On Shaping a New Practical Philosophy of Health

Recently, it was announced that Noma, often called the world’s best restaurant, is closing. This announcement was even more notable for the reasons behind it. Noma is not closing due to lack of demand—which, given the restaurant’s reputation, remains high. Nor is it closing because the co-owner and head chef, René Redzepi, is retiring. He is still relatively young and has already stated his intention to turn the Noma brand into something new, transitioning to a food lab with occasional pop-up restaurants. Instead, Noma in its current form is closing because Redzepi feels the business model is unsustainable, resting as it does on punishingly long hours and the labor of interns who, until recently, went unpaid for sometimes grueling and monotonous work. Redzepi said of this model, “Financially and emotionally, as an employer and as a human being, it just doesn’t work.”

I have written previously about how, in past eras, we have seen a similar reevaluation of the values that underlie much in our society, including the relationship between employer and employee. Often, these reevaluations follow disasters or social shocks which jolt us out of old ways of thinking and make us see how the status quo is unsustainable. For example, the disaster of the Triangle Shirtwaist Factory fire helped shape the labor movement and the Progressive Era in the US. Then there was the publication of Rachel Carson’s Silent Spring, which addressed the environmental harm caused by widespread pesticide use and helped usher in the environmental movement. These moments saw us awaken to a status quo that was not serving health, a status quo caused by a dysfunction in fundamental values.

If we look carefully, we can see similar changes and reevaluations growing in places close to “home” for public health. In the UK, for example, the National Health Service, long a source of national pride, has come under unprecedented strain due to a combination of COVID, years of austerity, crowded hospitals, and intense work for healthcare providers. In Canada, the country’s publicly-funded healthcare system is facing similar strain. These challenges have intersected with a healthcare labor force that is protesting for better working conditions, with strikes happening in the UK and new conversations occurring about burnout among healthcare workers. Underlying all this is the COVID moment, when we applauded frontline workers as heroes as they faced steep challenges, then arguably did not do enough to meaningfully support them. The contrast between the applause of the early COVID era and the subsequent lack of change in workplace conditions has led to a conversation about fundamental expectations in the healthcare field. Should the field really operate as a pressure cooker, like the kitchen of a high-end restaurant? Or might there be new ways of imagining what healthcare could be, guided by a concern for the wellbeing of both providers and patients?

Working in public health, I have long been concerned with how to improve the health of populations, with particular focus on the marginalized and vulnerable, towards narrowing health gaps as much as possible. This work is fundamentally shaped by philosophy, subject to the same process of reevaluation that shapes every intellectual system over time. The time is ripe for just such a moment of reevaluation. This is particularly clear when we consider that we have just been through a disaster on par with any prior shock that has motivated deep structural change. As of this writing, COVID has killed nearly 1,100,000 people in the US and about 6,700,000 people globally. After such devastation, it is not inappropriate, I think, to regard the present as a kind of “post-war” moment, when we should pause to take stock of what we have lost and work to establish the foundations for a better future. It is now more important than ever for us to engage with the philosophical questions that define our work at the level of first principles. Informed by the success and failures of the COVID moment, the evolution of values that shape the issues that matter for health, and the broader social and political disruptions of recent years, we need to ask the questions that can get us to what is next for public health. Here, I suggest, are some of them:

• What is the potential of science in this moment? What are its limits?
• How can we advance a vision of diversity that truly bridges divides?
• In a time when public health has much power, can we re-embrace the humility that allows us to accept uncertainty?
• How can we address the historical biases that have long shaped our institutions and systems of thought without jettisoning the best of our traditions?
• How can we create pathways to dignity and health for all at every stage of the lifecourse?
• What does it mean to articulate a radical vision for public health when these radical perspectives can lead us to impracticable places?

I will end on a geological note. According to a recent study in Nature Geoscience, earth’s rotating inner core may be changing its spin. While this sounds alarming, scientists believe this change may be part of a regular cycle, with changes in the core’s rotation occurring every 60 or 70 years. These findings reflect how, while the ground we walk on may seem solid, unchanging, it is, in fact, supported by geological processes that are always in flux. This dynamism likewise underlies the assumptions we accept as foundational about the nature of our work, our society, our existence. What seems like solid ground only appears this way because of a process of pressure and change and the application of time. It is a process which is constantly generating new baseline assumptions, new foundations on which we proceed. Unlike the processes which shape the earth’s foundations, the work that generates the fundamentals of our field is something we can, and must, participate in. I look forward to doing so together in the coming months.

This piece also appears on Substack.