Exploring the Nuance Under the Buzz

“So many marginalised people have been living for decades in toxic environments that have eroded their confidence and motivation.”

Those are the words of Graham Duncan, the Director of St Mary’s Community Centre in inner city Sheffield, UK. For the past decade or so, Graham has been exploring how to support local residents by building on the idea that value – or ‘assets’, to use the jargon – already exists in a community. 

‘Asset-based community development’ is a term that’s used more and more these days. But the problem with common terms is that the buzz around them can obfuscate the nuance beneath. Graham, however, hasn’t fallen for the buzz: 

“An asset-based solution isn’t necessarily quick or cheap. People don’t fulfil their potential just because others proclaim them to have – or be – assets.”

With this grip on reality firmly in place, Graham set about trying to find “a mechanism” to get the value that exists in the community working for the benefit of its residents. He came across the idea of ‘time credits’ – earning a credit for each hour spent on a community project, which can then be spent on rewards. In the last 12 months, the Centre has had 484 members earn 17,190 credits. One of the things the credits can be spent on is food in a community café. 

For many of us in health care, improving access to food is an end goal. Within that frame, Graham’s work is a success. But Graham and his colleagues wanted a more profound understanding of what was happening from earning to eating. And so, with the help of the local university they delved deeper.

What they found was that participating in a community project enabled people to experience some kind of success, whether it was learning something or contributing to something. “Most people aren’t used to success,” Graham says, so the experience increases their sense of what they’re capable of. Participation also creates the opportunity for people to experience positive, supportive relationships – again, something that many people aren’t used to. And because they are rewarded for their time with credits, they feel motivated.

Capability. Opportunity. And motivation. For Graham, this is the nuance under the buzz of asset-based community development. It’s what’s really going on. 

Too few people look under the buzz of terms that are getting traction. It leads to work that lacks the depth required for long-term change. One area we’re seeing this is in response to the opioid crisis. 

For many of us, the crisis was propelled onto centre stage by Case and Deaton’s 2017 report, Mortality and Morbidity in the 21^stCentury. The report made famous the term ‘deaths of despair’ defined as deaths from drug overdoses, suicides, and alcohol-related liver disease. The rise in these deaths is so pronounced amongst white, working-class men in America that it has off-set the reduction of deaths from cancer and heart disease so that, overall, life expectancy for this group of people has fallen. 

The link to the opioid epidemic looks obvious but Case and Deaton are clear in their report that the over-prescribing of these drugs only fuelled an existing crisis. It cannot be labelled as the cause. In fact, their report is a search for possible causes and along the way they debunk many assumptions, most of which are politically motivated. 

Some people think it’s all about employment but Case and Deaton show that after the 2009 global recession rates of unemployment in Spain were far higher than in the US and yet death rates were far lower. Some people think it’s all about income but Case and Deaton show that the fall in incomes after the 2009 global recession also occurred in some European countries and, again, there was not a rise in death rates. Some people think it’s all about education but Case and Deaton point out that this is near-impossible to conclude given that people with differing levels of education differ is so many other ways too. 

Through their search, they come to the broader idea of the erosion of economic and social supports over many generations. 

It’s less and less possible for a man to follow his father into a manufacturing job. It’s less and less possible for a worker to rely on a union for support, including a steady increase in wages and better working conditions. Marriage is no longer the only socially acceptable way to form intimate partnerships or rear children. And people have drifted away from the security of old religions that preach the importance of community towards new religions that promote individualism. 

Many people will see the above as progress. Men no longer have to follow in their father’s footsteps (or women in their mother’s). Industry is no longer straight-jacketed by unions. Partnerships can be based on love rather than the institution of marriage. And everyone can be free of the religious dogma that has constrained individual ambition and creativity. 

But Case and Deaton wonder whether all of the above has left people with less structure to fall back on when things don’t work out. This structure, they say, is what gives meaning to life.

For me, this nuance is missing from how we’re responding to the opioid crisis. As ever, our response in health care is technical, shying away from the difficulty of the social. More treatment for individuals addicted to opioids seems to make perfect sense but what does it do to put supportive structures back into society? How can a treatment clinic give meaning to life? 

So, if you’re in a community health meeting this week do double-down on those addiction treatment centres but follow the good examples of Duncan, Deaton and Case in trying to better understand the nuance under the buzz. Make space to explore what your role could be in the bigger solution of re-establishing supportive structures in your community.

Further Reading 

• My conversation with Graham Duncan is called When Trust is Not Enough; Graham does an excellent job of mapping his observations to a new framework for behaviour change 
• If you haven’t read Mortality and Morbidity in the 21^stCentury stop everything and do. It’s well-written and does an excellent job of unpacking a deeply thorny issue 
• If you think this is a US-specific problem, think again. Drug-related deaths in Scotland, for instance, have risen by 27% (in fact, Deaton and Case point out that the issue is very much concentrated on the English-speaking world) 
• Deaton is now doing work in the UK to explore the impact of inequality (although I think it’s a shame that they made that the focus rather than the impact of the class system) 
• There is currently a proposal out for review from the US Preventive Services Task Force to screen all US adult patients for illicit drugs; I think it’s a step in the wrong direction
• If you’re wondering whether we’ve thrown the baby out with the bathwater when it comes to religion read this article on the question of God by one of my former colleagues, Elizabeth Slade
• And finally, if you’re wondering what Graham Duncan’s work is pointing to this article on whether we’re seeing the end of our current version of capitalism is worth getting your head around (thanks to Catalina Denman for bringing it to my attention) 

Previous issues of Community & Health

• On Power, Co-Production and Feeling Overwhelmed: How co-production, self-management and health promotion all have the potential to increase social inequity, and what you can do about it
• Why Provision is not Enough: How atomising problems and providing programmes ignores what really matters in enabling people to turn their lives around
• Sectors, Partnering and Place: How cross-sector partnering demands thinking about place, and why thinking about place means thinking about people’s choices and freedom
• On Absurdity, Collusion and Silence: How our failure to effectively respond to non-communicable diseases may be because our science needs updating – if only our politics would get out of the way
• The Politics of Measurement: How eliciting social definitions of value may make emerging partnerships between health care and CBOs more effective
• The Social Determinants of Relationships: How other sectors are learning that the key to responding to social circumstances is deeper relationships with the citizens they serve
• The Fallacy of Behaviour Change: How a flawed idea got traction and what you can do to fight back

Recent Interviews

• The ‘Power Elephant’ in the Room: A conversation with Lauren Weinstein about how power differences are intrinsically present in co-production and what she’s doing to overcome them
• Halfway Between a Stranger and a Friend: A conversation with Maff Potts on how 20 years working at the sharp end of society has taught it him that only two things matter, and what he’s doing about it
• Lessons from the Frontline of Cross-Sector Partnering: A conversation with David Relph, formerly of Bristol Health Partners, on why collaboration has to be the core purpose of institutions concerned with health
• The Need for Human Learning Systems: A conversation with Toby Lowe on his journey from baffled Chief Executive to a key figure in the movement to find more effective ways to work in complex social environments
• The Challenge of Going Beyond the Usual Metrics: A conversation with Andrew Harrison of Revaluation and The Learning Studio on the promise and complexity of surfacing new types of value
• Effective Housing Goes Beyond a Home: A conversation with Paul Taylor, Innovation Coach at Bromford, a housing association in the UK, on why building homes is not enough

The photo behind the title is by Anastasiia Ostapovych on Unsplash.