may, in the long term, be able to change them.

A mismatch of values need not, should not, be the end of a conversation. Rather, it should be the start of a new one, as we remember that our job is to improve the health of all populations, not just those who share our values.

A version of this post also appears on Substack.