On Values and a Clearer Understanding of the Issues.

I have long admired the work of the physician epidemiologist Sir Geoffrey Rose, who wrote the seminal book Strategy of Preventive Medicine. Writing as a physician who was interested in prevention, Rose articulated more clearly than anyone before him the differences between identifying the causes of cases and the causes of incidence in populations, providing us with a framework for thinking about population health that informs much of what we do. Rose was a proponent of the analytic capacity and responsibilities of the quantitative public health scientist and, attempting to capture how he saw our role, wrote that:

“[Our task] is not to tell people what they should do. That is a matter for societies and their individual members to decide. [Rather, our task is] to analyze the options, so that such important choices can be based on a clearer understanding of the issues.”

Rose intended this as a caution that we, in population health, must be clear about our understanding of what it is that matters, and what should therefore inform our scholarship and action. I have tried to echo this point under the rubric of “what matters most” in some of my writing.

This perspective may suggest that a dispassion in our work might be desirable—that we should be value-neutral arbiters of data analysis, presenting causes of disease that are amenable to intervention for society to then decide whether it should act on them or not.

Which brings us, then, to a core question: How does society decide?

I would argue that, at core, societal decisions are informed by societal values—sometimes spoken, sometimes not—and that an understanding of the key role that values play in shaping decisions central to the promotion of public health should inform how we, as an academic public health community, carry out our work.

Why values? Values help us decide the worth, the usefulness of any particular construct, the extent to which a construct is important to us in life. Economics is predicated on the monetization of value, on the attribution of monetary value to all aspects of life, some readily transactional, some less so. In this manner, we value a car more than we value a laptop. We also, of course, place a value on all aspects of medical care provision in this country; for an enlightening discussion of the mechanics of monetizing medical procedures, see the recent book, America’s Bitter Pill.

But values also underpin what we elevate as a society—the ideas, concerns, and characteristics that we hold dear and aspire to protect. Values inform our national identities. The United States, then, clearly values concepts such as freedom—of the press, of free assembly, of religion—and a range of other constructs, many of which are enshrined in unifying national documents such as the Constitution or the Bill of Rights. International documents, such as the Universal Declaration on Human Rights, also expressly articulate standards of group and individual behavior valued by countries globally. The International Bill of Human Rights, including components such as the International Covenant on Economic, Social, and Cultural Rights (ICESCR), set agreed upon (and legally binding, at least theoretically) standards that should bind governments in multiple areas, including the right to health. Leaving the notion of the right to health for a separate Dean’s Note, the US failure to ratify treaties that are nearly universally adopted is a telling reflection of the value we place on health in this country.

There is little question that Americans value their health; an abundance of data show that health is one of the principal concerns voiced by Americans when asked. Insofar as monetary investment represents a valued commodity, we spend more on health than any other country worldwide, further suggesting that we value health dearly. What we do value, however, as evidenced perhaps best by our expressed spending preference, is the attainment of individual health—i.e., my capacity to be as healthy as I can be, and to spend as much money as I want to optimize my health. This is, of course, consistent with an American adherence to the notion of individual capacity for limitless achievement above all else.

Therefore, our society’s analysis of the options available is predicated on a value on individual health that far outweighs a value on group health. This, of course, stands public health in poor stead, and it is therefore not surprising that the US spends less than 5 percent of its health dollars on population health measures and more than 95 percent on medicines and curative approaches.

Returning to our opening precept, if we, as analysts, present, as clearly as we can, an “understanding of the issues,” our society will decide what it should do based on the values that it cherishes. Should our role then be, as advocated by Rose, the dispassionate analysis of options available, allowing society to choose?

Although I have spent much of my professional career as an epidemiologist, striving to analyze issues and present the options for intervention as clearly as possible, I have come to feel that this dispassion ill serves us, and in some ways shirks our collective responsibilities. Our role as an academic public health enterprise must indeed involve the presentation of the options, but it must also involve an effort to align society’s values with the goals of improving the health of populations.

Three realizations have brought me to this conclusion.

First, values are neither absolute nor unchanging. As I discussed in a previous Dean’s Note, circumstances that are acceptable at one point in time may well be unacceptable at another. This reflects an evolution in our values. Therefore, an elevation of values as an immutable characteristic that stands to guide societal action falsely suggests a particular place for values as an inviolable bedrock characteristic.

Second, there is an array of forces that aspire to inform and influence our values as a society, and as such influence how we, as a society, choose from among the options available to us. In some respects, all it takes for the forces that aspire to elevate values harmful to health is for those whose role it is to promote health to do nothing. Society’s codes of conduct are determined by laws and policies that shape how we behave and by incentives that determine our actions. Therefore, within a market economy, it benefits food companies to maximally promote calorie-dense, nutrient-poor products if those indeed maximize profits. It is also to the industry’s benefit to argue against laws restricting its capacity to promote its products to children, and the industry, motivated by its incentives, does just that. It therefore falls to an activist public health to provide the counterargument—to actively engage in shaping the values that inform the parameters set by legislation on what marketing to children is, or is not, acceptable. For an illuminating read about how the medical industry shaped the values that have elevated physician-based curative care above all other health approaches in the US, see Paul Starr’s The Social Transformation of American Medicine.

Third, I have worried that if I entertained the notion that I should contribute to shaping societal values, the honesty of my empiric work would suffer and I would draw inference from data that was explicitly intended to influence or bias the reader in a particular way. Several authors have written eloquently about the ineluctable role of personal biases and values in our scholarship. Incidental to this, I have come to realize that while we, collectively, as an academic public health may have a responsibility to shape societal values, it does not fall to each individual scientist to do so. This suggests that I may indeed best serve the cause by articulating the options clearly, even as I am part of an enterprise—population health scholarship—that participates in the broader conversation that aims to inform the values society employs to underpin its decisions. It strikes me as not implausible that some scholars among us are comfortable (and good at) doing both—creating empiric evidence that presents the options, and engaging in the work that aspires to influence societies—while others may be more comfortable doing one or the other.

In the end, values emerge from an ongoing societal conversation; they shift with time as the conversation changes with time. Societies in turn decide what they “should do” based on these emerging values as well as the ongoing public conversations. It thus falls to us in academic public health to contribute to those conversations, and to elevate health as a value. Who would, if not us?

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Professor, Boston University School of Public Health
@sandrogalea

Acknowledgement. This Dean’s Note was informed by conversations with Catherine Ettman.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/news/articles/category/deans-notes/