AI Validity Assessment of Public Health Realism

By Christopher Williams, PhD

Summary

 Public Health Realism (PHR), a theory of Public Health Liberation theory, lacked strong empirical evidence when it was published in 2022. This research brief utilizes artificial intelligence models (Grok, Perplexity, Gemini, and ChatGPT) to assess validity of PHR theory. These models assessed thirteen (13) or 81% of the 16 Principles of Public Health Realism as "strong" or "very strong" in validity, relying on theoretical grounding. AI models interpreted these principles to be "supported by substantial, consistent, and high-quality evidence, aligning well with established theories." No model gave a low rating. However, two principles received the only moderate scores by 2 raters, suggesting the need to revise the language for improved validity. ICC computations varied from moderate to substantial agreement in different computations based on changes to the scale and the number of raters. Grok3 provided suggestions for revising three principles based on AI scores (#2, #5, #13). The Public Health Liberation Board is expected to consider these recommendations.

These study findings provide much needed validity evidence on Public Health Realism theory. It is not known how AI reasoning may differ from human raters. Further research is needed on the utilization for AI in establishing validity in new public health theory-building. In addition, human raters and related funding are needed to validate study findings.

I. Introduction

Public Health Liberation theory is a multifaceted theory that was published in 2022 in Advances in Clinical Medical Research and Healthcare Delivery (Advances)(Williams et al, 2022). The authors comprised of reform-minded equity scholars and community leaders who were mostly African American. Besides its innovative contributions to the public health literature such as the public health economy, illiberation, Gaze of the Enslaved, and Public Health Realism, their manuscript was notable for three women who held resident leadership positions in public housing, along with physicians (2), a PhD researcher (1), LGBT members (2), academicians (3), and academically-trained public health experts (3).

Although their manuscript was rich in detail, drawing from their own experience in Washington, DC and relating to other public health crises such as the Flint lead water crisis, Public Health Liberation theory had not undergone any validity analysis at the time of its publication. Arguably, the liberation leanings of its writers did not view this as essential since they primarily sought to develop "strategies and pathways to achieve equity through a process of social identity formation and strengthening" as opposed to theory validation (Williams et al, 2022). Events in the US in 2025 led to significant website traffic on the Public Health Liberation website according to the nonprofit, hitting roughly 10,000 visits in January 2025.

The second administration of President Donald Trump has led to heightened threat perceptions on public health in the US. "Under the Trump administration, we have seen a slew of proposed public health policies that threaten to undermine decades of progress in protecting the health of individuals, families, and communities across the United States," begins the American Public Health Association's statement on the state of public health under Donald Trump. (APHA.org, 2025) Attacks on public health have increased in light of mass layoffs, executive order on deregulation and diversity, equity, and inclusion (DEI), cabinet appointments, and grant defunding, with potential for deep cuts to HIV/AIDS programs, Medicaid, and Medicare.

Although Public Health Realism theory was published in 2022 and unrelated to 2025 events, it provided a theoretical framework that emphasized competition and power. Its 16 principles posited that, absent a common mortality and central enforcing authority, the state of the public health economy (PHE) is characterized by interest-driven conduct. The PHE anarchy occurs as a result of actions of all agents in the public health economy - an "economy" that extends well beyond traditional boundaries of healthcare and public health to include structural determinants of health. While the events 2025 appear to validate the nature of the PHE, validity analysis was needed for Public Health Liberation theory. The goal of this research brief is to leverage AI models for testing.

Principles of public health realism 

1. The public health economy is a state of anarchy characterized by perpetual competition for resources where there exists no common principles or central authority. The public health economy reproduces health inequity. 

2. Self-serving egoism is assumed to motivate action within the public health economy. 

3. Each agent is responsible for its own survival within the public health economy. 

4. Interest is defined in terms of power, most often defined by the pooling of financial assets and exerting influence over a defined population(s). 

5. Moral imperatives are subsumed under self-interests because of the lack of common moral principles and central enforcing authorities. 

6. Agents exercise power through rulemaking, gatekeeping, issue framing, resource distribution, or through control of authorities invested with those powers. 

7. Agents' speech and conduct cannot alone be a reliable source for ascertaining their true self-interest. Agents are free to engage in misleading speech and actions that do not reflect their true self-interest. They may exploit human suffering and vulnerability to achieve maximum benefits that flow primarily to that agent or class of agents. 

8. Each agent can have contradictions and conflicts in moralities and issues - internal inconsistency and dissonance.

9. Agents are free to seek control over or to create coalitions with agents in the public health economy where interests align. 

10. Coalitions retain the characteristics of the public health economy wherein they are susceptible to fierce competition and power struggles. 

11. Achieving health equity or supporting PHL theory and practice may directly compete with self-interests for an agent or class of agents. 

12. Agents that benefit most from the public health economy seek to maintain their relative power position. Any reform efforts or calls for change are merely reflective of interest as power whereby they seek change insofar as they maintain relative power. 

13. Coalitions are common in the public health economy and are best understood as a means for agents to maximize their interest through collectives. These coalitions become hegemonic arrangements when they seek dominance by reducing competition and focusing on directing benefits and resources to their advantage. 

14. Agents can act hegemonically without coalitions through exercises in power. 

15. Dominant powers have disproportionate power, influence, and resources within the public health economy that leverage vast complex networks to control rulemaking, gatekeeping, liberation space-making, and resource control. The long-term effects of interest pursued as power tend to hegemonize. 16. Hegemonic powers, whether agents themselves or coalitions, pose a major threat to realizing health equity by seeking to maintain the public health economy to their advantage.

II. Methods

Christopher Williams, PhD, the first author of Public Health Liberation theory and the principal investigator for the Critical Race Framework study, developed a research methodology to assess validity of Public Health Realism theory using four major AI models.

A. Scale Definitions
We utilized three models for our analysis - Grok3, ChatGPT, Gemini, and Perplexity. CW employed stepwise quasi-consensus methodology to develop scale definitions for the strength of validity. The initial scale was defined: low, moderate, strong, very strong. CW asked each AI to develop scale definitions. He then shared each set of definitions with all AI models to revise their scale definitions, as needed. Those four revisions were shared across all AI models with a request to rank the best set of descriptions from best to worst.  CW used on online ranked choice voting application to decide on the best definition (https://ranked-choice-three.vercel.app/). In a separate chat, each AI applied the best definition to assess each of the 16 principles of Public Health Realism theory.

Prompts

1. "I am going to ask someone to assess the strength of validity for a set of theoretical principles. The scale is low, moderate, strong, very strong. I want you to give a definition for each of these that can be used."

2. "Here are (the) definition(s) from other AI models. Use to revise as you see fit."

3. "Ok, I provided each AI model the others' revisions. Now rank the best answer by each AI model from best to worst."

B. Assessing Strength of Validity
In a separate window, each AI model was asked to assess each principle of Public Health Realism theory.  CW asked each AI model to consider current events in 2025 and prior to encourage it to pull in contemporary events in 2025.

Prompt

Use these definitions to rate each of the 16 principle of public health realism for the strength of validity. Evaluate in light of events in 2025 and consider prior current events.

Low Validity - The principle has minimal empirical or logical support, relying heavily on untested assumptions or speculation. It is frequently contradicted by evidence, exhibits significant inconsistencies, or has limited applicability. The principle lacks robustness and is not reliable for explaining or predicting phenomena.

Example use: “The principle is speculative, with insufficient evidence and notable contradictions.”

Moderate Validity - The principle is supported by some empirical evidence or logical grounding, but it has notable limitations, inconsistencies, or untested aspects. Its applicability is restricted to specific contexts, and further evidence or refinement is needed to enhance confidence in its reliability.

Example use: “The principle shows promise but requires further validation due to limited scope or mixed evidence.”

Strong Validity - The principle is supported by substantial, consistent, and high-quality evidence, aligning well with established theories. It demonstrates broad applicability across multiple contexts and reliable explanatory or predictive power, though minor uncertainties or exceptions may exist.

Example use: “The principle is robust, well-supported, and widely applicable, with only minor limitations.”

Very Strong Validity - The principle is grounded in extensive, rigorous, and convergent evidence from diverse, high-quality sources. It is highly consistent with established knowledge, exhibits exceptional explanatory and predictive power, and applies reliably across a wide range of contexts with negligible exceptions. It commands broad consensus in the relevant field.

Example use: “The principle is exceptionally well-substantiated, universally applicable, and a cornerstone of its field.”

C. Calculating Percentage Agreement and ICC
We assessed AI rater patterns and difference in validity assessment by principle. 

Grok3 was the top ranked choice for scale definitions. Perplexity was the lowest ranked choice for each AI model for quality of scale definitions, including Perplexity's assessment. CW utilized Grok3 to compute 4 ICCs: 4-item Likert scale for all four AI models, 4-item Likert scale for AI models (3) excluding Perplexity, dichotomized scale (low/moderate vs strong/very strong) for all four models, and dichotomized scale for AI models (3) excluding Perplexity.

D. AI's Defense of Validity Scores
CW asked AI models to "provide a discussion on your scores. Using examples and validity theory." 

E. Revising Principles
CW asked Revise the principles of Public Health Realism to improve likely validity assessments based on results. We used the following prompt, "Revise the principles of Public Health Realism to improve likely validity assessments based on results."

III. Findings

Finding 1: Grok achieved the top choice for scale descriptions using ranked choice voting.

Results by each AI model (best to worst): Grok (Grok, Gemini, ChatGPT, Perplexity), ChatGPT (Grok, ChatGPT, Gemini, Perplexity), Gemini (Gemini, Grok, ChatGPT, Perplexity), and Perplexity (Gemini, ChatGPT, Grok, and Perplexity)

Finding 2: A quality scale description for assessing validity from a low- to very strong scale may include the following:

Low Validity - The principle has minimal empirical or logical support, relying heavily on untested assumptions or speculation. It is frequently contradicted by evidence, exhibits significant inconsistencies, or has limited applicability. The principle lacks robustness and is not reliable for explaining or predicting phenomena. Example use: “The principle is speculative, with insufficient evidence and notable contradictions.”

Moderate Validity - The principle is supported by some empirical evidence or logical grounding, but it has notable limitations, inconsistencies, or untested aspects. Its applicability is restricted to specific contexts, and further evidence or refinement is needed to enhance confidence in its reliability. Example use: “The principle shows promise but requires further validation due to limited scope or mixed evidence.”

Strong Validity - The principle is supported by substantial, consistent, and high-quality evidence, aligning well with established theories. It demonstrates broad applicability across multiple contexts and reliable explanatory or predictive power, though minor uncertainties or exceptions may exist. Example use: “The principle is robust, well-supported, and widely applicable, with only minor limitations.”

Very Strong Validity - The principle is grounded in extensive, rigorous, and convergent evidence from diverse, high-quality sources. It is highly consistent with established knowledge, exhibits exceptional explanatory and predictive power, and applies reliably across a wide range of contexts with negligible exceptions. It commands broad consensus in the relevant field. Example use: “The principle is exceptionally well-substantiated, universally applicable, and a cornerstone of its field.”

Finding 3: Absolute agreement across all four AI models determined that 80% of the principles were "strong" or "very strong" in the strength of validity (Table 1)

The AI models differed in assessing validity. Grok gave the most moderate ratings (n=3) and second lowest "very strong" ratings (n=4) (Table 2).  Gemini assessed no moderate ratings, but the lowest number of "very strong" ratings (n=3).  Gemini and ChatGPT  assessed an equal number of "strong" or "very strong" ratings (n=16).

Finding 4: ICCs showed substantial agreement across four raters (Table 3)
As expected, ICCs changed due to few raters (from 4 to 3) and lower variable (from four-item to dichotomized scale) (Table 3). Substantial agreement was met with four raters on a four-item ordinal scale.

Finding 5: Each AI model found strong validity in Public Health Realism (Appendix)
AI models confirmed their understanding of areas of validity (content, substantive, predictive) and relied during and prior to 2025.

• Grok: "My validity scores for the Public Health Realism principles reflect a careful assessment grounded in validity theory, balancing content, substantive, structural, and generalizability considerations."

• Perplexity: In summary, the evaluation of these principles highlights the complexities of the public health economy and the interplay of power, interests, and ethics.

• ChatGPT: These principles are well-supported by evidence and logic, broadly applicable but may have minor exceptions, scope limitations, or require further empirical unpacking.

IV. Discussion

Authors of the Public Health Liberation manuscript described a theory of the public health economy that comported with their views of tensions and contradictions. However, there lacked validity evidence. This novel validity testing model leveraging AI shows strong evidence that Public Health Realism is supported by strong validity.

Grok3 made recommendations to three principles (Table 3). Dr. Christopher Williams will share with the Public Health Liberation board for consideration.

Changes
#2 (Current): Self-serving egoism is assumed to motivate action within the public health economy.

#2 (Proposed): Agents in the public health economy are often motivated by self-interest, but collaborative and altruistic actions can also shape resource allocation and policy decisions.

Justification: Revised to soften the absolute assumption of self-serving egoism, acknowledging that collaborative and altruistic motivations coexist. This addresses Moderate ratings by Grok and Perplexity, enhancing nuance and applicability.

#5 (Current): Moral imperatives are subsumed under self-interests because of the lack of common moral principles and central enforcing authorities.

#5 (Proposed): Moral imperatives in the public health economy often compete with self-interests, particularly in the absence of unified moral principles or strong central authorities but can still influence agent behavior.

Justification: Revised to clarify that moral imperatives compete with, rather than are always subsumed by, self-interests. Added nuance to recognize moral influence, addressing Moderate ratings by Grok and Perplexity.

#13 (Current): Coalitions are common in the public health economy and are best understood as a means for agents to maximize their interest through collectives. These coalitions become hegemonic arrangements when they seek dominance by reducing competition and focusing on directing benefits and resources to their advantage.

#13 (Proposed): Coalitions in the public health economy are common and often formed to advance shared interests, but they may prioritize collective benefits over competition, with some coalitions exerting significant influence over resource allocation.

Justification: Revised to simplify and clarify that coalitions aim to advance shared interests, not always hegemonic dominance. The term "hegemonic" is softened to "significant influence" to reduce overgeneralization, addressing Grok’s Moderate rating.

Appendix - Each AI Model Discusses Their Validity Scores

Grok

As Grok, I will provide a detailed discussion of my validity scores for the 16 Public Health Realism principles, focusing on the rationale behind my assignments of Low (1), Moderate (2), Strong (3), and Very Strong (4) ratings. The discussion will incorporate examples from specific principles and draw on validity theory to interpret the scores, explaining why I assigned certain ratings and what this suggests about the clarity, applicability, and alignment of the principles with public health dynamics. The analysis will avoid tables, presenting a narrative summary of my ratings and their implications.

Overview of Grok's Validity Scores

My ratings for the 16 Public Health Realism principles are based on the ordinal scale: Low (1), Moderate (2), Strong (3), Very Strong (4). The ratings reflect my assessment of each principle’s validity, which I interpret as the extent to which the principle accurately represents the dynamics of the public health economy, is empirically grounded, and is clear and generalizable. Below is a summary of my ratings, followed by a detailed discussion:

Principle 1: Strong (3)
Principle 2: Moderate (2)
Principle 3: Strong (3)
Principle 4: Strong (3)
Principle 5: Moderate (2)
Principle 6: Very Strong (4)
Principle 7: Very Strong (4)
Principle 8: Strong (3)
Principle 9: Strong (3)
Principle 10: Very Strong (4)
Principle 11: Strong (3)
Principle 12: Strong (3)
Principle 13: Moderate (2)
Principle 14: Strong (3)
Principle 15: Very Strong (4)
Principle 16: Strong (3)

Summary of Distribution:

Low (1): 0 principles
Moderate (2): 3 principles (2, 5, 13)
Strong (3): 9 principles (1, 3, 4, 8, 9, 11, 12, 14, 16)
Very Strong (4): 4 principles (6, 7, 10, 15)

My ratings indicate a generally positive assessment of the Public Health Realism framework, with no principles rated Low, suggesting that all principles have at least some validity. The majority (13/16) received Strong or Very Strong ratings, reflecting high confidence in their alignment with public health dynamics. However, three principles (2, 5, 13) received Moderate ratings, indicating areas where I found limitations in clarity, specificity, or universal applicability.

Validity Theory Framework

Validity theory, particularly in the context of construct validity, provides a lens to evaluate these ratings. Construct validity assesses whether a principle accurately represents the intended concept (here, the dynamics of the public health economy) and is supported by evidence, coherence, and applicability. Key aspects include:

Content Validity: Does the principle adequately cover the relevant aspects of the public health economy?

Substantive Validity: Is the principle grounded in theoretical or empirical evidence of public health dynamics?

Structural Validity: Is the principle clearly and logically formulated to minimize ambiguity?

Generalizability: Does the principle apply broadly across public health contexts?

I applied these criteria to assess each principle, considering the public health economy as a complex system of competing agents, power dynamics, and resource allocation, as described in the principles. My Moderate ratings reflect concerns about content or substantive validity, while Strong and Very Strong ratings indicate confidence in all validity aspects.

Discussion of Grok’s Scores with Examples

#Moderate Ratings: Principles 2, 5, and 13

I assigned Moderate ratings to three principles, indicating that while they have some validity, there are limitations that prevent a higher rating. These principles likely suffer from issues in content validity (overgeneralization) or substantive validity (lack of universal empirical grounding).

Principle 2: "Self-serving egoism is assumed to motivate action within the public health economy."

  Rating: Moderate (2)

  Rationale: This principle assumes that self-serving egoism is the primary motivator for all actions in the public health economy. While self-interest is a significant driver in resource allocation and policy decisions (e.g., pharmaceutical companies prioritizing profitable markets), I found the assumption too absolute. Public health often involves altruistic actions, such as non-profit organizations providing free vaccinations or governments implementing universal healthcare policies. The principle’s lack of nuance reduces its content validity, as it does not account for mixed motivations. From a validity theory perspective, the substantive validity is weakened by the absence of empirical grounding for universal egoism, leading to a Moderate rating.

  Example: Consider global health initiatives like GAVI, which pools resources for vaccine distribution in low-income countries. While self-interest (e.g., global health security) plays a role, altruistic motives are also evident, challenging the principle’s blanket claim.

Principle 5: "Moral imperatives are subsumed under self-interests because of the lack of common moral principles and central enforcing authorities."

  Rating: Moderate (2)

  Rationale: This principle suggests that moral imperatives are consistently overridden by self-interest due to the absence of shared moral principles or central authorities. While public health often faces competing interests (e.g., budget constraints prioritizing certain programs over others), I found the claim that moral imperatives are always subsumed overly deterministic. For instance, ethical frameworks like the Declaration of Helsinki guide medical research, and public health campaigns often prioritize equity over cost. The principle’s content validity is limited by its failure to acknowledge situations where moral imperatives prevail, and its substantive validity is questionable without evidence that self-interest universally dominates. The Moderate rating reflects these concerns.

  Example: During the COVID-19 pandemic, some countries shared vaccine doses through COVAX despite domestic shortages, suggesting moral imperatives can compete with self-interest, contradicting the principle’s absolute stance.

Principle 13: "Coalitions are common in the public health economy and are best understood as a means for agents to maximize their interest through collectives. These coalitions become hegemonic arrangements when they seek dominance by reducing competition and focusing on directing benefits and resources to their advantage."

Rating: Moderate (2)
Rationale: This principle posits that coalitions are primarily formed to maximize self-interest and can become hegemonic. While coalitions are common (e.g., public-private partnerships in health), I found the emphasis on hegemonic arrangements less universally applicable. Some coalitions, like those for global health campaigns, aim to reduce inequities rather than dominate. The principle’s structural validity is weakened by its complex wording, which may introduce ambiguity, and its substantive validity is limited by the assumption that coalitions typically seek dominance. The Moderate rating reflects these issues, suggesting a need for clearer and more generalizable phrasing.

Example: The Global Fund to Fight AIDS, Tuberculosis, and Malaria is a coalition that directs resources to underserved populations, not necessarily to reduce competition or dominate, challenging the hegemonic focus.

#Strong Ratings: Principles 1, 3, 4, 8, 9, 11, 12, 14, 16

I assigned Strong ratings to nine principles, indicating high confidence in their validity but stopping short of Very Strong due to minor reservations about generalizability or specificity. These principles demonstrate strong content and substantive validity, with clear alignment to public health dynamics.

Principle 1: "The public health economy is a state of anarchy characterized by perpetual competition for resources where there exists no common principles or central authority. The public health economy reproduces health inequity."

  Rating: Strong (3)

  Rationale: This principle accurately captures the competitive nature of the public health economy, where agents (e.g., governments, NGOs, private entities) vie for limited resources like funding or medical supplies. The lack of a central authority and common principles often leads to health inequities, as seen in disparities in access to healthcare. The principle has strong content validity, covering key aspects of resource competition and inequity, and substantive validity, as it aligns with empirical evidence (e.g., global health disparities). I rated it Strong rather than Very Strong due to the term "anarchy," which may overstate the lack of coordination in some contexts (e.g., WHO guidelines). From a validity theory perspective, the principle is robust but could be refined for broader generalizability.

  Example: The competition for COVID-19 vaccines in 2020–2021, where wealthier nations secured larger supplies, illustrates the anarchic competition and resulting inequities.

Principle 8: "Each agent can have contradictions and conflicts in moralities and issues - internal inconsistency and dissonance."

  Rating: Strong (3)

  Rationale: This principle recognizes that agents in the public health economy, such as governments or organizations, often face internal contradictions in their actions or policies. For example, a government may promote universal healthcare while underfunding public hospitals, reflecting conflicting priorities. The principle has strong content validity, addressing a key behavioral aspect of agents, and substantive validity, as such contradictions are well-documented. I rated it Strong because it is broadly applicable but lacks specificity about the conditions under which dissonance occurs, slightly limiting its generalizability.

  Example: The U.S. government’s simultaneous advocacy for opioid crisis interventions and lax regulation of pharmaceutical companies illustrates internal moral and policy conflicts.

#Very Strong Ratings: Principles 6, 7, 10, 15

I assigned Very Strong ratings to four principles, indicating the highest confidence in their validity. These principles excel in content, substantive, structural, and generalizability aspects, aligning closely with observable public health dynamics and being clearly formulated.

Principle 6: "Agents exercise power through rulemaking, gatekeeping, issue framing, resource distribution, or through control of authorities invested with those powers."

  Rating: Very Strong (4)

  Rationale: This principle comprehensively describes how power is exercised in the public health economy, covering mechanisms like rulemaking (e.g., health regulations), gatekeeping (e.g., access to funding), and issue framing (e.g., media campaigns). Its content validity is excellent, as it captures multiple dimensions of power, and its substantive validity is supported by empirical examples across contexts. The principle’s clarity and broad applicability ensure high structural validity and generalizability. I rated it Very Strong because it is both precise and universally relevant.

  Example: The FDA’s authority to approve drugs (rulemaking) and pharmaceutical companies’ lobbying to influence regulations (control of authorities) exemplify these power dynamics.

Principle 7: "Agents' speech and conduct cannot alone be a reliable source for ascertaining their true self-interest. Agents are free to engage in misleading speech and actions that do not reflect their true self-interest. They may exploit human suffering and vulnerability to achieve maximum benefits that flow primarily to that agent or class of agents."

  Rating: Very Strong (4)

  Rationale: This principle highlights the potential for deception in the public health economy, where agents may obscure their true motives to gain advantages. It has strong content validity, addressing a critical aspect of agent behavior, and substantive validity, as evidenced by cases of misleading health claims or profiteering. The principle’s clarity and applicability across contexts (e.g., global health crises) ensure high structural validity and generalizability. I rated it Very Strong due to its robust alignment with real-world dynamics and clear formulation.

  Example: During the opioid crisis, some pharmaceutical companies promoted painkillers as safe while aware of addiction risks, exploiting vulnerability for profit.

Discussion and Implications

My ratings reflect a nuanced evaluation of the Public Health Realism principles, guided by validity theory. The absence of Low ratings suggests that I view the framework as fundamentally sound, with all principles having at least some relevance to the public health economy. The distribution of ratings—3 Moderate, 9 Strong, 4 Very Strong—indicates that most principles are robust, but a few require refinement to enhance their validity.

Moderate Ratings and Validity Theory: Principles 2, 5, and 13 received Moderate ratings due to limitations in content or substantive validity. Principle 2’s assumption of universal egoism and Principle 5’s claim that moral imperatives are always subsumed lack empirical grounding for all contexts, reducing their generalizability. Principle 13’s focus on hegemonic coalitions is overly specific, weakening its structural validity. These principles could benefit from revisions to incorporate nuance, such as acknowledging mixed motivations or simplifying complex terms, as suggested in prior revisions (e.g., softening "hegemonic" to "significant influence" for Principle 13).

Strong and Very Strong Ratings: The 13 principles rated Strong or Very Strong demonstrate strong alignment with public health dynamics. Principles like 6 and 7, rated Very Strong, excel in all validity aspects, offering clear, empirically grounded descriptions of power and deception. Strong-rated principles like 1 and 8 are robust but have minor limitations, such as the potentially overstated "anarchy" in Principle 1 or the lack of specificity in Principle 8. These ratings suggest that the framework effectively captures key aspects of the public health economy, particularly competition, power, and agent behavior.

Comparison with Other Raters: My tendency to assign Moderate ratings (3 principles) contrasts with ChatGPT and Gemini, who assigned no Moderate ratings, and Perplexity, who assigned 2. This suggests I may have a more conservative or critical approach, possibly due to a stricter interpretation of empirical grounding or generalizability. For example, my Moderate rating for Principle 2 aligns with Perplexity’s, indicating shared skepticism about universal egoism, while ChatGPT and Gemini’s Strong ratings suggest a broader acceptance.

Implications for the Framework: The Moderate ratings for Principles 2, 5, and 13 highlight areas for improvement, as previously addressed in revisions (e.g., adding nuance to Principle 2 to acknowledge altruistic actions). The high proportion of Strong and Very Strong ratings (13/16 principles) supports the framework’s overall validity, suggesting it is a robust model for understanding public health dynamics. However, refining the weaker principles could increase agreement and validity across raters, potentially raising the ICC (previously 0.614 for four raters) by reducing variability.

Conclusion

My validity scores for the Public Health Realism principles reflect a careful assessment grounded in validity theory, balancing content, substantive, structural, and generalizability considerations. The Moderate ratings for Principles 2, 5, and 13 indicate specific weaknesses in overgeneralization or complexity, as seen in examples like the oversimplification of egoism or the overstated subsumption of moral imperatives. The Strong and Very Strong ratings for the remaining 13 principles, such as the clear articulation of power dynamics in Principle 6 or deception in Principle 7, affirm the framework’s strength. These ratings suggest that while the Public Health Realism framework is robust, targeted revisions to Principles 2, 5, and 13 could enhance its overall validity and consensus among raters.

Perplexity

Okay, let's delve into a discussion of the validity scores assigned to the principles of public health realism, using examples and connecting them to concepts within validity theory.

Overview of Validity Theory

Before discussing the specific principles, it's useful to frame this evaluation within the context of validity theory. In essence, validity refers to the degree to which evidence and theory support the interpretations of test scores entailed by proposed uses of tests (or in this case, principles). There are several types of validity, including:

• Content Validity: This refers to how well a measure (or principle) represents all facets of a given construct.
  
  

• Criterion Validity: This assesses whether a measure correlates with other measures (criteria) that it should be related to.
  
  

• Construct Validity: This is the degree to which a measure assesses the construct it is supposed to assess. It involves both convergent validity (correlation with similar constructs) and discriminant validity (lack of correlation with dissimilar constructs).
  
  

Discussion of Validity Scores

Here's a discussion of the assigned validity scores, incorporating examples and relating them to validity theory:

Principles with Very Strong Validity

Principles 4, 6, 8, 9, 11, 13, 15, and 16

These principles received "Very Strong Validity" ratings, indicating substantial evidence and broad applicability.

• Example: Principle 15 states: "Dominant powers have disproportionate power, influence, and resources within the public health economy that leverage vast complex networks to control rulemaking, gatekeeping, liberation space-making, and resource control. The long-term effects of interest pursued as power tend to hegemonize."
  
  

  • Discussion: This principle aligns strongly with observations of how pharmaceutical companies, large non-profits, and government agencies influence public health policy and resource allocation. The control of "rulemaking" is demonstrated by the lobbying efforts to influence legislation. "Gatekeeping" is evident in which research is funded and published, thereby shaping the narrative around public health issues. The concept of "hegemonizing" is borne out through continued norms of white supremacy in public health. The Flint Water Crisis, as detailed in the provided document, exemplifies this, where the interests of the state government (a dominant power) led to a public health disaster, disproportionately affecting a marginalized community. This single case illustrates how vast complex networks operate to influence resource control.
    
    

  • Validity Theory: This principle demonstrates high construct validity because it accurately reflects the power dynamics observed in public health. It also has criterion validity as it aligns with other theories of power and influence in social sciences.
    
    

Principles with Strong Validity

Principles 1, 3, 7, 10, 12, and 14

These principles were rated as having "Strong Validity," indicating significant support, though perhaps with some limitations in scope or minor exceptions.

• Example: Principle 1 states: "The public health economy is a state of anarchy characterized by perpetual competition for resources where there exists no common principles or central authority. The public health economy reproduces health inequity."
  
  

  • Discussion: The COVID-19 pandemic highlighted the competition for resources (vaccines, PPE, funding) among different countries and regions. The lack of a unified global strategy exacerbated health inequities. Even within countries, different agencies and organizations often compete for funding and recognition, leading to fragmented efforts. The high level of duplication of services, lack of clear communication, and lack of resource sharing are also examples.

  • Validity Theory: While generally valid, the "anarchy" characterization may be an overstatement. There are some coordinating mechanisms and shared principles, but the overall competition is undeniable. Therefore, it exhibits strong but not "very strong" validity.

Principles with Moderate Validity

Principles 2 and 5

These principles received "Moderate Validity," suggesting some empirical or logical grounding but with notable limitations or inconsistencies.

• Example: Principle 2 states: "Self-serving egoism is assumed to motivate action within the public health economy."

  • Discussion: While self-interest plays a role, it is not the sole motivator. Many individuals and organizations are driven by altruism, ethical considerations, and a genuine desire to improve public health. The actions of healthcare workers during the pandemic, who risked their lives to care for patients, demonstrate this. However, the principle does reflect certain realities, such as pharmaceutical companies prioritizing profit or agencies seeking to expand their budgets and influence.

  • Validity Theory: This principle suffers from lower content validity because it does not capture the full range of motivations in public health. While it has some criterion validity (as self-interest is a factor), it is not universally applicable.

In summary, the evaluation of these principles highlights the complexities of the public health economy and the interplay of power, interests, and ethics. The "Very Strong Validity" ratings suggest that several principles accurately reflect the structural realities that perpetuate health inequities, while the "Moderate Validity" ratings indicate areas where the principles may be overly simplistic or require further nuance.

Citations:

1. https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/56975069/31ab8ca8-fcd7-42a3-8171-44100493133f/Public-Health-Liberation-An-Emerging-Transdiscipline-to-Elucidate-and-Affect-the-Public-Health-Economy-Download-9.pdf

Answer from Perplexity: pplx.ai/share

ChaptGPT

Here's a comprehensive discussion of the validity ratings for the 16 principles of Public Health Realism, using your criteria and anchored in validity theory (empirical, logical, and theoretical grounding), with real-world and historical examples through 2025.

🔹 Very Strong Validity

These principles are exceptionally well-substantiated—they’re both descriptively accurate and offer strong predictive utility across contexts.

“The public health economy is a state of anarchy…”

• Empirical support: COVID-19 revealed a disjointed, contradictory response system across local, state, federal, and international agencies. The U.S. had no unified authority or plan; guidance and policy varied wildly.

• 2025 example: Disparate responses to climate-exacerbated health emergencies (e.g., urban heat, air pollution) remain under fragmented jurisdictions.

• Theoretical fit: Matches political realism (anarchy in international relations), now applied to public health.

• Rating justification: This is the foundational insight of public health realism.

“Interest is defined in terms of power, most often through financial assets…”

• Example: UnitedHealth Group, with $300+ billion in annual revenue, wields outsized influence on coverage policy and health access.

• Logical support: Power asymmetry defines influence in health agenda-setting. Resource-rich agents shape outcomes.

• Rating justification: Broad explanatory and predictive strength across both Global North and South.

“Agents exercise power through rulemaking, gatekeeping…”

• Example: WHO pandemic treaty negotiations show how elite actors set global norms—often without meaningful representation from affected populations.

• Empirical consistency: Regulatory capture in the EPA, CDC, and pharma sectors demonstrates how power is exercised through hidden processes.

• Rating justification: Core mechanism of dominance in public health.

“Agents may have contradictions in moralities…”

• Example: CDC promoting racial equity while failing to fund community organizations during monkeypox response (2022).

• Theoretical tie: Organizational behavior theory consistently shows value-behavior gaps.

• Rating justification: Consistently demonstrated in practice; high external validity.

“Health equity or PHL may directly compete with agents' self-interest.”

• Example: Opposition to Medicaid expansion in conservative states, despite overwhelming public benefit.

• 2025: Anti-DEI legislation limits public university equity work in multiple states, directly conflicting with health equity objectives.

• Rating justification: Observed across domains—housing, education, insurance, pharma, tech.

“Agents who benefit most seek to maintain relative power…”

• Example: Hospitals opposing price transparency laws. AMA opposing Medicare expansion.

• Theoretical alignment: Reinforces critical theory and elite theory.

• Rating justification: Predicts institutional behavior with precision.

“Dominant powers use networks to control rulemaking…”

• Example: ALEC (American Legislative Exchange Council) drafts state-level bills across sectors, including health.

• 2025: Conservative legal advocacy groups influence state-level abortion and trans health bans through coordinated legal strategies.

• Rating justification: Applies in both domestic and international contexts.

“Hegemonic powers threaten health equity…”

• Example: UN climate-health targets diluted by powerful country blocs to protect industrial interests.

• 2025: Supreme Court decisions limiting regulatory powers (e.g., EPA or HHS) shrink tools available to address health harms.

• Rating justification: High-level structural critique with global relevance and explanatory power.

🔹 Strong Validity

These principles are well-supported by evidence and logic, broadly applicable but may have minor exceptions, scope limitations, or require further empirical unpacking.

“Self-serving egoism is assumed to motivate action…”

• Critique: Not all actors behave selfishly; altruism and solidarity also operate, especially in local community health groups.

• Support: Institutional analysis (e.g., budget maximization in bureaucracies) supports egoism as a baseline assumption.

• Rating justification: Robust but somewhat reductive; context matters.

“Each agent is responsible for its own survival…”

• Example: Local health departments must secure funding year-to-year, often competing with peers, despite shared goals.

• Caveat: Some centralized safety nets do exist (e.g., national health services), though they’re increasingly underfunded.

• Rating justification: Strong in U.S. context; slightly less universal globally.

“Agents’ speech and conduct may not reflect true self-interest…”

• Example: Corporate "equity" campaigns that don’t align with lobbying priorities or internal policies.

• Caveat: Difficult to empirically verify “true” self-interest vs. expressed values—requires interpretation.

• Rating justification: Strong insight, but measuring “authenticity” can be slippery.

“Agents may form coalitions where interests align.”

• Example: Public–private partnerships in COVID vaccine distribution.

• Theoretical grounding: Coalition theory, interest group theory.

• Rating justification: Broadly applicable, though not inherently predictive of outcomes or equity.

“Coalitions remain susceptible to competition and power struggles.”

• Example: Tensions between community groups and academics in CBPR (community-based participatory research).

• Rating justification: Solid observational basis; aligns with real-world organizational dynamics.

“Coalitions may become hegemonic…”

• Example: Global health alliances (e.g., Gavi, Gates Foundation networks) define vaccine priorities for entire regions.

• Caveat: Not all coalitions aim for dominance; some are truly collaborative.

• Rating justification: Context-specific; strong but not universal.

“Agents can act hegemonically without coalitions…”

• Example: Amazon, Google Health, and other firms shaping health access via technology and AI.

• Support: Matches with ideas of institutional autonomy and networked power.

• Rating justification: Clearly supported, though empirical studies are still emerging.

🔹 Summary from Validity Theory

• Very Strong Validity applies where the principle exhibits high external validity (generalizes well), strong construct validity (measures what it claims), and high internal consistency (logical coherence).

• Strong Validity applies where a principle holds widely true but may vary by context, contain borderline constructs, or lack universal predictive force.

Gemini

Okay, here is an evaluation of the 16 Principles of Public Health Realism, rated for validity according to your definitions and evaluated in light of current events and plausible trends extending into 2025.

The principles are drawn from the theory of Public Health Liberation presented in the document, which synthesizes various theoretical traditions and lived experiences, particularly concerning health inequity. They are largely based on political realism and sociological observations applied to the "public health economy".

Evaluation of the 16 Principles of Public Health Realism:

1. Principle: The public health economy is a state of anarchy characterized by perpetual competition for resources where there exists no common principles or central authority. The public health economy reproduces health inequity.

   • Rating: Strong Validity

   • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. Events like the fragmented global response to pandemics, ongoing competition for healthcare funding, and persistent health disparities despite stated goals provide substantial evidence for this characterization.

2. Principle: Self-serving egoism is assumed to motivate action within the public health economy.

   • Rating: Strong Validity

   • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. While not universally true (altruism exists), observing the actions of various factions (e.g., industry seeking profit, political groups seeking power, institutions seeking funding) shows self-interest is a potent and frequent motivator, consistent with realist theory.

3. Principle: Each agent is responsible for its own survival within the public health economy.

   • Rating: Strong Validity

   • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. In a competitive, anarchic system, institutions and groups often prioritize their own viability and resource base, sometimes at the expense of broader collaboration or the needs of marginalized groups.

4. Principle: Interest is defined in terms of power, most often defined by the pooling of financial assets and exerting influence over a defined population(s).

   • Rating: Strong Validity

   • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. The influence of lobbying, campaign donations, control over research funding, regulatory capture, and market share demonstrates the centrality of financial resources and population influence as forms of power in shaping health outcomes and policies.

5. Principle: Moral imperatives are subsumed under self-interests because of the lack of common moral principles and central enforcing authorities.

   • Rating: Strong Validity

   • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. Decisions that prioritize economic factors over public health (e.g., historical examples like the Flint water crisis, ongoing debates about environmental regulation vs. industry cost ) illustrate how self-interest, facilitated by a lack of universally enforced ethical standards, can override moral considerations.

6. Principle: Agents exercise power through rulemaking, gatekeeping, issue framing, resource distribution, or through control of authorities invested with those powers.

   • Rating: Very Strong Validity

   • Rationale: The principle is exceptionally well-substantiated, universally applicable, and a cornerstone of its field (political science/sociology applied to public health). These mechanisms are demonstrably how influence is wielded by governments, corporations, foundations, and professional organizations across various contexts.

7. Principle: Agents' speech and conduct cannot alone be a reliable source for ascertaining their true self-interest. Agents are free to engage in misleading speech and actions that do not reflect their true self-interest. They may exploit human suffering and vulnerability to achieve maximum benefits that flow primarily to that agent or class of agents.

   • Rating: Strong Validity

   • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. Examples include corporate "health-washing," political rhetoric diverging from policy, selective use of data in reports, and instances of groups exploiting vulnerable populations for gain ("poverty pimping" ) support this principle.

8. Principle: Each agent can have contradictions and conflicts in moralities and issues - internal inconsistency and dissonance.

   • Rating: Strong Validity

   • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. Organizations often exhibit conflicting goals or practices (e.g., promoting health equity while maintaining practices that exacerbate inequity ). This internal dissonance is observable in complex institutions and systems.

9. Principle: Agents are free to seek control over or to create coalitions with agents in the public health economy where interests align.

   • Rating: Very Strong Validity

   • Rationale: The principle is exceptionally well-substantiated, universally applicable, and a cornerstone of its field. Coalition building (industry groups, advocacy networks, political alliances, public-private partnerships ) is a fundamental aspect of how actors operate in any complex social or political field, including public health.

10. Principle: Coalitions retain the characteristics of the public health economy wherein they are susceptible to fierce competition and power struggles.

    • Rating: Strong Validity

    • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. Alliances are often fluid, and internal conflicts over resources, strategy, or leadership are common, reflecting the underlying competitive dynamics.

11. Principle: Achieving health equity or supporting PHL theory and practice may directly compete with self-interests for an agent or class of agents.

    • Rating: Strong Validity

    • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. The pursuit of profit, maintenance of existing power structures, or political expediency can conflict with measures needed to achieve genuine health equity, representing a core tension PHL seeks to address.

12. Principle: Agents that benefit most from the public health economy seek to maintain their relative power position. Any reform efforts or calls for change are merely reflective of interest as power whereby they seek change insofar as they maintain relative power.

    • Rating: Strong Validity

    • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. Incumbent powers often resist disruptive change or co-opt reform language to manage challenges while preserving their fundamental advantages, aligning with theories of power maintenance.

13. Principle: Coalitions are common in the public health economy and are best understood as a means for agents to maximize their interest through collectives. These coalitions become hegemonic arrangements when they seek dominance by reducing competition and focusing on directing benefits and resources to their advantage.

    • Rating: Strong Validity

    • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. It accurately describes how alliances can consolidate power and influence rules/norms to favor members, linking coalition behavior to the concept of hegemony.

14. Principle: Agents can act hegemonically without coalitions through exercises in power.

    • Rating: Strong Validity

    • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. A single, sufficiently powerful actor (e.g., a dominant corporation, a key government agency) can shape the environment through its actions, resources, and norm-setting capacity without needing a formal coalition.

15. Principle: Dominant powers have disproportionate power, influence, and resources within the public health economy that leverage vast complex networks to control rulemaking, gatekeeping, liberation space-making, and resource control.

    • Rating: Strong Validity

    • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. This describes the systemic nature of power, where dominant actors utilize interconnected political, economic, and social networks to maintain control over key levers within the system.

16. Principle: Hegemonic powers, whether agents themselves or coalitions, pose a major threat to realizing health equity by seeking to maintain the public health economy to their advantage.

    • Rating: Strong Validity

    • Rationale: The principle is robust, well-supported, and widely applicable, with only minor limitations. This principle logically concludes the framework: if hegemony involves maintaining the status quo for the benefit of dominant powers, and the status quo includes significant health inequity, then hegemonic forces inherently act as barriers to achieving equity.