Embracing Optimism and the Potential of Achieving Population Health: From Silos to Systems

The pandemic this past year brought a unique opportunity to reflect on many personal and professional aspects of my life. Since it feels like we are now at a different place as a country in our efforts to reopen, return to work in some manner, embark on changes, or establish new norms, this seemed like an appropriate time to decide on several key priorities that matter for a variety of reasons. As a faculty member at a faith-based, academic health sciences university, my thoughts immediately turned to several things that I believe will enable those in higher education and beyond to reemerge for the better as we plot a path forward. Please allow me to preface my comments by saying they are not intended to be inclusive of every viable option that is available to us. Additionally, I certainly believe that your list may look quite different from mine. Instead, my purpose here is to suggest just a few of the items that I believe deserve thoughtful consideration if we are to make progress as a country post-pandemic. 

First, I believe that we must shift our view about how we see health in relation to other facets of our lives and well-being. Can we really afford to see each aspect of our lives as being separate and distinct? That is, health is different from education, work, and the economy, and such, where the burden of disease exists in isolation from other facets of being. It is often natural and easiest to view the world through a lens that is most familiar to our lived experiences, training, relationships, etc. I would call this “life in the silo.” Professionally speaking, most of our time is spent in disciplinary-specific domains of subject matter expertise. Our interactions and networks tend to also fall mostly within those domains. However, to make improvements in the population’s health, I believe that we must expand our view (and ultimately our networks) by stepping back and considering the whole picture. In teaching graduate students, I have learned this skill is not something that always comes naturally to us, especially when many of our efforts to make sense of complex phenomena involve reductionist thinking to simplify elements to their basic components. While this type of thinking has its place in learning and sensemaking, embracing a holistic view of health has equal merits, if not better potential for greater impact. This action will require our ability to cultivate stronger systems thinking skills, relationship building and engagement and to develop and understand the role of syndemics* in affecting the health outcomes that we care most about. Here is where a shift from thinking in silos to thinking in systems comes in. These concepts may be new to some individuals but remain an essential part of our ability to ask different (albeit better) and distinct questions that will prepare us to make the types of strategic investments that enable us to build more resiliency (individuals, communities, and systems) against potential future threats that can adversely affect our ability to maintain our nation’s health and viability. 

Second, system scientists (or the professionals trained to study systems, their interactions, and behavior) have long emphasized the significant role system structure plays in driving the behavior of what we observe. Many innovations, policies, and system reforms are currently underway in our country to help improve our notions of health, from efforts to expand access to developing more robust systems and services that put individuals and communities at the center of design and delivery of those activities. In that context, health is not simply about what happens in care delivery or what transpires in a clinical setting but acknowledges the array of other areas that impact a person’s life. Some refer to this as the social and ecological aspects of our environments. In professional settings we tend to think about the need for greater interprofessional practice and collaboration in working in these ecosystems, where a variety of disciplinary areas interface to best serve the needs of patients, clients/customers, and communities. This is a critical component of effectively training the future workforce of health professionals. In public health, we tend to think in these terms by default.  However, we have the need to not function in our own silos either.  Together, we have opportunities to design learning experiences that are integrated, interprofessional, and spanning disciplinary silos. I emphasize training environments here because I believe that higher education has an important role to play in ensuring students not only learn about the diverse contexts they will be working in, but also in equipping them with the knowledge to advocate for the types of changes that move us from longstanding inequities and discussions to sustainable actions that matter. For example, I am encouraged by the development of a curriculum on health systems science as an important starting point in medical education.  While designed for medical students, it also includes other health professions.  However, I would like to see this type of curriculum include more opportunities for true integration with other professions (not just those in health professions), along with the creation of systems that better align with the needs of our communities. If we do not teach our graduates about how to create these accountable community-based systems, how will we ever be able to elevate our collective standards of practice for everyone we serve? This is not an issue of technical competence but of how we adequately prepare our professionals to create systems that function in ways that fully realize the potential of the country’s precious resources and investments, ultimately to better align with the outcomes being achieved in other industrialized countries that spend far less and achieve better results for their citizens.

Third, and last, I choose to embrace optimism and the potential of doing better. I am incredibly grateful for the immense privileges we enjoy in this country while also recognizing that we can create a far more equitable system of health for everyone. I am committed to pursuing practical and pragmatic solutions that have a real impact on this region of the country and feel fortunate to have colleagues and friends who want to do the same. How about you? There is plenty of work for us to do. If you have not done so already, I hope you will consider joining me on this journey and making a similar commitment.

*Singer, Bulled, Ostrach, and Mendenhall (2017, p. 941-942) aptly define syndemics “as the aggregation of two or more diseases or other health conditions in a population in which there is some level of deleterious biological or behavior interface that exacerbates the negative health effects of any or all of the diseases involved.  Syndemics involve the adverse interaction of diseases of all types (eg, infections, chronic non-communicable diseases, mental health problems, behavioural conditions, toxic exposure, and malnutrition). They are most likely to emerge under conditions of health inequality caused by poverty, stigmatization, stress, or structural violence because of the role of these factors in disease clustering and exposure and in increased physical and behavioural vulnerability. Indeed, this concept moves beyond common medical conceptualizations of comorbidity and multimorbidity—when diseases simply occur in tandem—because it both concerns the consequences of disease interaction and the social, environmental, or economic factors that cluster with the diseases and shape their interaction."

Author Bio

References

• Fox, L., Onders, R., Hermansen-Kobulnicky, C.J., Nguyen, T.N., Myran, L., Linn, B., & Hornecker, J. (2018). Teaching interprofessional teamwork skills to health professional students: A scoping review. Journal of Interprofessional Care, 32(2), 127–135.
• Fukuzawa, D.D. (2013, Winter). Achieving healthy communities through community-centered health systems. National Civic Review, 57-60.
• Golom, F.D., & Schreck, J.S. (2018). The journey to interprofessional collaborative practice: Are we there yet? Pediatric Clinics of North America, 65(1):1-12.
• Harvard Kennedy School of Government. How COVID-19 has changed public policy.  Accessed from How COVID-19 has changed public policy | Harvard Kennedy School.
• James A. Johnson, J.A., Anderson, D.E., & Rossow, C.C. (2020). Health systems thinking: A primer. Burlington, MA: Jones and Bartlett Learning.
• Leischow, S. J., Best, A., Trochim, W. M., Clark, P. I., Gallagher, R. S., Marcus, S. E., & Matthews, E. (2008). Systems thinking to improve the public’s health. American Journal of Preventive Medicine, 35(2S), S196-S203.
• Singer, M. (2009). Introduction to syndemics: A critical systems approach to public and community health. San Francisco, CA: Jossey-Bass, A Wiley Imprint.
• Singer, M., Bulled, N., Ostrach, B., & Mendenhall, E. (2017). Syndemics and the biosocial conception of health. The Lancet, 389, 941-950.
• Skochelak, S.E., Hammoud, M. M., Lomis, K. D., Borkan, J. M, Gonzalo, J. D., Lawson, L. E., & Starr, S. R. (Eds.) (2021). Health Systems Science: AMA (American Medical Association) Education Consortium. Philadelphia, PA: Elsevier.
• Roosa Tikkanen, Multinational Comparisons of Health Systems Data, 2019 (Commonwealth Fund, Jan. 2020). https://doi.org/10.26099/18mm-kd11