As discussed in prior Management Moment columns, public health leaders are called to develop more effective messages that appeal to a broader range of “moral foundations” and also to the new millennial generation who represent the future of the public health workforce.1–3 In this column, we build upon those prior columns and turn the focus from the tools we can use to craft persuasive messages to the virtues that can make us worthy of being heeded.
Building Upon Moral Foundation Theory
As we noted in our earlier columns, Jonathan Haidt's4 moral foundations theory offers some powerful insights. His research showed that moral thinking is intuitive: we adopt our views of right and wrong without conscious thought. Haidt's theory, as part of a larger development in cognitive psychology,5 told us that we all form beliefs in a rapid-acting cognitive process of which we are largely unaware and then treat those beliefs as if they had been carefully reasoned out in dialogue with Plato and Stephen Hawking. When we then turn to persuading others, we are not really reasoning with them but talking at them about truths we believe to be self-evident. Haidt provocatively argues that we are not as reasonable or open-minded as we think. Almost as annoying is his insistence that those who disagree with us are not as meanspirited as we thought.
Our first 3 articles were most interested in Haidt's description of these moral intuitions and the insights they offered for public health messages. Haidt identified 6 distinct moral foundations, intuitive moral nerve endings that he claims are more or less present in all people:
- Care/Harm, a concern for caring for children and those in need, and preventing harm.
- Liberty/Oppression, a preference for freedom and a disdain for bullies and dictators.
- Fairness/Cheating, an appreciation of equal opportunity (and for some, equity) and a commensurate disdain for cheaters and laggards who do not play by the rules.
- Loyalty/Betrayal, treasuring the group and despising traitors.
- Authority/Subversion, a feeling that rightful authority should be obeyed and that it is wrong to undermine legitimate leaders.
- Sanctity/Degradation, a sense of the transcendence of life and a powerful rejection of taboo thoughts and actions of degradation.
Even more stimulating is Haidt's finding that the sensitivity of these moral nerves varied consistently with political orientation. Conservatives respond about the same to all the 6 moral foundations, whereas liberals are much more sensitive to harm and fairness than the others. Conservative advocates thus have more ways to rally moral fervor than liberals and are better at using the full range of moral arguments. Haidt called this the “conservative advantage,” and it pointed us toward a chronic public health disadvantage. Public health has an inherent focus on disparities and unfortunate outliers, which lead us to sound like liberals, leaning heavily on care—preventing harm. While we often fall back on the authority of science—a “conservative” moral foundation—we neglect complementary perspectives that might arise from loyalty or sanctity. While we authors each had our particular criticisms of Haidt's work, we all warmed to his suggestion that people could learn to speak in more moral languages to craft broader and richer messages about public health.
Despite the potential usefulness of these perspectives in framing our moral argument, an approach rooted only in framing risks falling into a practice of manipulation rather than promoting true conversation and mutual understanding. Only if we accept moral diversity through empathetic, respectful relationships with people who think differently than we do can we all cross the bridge of understanding together. We do not just persuade better; we understand better. Thus, at our best, we do not treat empathy as a technique to manipulate others but as a connection that changes us, too. Discussing these strands of humility, relationships, and the cause of public health itself, we realized that crafting richer messages was necessary but not sufficient to our impact.
Building upon this framework, we now conclude that we, as public health leaders, may have a “public health advantage” as we craft richer messages. This powerful advantage arises from what public health workers know, who public health workers are, and what public health workers are trying to do.
The Public Health Advantage
What public health knows
Our greatest power is what we know. In a time when factuality and reason seem fragile, we double down on science and the scientific method of understanding the world around us. We are skeptical and resist jumping to conclusions. We have scientific tools to help us better see the facts and, more importantly, to distinguish facts from values. Before we try to persuade anybody else, we can use these tools to guide ourselves away from lazy assumptions, undue optimism, and group-think. Note that we speak of virtue here, not traits. If we are mostly right more often than not, it is not because we are naturally brilliant but only because we are tethered by discipline and habit to the authority of science and data.
Science teaches the core virtue of humility because its findings never answer all questions, especially not moral ones. Science provides one standpoint but has its limits, too. We in public health have plenty of work stories of people who confuse science and fashion, fact and inference. We know the pathologies of the “white coat syndrome.” Science is our guide, never a cudgel that ends a conversation. For all its frustrating limits, though, strength in our commitment to the facts is more important than ever. Sharing what we know—forthrightly but humbly—makes possible relationships that hold open the possibility of true dialogue.
Who we are in public health
We are people who can be relied on because we are passionately committed to the public's health. That is a creditable and selfless cause. Even those who may disagree with us on some matters appreciate clean water and hygienic restaurants and can readily see that we come in peace. When we speak of the public, we mean we work for everyone—equity in the distribution of health is more important than attaining the highest possible level of health for some. As well as passionate, we are persistent. Public health, like family, is a long game. We have been fighting about vaccination since Cotton Mather promoted inoculation. Even “quick” victories, such as tobacco control, take decades and are never really won for good. Very few of us leave public health to work in hedge funds or show business. We are people who stick with our communities. If we do not succeed this year, we will be back next year. When called, we will come early and stay late.
What public health does
We are pointing the way toward healthier people and places. This is not the same thing as bossing people around, let alone banning pleasure. The complaints about the “nanny state” and paternalism are an understandable reaction to regulation, but even those complaining can remember that nannies and parents can be pretty useful overall in their time and place. In policy battles, we provide the best information we can and offer our best judgments about what it means. We do our best to persuade, but we respect the democratic process and different values and so we do not belittle those who oppose us. We trust that facts will protect themselves over time, and we give the public time to consider what we offer. Even people who disagree with us can respect our efforts as stewards and passionate advocates of long-term visions and possibilities.
Practicing the Public Health Advantage
We public health people love to act and intervene. This is a valuable impulse that has turned back many health threats and built landmarks of rational collective action, from sepsis to seatbelts and from cholera-spreading pumps to polio vaccines. We focus on action and bring that interventional instinct to the fundamental task of talking to the public. It may be that we have come to a time when the tool-making bias of public health needs to be balanced by character development. Good interventions are not enough. Better messages are not enough. We must learn how to become better messengers.
The public health advantage counts on skills of scientific analysis and civil discourse, but it is, first and foremost, a set of virtues. Virtues are not just tools to persuade others; they first hold us accountable to our true strengths, credibility, and character. Our advantage should make us humble, not proud. Part of our strength is, of course, scientific rationality, but we apply that to our own thinking, too, not just the ideas of others. Finally, our advantage is that it is not about us but for those we serve, the public. When we embody that way of being in the public, the public of every flavor, accent, and perspective may find us worthy of listening to.
A fundamental competency of the 21st-century public health leader is to be able to work with those perceived to have an opposite point of view. This is not about girding for combat. It has a lot more to do with having coffee and listening in appreciation for points of commonality than rigidly pummeling others with our views. We must value the right to speak of our own common humanity, of our learning journey, and why we have come to care so much about the people called the public and the techniques we hold dear that create the conditions for health to flourish among them.
Jonathan Haidt gave us some clues about how moral intuitions emerge with such quiet and quick power. We have followed these clues to find our own history as a field. The future clues lie exactly there; in how we have come to trust in specific tools of inquiry and evidence so that we are never trapped in our own partial judgments, always open to new facts and hypotheses. The more we speak of how we have learned to walk, of how we have come to be the people we are, the more others may wish to walk with us.
Although moral foundations theory, as applied to public health, does provide a useful way to frame richer messages, we advocate for consideration of our powerful public health advantage that is anchored in what we know, who we are, and what we do. We realize, perhaps, that framing cannot beat being and that what makes public health powerful is something captured in a concluding homily from pastor Gunderson:
Our counsel to our beloved field of public health is NOT to stop talking in well-framed messages about facts, analytics, determinants, vectors, patterns, and predictors. But we, as a field, must ALSO talk about our crazy love for the people—the public. And we talk about why we continue to hope for better, hope for more, and simply won't quit hoping no matter what. You can take our money, put us in the dumpiest offices, and cut our staff. You can relocate our building to a place so far down the road you can't find it in broad daylight. You can treat us as pitiful, hardly even as honorable as a primary care doctor, which in hospital world is hardly on the map. We won't quit. Why? Because we are in a lover's quarrel with the public we love.
This is the time for those who just can't stop loving the messy, disappointing, ever-muddling gaggle of humans called “the public.” We are in JUST the right work at just the right time. While others rant, we must speak out of that love. Bring our facts and laptops, as we know that science is a friend of humans and what we are capable of. But we must speak out of love first, especially in public, especially with the public, especially about the public.