By: Scott Orsey
Change is hard, especially where structure creates imbalance in perspectives, power and impact. When years of good intentions yield underwhelming results for children and families, it is time to question the approach. In this four-part blog series, Scott Orsey explores the model used by scientists to measure health and well-being. He arrives at three conditions for change. Might these be the building blocks for the transformation we seek?
In my most recent article, I wondered whether the structure of mathematical models we typically use to estimate program success might suggest other truths in solving social problems. Over the next several articles, I will discuss some of the implications that I see. This blog post will focus on the first pre-condition needed for change: Those with power and influence must recognize that they cannot solve everything and that there is a problem with the current structure.
To do so, I will explore the iconic hero’s journey story – that’s the story where isolated or protected characters step out into the “real world” and discover that they actually are not as special as they once thought. Then they learn something new about themselves that makes them more effective at understanding or changing the world around them. This story repeats itself in every walk of life and, indeed, in every field of study.
Astronomy’s Hero’s Journey
I am particularly fond of examples from science, specifically astronomy, where we progressively learn that we, humans, are not as special as we like to think. The first “modern” theory of humankind’s place in the universe was posited circa 350 BC by Aristotle when he developed the geocentric model. At that time, people came to believe that our planet lies at the center of the universe and that heavenly bodies move about the earth in complex patterns. Then, 1,800 years later, Copernicus proposed that the earth is not the center of the universe after all. He ushered in heliocentrism with the sun at the center. Heliocentrism simplified the complex motions of the planets and stars. Two hundred years later, Thomas Wright proposed that everything really revolves around the center of our galaxy, the Milky Way. Then, in 1925, Edwin Hubble made the definitive discovery that proves our galaxy is just one of billions of other galaxies in the universe by showing that some objects, previously known as spiral nebulae, are actually other galaxies far outside of our own. If someone could have lived through these 20 centuries, that would be one humbling experience! This loss of human-centric thinking doesn’t stop there. Every few decades, we learn of a new observation that makes our place in the universe seem ever less special. We are even learning that our universe itself may not be that special.
Thinking More Broadly about Health
This same story is playing out in our understanding of the role of health care in promoting healthy childhood development. Paul H. Dworkin, MD, often talks about the evolution of the field: of working in the 1980’s to improve medical practice; of the 1990’s where we expand our thinking to include the important sectors of early education and family support; of now when we understand the influence of a whole host of sectors beyond health care. We have a far more holistic view, yet are still early in building collaborations that respond to the reality that improving developmental outcomes is not the work of health professionals alone. Health care is just not that special.
Modeling Determinants of Health (DoH)
But what does our mathematical model say about this? In my previous blog post, I derived a simple representation of the “odds” of success of a hypothetical program for improving an outcome. It looks like this:
Ϲ is a constant.
fi = eβixi are functions representing the influence of each of our determinants on the odds of success.
Health care leaders often refer to these factors as the determinants of health (DoH). DoH serve as a shorthand way of saying that health outcomes are not driven solely by the quality of health care that a person has access to or receives. In addition to quality health care, outcomes are influenced by genetic, social and environmental, and behavioral factors or determinants.
To represent this concept using our simple model, we need to group the relevant factors:
Ϲ is a constant.
fn are functions representing the influence of each sector on the odds of success.
By describing this mathematical model, can we infer anything from its structure? Perhaps you will agree that it is self-evident that the model supports the concept that outcomes are driven by factors beyond health care. This should not be too surprising and it is perhaps circular logic since we structured the model in this way.
Read the first article in this series.
More than Meets the Eye
However, I see something more. This representation might suggest a deeper insight – one very similar to yet another implication of Edwin Hubble’s discovery about the universe: In proving that lots of the stuff in the sky is actually farther away from us than stars in our own galaxy, Hubble also showed that all galaxies are moving away from us. The farther away a galaxy is, the faster that galaxy is moving. This became the empirical basis for support of The Big Bang Theory. If we observe that everything is expanding away from us, we might conclude that we are indeed near the center of the universe, taking us right back to Aristotle’s theory. However, that’s not the right conclusion. The Big Bang Theory also requires that this universal retreat holds true for every other point in the universe – everything is moving away from everything else. Therefore, we are not the center of the universe. Everywhere is the center of the universe or alternatively there is no center of the universe – pick your poison. Our little galactic neighborhood is not that special.
Back to our odds equation: The right hand side of the equation contains a bunch of factors multiplied together. Effects are compounded and amplified by other effects. No single factor is that special. If one of the determinants (x and therefore f) is particularly adverse, then it can derail the outcome. Every determinant matters. You cannot neglect one at the expense of others. It’s likely hard to improve the odds of a good outcome without addressing the most adverse factors.
All Sectors Matter
It’s not that we are not the center of the universe. It’s that everywhere is the center of the universe. It’s not that outcomes are influenced by more than good health care, it’s that outcomes are influenced by all factors. It’s not that health care is less special than we like to think. It’s that all sectors matter.
Which leads to a key premise: In order to promote the outcomes we want, we must consider all sectors in the solution. It is only through the actions of all sectors that we will realize the change that we desire in our communities. Yet, the healthcare sector is all-to-often placed at the center of the system – as holding the answers and solutions. This affords the healthcare sector disproportionate power and influence. It is therefore incumbent upon the leaders in healthcare to recognize this imbalance. It’s an imperative supported directly from the structure of the math we use to model outcomes. Now, how will we use this lesson within our hero’s journey?
In the next blog post in this series, I will demonstrate how this model supports the importance of making room for others to lead.
Author’s Note: My deepest gratitude to Amy Hunter, PhD, MPH, who reviewed this series, challenged my thinking and offered feedback and insight.
Scott Orsey is the associate director of operations, business strategy and institutional engagement for Connecticut Children’s Office for Community Child Health.
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Categories: Health Promotion