Ethical Reflection Is Essential for Public Health and Is Not the Same as Political Reflection.

Galea and Vaughan opine that because "the places where we live" and other social and ecological conditions are drivers of our health, "the health of populations is inherently political."[1](p966) The authors propose three prescriptions for how we might align politics and public health.

First, public health professional education should change to become more interdisciplinary and attentive to "eco-social frameworks that start perhaps with the political."[1](p967) Second, the "practice of public health" (authors do not make clear whether they mean public health professionals in their individual roles making up their own minds or public health agencies and organizations such as local or state public health departments supporting or opposing local or state political processes, or organizations like the American Public Health Association [APHA] endorsing political candidates, or something else) should "embrace the political implications of our work," which would include involvement in the "calculus that dictates which resources are deployed, how, and when."[1](p967) And third, public health must "[create] a narrative that makes the creation of health in populations meaningful... creating meaning, informing the political action that generates our health."[1](p967)

On their face, these three prescriptions do not seem out of order. On the contrary, they seem apt for our current social order that is profoundly politically divided, informed by politically inflected media (on jumbo screens and on tiny devices), with discourse peppered with politically driven stereotyping of persons and communities (e.g., "out-of-touch socialists," "rural Trump voters"), in particularly strongly politically partisan times.

APHA is about to launch a new Code of Public Health Ethics. Early drafts presented conceptions that resonate with the first and second prescriptions of Galea and Vaughan: interdisciplinary attention to social determinants of population health and engagement with communities impacted by public health disparities including those communities' social, economic, and political analyses regarding the disparities they suffer and possible remedies for those disparities. Galea and Vaughan's third prescription—that "we play a role in creating meaning, in generating the narratives that shift political actions" [1](p967)—must be examined particularly carefully.

There are, will be, and must be pluralistic meaning-giving narratives in public health. Societies, even small societies, can have great differences and disparities with different moral values and foundations for those values that are sometimes in conflict. Narratives will be competing, contrary, or antithetical to one another. Powerful narratives include ancient ones, contemporary ones, and emerging ones. The forms of narratives are diverse. Narratives are not heard in the same way by different audiences.

Ethical reflection helps us maintain mutual trust across pluralistic values, meanings, and narratives of public health. Can politically driven narrative do that as Galea and Vaughan propose? Who decides if and how one narrative is superior to other narratives? Might narrative-makers with particular—or partisan—political aims exert power to suppress or silence contradictory narratives? Might some narrative-making elite(s) subordinate, subvert, or oppress narratives of subaltern communities?

I know of no conflicts of interest—personal, commercial, political, academic, or financial—because of which I have intended to mislead or deceive the reader.