I’m writing this post on the plane back from the US; Dulles to Heathrow, my mind overflowing with the thoughts of the many I have met in the past three weeks. I thought I’d jot down my strongest memories, as much a challenge to myself as possible food for our thoughts.Perhaps my favourite sound bite was “middle-out”. The impressive John Vu of Kaiser Permanente offered it as we discussed how to engage communities in order to activate their assets and build resilience. I have long worried that medicine – and especially public health – is a top-down, patriarchal, almost condescending profession. At the same time, given how complicated health care is it’s hard to see it ever becoming bottom-up. John said that Kaiser is experimenting with what he describes as “middle-out” ways to engage with local communities. Fascinating.
I got a glimpse of a real community at an evening Q&A with the inimitable Zubin Damania of Turntable Health, a new primary care service being developed in Las Vegas aided by the ever-impressive Iora Health. It was interesting to hear their questions, many of which betrayed the sheer confusion around the Affordable Care Act (ACA). Damania was both eloquent and informative in his responses, if not downright reassuring that everything will be all right. Despite the sheer size and complexity of the ACA I was left feeling that with new thinkers like Damania at the helm (ably supported by the Regional Medical Director of Iora Health, Anjali Taneja) the US may well learn how to deliver a more equitable form of health care.
But that’s the future. I got a glimpse of the present through my friends, Attending Physicians at UCLA and Johns Hopkins. The sheer unstoppable tsunami of demand for health care hit me while touring an ICU. To be frank, it’s hard to see the sense of some of the machine-assisted “living” that I witnessed. My whispered comments to my friend led him to agree but confess there’s nothing he can do. It’s what people expect, despite the sheer awfulness of “life” when normal biological functioning has left the building. There’s something about what we seem to want that needs new thinking.
My favourite moment of new thinking was talking to Tom Thomison of Holacracy One. His organisation is helping organisations, err, organise completely differently. Rather than rely on a top-down, hierarchical form, he advocates interconnecting but autonomous units, all working within clear parameters. The net effect is localised empowerment and autonomy, greater innovation at the unit level, and greater efficacy as a whole. I was intrigued and interested in how the methodology might be used to engage local populations to better express their health-related wants. Tom explained that that’s not quite what holacracy is about but I remain fascinated on how we can amplify citizen’s voices, even if the halocratic approach isn’t quite the right fit.
There’s something indulgent, perhaps even plain navel-gazing, about touring a country in search of Wellth. The engaging and insightful Alice Chen of UCSF quite rightly put me in my place. We shared insights on what Wellth might be, and, although she was interested, she said something that has stayed with me since: “Come back when you’ve figured how it helps the underserved”. Good call, Alice; I’m on it.
That said, I’m not as “on it” as the chap I spoke with as I headed for the plane home – Prabhjot Singh of Columbia University and the Lead Strategic Advisor of the downright inspiring City Health Works. Through a calm that suggested a deep wisdom he explained how he and the Executive Director, Manmeet Kaur, raised funding to try a new way of delivering care in one of the most disadvantaged parts of the US, East Harlem, New York. Although on the surface it looks like the increasingly common health-coaching model, City Health Works is embracing the insights from social network analysis to look at how people’s three best friends (or social champions, as they call them) can be harnessed to create better health-related behaviours. Their work is informed by his eight years working on the Millennium Villages Project in ten low-income countries, making it a brilliant example of reverse innovation. I’ll write more about City Health Works soon but, as I said in a tweet soon after he and I spoke, I think I saw the true future of health and health care in their thinking and experimentation.
Another highlight included breakfast with a super smooth former police sergeant who changed downtown policing in Las Vegas by engaging members of the community, companies, public organisations and individuals to build a willingness for them to find their own solutions and not just rely on someone being arrested – something he said that “rarely works”. Although that sounds like vigilantism, it’s not; it’s about us taking a moment to realise that sometimes there is both compassion and capacity within a community that can create self-reliance. Our breakfast made me realise that we really are coming to an end of a paradigm, an end to the idea that the state holds all the cards and we comply. People have the solutions; the state is only there to assist.
I have other reflections to share, but these are the ones that have stayed with me. One meta-reflection, though, is the US’ willingness to think, and think big. It’s a deep privilege to spend three weeks engaging with such thoughtful and purpose-driven people. As I have reflected elsewhere, I have a deep concern that Europe has stopped thinking, busy enforcing austerity that may make the continent more competitive in the long-run but may stall – if not completely kill – the engine in the short-term. I won’t argue about whether we need austerity, but even if we do we also have to find new value, especially in health and health care. The US seems to get that.