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Health, and the sharply felt divides that characterize it, have been at the heart of the storm we have lived through in the early years of the 2020s. The pandemic served as a powerful reminder of two long-ignored, yet fundamental, realities: Health is shaped by inequity, and poor health anywhere is—to borrow from Martin Luther King Jr.—a threat to health everywhere. It seems appropriate, therefore, to think of the pursuit of health as a catalyst for necessary transformations: for the creation of a world that is resilient to future pandemics, that apportions assets in such a way that the disproportionate burden of poor health does not accrue to a few groups, and that allows the opportunity for all to achieve a richly realized life, free of unnecessary and preventable illness.
We can perhaps take the argument a step further and suggest that it is our responsibility in public health to see the opportunity in the moment; and that anything short of seeing the moment as a chance for transformation makes us complicit in the structures that hold back the achievement of a healthier world. This calls for public health to engage forthwith in the project of creating such a world by envisioning it and helping to bring it to fruition. Such an engagement would build on a conversation that has been ongoing in modern public health. The past few years—in some cases, predating the COVID-19 moment—have seen many calls for a re-imagining of public health to embrace a forward-looking and aspirational agenda, one that sees as its role the creation of the structures that generate health. This surfaces, then, not questions about our vision, commitment, or intent, but questions of execution. These questions ask: How do we get to the sort of world to which we aspire?
This is where we have been far less clear as a field, and where clarity about the approaches we can take to achieve our radical vision would serve us well. Public health is fundamentally concerned with collective action that can generate health, which, by extension, must involve the creation of structures that generate, rather than hinder, health. We should make no mistake about it: It is a radical vision, one that departs from the more recent understanding of a public health grounded in core functions of assessment, policy development, and assurance.
But, to paraphrase the oft-quoted aphorism, vision, without execution, remains hallucination. How then do we go about achieving this radical vision? How does public health move from a field that, until relatively recently, was seen by the public, and in large part saw itself, as being concerned with core functions of disease control and prevention, to one that is seen, and sees itself, as engaged in the business of creating social structures that generate healthy populations? This is where, I would argue, we need to marry our radical vision with an incremental approach that recognizes the complexity of the task at hand.
I recognize that this may seem like an inopportune political and societal moment to suggest incrementalism of any kind. Revolutionary times call for bold and dramatic actions. In this context, suggesting the value of incremental change can seem to reflect a want of boldness of vision, a failure to see past the moment to the opportunity it represents. But I would argue that it is precisely because we should be bold and serious in our intent to achieve our radical vision that we should embrace the path of incremental change to get there.
If we understand that health is shaped by a complex set of powerful forces, we need to also understand that these forces reflect structures that themselves reflect interests that have much to gain by maintaining the status quo. If we are to put health at the heart of policy actions around areas as disparate as transportation and education, we will need to learn how to work with those who have been in those arenas for decades, who have been socialized to think about education and transportation in a particular way, and for whom health has never been more than a secondary concern consigned to someone else’s area of focus.
Engaging stakeholders in these sectors requires patience, persuasion, empathy, and persistence. It requires us to adopt a posture of learning. It requires, perhaps above all, our willingness to accept small changes that together accrete to create bigger change, one step at a time. It requires us to bear witness to forces long-ignored in the pursuit of health. And it requires our unflinching commitment to achieving our radical vision, recognizing that doing so takes years and decades. We could well learn from Frederick Douglass, who, in reflecting on Abraham Lincoln’s embrace of conciliation and incrementalism in politics, said:
“He never shocked prejudices unnecessarily. Having learned Statesmanship while splitting rails, he always used the thin edge of the wedge first, and the fact that he used this at all meant that he would if need be, use the thick as well as the thin.”
It seems to me that a radical incrementalism in public health—defined as the articulation of a radical vision combined with an incremental approach—stands to best capitalize on the promise of the moment. Embracing such an approach takes courage and boldness on two fronts. It takes courage to say that health should be a motivational force behind how we build our world and, as such, should be integral to the breadth of sectors that create such a world. It also takes boldness to say that, in order to get there, we will need to create the partnerships that take time to forge, to re-think how we teach and learn public health, and to make changes one at a time that eventually will see our vision flourish.
The hard work of advancing a radical vision lies with the small incremental gains that accrue every day as we work to transform complex systems that are not likely to yield quickly, consistent with the sociologist Max Weber’s observation that “Politics is a strong and slow boring of hard boards. It takes both passion and perspective.” A radical incrementalism in public health stands as a viable, tractable agenda, consistent with our aspirations, and attuned to the realities within which we operate. It means applying “both passion and perspective” to the hard work of building a healthier world.
A version of this post also appears on Substack.
A version of this piece appeared in The Milbank Quarterly Opinion on October 29, 2020.
