In 1920 Charles E. A. Winslow defined public health as:
…the art and science of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of the social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.
Winslow’s definition is still used by the CDC and by introductory public health textbooks.
While many public health scholars have developed the science of public health through epidemiology, statistics, and other fields that improve our understanding of the conditions that influence the health of human populations, perhaps it is time to revisit the artsy side. Contrary to how we commonly denote art with fuzziness or ad hoc logic, the art of public health acquires a more profound meaning as we come to appreciate the values and knowledge only individuals possess.
Enter Friedrich Hayek. His arguments that eschew scientism—the uncritical application of the scientific method—and recognize how knowledge is tacit, dispersed, and unquantifiable provide many insights for public health.
A Hayekian Regimen for Public Health
Across a series of articles and books, Hayek notes that the knowledge that guides individual behavior is tacit and dispersed. Such arguments have myriad implications for our understanding of human behavior—some of which influence private and public health outcomes. They suggest, for example, that beliefs matter more than the physical attributes of an item. That is, how we behave and interact with objects and with people depends on our ideas and beliefs about cause and effect.
Pulling from “The Facts of the Social Sciences,” Hayek argues that we often conflate intentions behind a person’s behavior with explanations based on our own perceptions. The more we make such conflations, the more we are likely to misunderstand such behavior and the more we are likely to devise poor policies.
For example, I once saw the child of a friend use a toy tractor to pick up some confetti he had strewn over the floor. I thought, “How silly! That’ll take ages to clean up.” I realized afterwards—with the help of the child’s grandfather—that the child wasn’t solely interested in cleaning up. He cared more about using his tractor to play. This is exactly what Hayek urges us to consider: people have values and goals that are tacit and often difficult to articulate. Moreover, these factors influence how we view the world and perceive choices. Toy tractors are both play things and cleaning instruments.
Hayek gives a more pointed warning:
If what we do when we speak about understanding a person’s action is that we fit what we actually observe into patterns we find ready in our own mind, it follows, of course, that we can understand less and less as we turn to beings more and more different from ourselves.
The worry, then, is to what extent do we understand less and less as we engage in various conversations about public health.
More Art, Less Science
Hayek’s warning applies to many fields, not just public health. Yet, public health scholars run afoul of this warning when, for example, they advocate for broad, sweeping policies like lockdowns. Such policies ignore the values individuals have, of which health, hospital capacity, and disease prevention are among many.
Moreover, Hayek’s warning applies when novel technologies and data-based techniques are heralded as panaceas to complex social problems. To be clear, public health innovations can unambiguously improve private and public health outcomes. Conscious public health interventions also have a long history of improving the quality of life and saving lives, e.g., cleaning water supplies, organizing sanitation services, smallpox vaccinations, etc.
More recently, smartphones and, perhaps, smart toilets could detect cancerous cells long before eyeball tests. Nanotechnology can improve the quality of water, medicine, and consumer products, and artificial intelligence can improve disease surveillance. All of these developments should inspire awe in our ability to improve standards of living.
Developments like precision public health (PPH), however, warrant additional scrutiny. This relatively new approach to public health problems, briefly, utilizes advances in data collection to design public health policies for specific groups and, perhaps, individuals. Tarun Stephen Weeramanthri and his colleagues define PPH as “the application and combination of new and existing technologies, which more precisely describe and analyze individuals and their environment over the life course, to tailor preventive interventions for at-risk groups and improve the overall health of the population.” PPH has been used to tailor responses block-by-block, e.g., to monitor the spread of Covid-19 and to spray insecticide against Zika in Miami.
Such approaches might be preferred to sweeping lockdowns, but there are lingering problems related to the analysis of individuals, the knowledge they possess, and what newly accessible data means. Detractors within the field note that PPH lacks a defining universally accepted set of terms and scope. Most of the methods are not new to public health, e.g., John Snow’s response to cholera. Moreover, PPH can obscure foundational public health approaches, and there are still political, economic, and logistical problems that impede implementation.
These problems indicate we should take Hayek’s arguments on knowledge and the meaning of behavior seriously. It is not clear how precision and fine-grained data can dramatically improve welfare or resolve complex social problems related to public health. Mira Vetger hints at this critique when she states: “We can be blinded by the data opportunities at the expense of some of the more dynamic social questions.”
PPH can clearly improve health outcomes for some populations, but there are deeper questions to wrestle with—questions that public health-as-science alone cannot answer. This is where public health as art becomes relevant, especially when combined with Hayek’s insights regarding knowledge. He urges us to consider that individuals have myriad values and goals, such that health is one among many. Moreover, what those values are cannot be encapsulated in quantifiable data, which is why public health as science can only provide narrow answers to larger questions.
For example, how do people coordinate scarce resources to improve private and public health? What are the processes through which people discover innovations in healthcare? What are the incentives people face to improve water systems, to prevent infectious diseases, and provide other goods and services that influence health?
There are many answers to these questions—and there are more questions to consider—but data alone narrows the questions we ask and the answers we provide. This is the case even if we have novel, fine-grained data, increasingly advanced techniques of data analysis, and sophisticated technology.
Public health as art, following Hayek, becomes a social science, or the study of how people make choices based on their values and tacit knowledge, how they interact with others, and how those behaviors and interactions influence health. This kind of art provides a greater understanding of human behavior and how such behaviors influence health, including one’s social and physical environment, and perhaps ways to improve health and well-being.