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?

systems thinking

Making the Invisible Visible

This was a remarkable week for me for many reasons, most of which had to do with getting a new slant on reality or a new view of some of the systems that I am a part of and those that I am not.

I had the pleasure to spend four days in Bogota, Colombia meeting with the amazing folk at CINTEL and presenting at the 4th Encuentro de Invsestigacion Innovation e Ingernieria on Techno-wellbeing. I had the privilige to share the work that the Youth Voices Research Group is doing on health promotion with youth and our integrated eHealth model for community engagement including our Food4Health and Public Health Gambling Projects.

The first morning of meetings I was writing at my computer and then got up to look out the window of my hotel at the bustling morning rush hour of Bogota. As I was admiring the dogs playing in the park, the roar of the motorcycles and the beauty of the tree-lined boulevards outside my window I felt my back go into massive spasm. It hurt so much that I could hardly move. Realizing that I could not stand at the window in pain forever I fought through the ‘lightning bolts’ and managed to get to my bag where I had Advil tablets to manage the pain. But even at the best of times, it hurt – a lot. Over the past week the pain has subsided considerably, although I am still not 100% and probably won’t be for a few more days. But the pain isn’t the story here as much as the revelation it brought to me about the role that accessibility plays within the systems we engage in. Even simple things like stairs became a real pain (literally!) to take. Where I normally bound up the stairs two at a time, I found myself gingerly lifting one leg at a time up each step.

On my first day back home I had to shuffle on my way to the office. In process of shuffling, I realized how I had ‘become’ one of ‘those people’ who walk so slowly that I often get frustrated at in my effort to go somewhere quickly. My back should get better soon, but what hopefully remains is the lessons that this brought (including the one about taking better care of myself to prevent this from happening). As a systems thinker, I see these lessons or affirmations as including:

1. Diversity of perspective is critical. Just in one morning shuffle to the university I realized massive design flaws in the city I live in that favour the able-bodied. For example, some of these street lights can’t be adequately navigated in time if you can’t walk at a normal pace. Another big flaw is the heavy weight of the front doors of my building. I damn near pulled my back out again just opening the doors, which are exceptionally heavy.

2. Accessibility has many forms. Public health leaders are getting better at recognizing the social barriers to health engagement created by issues of race, social class, sex and gender, and geography. But one thing that can easily get lost is physical accessibility via disability. In eHealth for example, we often create elaborate websites that have tiny fonts that people with limited eyesight can’t see. Ever try reading a Blackberry or iPhone for long periods of time? It’s only for the good-sighted. Or we make assumptions that people can sit at computer and type (like I am now) and don’t have bad backs (like I did).

3. The mundane is where the action is. In systems we are often attracted to events, because that’s where the action appears to be. Yet, the mundane activities of a system is where most activities happen. For example, tying your shoes is something that happens every day and is never paid attention to until you break your shoelace or (in my case) hurt your back. In order to prepare for systems change, we need to anticipate how change might occur within the everyday actions in the system.

4. The edge of chaos always shifts. Creative systems tend to function at the edge of chaos, yet this edge has a dynamic position. My personal creative edge took a major directional change this week when my back went out. I continued to creatively navigate through my world, but instead of imagining new possibilities that hadn’t been created before, I found my creative edge focused on trying to get close to my former level of equilibrium on day-to-day activities like walking, shoe tying, and just getting dressed.

As I move into a new Fall term and am about to teach a new course on systems science these lessons are particularly apt. While I don’t think I’ll get my students to throw their back out, I will have them imagine how their current assumptions about a system can radically change with a very simple shift in vantage point, making the invisible visible.

Uncategorized

e(un)Health

Every time I sit down at my computer I find myself in awe at the power in my hands. I was listening to a podcast on a plane yesterday (just think of that: listening to a radio show, downloaded via the Internet for free to listen whenever I want, on a device that fits in my pocket, and lets me tune in at 34,000 feet over the Caribbean Sea). The podcast was on the Great Library 2.0: Google’s efforts to digitize nearly every book in the world and make it searchable. I find all of this amazing, and unlike some I am happy with how amazing things are in terms of technology.

Yet as Marshall McLuhan so astutely noted, technology first serves as an appendage that serves and then as a master.

Looking at the score between appendage and master I’d say we’re about tied when it comes to how technology affects health. And that’s not necessarily a good thing.

Email Overload

Consider the concept of time poverty. Take the United States, arguably one of the most technologically sophisticated societies, yet also among the most time poor. One poll looking at U.S. vacation time suggests that only 14% of Americans will get a vacation of two weeks or longer this year. That is despite having all of the tools to reduce work time, maximize efficiency, and engage in leisure activities in a way that was once unfathomable. Yet, time poverty is certainly something that I live with despite having the ability to do far more in less time thanks to technology. The problem is the ‘far more’ part of that statement.

When I look at my life and that of others working with eHealth (or academia — or just about every knowledge-based profession), the same storyline come up: too much communication and not enough time to process or participate in it fully. I don’t know of a colleague who doesn’t feel that their email is difficult to manage. I appreciate being able to communicate with colleagues easily (McLuhan’s extension argument), but when I get back from a couple days offline to find hundreds of email, dozens of phone calls, tweets, blog updates, Blackberry messages, and Skype calls waiting for me, I feel very time poor indeed. So ironically, these tools that enable me to do so much so fast contribute vastly to time poverty and stress.

This can’t continue for long – -can it? So far, there is no sign of it stopping with 3G communications and the mobile web. But there are things we can do to change ourselves relative to the technology and avoid becoming the slave to its master. I recently read John Freeman’s Manifesto for Slow Communication and think he might be on to something. He writes:

“In the past two decades, we have witnessed one of the greatest breakdowns of the barrier between our work and per sonal lives since the notion of leisure time emerged in Victorian Britain as a result of the Industrial Age. It has put us under great physical and mental strain, altering our brain chemistry and daily needs. It has isolated us from the people with whom we live, siphoning us away from real-world places where we gather. It has encouraged flotillas of unnecessary jabbering, making it difficult to tell signal from noise. It has made it more difficult to read slowly and enjoy it, hastening the already declining rates of literacy. It has made it harder to listen and mean it, to be idle and not fidget.”

This fits with a recent study in the Proceedings of the National Academy of Sciences by two psychologists who looked at multitasking and cognitive performance and,” in every test, students who spent less time simultaneously reading e-mail, surfing the web, talking on the phone and watching TV performed best.

Is the ‘e’ part of eHealth becoming a source of illness rather than wellbeing? As Freeman states:

“This is not a sustainable way to live. This lifestyle of being constantly on causes emotional and physical burnout, work place meltdowns, and unhappiness. How many of our most joyful memories have been created in front of a screen?”

Indeed.

The system in which we utilize these tools best determines their ultimate impact on health and wellbeing. I use all types of media to learn about them and their potential and find it fascinating. But we have no users guide to healthful communicating and frankly, things are happening so quickly I question whether we can even come up with a good one that is timely and relevant. But the question about how eHealth communications and the speed and volume at which this takes place is one that warrants serious attention for us as researchers, teachers, health professionals and citizens. Otherwise, eHealth risks becoming a 21st century version of bloodletting.

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?

complexityemergencesocial mediasystems science

Tr.im and Community Ownership

It occurred to me that I haven’t been tweeting as much as usual the past week. I’m about a 5-10 tweet per day blogger on the same range of topics that I discuss here at this blog. That doesn’t mean that there hasn’t been anything to write about and one of the most tweeted stories of the past week was one that has quite a systems flavour to it.

For those in the Twitter world, you probably heard about (even if you didn’t care or follow) the story about Tr.im shutting down and then getting resurrected as an open source, community owned URL shortener. For 99% of the world, this past sentence might as well be written in Klingon. URL shorteners are services that enable you to take a very long web address and shrink it down into something much smaller. For example, the Wikipedia link to URL shorter is included in the last sentence, however the same link might look like this when shortened: http://tr.im/wKxd

Early last week Tr.im’s owners decided it would pack up and quit, citing myriad reasons for dropping its support for the service. Interestingly, this got the blogosphere humming and soon Nambu (its parent) reversed position (of sorts) and declared that Tr.im’s source code would be released and that it would become community owned.

What the Tr.im experience reveals is a lot about the power of collective action in a Web world. Something that could seem relatively benign like a URL shortener quickly became something that was discussed by all kinds of people who previously couldn’t care less about what they used. What might make it even more intriguing is to watch how it moves from a private, closed system to an open one that is decentralized in how it runs as a community-owned entity. What is also interesting is how the term community has been used, yet how it hasn’t been articulated. It will be interesting to see what this ‘community’ looks like, particularly seeing that Nambu’s first option was to sell Tr.im. As a case study in emergence, self-organization and social action, this is one that is worth following — whether you’re a techie or not — because the lessons learned here could mean a lot for other community tools and technologies.

behaviour changecomplexityeHealthemergence

eHealth Isn’t Rocket Science…But Maybe it Should Be

For those of us in the eHealth area and working in Ontario, these are dark days. While the opportunities for electronic tools can make a substantial different to patient care, health promotion, and health innovation are greater than ever, the events surrounding eHealth Ontario, it’s former CEO, its governance, and its outputs have made eHealth a bad word in many circles. When a term that could stand for innovation, quality, accessibility and efficiency is equated with $25K speeches and Choco Bites, we’ve got problems.

But as Andre Picard wrote in the Globe and Mail, it wasn’t about the Choco Bites. The eHealth ‘boondoggle’ is about most everything, but what it was supposed to do. It became about the technology and not about designing a system to support the health and wellbeing of the public and the delivery of care by professionals. But when it became about the technology, we relied on well-worn and inefficient means of building it because people thought it was too important and too big not to trust to the ‘experts’. The problem is, the experts in this system are designing things to make money as their first priority, not health. The result? Large, inefficient systems that are technology first and people second, meaning they don’t do the job.

It is understandable that people might feel a little overwhelmed trying to imagine how a computer system could connect all the myriad paper records together to provide timely, accurate and secure information to physicians and care providers all across a large province like Ontario. It may be this very feeling that has inspired the decisions to pursue such outlandishly expensive electronic solutions that, to date, appear to have little value for dollar.

We’ve seen this before. The Canadian Firearms Registry was one example. So have been the examples of various database programs to support child welfare programs and track paroled sexual offenders. More often than not, these become big expenses with outcomes that are less than stellar.

Building databases is complicated, but it isn’t rocket science. Maybe it should be.

In the Shadow of the Moon is a remarkable documentary that looks at the race to the moon as told by the only men who had ever stepped foot on it. What stood out for me in that film was how, with some inspiration, determination, and resources, the U.S. was able to mobilize its talent to go from rockets that blew up on the launch pad to sending men to the moon multiple times to win the Space Race. This was a feat of innovation that was staggering. 40 years later, the Ansari X-Prize was awarded to the first team “to build and launch a spacecraft capable of carrying three people to 100 kilometers above the earth’s surface, twice within two weeks.” It set off a new phase in commercial space flight. Just as Charles Lindberg won the Orteig Prize, which initiated transcontinental air flight, the X-Prize has initiated a new industry. Yet, at the end of all that, we remember the people and the amazing things they did much more than the technologies they used to get there.

Maybe we need the X-Prize for eHealth. What if we enabled the power of collective thinking, self-organization, and the motivation that comes from winning a prestigious prize? What new ideas would we come up? How much money would we save? The X-Prize was $10M and kick-started a $300M nascent market for commercial space travel. eHealth Ontario has spent more that $650M and achieved little.

Bring on the rocket scientists, our health system apparently needs them.

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.