Category: public health

Public and population health

complexityhealth promotionsocial systemssystems thinking

Cohesion vs. Diversity

I just watched (yet another!) great TED talk that solidified something that’s been on my mind all week: diversity.

The talk by Cary Fowler, the leader of the global seed bank, a remarkable initiative aimed at saving the world’s seed for future use should that day (or many days) come when we need to draw upon the diversity on our planet to support life. Even though we think we live in a world of apparent dietary diversity (after all the average supermarket literally carries thousands of products — just look at the number of types of yogurt you can buy at a typical store), the truth is that we are in deep trouble when it comes to the diversity of natural food choices available to us. It is estimated that there are about 7500 different types of apples alone. But we rarely see that expressed in food choices. Shop your local supermarket and you’ll find that variety sharply drops down to about a dozen or less. And this dozen or less is the same at most of the other shops. The truth is, we are limiting our diversity in food dramatically and are potentially harming our potential survival in the process.

In Canada, we praise ourselves for being an accepting society and our social, cultural and linguistic diversity. My home, Toronto, may be the most ethnoculturally diverse city in the world when measured by these aforementioned characteristics. Scott Page, a systems scientist from the University of Michigan, has written a fantastic book on diversity that provides a strong case for diversity in many different contexts from school to work to community life.

But diversity has a dark side. The less we have in common (i.e., the more diverse we are) the less cohesion we are likely to experience as a duo, group or society. It was that very topic that Michael Valpy wrote about in the Globe and Mail this week. In his article, he quotes another Canadian and now Liberal Party leader Michael Ignatieff from his new book:

“We need a public life in common,” he writes, “some set of reference points and allegiances to give us a way to relate to the strangers among whom we live. Without this feeling of belonging, even if only imagined, we would live in fear and dread of each other. When we can call the strangers citizens, we can feel at home with them and with ourselves.

And reaching for a codicil from his intellectual hero, he adds: “Isaiah Berlin described this sense of belonging well. He said that to feel at home is to feel that people understand not only what you say, but also what you mean.””

Anyone who has worked on projects where there is a diversity of opinion knows the benefit of having someone not only understand what you say, but also what you mean. That trait alone may be the reason we commit to working together at all and, when it doesn’t happen, why we might choose to do things apart. A healthy system has both diversity (represented by chaos at its extreme) and cohesion (represented by rigid order at its opposite pole). Having watched Cary Fowler’s talk shortly after reading Michael Valpy’s article has me questioning what the balance is in fostering diversity within a system. How does one know when you’re ‘diverse enough’ or when you’re too rigid and inflexible? In the case of Cary Fowler, he’s not planning to have all 7500 apples growing at the same time and place if he even gets all those seeds saved, but he’s not planning on saving just the tastiest, crispest or hearty of them either. That strikes me as a good thing.

In my eyes, a great community is one that is diverse and cohesive — living at the ‘edge of chaos’ in systems terms. Toronto is one of those cities, with many small villages within it, and has been highlighted by urban thinkers like the late Jane Jacobs and Richard Florida as a place that does diverse urbanism rather well. As imperfect as it is, Toronto is pretty cohesive.

But it is also seeing a large gap between the wealthy and the poor – and likely the healthy and the unhealthy. This gap was driven home yesterday as I took part on a panel on the social determinants of health at the Dalla Lana School of Public Health.The concept of ‘poverty by postal code‘ and the gap between those with choices and those without was clear. Along with Carol Timmins and Stephen Hwang, we spoke separately and as a panel about issues of public health practice, homelessness, and youth. As we explored these issues I thought about this ‘cohesion’ amongst the diversity and wondered whether this is as good as it gets? Can we create greater social cohesion than this or are we doomed to some level of diversity that has lots of upsides, but also many downsides. Can we have it all?

What is the balance here and would we know it if we achieved it?

health promotionpsychologysystems thinking

Specialized and Generalized Systems Thinking and Action

This weekend my wife and I had the pleasure to host one of my best friends in the world and his fiancee for a weekend visit to Toronto. It’s perhaps no surprise that we spent a lot of time talking and laughing over a meal. Last night we talked about the impact of our work and the focus we’ve chosen to take and it got me thinking about the challenge of finding balance between specialization and generalization in health promotion work relative to impact. My wife is a social worker who specializes in domestic violence issues. Although she is a trained psychoanalyst, she came to find her greatest opportunity to contribute to the world lay in tackling problems from a systems perspective. She builds multi-sector partnerships, collaborations and works to address the problem of domestic violence at its root and its consequences from multiple perspectives including treatment & prevention and policy & practice. It is a systems approach from the beginning to the end.

Readers of this blog will know that this is a similar approach I take to the problems that interest me like food systems change, tobacco control and gambling. These are often ‘wicked’ problems — those with no clear source or obvious solution requiring collaboration and broad stakeholder engagement to solve. I work and study in the field of health promotion, which is (I argue) a systems science and practice even if it doesn’t identify itself as such. It looks at the bigger picture and tries to use that lens as a means of understanding the world and solving social problems.

My friends are both quite attune to this and I would argue also apply systems thinking to their work, yet they do in a very different way. They are counseling psychologists and, for the most part, they work one-to-one or in small groups. What our conversation revealed was the myriad ways in which systems thinking can be applied to the big and small picture. Family systems therapy for example, is one way in which these ideas are applied to small groups or individuals. But there are many more.

This got me to thinking about the opportunities and challenges associated with promoting systems transformations at the macro and micro levels. The way my friends approach their work is fundamentally different even if it shares much of the same interests in systems change as the approach that I take. Yet, that difference has a huge impact on a few people (hundreds) rather than an almost imperceptible impact on thousands.  In applying systems thinking outside of the clinical encounter, the problem they face is that they are not paid (that is, they are not reimbursed for clinical time) when they go beyond the one-to-one and small-group approach; so even if they wanted to do that work, they couldn’t unless it was on their own time. Health promotion is almost the opposite: we have become so good at working with large groups that we’ve stopped developing strategies that can help individuals that fit with the health promotion values. It’s true, that there is a season for each of these approaches. Health promotion has worked hard to escape the individual-focus that other fields like health education still use and psychology is pretty good at doing the individual thing. It just seems that there is room for both specialized and generalized systems thinking and action working together. I just haven’t figured out how. Any suggestions?

behaviour changecomplexityenvironmentfood systemssystems science

The limits to individual action

I’m writing this from a Starbucks. With free wireless Internet, decent cafe Americanos and fast breakfast foods that are both reasonably healthy, tasty and not too expensive, its one of the few chains I look for when I’m in need of a place to sit down when a comparable locally-flavoured establishment isn’t available. As someone who both works long (and often early) hours and travels a lot, places that offer decent food and drink and productivity space are valued above almost anything.  When you don’t have time to shop for healthy foods for home and have to eat out it can take a real toll on your health.

I bring with me a travel tumbler, reusable bags and even portable chopsticks to eat with. I buy local and responsibly whenever possible, and when eating at home I aim to buy items with little packaging and, what packaging there is gets recycled with the food waste organics separated and composted in biodegradable bags. When I took the David Suzuki Foundation challenge I got high marks. All is well– right? No. And that’s why climate change and protecting our environment is truly a grand challenge that requires a systems approach. Grand challenge problems refer to exceptionally difficult tasks that stretch the limits of any one group to be able to address them. They are the complex problems that have no single source or simple solution.

No matter what I’ve done to address climate change and help the environment, I am only making a small difference. I’ve been reminded by that because of one product: The Starbucks Vivanno.

This morning my wife and I had a Starbucks Vivanno — a fruit smoothie that is reasonably healthy and pretty decent food option if you’re pressed for time and want some low-fat protein — which is no easy task at the best of time, particularly if you don’t eat meat. If you’ve watched people make these things, they are messy and they are designed for a disposable cup – one that is outside of the regular size cups that a person brings around with them, making it difficult to use the reuasble cup option. This leaves us with a lot of options: 1) Take the disposable cup and make more waste, 2) find a very large cup and bring that around, adding bulk to your bag, 3) don’t drink smoothies at all and either not eat or eat something unhealthy.

Thinking about this a little further, one realizes how tied up layers upon layers of issues are in this drink.

> Why aren’t there other food choices available? (this speaks to the market, to innovation, to location — an easy thing to overlook when you live in downtown Toronto)

>Why am I so busy that I can’t make a decent healthy meal at home? (issues: work demands; social expectations; lack of funding for university research requiring me to work long hours; the expectations of my employer, employees, students and colleagues — requiring me to work long hours; my personality; availability of healthy foods in local grocery stores; ability to cook something I want to eat and meets my nutritional needs)

>Why can’t stores serve drinks in reusables? (issues: cost, breakage, theft, no proper recycling options, people’s busy schedules and need to ‘take away’, no exchange program for containers)

>Why can’t we just get better travel mugs? (issues: our bags are already making us look like sherpas with laptops, pens, books, workout gear, batteries and so forth; they cost a lot for a good one — or you buy a cheap one and add more waste when it breaks, market, etcc.)

These are just four questions with lots of issues — there are many more that you can probably think of. I write this from downtown Toronto, Canada. There are more than 20 other Starbucks locations within a 30 minute walk from my current location and dozens of other coffee shops, pastry places and food outlets to choose from. In some ways, this is really a luxurious problem to have. What about places where you have to drive to get somewhere? What about rural communities where one or two shops is all you have? Yes, the cultural standards will change in each place, but the more I look at this the easier it is to see how I can become the David Suzuki poster boy and still make only a dent on the environment without considering these myriad other issues that influence how a simple product (a cup) becomes a complex issue.

food systemssystems science

Ideology-Free Food Systems Change

Food is one of my great passions. It’s nice to have one that just happens to overlap with a basic need for survival and is a topic that is perhaps the single most powerful lever for social change in the world. We all have to eat and when we can’t eat, or consume enough, or eat food that’s appropriate to our culture or taste sensibilities our quality of life suffers greatly.  Since devoting more of my energies to food systems as part of research I’ve found myself reading a LOT about food: where and how it is grown, it’s environmental footprint, and it’s health effects on individuals and the world around us. Needless to say, there is a lot to read. There are those that look at what to eat like Michael Pollan’s Omnivore’s Dilemma & Marion Nestle’s What to Eat. Both authors have penned books on the politics of food as well such as Nestle’s Food Politics and Pollan’s In Defence of Food. Add to that the books on the food system as a whole such as Raj Patel’s Stuffed and Starved and Paul Roberts The End of Food and you’ve got a lot on your bookshelf.

Most of this reading does not paint our current Western food system in such good light.

Then there are books like the 100 mile diet by Alisa Smith & J.B. MacKinnon or Animal, Vegetable, Miracle by Barbara Kingsolver chronicle the real challenges of living life of local eating. I liked them both because they didn’t paint an unrealistic picture of what is involved in growing and eating in a manner that reflects (in places like Canada and the United States at least) a largely bygone era of food production.

I have found these books useful, interesting and (mostly) enjoyable to read. My consciousness around what I eat and my role in the food has expanded greatly since diving into this issue. I grew up in Southern Alberta and spent a lot of time in the country growing up, including visiting farms. It is a (literally) dirty business for hard-working people and a vocation that few non-farmers truly understand. It is for that reason that the themes of the books above can easily skate over perspectives that don’t gel well with with their central thesis (namely, that our current food system is unsustainable, perhaps inhumane, and not helpful to people — including farmers). And while I agree with all three of these statements, putting on my systems thinking cap and viewing the problem from that perspective has me cautious in wholeheartedly recommending that we abandon our current system. It is this critical perspective that drew me to an essay by farmer Blake Hurst that tries to put these recommendation into the perspective of the farmer and modern agrifood. Although the article is in the right-wing, business-first journal of the American Enterprise Institute I found it quite balanced and congruent with the conversations I’ve had with farmers over the past few years as I’ve become much more professionally engaged with the agrifood sector.

What I found interesting in Hurst’s article was how it burst a lot of the myths around farming that have been set up by many advocates of organic, small-scale farming that use the books I mentioned at the beginning as their defence. Hurst writes:

I’m dozing, as I often do on airplanes, but the guy behind me has been broadcasting nonstop for nearly three hours. I finally admit defeat and start some serious eavesdropping. He’s talking about food, damning farming, particularly livestock farming, compensating for his lack of knowledge with volume. I’m so tired of people who wouldn’t visit a doctor who used a stethoscope instead of an MRI demanding that farmers like me use 1930s technology to raise food…But now we have to listen to self-appointed experts on airplanes frightening their seatmates about the profession I have practiced for more than 30 years. I’d had enough. I turned around and politely told the lecturer that he ought not believe everything he reads. He quieted and asked me what kind of farming I do. I told him, and when he asked if I used organic farming, I said no, and left it at that. I didn’t answer with the first thought that came to mind, which is simply this: I deal in the real world, not superstitions, and unless the consumer absolutely forces my hand, I am about as likely to adopt organic methods as the Wall Street Journal is to publish their next edition by setting the type by hand.

It is here that I saw congruence and the levers for systems change: “unless the consumer absolutely forces my hand“. Indeed, if systems change is to come it must come from the bottom as much as the top, but do so in a manner that acknowledges the realities that Hurst outlines. I once spent almost two hours talking with Alisa Smith and J.B. MacKinnon about their book on the 100 mile diet. I’ve also met Marion Nestle and spoken to her about these challenges. Both parties were passionate advocates, but neither were zealots or ideologues. Yet, ideological rants are what is coming out loud and clear from those who are against conventional farming. This was loud and clear when the U.K. Food Standards Agency published their study showing that organics were no more nutrient rich as conventionally grown food (see my earlier post). The news and the web are full of criticisms of it, driven (presumably) by an ideology that simply see the report as an attack, rather than a reflection of science.

Diversity of perspective is an essential ingredient for healthy systems change. Hurst’s article motivated me to write this because I think he has a valuable thing to say. While many might favour organics and small scale farming for the reasons I’ve cited earlier, the truth is that there are some things that conventional farmers do now that isn’t incongruent with this perspective and that perhaps ideology should be put into the backseat. As Peter Senge and others have outlined, we need to have all groups at the table to develop our systems change strategy and this won’t happen through attacking the others, only through listening. Maybe through being present with others, listening to their perspective, and developing a strategy based less on ideology and more on collaboration will be successful in getting the healthy food system we want.

food systemshealth promotionpsychology

Asking the Right Question / Adding to the Organics Debate

Another interesting note of argument to the growing chorus of voices on the organics and health issue coming from New Scientist magazine writer Jim Giles. In his article the quote I like most is this one: “It’s not about whether organic food is good or a sham,” says Jules Pretty, an agricultural scientist at the University of Essex in Colchester, UK. “That’s the wrong question. We should be asking how we can make all of agriculture more sustainable.”

Asking the right question is an important thing to stop and consider. So often the debates in science go off into different directions without stopping to ask whether the science is answering the right (or the most important) question. This makes me think back to the presidential address by Pat O’Neill at the Canadian Psychological Association’s annual meeting a few years ago. Pat is a community psychologist and someone who’s work I’ve long admired. For those not familiar with the field, community psychology was formed largely out of the frustration of psychologists working in clinical settings who were trying to ‘treat’ psychological problems at an individual level when the problems were less about the individual, but much more about the environment that they live in. This is what we often refer to as the social determinants of health (and wellbeing). For community psychologists, asking whether or not a person had the resources to cope with the problems was the wrong (or less productive) question to ask. Why were these problems there in the first place? What was their causes? And how could psychological knowledge contribute to alleviating those problems and changing the systems that sustain them?

Anyway, what Pat argued in his presidential address is for some re-consideration of the questions that psychologists ask. He argued (quite well) that much of the knowledge we have is constrained by the questions we’ve asked. One of the reasons we don’t have the data to address the big problems is that we haven’t asked the questions (in research terms) that address these problems.

Asking whether organics is equivalent to conventional food is a worthy question from a scientific standpoint and from a nutritional science perspective. But whether that is the question that we ought to base our food choices and food policy on is quite another.

food systemshealth promotionpublic healthsystems scienceUncategorized

The Organic – Health debate

This week the health blogosphere, newswires and cocktail party circuits were buzzing over the report from the report for the U.K. Food Standards Agency that came to the conclusion that organic food offered no more nutrients than ‘conventionally’ produced foodstuffs. (I find it strange to call the way we mass-produce food conventional, particularly when you think that most of what we eat today didn’t exist 50 years ago and the stuff that did exist is now produced in a way that is so foreign to the way its been done for the thousands of years before that calling it conventional is about as realistic as calling one of those ‘meal replacement‘ products a meal…but I digress — for an interesting take on this go see Food Inc. in theatres).

This finding didn’t surprise me at all. There isn’t any particular reason why ‘conventionally’ grown food should be any less nutrient rich than organics. But as Marion Nestle writes, that misses the point. It’s the same case that I’ve been making in my social circles the past few days as people talk about organics and how this has them reconsidering things. It shouldn’t — unless physical health is the only reason why you eat something. And I would argue that there are many good reasons to eat organics that have just as much to do with health, but do so in a way that goes beyond nutrients.

Organics are much more friendly to the planet for starters. The problems with birds & wildlife, and environmental degradation due to pesticides has been well-documented.

Pesticides are also highly toxic to those who are administering them — very often low educated, non-protected workers and their families – despite efforts to reduce this.

Organics also provide a vehicle for supporting local farmers, which brings added environmental and economic benefits.

All of these things produce health in our community. These are the social determinants of health of the food system and not just the nutrient portion of it. And there is much reason to believe that these social and environmental determinants play as big of a role in our health as anything we gain from nutrients.

Health is indeed a complex system both physically, socially, and as a concept in its own right. Viewing the link between organics and physical health (vis nutrients) as straightforward (and one that some organic supporters are doing through their critique of the report) reduces this complexity and potentially does the organics movement more harm than good. My suggestion would be to look at all the other benefits that organics can confer and focus on that.

This doesn’t mean the door is closed and that more research shouldn’t be done, but I think a lot of people will be happy enough knowing that the organic food they eat is doing the planet good, animals good and their local economies good and that is healthy in its own right.