If we aren’t part of the solution, we are part of the problem

2016

This is the question I grapple with every day — is my job (and livelihood) actually causing more harm than good? Are my attempts to improve public health actually reinforcing the very structures that cause the public to be sick?

In my job, I implement strategies to “improve health,” but some of these strategies imply huge cultural judgments. For example, what if some people or cultures value quality of life or length of life and are just not interested  in losing weight?

Moreover, the factors that have driven this obesity epidemic are 99% systemic. That means the things that cause obesity are not simply because people are lazy and don’t eat enough. The things that cause obesity are happening on a much more societal scale – crime and pollution make it difficult for people to exercise, segregation and lack of mass transit make it difficult for people to access healthy food.

You wouldn’t blame an individual for getting the flu (epidemic). Why are we blaming people for getting fat? Yeah, I said it. FAT. Who cares, anyways? Why the huge value judgment? Fat is only a bad word in the US. In other countries it’s just an adjective.

Anyways, the things that make us sick are the societal structures like segregation keeping our kids apart and creating rich and poor neighborhoods.

To fight for public health, we gotta fight for public wealth.

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Tensions I am holding now

I don’t want to do things that are performative allyship

AND

I want to speak up about my mistakes to normalize examples of white supremacy and learn from them

I’m scared to act because I know I am likely furthering white supremacy with my words

AND

White people need to speak up. White silence = violence

I have an urgent need to educate myself to do less harm

AND

I need to take (imperfect) action now in this moment

I want to remove myself from leadership of orgs where I have created white supremacist structures

AND

I feel guilty about creating these orgs and want to do the work to improve them

I want to take swift action against white supremacy within my organization

AND

I don’t want to punish/scapegoat people who may have simply been acting within the white supremacist structures I helped create

Data is not the answer.

I am so sick of “experts” talking about the “importance of using data” to develop programs that will make people healthy.

As if doctors having more information is what will make people lead longer happier healthier lives.

This might be true if you are a) white, or b) middle to upper class. For those people, access to better medical care might actually matter. Because changes in resource allocation won’t really affect them. Even if money is taken from the rich and given to the poor, they will still be fine.

For non-white, non-rich people, giving doctors more data will not affect them.

What will affect them is better policies that redistribute wealth, provide access to quality educational opportnities, and provide affordable housing in non-segregated, mixed income neighborhoods that means all residents benefit from the services and utilities offered.

Campaign finance reform would help, too. (But not the rich white people)

A multi-party system would help bring some of this about as coalitions could be formed and money (if campaign finance reform passes) wouldn’t be the primary driver for getting into politics.

 

More health care = worse health.

Smart people working in health care think they know how to make people healthy. They think people need health care services, and access to social services. They think people aren’t getting social services because they simply don’t know about them. They think once people are educated about and referred to these services, they will access the services and improve their income, housing, transportation, and quality of life.

I believe this line of thinking is 1) flawed and 2) a result of white privilege and systems that have come about because of white privilege.

  1. This thinking is flawed. Why? Because we know why people are unhealthy, and we know what to do to make them healthy. Providing MORE health care is not on the list of evidence-based interventions. Certain topics have evidence-based interventions that need to be implemented. But simply providing MORE health care is not proven to improve people’s health. In fact, given that medical harm is the 3rd highest cause death in the US, more medical care will likely lead to further injury.

Health ain’t health care.

“Population health.” A term co-opted by hospitals describing the efforts they are taking to improve the health of the community.

The approach is aligned with what hospitals know – clinical care. We are simply further medicalizing things. Instead of illness in the body, the “chief complaint” is a shifting payor mix that hurts executives pocket books, the “diagnosis” is government regulations, and the “treatment” is a population health approach that reduces ER readmissions.

Hospitals have already begin to screen for (see ACEs), diagnose, and ‘treat’ the social determinants. Vast sums of money are being spent on collecting patient data on items such as poverty, social distress, and educational access. Data are then used to “screen” for the presence of social needs. A positive screen triggers a referral to a social service agency, assuming one exists. It is assumed that the visit to the social service agency addresses and resolves the social need. Several models are being highlighted (Health Leads, Camden Coalition, Health Begins, etc.)

It’s possible this might work, I want to be open to it. But right now I am skeptical, mainly because it’s using the same model (individualized medical care) to treat a very different problem (systemic social ills).

And even if this model did work, most people, even most people in non-profits, aren’t trying to work themselves out of a job. Why would they?? To expect them to is not realistic.

Incentives are not aligned! This is why I believe in government. Government, especially democratic government, is about the social contract. We agree not to commit anarchy, if the government provides basic social services that meet our basic human rights and allow us life, liberty, and the pursuit of happiness. If most people agree on these basic principles, we can collect a modest amount of taxes to pay for those basic human rights. With these basic needs mets met, we cure (alleviate) 99% of social ills – petty crime, gangs, violence, drugs, joblessness, ignorance, illiteracy, polluted air and water, etc.

Millenials want people to do things because it is the right thing to do. They want hospital executives to invest in community health because they should, even if that means less money for the health system. <– in full disclosure, that’s me. I want that. I want nonprofit hospital execs to say – “y’know. I am making $2 mil a year. Maybe it’s time for me to take a payout, operate this company on slimmer margins, and work toward making myself obsolete.” What’s the worst that could happen? People get healthier, the hospital shrinks to providing critical care services, and many people lose their jobs.

But when in human history has that actually happened? I heard several people complaining that the (Republican) Governor of Georgia only veto’d a religious freedom/anti-LGBTQ bill because of economic forces driving him to do it. Well, so what? Do they actually expect him to change his values? Or to not care about his base? Or to completely write off the funders who were backing him?

People do things because it is in their best interest. (I wonder if my 21 year old self would agree with me.)  To expect something else is a clear indication that the speaker/author is of privilege, such that survival is not the most pressing issue.

I am great! I am terrible.

I know we all feel this. Days when we are on top of the world, only to be followed by days filled with despair. Sometimes only days or even hours apart.

Sit on a career panel for college kids and supposedly say inspiring things. I am great! Accidentally cc someone on an email about them that wasn’t meant for them. How could I?

Create opportunities for women and girls to play sports. I am saving the world! Fall in love with someone I wasn’t supposed to and make good people suffer. WTF????

Get recruited for fancy job. I must be special! Realize I can’t really do the job and have put my boss in a horrible position. I am selfish.

Meet amazing person who fulfills my desires for a mature, loving, fun relationship. I knew it was just a matter of time! Manage to commit to everything else in the entire universe BUT spending time with him. What is my problem?

I don’t have any summary statements. Nothing really insightful to say. Buddhists would say – that’s life. Get used to it. Better yet, make friends with it. Yeah, I don’t disagree with that. It’s just much much easier said than done.

 

Does accountability really matter?

“The flaws in the traditional approach to impact measurement have led to an accountability gap. Social entrepreneurs have fallen into the habit of conducting evaluations that meet the needs of upward accountability: They collect data to meet the requirements of their investors. (And investors, in turn, often set those requirements in response to the reporting expectations of their limited partners.) What is often missing is a commitment to downward accountability—to making sure that social enterprises are using data to improve the lives of their intended beneficiaries.5″ – See more at: http://ssir.org/articles/entry/the_power_of_lean_data?utm_source=Enews&utm_medium=Email&utm_campaign=SSIR_Now&utm_content=Title#sthash.WcmRHBqq.dpuf

This quote has me thinking about so many things.

  1. The word accountability. Here I am defining it for use in public health as systems in place to ensure business practices that improve people’s lives. Which sectors have it? Which don’t?

Accountability doesn’t matter in the for-profit sector unless by chance a values-driven leader/board sets in place systems to ensure certain standards are met (e.g. Patagonia meeting environmental standards).

Philanthropy has virtually zero accountability. Funders can pretty much do whatever they want, give to whomever they want, regardless of evidence base or need, and no one can say anything. But the National Committee for Responsive Philanthropy is doing some pretty cool watchdog type stuff like asking where Walmart family’s foundation money goes.

Government seems to have some level of accountability at some levels but is greatly lacking systemic methods of funding effective, proven programs. I don’t know enough about this sector so I will leave this one with a ?

That leaves us with non-profits. To whom are non-profits accountable? The first audience that comes to mind is donors, investors, funders. But isn’t that messed up? Shouldn’t the primary audience be those who are being helped BY the non-profits? Not those who have the checkbook?

There’s the accountability to do good work. But there’s also an accountable to do be EFFECTIVE. If an organization is providing needed services to people with low-incomes but treating it’s own employees like crap, it is very unlikely that those services will be able to meet standards of high quality.

 

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