Key findings from public health

Healthy "people" aren't localized rocks, but are normally well-interconnected bidirectionally into the social fabric around them.

Social connectivity is the most robust predictor of internal, "physiological", "biomedical" outcomes, such as morbidity, mortality, survival rate of surgery, resistance to infection, level of depression, outcome of diabetes, obesity, "mental" health, you name it.

Prevention is a thousand times more cost effective than repair. ( A lesson from software engineering and many other fields as well.)

The caring human loving touch of another individual is very important to human health and healing. Infants who aren't touched do poorly or simply die.

All interesting social phenomena (such as relationships, jobs, teams, family, stress, love, sex, the economy, depression) involve intimately bidirectional feedback loops.

But, classical statistical measures and attitudes, based on prediction of yields of crops, assume critically that causality is defined in one direction only, and that all phenomena of interest can be "isolated" from context and one part of it varied by the experimenter while other parts of it are "held constant." None of that applies to "complex adaptive systems", including social systems, which are inextricably interconnected, context-dependent, interdependent, and riddled with bidirectional feedback loops. Since the tools and expertise breakdown when applied to these areas, rather than admit that the tools and expertise are inadequate, the problem space is instead defined as "non-scientific" or "soft-science" and demeaned as unimportant or "non-scientific."

Possibly due to such schizophenia, the US "healthcare" system behaves as if none of the above solid empirical facts were known. There is no focus on social connectivity, less than 2% of the budget is spent on prevention, and machines and processes have replaced people at the bedside. People are treated like machines, and diseases are treated as if they were independent of each other and the rest of peoples lives. "People" are reduced to "patients". "Caregivers" are too busy to stay and chat for a while with "patients" and are increasing renamed "providers" which is ironic, since mostly they consume resources, particularly money, while being forced by "the system" to be too busy to stick around and observe the actual outcomes of their "treatments" on the people they serve. It's a lose-lose scenario, disliked by the patients, disliked by the caregivers, and apparently continues to exist because it's loved by the insurance companies. The whole thing needs to be rethought based on the above new facts of life.

Perhaps, not surprisingly then, the outcomes of the US Healthcare system are terrible, compared to peer countries. Infant mortality is something like 19th in the world. Costs are huge but a recent study showed that the BEST quartile of US citizens (the rich) have health outcomes worse than the WORST quartile of British citizens in the UK. (ref ?). Depression, obesity, diabetes are widespread and rampant epidemics in the US.

But, efforts to build healthcare interventions that are designed around social connectivity and whole persons are demeaned and ridiculed as being "non-scientific", or avoided because the feedback loops make computing "p-values" problematic for academic researchers, for whom such mathematical bases for certainty are held with a sort of blind obsession despite the fact that the assumptions of the theory (General Linear Model) don't fit the problem they're trying to address.

The result is that the most effective interventions are known, and involve teams of people assisting individual humans to modify or control their behavior and life style, but the advocates of these interventions are academically shunned and have to present their work in embarrassment in back rooms. The Office of Behavioral and Social Science Research (OBSSR) within NIH is treated like an awkward in-law.

Probably the single best book that summarizes interventions in health care that actually work is Health Program Planning : An Educational and Ecological Approach by Lawrence W. Green and Marshall W. Kreuter, now in it's fourth edition. (c) 2005 McGraw Hill, initial version written in 1961. It was around that year that non-communicable diseases began to replace communicable diseases as the leading causes of death, disability, and impaired quality of life, but the older, biomedical model had a very tightly held death-grip on the "health care industry."

On page 3 of that book the authors note:

Ecological approaches have proven difficult to evaluate because the units of analysis do not lend themselves to rand assignment, experimental control, and manipulating characteristic of preferred scientific approaches to establishing causation. Although the linear isolatable cause-effect model of scientific problem solving remains the point of departure for the training of health professionals, practitioners find ... they cannot ignore the contextual reality that health status is unquestionably influenced by an immensely complex ecological system. ...

To address those systems in our planning, we must first be able to see them ...
By definition, ecological sub-systems do not operate in isolation from one another ... [but] interact with one another to influence health. [We need] a kind of ecological map or "web" or "systems model" enabling us to visualize the network of relationships that need to be taken into account as we plan our intervention strategy tailored to the unique circumstances of the target population and the place where they live and work.

The primary tools up to this task are described by John Sterman in his tome Business Dynamics, 999 pages in length. The simpler techniques of mapping on a white-board is known as Causal-Loop Diagramming or CLD. These qualitative webs can be assigned some semi-quantitative values, such as directionality and general magnitude (large, small, strong, weak) and then simulated using tools such as Vensim (tm).

That, however, is a lot of work. "Systems thinking" didn't show up in the MPH curriculum until 2006, and is absent, by that name, in most courses, even at leading universities. Only MIT and Worcester Polytechnic Institute seem to have embraced these tools, although the Ross School of Business at the University of Michigan is starting to build a systems thinking program after the auto industry started demanding it.

Note that the pressure for innovation here is from business, and the academics are lagging behind, sometimes kicking and screaming, in stage 2 of Schopenhauer's three stages:

All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self-evident.
Arthur Schopenhauer

So, this pretty much summarizes the state of affairs today. Johns Hopkins Bloomberg School of Public Health has started a new department of Health Behavior along the lines of the new theory, but most health and public health people are famously non-quantitative, and so they are attempting to think through such problems mentally, unassisted by available tools used in other industries for over 50 years now in systems dynamics.

And, the biomedical establishment has a strong lock on most thinking and peer-review journals, and alternates denial and violent opposition to the "new paradigm" which it perceives as a throwback to mystical soft thinking instead of a more general version of the scientific method that can embrace feedback loops and complex adaptive systems without distortion of the tools or violation of the assumptions behind the models and statistics.

Even at Hopkins in the department of Epidemiology, the ratio of new thinkers to old-paradigm thinkers is essentially 3 to 70, and this new paradigm is ridiculed, rejected, opposed, despised, by most old-school thinkers who wish the answer to health had stayed down the microscope, under control, where they had strong muscles and good intuition - instead of showing up increasingly outside the window of the lab, in the social fabric of society, in all the places the scientists grew up despising and where their tools and muscles and intuition all fail.

So, where does that leave us humans?

Apparently, we can't expect either academics or health care workers to take the lead in fixing this terrible mess, and business is going to have to get down to business and do something about it.

(This is not without precedent - the center of innovation in the USA has increasingly moved out of universities and into businesses, despite the very strong marketing campaign with the opposite message. Witness the pulling-teeth it's taken to get systems thinking into the Ross Business School curriculum.)

Business today is much more cybernetic on a real-time basis than academia, and utilizes "good enough" models which, with cybernetic feedback control, get the job done and produce the desired outcomes - - while driving academics crazy because the underlying models are "so bad."
The National Institutes of Health is still heavily dominated as well by biomedically oriented researchers of the old school, who resist the new paradigm.

So, with a few exceptions, industry money may be the only way to advance health care in serious ways, and address the findings at the top of this post sometime this century when we're still alive to care about it.

We have, as in so many of M.C. Escher's paintings, (see this link:
http://en.wikipedia.org/wiki/Image:Escher_Waterfall.jpg
created a world that is locally-sensible and globally nonsense, but few people working locally are motivated to address the global wrongness, and no Masters or PhD student or young researcher would be encouraged to tackle a "large" problem, and so it sits there, unaddressed by academia and a thorn in the side of everyone: patients, doctors, nurses, payers, industry.
Like Escher's paintings, one is hard pressed to see or point to exactly "where" the wrongness is, and yet, standing back, it's clearly wrong.

That's where things are today.


[ M.C. Escher website: http://www.mcescher.com/ ]

Spiritual solutions for technical problems

If we reframe an intractible "technical" problem as a "spiritual" problem, it can reveal a hidden solution.

Here's an example. I worked in a lab once where we had special glass vials we needed to do our tests. The supplier was back-ordered over 3 months and we ran out and were stopped cold. So, this was clearly a "technical problem." Then I found out that there were crates of these vials 40 feet away in the next lab down the hallway. But, we weren't allowed to use those, because that researcher had a long-standing gripe with out lab's boss over some incident 10 years prior, and they weren't on talking terms.

The point is, solving the underlying spiritual problem of lack of reconciliation of these two researchers was an alternative way to get our lab functioning again.

This is not an isolated case. In fact, when you think about it, there are many "techical" and "economic" problems in our own lives that would go away if we addressed some interpersonal spiritual issues that are in the way. I hate to think of what fraction of corporate and national resources are spent trying to make it possible for us to avoid facing our broken personal relationships and dysfunctional organizations.

What brought this to mind this morning was an article in the New York Times on new $400 antennas that increase your cell phone's reception.

Coaxing More Bars Out of That Cellphone
New York Times
March 1, 2007

Garbled conversations and dropped calls are the bane of cellphone users — not to mention the dead zones where calls cannot go through to begin with. But some recent products are designed to overcome these annoyances, improve cellular reception, and, in some cases, even extend coverage....

So, probably, if everyone spent an additional $400, we could get better reception. That would be the "technical solution."

Take a minute before rushing on and consider what a "spiritual solution" would be. Hint - it would involve cooperation instead of fragmentation between people, with each person trying to reinvent the wheel on their own.

Here's another clue. Glance at my prior post
One laptop per child - grid computing for the poor.

The New York Times covered this yesterday (november 30,2006) in an article "For $150, Third world laptop stirs a Big Debate" by John Markoff. Compare to "Microsoft would put Poor Online by Cellphone", also by John Markoff, Jan 30, 2006.

According to Markoff's article yesterday "Five countries — Argentina, Brazil, Libya, Nigeria and Thailand — have made tentative commitments to put the computers into the hands of millions of students, with production in Taiwan expected to begin by mid-2007." Much of the rest of the article deals with pricing, technology, and competing views about the impact of this computer on education.

That misses the most important aspect of this, in my mind, which Markoff mentions near the end of the piece:

One factor setting the project apart from earlier efforts to create inexpensive computers for education is the inclusion of a wireless network capability in each machine.

The project leaders say they will employ a variety of methods for connecting to the Internet, depending on local conditions. In some countries, like Libya, satellite downlinks will be used. In others, like Nigeria, the existing cellular data network will provide connections, and in some places specially designed long-range Wi-Fi antennas will extend the wireless Internet to rural areas.

When students take their computers home after school, each machine will stay connected wirelessly to its neighbors in a self-assembling “mesh” at ranges up to a third of a mile. In the process each computer can potentially become an Internet repeater, allowing the Internet to flow out into communities that have not previously had access to it.

The distinction between "computers" and "cell phones" has become almost irrelevant these days, so what does this suggest.

It suggests that a different way of connecting cell-phones to the national grid would be to have them able to self-assemble a communications grid, in real-time, borrowing a little spare capacity from any other phone or computer in the neighborhood.

In other words, I don't really need my phone to be in line-of-sight to a cell-phone tower if the phones cooperate and silently set up their own relay chain behind the scenes. My phone can talk to my upstairs neighbor, which talks to the phone 2 floors above that, all the way to the top of the building, where someone's phone can talk to another distant building's phones which in turn are in line of sight of the cell-phone tower on the other side of the mountain. Voila, I have a path for my call.

We don't need new $400 antennas for each cell phone - we only need the existing cell phones to talk to each other.

Aside from finding a clear path, the phones could also automatically deliver much more power. This is the sort of thing that radio astronomers use, to connect 20 different radio antenna "dishes" across the world into a single virtual antenna that can be "virtually" pointed directly at the target, delivering thousands of times the effective power because it all goes the right direction instead of off into space.

The downside is that different phones and phone systems and even people would have to be willing to let "their" phone participate as part of a larger social grid. The upside is that this would work even in some Katrina type disaster, and auto-assemble a pathway from the existing phones to a cell-tower or satellite that could relay calls out of the disaster area.

The changes are essentially all in software and procedures. Probably this could be done with existing phones today, if we, collectively, decided that's what we wanted to do.

Without a single new cell-phone tower, or a single dollar being spent for new hardware or phones, everyone in the country could get 100 times better service.

There are no "technical" reasons we couldn't do that.
There are only "spiritual" reasons we put up with that make us dysfunctional.

This kind of problem is very widespread, especially in the USA today, where cooperation and collaboration seem to have gone the way of the phonograph in many places. We're all working overtime, way more hours than any other country, trying to make the payments on purely technical solutions that we mistakenly think we need to solve our issues.

Quoting my earlier post, looking at the chaos caused by lack of communications following Katrina in New Orleans,

By W. David Stephenson International Conference on Complex Systems June 26, 2006

So we know that emergent behavior is possible even under the trying circumstances of a terrorist attack or a natural disaster.

... Equally important but less understood by decision makers, unlike landline phones or the broadcast media, these devices are themselves increasing networked, self-organizing, and self-healing. In many cases, such as mesh networks that were originally developed for the military in battlefield conditions and now are being used by civilians, the networks don't require any kind of external networking: simply turn them on and the network self organizes.

I am convinced that such a networked homeland security strategy is feasible today, using existing technology and requiring much less time to create and deploy than some of the costly, dedicated emergency communications systems government is creating. Equally important, by facilitating those three qualities needed in a crisis: flexibility, robustness, and self-organizing, it could transform the general public from hopeless victims, waiting for aid that may never come, into self-reliant components of the overall response. To paraphrase Dr. King, which will it be, chaos, or community? [emphasis added]

On a larger scale, communications is just one problem we saw in New Orleans. Tens of thousands of cars left the city with one passenger, while a hundred thousand people were stranded without transportation. Food and water were hoarded not shared.

One explicit principle of the Baha'i faith is where this line of thinking ends up, and it's a lesson
that Michigan and the USA need to pay attention to. The economic downturns can be viewed
as "technical" problems, yes, but that hides the much closer, much cheaper solutions, that don't
require new technology.

PRINCIPLES OF THE BAHÁ'Í FAITH

#10 -
A spiritual solution to the economic problem.



I'm reminded of the monkey traps used in some countries. A cocoanut has a hole cut into the side, just large enough for a monkey's paw to fit into it. Then the cocoanut is chained to the ground, and some delicious nuts put inside it. Then we wait. The monkey comes along, smells the nuts, reaches in, grabs a handful, and then can't get it's overstuffed hand back out the hole. At that point people can just walk over and drop a net on the monkey, who will refuse to let go of the nuts that are "so close."

Americans have this fixation on having to fix everything with individual solutions - everyone has to have their own car, their own house, their own everything -- and even the phones or computer lines, if not being used, can't be shared with others for a whole variety of invented "legal" reasons.

There's a lesson here. In our case, it's not some guy with a net coming after us, it's the entire economy going south on us, loss of jobs, etc. Within each company, there's a collapse of innovation, all to protect this competitive concept and a myth of rugged individualism, that probably was never true. Like our SUV's that dress like they're going off-road, but never do, we have these attitudes that dress like we don't need anyone else to survive, but we do.

If we admitted that, and went from there, most of the rest of these problems could be solved. It's like everyone is trying to be the most fanatastic word or note in the universe, and forgetting that great books and great music need lots of different words and notes to work.

We need each other. We don't need more technology to make up for our lack of friends. We need to help each other learn how to make friends again. It seems to be a lost art for at least one in five people in the USA today. We should fix that, then see how much "depression" is left.