Tomorrow, July 27, is the last day to register for the Robert Wood Johnson Foundation and Grantmakers in Health 90-minute webinar:  “A New Way to Talk About the Social Determinants of Health.”

Scheduled for Thursday, July 29, 2010 at 3:00 p.m. (EST), this webinar will summarize research and share the most effective way to reach the widest audiences:

• Better frames and messages for “social determinants”;
• Best practices and principles in language;
• How to use data to support your case;
• Deeply held perspectives that affect how policymakers see health; disparities.

Register here.

Before getting into why I think we should be leery of commonplace notions, I should define what I mean by the term. First of all, merely suggesting that there’s something wrong with commonplace notions might itself sound wrong. After all, commonplace notions are commonly understood to be the agreed understandings of the world that keep the world on track. But when we see that in certain respects the world is not really on a track anyone would call a good track, we might want to look at the commonplace notions keeping it there as a reason for this. One of the ways I define commonplace notions is that they lead us astray and compel us into actions that betray our best interests. Both to make this argument and to further define the term I offer the following examples.

This morning for reasons that aren’t important I began thinking about the commonplace notion that fifty-percent of marriages end in divorce (well, maybe they are important: I listened to a radio show discussing the institution of marriage, in light of the Gores’ recent announcement that they are separating; a decision, I was told by the show’s host, that’s sparked a “national conversation” on marriage).

For as long as I can remember people have talked about a fifty-percent divorce rate. We have been told and told each other and told ourselves that one out of every two marriages ends in divorce. The effect of this notion is profound. It creates a backdrop against which we think about marriage. It turns marriage into a gamble — a crapshoot, or a coin toss — which in turn can make it seem as if a decision to end a marriage is all but fated. It corrupts the equally fraught notion of commitment.

The commonness of the fifty-percent notion is built upon a foundation of slipshod thinking. It turns out the fifty-percent statistic is an aggregate of all marriages, i.e., marriages in all age groups, in all economic conditions, in every social stratum, etc. The function of a commonplace notion is to personalize a general observation. For example, a person of any age, any economic circumstance, any background can come to believe that his or her marriage has only a fifty-percent chance of lasting a lifetime. That’s what the commonplace notion tells us. The data, however, show something else. For people from certain specific age groups the chances of having a marriage that lasts a lifetime are much better than fifty percent. This fact is much less well known than the commonplace notion that fifty-percent of marriages end in divorce.   

Commonplace notions seduce us into a faulty understanding of some part of the world and then to act in ways that disregard less well-known facts about that part of the world. And it is a seduction, speaking seductively to a pervading resistance to the subtler enticements of rigorous thinking. This phenomenon has direct application to work being done by public health officials, community agencies, government, academia and business to improve health by championing wellness and pursuing a social determinants approach to health. Again, an example might be helpful.

For several years the trend in health insurance has been to ask subscribers to assume more responsibility for their health. In the euphemistic vernacular of the industry this is called employee engagement. (It probably shouldn’t go unsaid that they’re also being asked to assume more of the cost for treatment when their health fails.) Asking this of subscribers runs afoul of the commonplace notion of health, which exclusively associates health with medical treatment, medical treatment subscribers don’t know how to value. Accordingly even for those with unmanaged chronic conditions health is a background concern; it’s a given until such time the condition flares up and they’re forced to seek medical treatment. Asking people to participate in wellness and prevention programs under the auspices of a health insurance plan is an affront to the commonplace notion of health; read, an affront to the way people have come to take a place in the world.

I wonder if the challenges and failures of employee engagement aren’t somehow evidence of this running-afoul of the commonplace notion of health-as-medical-treatment. It might be that for the ninety percent of employees who aren’t engaged (don’t take advantage of the benefits provided to them) it just doesn’t fit the norm to think of health in terms of wellness and prevention. Which means they’re not intrinsically motivated to take advantage of their benefits. Add to that the implicit admonition that attends messaging telling them to change the way they live, and it’s a wonder an employer can claim even ten percent compliance with the new dictates.

This is where a community/social/ecological approach can potentially change the game. If a community/social/ecological approach can be notioned as vitality (to pick one word not thoroughly usurped by the health-as-medical treatment notion), and if it can be partitioned from health insurance benefits, there is the possibility of people changing their behaviors, not because they’ve been told that what they’ve been thinking all this time is wrong but because they’ve been given the space and permission to think anew about their health.

A federal working group report released last week highlights 11 categories of diseases and other health consequences — from asthma and cancer to neurological and stress-related disorders — linked to climate change. “This white paper articulates, in a concrete way, that human beings are vulnerable in many ways to the health effects of climate change,” said Linda Birnbaum, Ph.D., director of the National Institute of Environmental Health Sciences (NIEHS) and the National Toxicology Program, whose institute led the interagency effort.

A workaround, according to Wikipedia, “is a bypass of a recognized problem in a system…a temporary fix that implies that a genuine solution to the problem is needed. Typically they are considered brittle in that they will not respond well to further pressure from a system beyond the original design. In implementing a workaround it is important to flag the change so as to later implement a proper solution.”

Of course, “later” is always “later.” And “implementing a proper solution” means that we will need to acknowledge the underlying causes of the problem we had previously decided to “bypass.” And when we do decide that “later” is now (perhaps when “further pressure” from the “system” becomes too much for our “brittle” workarounds to bear) – and we are finally willing to address the “recognized problem” with a “genuine solution” — will we undo all these “temporary” changes we so diligently remembered to “flag”?

Phew! Makes me wonder why we bother with workarounds in the first place…

And yet, even as First Lady Michelle Obama hits the airways to promote Let’s Move, the national campaign “to solve the epidemic of childhood obesity within a generation,” we are seeing a range of very inspired, apparently well intended, though too often superficial, fixes. It all seems a bit nip-here, tuck-there when the “genuine solution” we need is nothing short of a complete transformation.

But let’s give credit where credit is due. Quite a few of these fixes are, as the Wikipedia definition goes, “as creative as true solutions.”

For example, just last week we read about an innovative effort in Baltimore that uses libraries as “virtual supermarkets” to work around severe nutrition gaps in the city’s food deserts.  We heard snack and soda companies vow to alter their ingredients and distribution practices to work around the prospect of a more drastic step: abolishing or taxing their products. And we learned of a new bill that dramatically reduces the money requested for school food reform to work around the lack of support for an earlier proposal.

One could argue that this is good, tangible progress. To be sure, each of these actions will produce a result. And perhaps quick fixes are a way to get us moving, which seems to be the spirit of the Let’s Move campaign. One could also argue that, for the most part, we are tiptoeing around the edges of a fundamentally broken system, which we avoid like the elephant in room, as we go about the business of gathering low-hanging fruit.

A step further would be to acknowledge these and similar fixes as provisional, and to commit to measuring their impact as well as their shortcomings, as we continue with equal passion the ongoing work of uncovering the roots of the epidemic. In this work, we begin with questions rather than fixes. We ask, for instance, why is it that food deserts exist in the first place?

We might even begin to unravel that most gnarly of hairballs at the center of the obesity epidemic: How is it that America became, as Newsweek’s Claudia Kalb puts it, “the world’s preeminent fat-making machine”?

We got here through multiple innovations, many of them meant to improve, not corrupt, our lifestyles. Fast food is a quick fix for hungry working families. Cars and buses get kids to school faster than sidewalks. We have grown used to a world order of speed and convenience…

“The National School Lunch Program, signed into law in 1946 by President Harry Truman, was designed to feed hungry children who needed extra calories… With a focus on standards of learning propelled by the reading- and math-focused No Child Left Behind Act, many schools cannot afford, financially or academically, to offer physical education… Our suburban designs, influenced by age-old zoning laws, also work against us… And then there’s rampant marketing. Food and drink advertising to children… (And) government subsidies on abundant commodities like corn and soy. High-fructose corn syrup, synthesized from corn, is a main ingredient in a multitude of sweetened drinks and snacks.”

In short, she concludes, “An entire cultural shift is required.”

So, when it comes to childhood obesity, will a new round of workarounds work? Will they see us through until we get to a genuine solution? Will we question after the root causes? Or will we keep adding workarounds to our workarounds, with the illusion of progress, until our passion turns to complacency, or resignation, or distraction — or whatever it was that consumed us when we first saw the trends (5, 10, 20 years ago?) and decided that a “proper solution” just wasn’t palatable?

As the First Lady writes in her recent Newsweek article, “For years, we’ve known about the epidemic of childhood obesity in America.” The good news, she notes, is “that we can decide to solve this problem.”

A genuine solution will not just tweak the existing structures and make up for the inadequacies. Deciding to “solve this problem” requires a more fundamental examination of, in Kalb’s words, how “we got here.” Just how is it that we have created a system perfectly engineered to produce the results we’ve got (nearly one-third of American children and adolescents are overweight or obese)?

More precisely, we need to examine who we were being when we created the current system. And who we must be to transform the system (and ourselves) to produce the results we really want.

Additional coverage of the story unfolding in Benton Harbor, Michigan: “Businesses join to educate community on health,” Employee Benefit News.

See previous post and stay tuned for updates here.

One of the insights that came flooding over me watching HBO’s new movie about Temple Grandin is how my day-to-day experience of the world is so perfectly arranged – and limited – by my particular brain and conditioning. What I think I see, what I affix shape and meaning and language to – the particular way I make sense of the world – is also a kind of blindness to anything else.

Grandin, a doctor of animal science and noted autism advocate whose rare ability to explain the condition’s effects changed the way both science and society perceive it, tells us right from the start, “I’m not like other people. I think in pictures. And I connect them.”

An early scene makes the point. Grandin and her aunt drive up to the gated entrance of a sprawling Arizona cattle ranch, and what might appear as nothing more than a pass-through (the gated entrance) suddenly becomes a complex interplay of angles and trajectories, of geometry and relationships, through Grandin’s unique consciousness (and some rather stunning visual effects).

Clearly, there’s a lot more going on than we perceive. For most of us, it’s the gated entrance we see, the instantaneously configured end product of our perception. We lock in on the world-as-objects so that we can move through it in expedient ways.

Grandin sees the configuration process itself – the interplay of past experiences, physical stimuli and their perceptual effects. Just as the gate is more than a gate, Grandin’s mind, her science teacher explains, is like a door that opens up on a whole new world.

Seeing our seeing, and the limitations of our seeing, is useful and important. You might say it is the only way we ever perceive anything “new.”

That’s one of the reasons I found today’s blog post by Altarum Institute’s Stanley Chin so refreshing (“Just How Do We Define a ‘Culture of Health’?”). Rather than provide pat answers and superficial solutions, researcher Chin poses some big questions that challenge long-held and mostly unexamined assumptions about health, health behaviors and health “determinants,” a word he says is itself problematic: “Health is surely not ‘determined’ or cast in stone but is the result of interacting risk factors, environment, genetics, chance, and individual choices.”

The challenge is furthered when we build assumptions on our assumptions. For example, notes Chin, while education is correlated with health, the precise “pathways from educational attainment to improved health status are not clear,” which of course leaves interventions to guesswork. Chin observes:

That the health policy research community does not know much about such pathways, despite decades of work, says something about the data available, the methods used, and the very nature of the problem. Communities and their health are more than just complicated and full of surprises. Formally, they may be examples of ‘complex adaptive systems’ – ecologies with a complex web of feedback loops over time and spatial dimensions. These loops mean that direct causation may be difficult or impossible to demonstrate, that history can be as important as current levels or capacities, and that what we normally think of as the background (context and details of implementation) may actually be the key success factor.

Chin hasn’t cracked it all the way open (yet) – How about deconstructing what we mean by “health”? – but it’s a start in the right direction. A shift in perception might be our best and only hope to get to “the very nature of the problem.”

Here is one of the outputs of an amazing gathering yesterday in Michigan, where community transformation leaders from the east (Detroit) and west (Benton Harbor) edges of the state came together to share stories, aspirations and possibilities for collaboration: article in Detroit News.

The article missed a few facts; what’s more important is the story behind the story, which will continue to emerge through this growing network of leaders. Participation is welcome!

“This initiative is an example of ‘positive deviance,’ an approach to behavioral and social change. Instead of imposing solutions from without, the method identifies outliers in a community who, despite having no special advantages, are doing exceptionally well. By respecting local ingenuity, proponents say, the approach galvanizes community members and is often more effective and sustainable than imported blueprints.

“Unlike a lab experiment or ‘best practices’ transferred from elsewhere, the strategies have already been shown to work in context. As it takes root, positive deviance could instill a new way of looking at hard problems.

“Often, the positive deviants are unaware of the benefits of their habits, and are, in fact, ashamed of them because they violate cultural norms. The approach also works best, ironically, with the most formidable problems, perhaps after other solutions have failed, because the community must be highly motivated to solve the problem.

“In places known for their rigid pecking orders, these interventions often disrupt long-established dynamics. The efficacy of positive deviance…is ‘related to the issue of ownership. The solutions tend to last longer because it’s just human nature that we don’t turn our backs on what we create.’

“At bottom, positive deviance amounts to simple common sense. But that may be what’s most revelatory about it. Instead of throwing money at a problem or devising grand solutions, it urges us to look a little more closely at what’s already happening.” – from “The Power of Positive Deviants,” by Rebecca Tuhus-Dubrow, Boston.com, November 29, 2009

“Why do children love imaginary figures like Santa Claus…? Because they like to pretend. And when children pretend, they are exercising the evolutionarily crucial human ability to envision alternative ways the world could be. In adults that ability is at the core of our very real capacities for invention and innovation.” – Alison Gopnik, author of “The Philosophical Baby: What Children’s Minds Tell Us About Truth, Love and the Meaning of Life”; full story in December 22, 2009, The New York Times.

“Pocket parks — also known as miniparks and vest-pocket parks — are small patches of landscaped nature generally built on vacant building lots or scraps of city land that fall between the cracks of real estate interests… (Thomas Hoving, former New York City parks commissioner) recognized that they offered the city not only ‘lungs’ and a respite from noise, but opportunities for collective action by the surrounding communities whose help he enlisted in reclaiming the land. He believed that the communal act of making these spaces of quiet itself promoted harmony.” – from “City of Earthy Delights,” George Prochnik, Opinion, The New York Times, December 13, 2009.