What we’re dying from has changed.
Not entirely, of course. We still die from infectious diseases and trauma but – as you well know – more and more of us are now dying from non-communicable diseases. These diseases are, in fact, the major killers in high-income settings. And yet, despite this change, what’s not changed is how we try to tackle illness. And there’s something absurd about that.
Last week, I published a conversation with Toby Lowe, a former Chief Executive of a charity and now a Senior Lecturer in Public Management and Leadership. Toby changed jobs because the way in which funders were asking him to run his charity failed to “deal with the complex reality of the world”. He was asked to prove that four hours of arts activity with youth could prevent re-offending. Making that link was fundamental to the charity’s ongoing funding. And yet, to make that link – to draw a clear line from those four hours to a kid staying out of trouble – he’d effectively have to lie.
In health care, the rise of non-communicable diseases is forcing us to think about the complex reality of the world. We increasingly understand that health and sickness are influenced by social context. We have described this context, often through succinct diagrams, and are beginning to explore where we might focus. But what too few people are doing is asking how.
There’s an assumption – largely unstated – that how we’ve worked in the past is how we should work now: decide what outcome you want, identify what makes that outcome more or less likely, intervene accordingly, measure the change, calculate efficacy. But this linear approach ignores the fact that in complex environments the thing you’re trying to influence is the product of hundreds of different factors all working together, most of which have nothing to do with your organisation. As Toby says, “it’s basically impossible to say an outcome can be attributed to the actions of an organisation”.
So, how should we be working?
Somewhat echoing the work of Paul Taylor of Bromford, a housing association (see our recent conversation), Toby sees three parts to the how:
- Trusting the intrinsic motivation of people doing the work on the ground
- Using learning as the driver for performance improvement
- And creating healthy systems because only healthy systems produce good outcomes
The one that interests me most is number two – learning. An organisation dedicated to learning looks fundamentally different to an organisation dedicated to service delivery. Most of the community health efforts that I’ve seen are about service delivery. They operate on the basis that for health to improve, something needs to be delivered. Once delivered, outcomes should improve. Not only do these organisations often fail to improve health, they fail to understand why they failed. While the former failure matters, the latter failure is, to my mind, more troubling.
Medicine likes to think of itself as a science. So, how is it that we’re not systematically studying how to operate in complex environments, such as our social contexts, when the changing burden of disease clearly demands it? Two researchers in Australia have explored medicine’s inflexibility. Baum and Fisher looked at why governments continue to push policies designed to influence individual behaviours when it’s clear that social context matters more. Although they numbered them differently, I saw six ‘reasons’ in their paper.
The first is what they called ‘historical factors’ – effectively, it worked in the past so we’ll keep doing it. I’ve talked about that above.
The second is political ideology. Most high-income countries have embraced the ideas of neoliberalism – reduced government intervention in the belief that markets are self-regulating. Part of this ideology is the idea that one’s status is defined by one’s actions and so neoliberalism offers little space to the idea that one’s health status is shaped more by societal structures than individual choice.
The third makes my head hurt. Baum and Fisher suggest that we cling to ideas not so much because we believe in them but because they protect our place in society. Adopting an alternative view of health, one that sees it to be the product of our social and economic structures, forces us to examine our own role in these structures. Doing so may not only be uncomfortable but also force us to face how complicit we are in maintaining these structures.
The fourth is plain and simple political cowardice. Unless you’re a staunch neoliberal ideologue, it’s possible to see that complete faith in markets isn’t good; some corporations need to be regulated (think Big Tobacco or Big Food). Few modern-day politicians have the stomach for this.
The fifth is how we’re all being driven to produce ‘evidence’. As Toby says, it’s basically impossible to say an outcome can be attributed to the actions of an organisation and yet that’s what policy wonks demand in order to package ‘evidence-based practice’. While I completely agree that policy should be evidence-informed, it needs to be the right evidence, not just what could be packaged neatly enough.
And the sixth is the lobbying power of those for whom the status quo is working. The obvious example of this is food companies that continue to fund think tanks and political parties to ensure that their view is heard above all else. While this may seem related to the fourth reason (political cowardice), in my experience some politicians don’t even know they’re being influenced let alone know where the fight is.
So, does having six ‘reasons’ for inflexibility let medical practice and policy off the hook? Not to my mind. But in the same way that Toby’s work has given a language to those working in a complexity-informed way, perhaps Baum and Fisher have given us a mirror with which to examine our work. So, if you’re in a community health meeting this week, ask yourself whether one of the six ‘reasons’ is influencing your work. If it is, are you comfortable with the absurdity or are you colluding in the silence?
I know, as ever, difficult questions; but the easy ones have been asked.
- In my conversation with Toby Lowe he describes how working in a complexity-informed way means building ‘human learning systems’ – read the conversation here
- Baum and Fisher’s article is called, ‘Why behavioural health promotion endures despite its failure to reduce health inequities‘ (it’s an interesting, if sometimes head-aching, read)
- Their article is part of a special issue of the journal on the need to think broader than health behaviours
- And I quoted some of it in the first issue of Community & Health, The Fallacy of Behaviour Change
- Paul Taylor is doing incredible work to reimagine the role of housing in people’s well-being, and you can see my conversation with him here
- The succinct diagram I used for the social determinants of health was taken from this page on Healthy People 2020, a programme of the US Office of Disease Prevention and Health Promotion
- And if the link between neoliberalism and health interests you, here’s some difficult reading on how its potentially weakening the work of the World Health Organisation when it comes to reducing sugar in our diets and how it’s potentially dismantling universal health care in Brazil
The photo behind the title is by Hans Reniers on Unsplash.