Heroes Not Zombies

The Resilience Alliance give this description of resilience, using forests as an example of a complex adaptive system which exhibit resilience.

Natural systems are inherently resilient but just as their capacity to cope with disturbance can be degraded, so can it be enhanced. The key to resilience in social-ecological systems is diversity. Biodiversity plays a crucial role by providing functional redundancy. For example, in a grassland ecosystem, several different species will commonly perform nitrogen fixation, but each species may respond differently to climatic events, thus ensuring that even though some species may be lost, the process of nitrogen fixation within the grassland ecosystem will continue. Similarly, when the management of a resource is shared by a diverse group of stakeholders (e.g., local resource users, research scientists, community members with traditional knowledge, government representatives, etc.), decision-making is better informed and more options exist for testing policies.Active adaptive management whereby management actions are designed as experiments encourages learning and novelty, thus increasing resilience in social-ecological systems.

The main point made here is the importance of diversity. They mention “socio-ecological” systems, but in fact organisations can also be considered as complex systems. This is one of the ways we are going wrong with the way we deliver health are these days. Due to the vast diversity of human beings, and the reality that large organisations behave as complex systems, we need diversity in our organisations and in our practices.

There just is no one size fits all when it comes to health care and a health service managed by protocols, rules and tight controls, will ultimately fail.

Steven Charlap tells the story of the failure of his MDPrevent business which he had to close down last month. It’s an honest and thought provoking reflective piece. His idea was to have a medical practice which focused on health instead of disease, which advised patients and supported them in making lifestyle changes instead of prescribing for them. It didn’t work out. For a number of reasons……he didn’t get enough referrals from other health care providers, had many problems with health insurance companies, and, he says, the patients weren’t really up for it.

Based on our review of the credible research, our model mostly excluded dietary supplements and multivitamins because the science mostly did not support their use. When it came to pharmaceuticals, we didn’t rush to prescribe if there were a non-drug alternative. This approach was a turn-off to many patients who expected a prescription or emphatically clung to beliefs in supplements. And the no-cost, no-deductible, no co-payment provisions in Medicare’s preventive benefits may have had an adverse effect on people’s sense of its value. How much would you appreciate something that has no cost to you? For many patients, it seemed easier to take supplements than to be more attentive to food labels and exercise habits.

I have a lot of sympathy for this doctor. I think the present system of health care is not about health, and is not sustainable. I’m not so sure about the emphasis on prevention however…..let me explain – to prevent something has a negative tone for me, and I think health is a positive attribute. I prefer a focus on positively creating health, rather than negatively trying to prevent, or avoid disease.

His conclusion is particularly striking –

Patients loved my practice because I was willing to spend up to two full hours with them, most of it not reimbursed by insurance. The extra time often meant successfully making a diagnosis that had eluded other doctors for many years. It takes a very long time to get a thorough history and do a good exam and almost no time to prescribe a medication for a presumed illness. I chose the former. Insurance pays for the latter. Unfortunately, we still have a healthcare system that makes money by treating disease, rather than by preventing it.

and that last sentence is the real indictment in this story “we still have a healthcare system that makes money by treating disease, rather than by preventing it.”

What do you think? Do you think we need health care which helps people to create health? Would you like a service like that?