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Perceiving Dynamic Conditions
The Mismatch: Using Step-wise Strategies to Direct System-wide Change
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Since the 1970s, health planners have understood that effective responses to the intertwined afflictions in populations require system-wide interventions (Canada Department of National Health and Welfare and Lalonde, 1974; Fawcett, 1991; Freudenberg, 1978; Green, Richard, Potvin, 1996; McLeroy, Bibeau, Steckler, et.al., 1988; Milio, 1981; Stokols, 1992; Syme, 1986). But the desire to achieve systemic change stands in opposition to what most health agencies are prepared to do. Ingrained in financial structures, problem-solving frameworks, statistical models, and the criteria for professional prestige is the idea that each affliction can be prevented individually by understanding its unique causes and developing targeted interventions. Evaluations confirm that this single-issue approach can be effective in reducing temporarily the rate of a given disorder, but it cannot serve as a means for fulfilling society’s ongoing interest in assuring the conditions in which all people can be healthy. Nevertheless, most health ventures operate with resources focused on one disease or risk factor, leaving other problems to be addressed by parallel efforts. Health care reform—or rather, the failure to achieve it despite six decades of repeated attempts—provides a stark example of how dynamically complex problems resist change when they are approached in a piecemeal way. That same history also teaches us that overly-ambitious schemes can be equally ineffective because they tend to be undermined by numerous special interest groups. So how can those of us who share the goal of protecting the public’s health better govern change when, like so many other phenomena, the health system exhibits policy resistance: that is, when it tends to “delay, dilute, or defeat the effects of planned interventions” (Meadows, Richardson, Bruckmann, 1982; Sterman, 2000, 2006)? One important—and still largely neglected—step is to try to see our health problems and our corresponding problem-solving strategies as part of a large, dynamic enterprise. Failure to do just that is precisely what sociologist Max Heirich identifies as the main analytic oversight contributing to so many unsuccessful health reform ventures.
Earlier efforts at reforming health-care policy have been ineffective for at least three reasons. First, problems were often tackled piecemeal, as though a single intervention in one area (even a major one) would correct the larger dynamic at work...Second, the more comprehensive reform plans...roused the opposition of interest groups and the larger public who distrusted government regulation; but even if they had succeeded politically, those proposals probably would not have succeeded practically, because they did not address more fundamental dynamics which were creating problems in health care....Third, even though problems in health care were approached using the same problem-solving formulas that were being applied elsewhere in the political economy, health-care dynamics were treated as if they existed independently of everything else that was happening in the political and economic system-a serious miscalculation....Had problems not been approached in isolation, but instead viewed in terms of their relation to a larger series of changes occurring in the national and international political economies, a different series of policy options might have been explored. They were not explored, perhaps because most of the analytic strategies popular among academics, politicians, and policy makers fail to observe the system as a whole in ways that let policy makers shape individual choices. Even fewer analytic strategies have made it possible to discuss processes of mutual change that are occurring, or to analyze how innovations fit into larger nonequilibrium dynamics that are developing
(Heirich, 1999).
Seeing an entire system, rather than a set of discrete health problems demanding discrete responses, requires a certain amount of distance and perspective—something more akin to looking through amacroscope than a microscope (Rosnay, 1979). Just as the first astronauts were awed and profoundly moved by their first glimpses of the Earth from space, seeing and understanding a familiar terrain that they had never seen whole before, so can a macroscopic
view of the health system reveal useful insights about how to navigate on the ground (White, 1998).
| WHAT IS A MACROSCOPE?
 We
have only our brain--our intelligence and our reason--to attack the
immense complexity of life and society. True, the computer is an
indispensable instrument, yet it is only a catalyst, nothing more
than a much-needed tool. We need, then, a new instrument. The
microscope and the telescope have been valuable in gathering the
scientific knowledge of the universe. Now a new tool is needed by
all those who would try to understand and direct effectively their
action in this world, whether they are responsible for major
decisions in politics, in science, and in industry or are ordinary
people as we are. I shall call this instrument the macroscope (from
macro, great, and skopein, to observe). The macroscope is unlike
other tools. It is a symbolic instrument made of a number of methods
and techniques borrowed from very different disciplines. It would be
useless to search for it in laboratories and research centers, yet
countless people use it today in the most varied fields. The
macroscope can be considered the symbol of a new way of seeing,
understanding, and acting. Let us use the macroscope to direct a new
look at nature, society, and man and to try to identify new rules of
education and action. In its field of vision organizations, events,
and evolutions are illuminated by a totally different light. The
macroscope filters details and amplifies that which links things
together. It is not used to make things larger or smaller but to
observe what is at once too great, too slow, and too complex for our
eyes (human society, for example, is a gigantic organism that is
totally invisible to us). Formerly, in trying to comprehend a
complex system, we sought the simplest units that explained matter
and life: the molecule, the atom, elementary particles. Today, in
relation to society, we are the particles. This time our glance must
be directed toward the systems which surround us in order to better
understand them before they destroy us.
-- Joël de Rosnay, 1979 |
To illustrate the implications of this sort of macroscopic thinking, consider the three core public health functions: assessment, policy development, and assurance (Institute of Medicine, 1988, 2002a). Each of these functions can be approached either with a focus on a single, categorical problem or on the larger, more encompassing task of assuring equitable conditions for health. In large part, the core functions have been used primarily to organize and describe approaches to single, categorical programs. But with a syndemic orientation they may also be seen as equally appropriate aids in the craft of assuring conditions, provided that the concepts and methods that guide their fulfillment are changed to accommodate the shift in scale (Figure 5). Figure 5: Core Public Health Functions and Selected Analytic
Methods Supporting a Syndemic Orientation
 Analytic techniques that demand linear approximations and similar kinds of simplifying assumptions may be acceptable when working under narrowly circumscribed conditions (i.e., within highly constrained organizational and temporal boundaries). But when operating on an ecological level, addressing the long-term effects of multiple, interacting afflictions in a region or given population—along with the many programs and policies designed to affect them—those former analytic conventions no longer suffice. System-oriented techniques with a greater capacity for understanding dynamic complexity must come to the forefront (Midgley, 2003). These methods do not replace, but rather extend the reaches of what we can learn about the forces that govern the public’s health. The next section examines in greater depth some of the more significant shifts in thinking and practice that come about when using these techniques.
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Page last reviewed: January 30, 2008
Page last modified: January 30, 2008
Content source: Division of Adult
and Community Health,
National Center for Chronic Disease Prevention and Health Promotion
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