Community, Movements, and Spread: It's the Process That Matters
Rather than rest on the seventh day, God might have put a little thought into futureproofing the design of human beings. As societies age, the weaknesses in our design, combined with changing lifestyles, mean that sickness has become the normal human experience. Against that backdrop, staying healthy—defined as the absence of biological deficits—becomes an unattainable goal.
The good news is that people don’t actually want to be healthy, i.e., they won’t describe health as their ultimate goal. They want to lead satisfying lives, with definitions of satisfaction being as individual as they are. The absence—or control of—biological deficits is only part of that definition. Other parts encompass things like physical functioning, fulfillment from daily activities, financial competence, emotional security, a sense of community, nourishing personal relationships, and meaning. Life satisfaction is about finding balance in the complex interplay between these things. People understand, begrudgingly or otherwise, that “shit happens” – not everything can be perfect all the time.
Health care, however, seems yet to learn this lesson. Tackling biological deficits has become big business, fueled by admirable successes in care made possible by reducing sickness to linear causality. The industry’s commercial and clinical successes have given rise to a self-confidence that borders on hubris. But in aging societies, the future of health cannot just be about managing biological deficits.
How do we create life satisfaction? We don’t. People do, and they do it for themselves. This is partly because there are so many definitions of life satisfaction that it would be impossible to create a service that provides it. But it’s also because as society changes, the only true experts about communities are those living within them.
Ask people what they want, don’t tell them what you think they need. Learn their language, rather than impose technocratic approximations. Help them define and deliver the interventions that make sense to them. Agree on how you’ll evaluate, ensuring that you use their sense of value. And throughout the process, shield them from prescriptive academic theories born of dispassionate observation and aggregation; allow them to own their experience.
These appear to be the emerging principles of creating life satisfaction, part of which includes health. The clear consequence is that it’s local, specific, tailored to the people that wanted, defined, delivered, and evaluated, all in their own language. As well as being local, creating health is unpredictable—because life is unpredictable.
Change is the only constant, as they say; communities are a chaotic dance of confounding variables. To seek linear causality in order to discover “what works” would be naïve.
So if interventions to create health are local and their results unpredictable, what chances are there that they might scale and spread? I suspect little to none. But it’s not the interventions and the results that we should be worrying about. It’s the process by which they’re done that matters. This is what’s most likely to scale and spread.
I mentioned above the verbs that outline the process of creating health. Ask. Learn. Help. Agree. Shield. Not only do these five verbs outline the process but they— hopefully—communicate a core tenet: parity. It takes true parity between professionals and communities to create health. While the professionals ask, learn, help, agree, and shield, the community defines, delivers, and evaluates.
For creating health to scale and spread, we need to invest in the process by which interventions are defined and delivered, and the process by which they’re evaluated.
The health debate in the United States is at a dangerous moment. There is growing appreciation of the need to think more broadly about health, but its tethering to the so-called “social determinants of health,” especially poverty, is inhibiting deeper reflection. First, the analysis of the social determinants is based on the likelihood of developing biological deficits, effectively limiting the definition of health. Secondly, and as a consequence, it makes the focus what professionals think people need, not what they want. And third, focusing on poverty just makes it too big.
This is a singular moment in the history of health. If professionals can show the discipline required to focus on the process of creating it—ask, learn, help, agree, shield—we have the opportunity to genuinely understand health beyond health care.