To manage syndemics think like an octopus
In the age of syndemics, it is time to think differently. We need more global health organisations to focus their energy outside the clean lines of health care to re-imagine what health means at a local level. The question is: how do we do that?
The views expressed are those of the author and do not necessarily
reflect the position of Re:solve Global Health.
For a year and counting, covid-19 outbreaks and deaths have continued to cluster in underserved and marginalised communities. Global health leaders watch as health disparities deepen against a backdrop of inequity in access to basic social needs: good food, clean air, green space, shelter, physical safety, education, employment. We’ve come up short. Despite decades of global health initiatives, we have clearly failed to adequately address health inequity and its root causes.
The notion that so-called “social determinants of health” drive health outcomes is not new. Nor is the idea that these social determinants are key to understanding the patterning of epidemics in populations. In the 1990s, medical anthropologist Merrill Singer coined the term “syndemic” to describe the idea of two or more coinciding epidemics amplified by the interplay of biological and social factors. Much has been said about the syndemic of covid-19 and chronic disease, about the importance of social determinants, and about the reality of 80% of health outcomes being determined outside the bounds of the traditional health system. And yet, in terms of policies and actions, we are stuck firmly within the paradigm of traditional health care delivery.
In the age of syndemics, it is time to think differently. We need more global health organisations to focus their energy outside the clean lines of health care to re-imagine what health means at a local level. To do this, healthcare practitioners need to spend time embedded in the social context to map problems and co-create solutions alongside individuals and communities. Another anthropologist, Clifford Geertz, called the nuanced and sometimes messy understanding of context, history, culture, and behaviours the “thick description.” Global health needs more thickness to be integrated in how we design systems, programmes, interventions and how the patient experiences care. It is not that global health organisations should abandon simple, life-saving protocols or expertise in delivering cost-effective interventions at scale. Rather, we must complement our efficiency in focused areas with exploration to find new solutions to the underlying thick problems.
The efficiency-exploration trade-off
It is hard to efficiently deliver proven interventions and innovate radically new approaches at scale, as the challenges of mass vaccination demonstrate. We know the capabilities required to rapidly deploy millions of vaccine doses are different from those required to understand and resolve the root cause of vaccine hesitancy at community level. This tension between efficiency and exploration runs deep, not only in our organisations but in our own biology. Developmental psychologist Alison Gopnik describes this efficiency-exploration trade-off in her study of human consciousness. Children’s minds, she finds, are physically and chemically primed for open exploration while adult minds are built for efficient task execution; we often lose the former as we grow into the latter. There is, according to Gopnik, one creature that can do both simultaneously: the octopus. Octopi have a split consciousness, with their “head brains” executing efficiently on day-to-day tasks and their “tentacle brains” constantly taking in new information, synthesising and developing new solutions.
To overcome the tension between exploration and execution, perhaps we should look to octopi to inspire our own organisational design. In its simplest form, this could mean carving out space for two distinct but connected approaches: one focused on executing the strategic priorities of an organisation—the “head-brain”—and one focused on driving fresh thinking and innovation—the “tentacle-brain.” If an organisation is “head-brain”-dominant (as most are), it is critical to make time and space for the “tentacle-brain” to flourish.
At Medtronic LABS, the global health innovation arm of Medtronic, we purposefully built an organisational structure to insulate the “tentacles” from the day-to-day tactics and key performance indicators so critical to the operation of our social enterprises. We started with a two-person innovation team with expertise in human-centred design, ethnographic research, service design, and UX/ UI design. The team initially operated independently, exploring and developing and prototyping new concepts for health care delivery models. Over time, the innovation team has tripled in size, grown in influence, and strengthened its interface with the main organisation as its concepts become part of the wider operation. Today, design-based and exploratory methods are driven by the innovation team but practised by everyone at every level of Medtronic LABS, from field operations specialists to commercial leaders. Typically, team-members spend 15% of their time embedded with communities they are serving to explore new ideas and approaches. It all started with establishing the right octopus-like team structure to allow our “tentacle-brain” to start exploring, while remaining clearly connected to our “head-brain” over time.
What does it mean to explore? And how does exploration translate into better approaches to syndemics and associated health disparities? In a sense, the lack of a simple answer to these questions is exactly the point: exploration is about understanding the “known unknowns,” discovering the “unknown unknowns” and ultimately arriving at the root of the problem to create novel solutions. We may not know where the journey ends, but we do know where to start. At Medtronic LABS, all of our exploration begins and ends with the people we are serving, upending old power dynamics by putting the patient and the community in the driver’s seat. Over the past year, our exploration with communities has centred on two key themes: reimagining value and putting “health” back in health care.
Health systems have been designed to optimise “value” for doctors, for governments, for payers, but rarely for patients. We have been working to reimagine what patient-centric value means in health care through a series of ethnographic and co-creation exercises with groups of men and women from the slums of Bangalore and Nairobi to villages in Ghana and The Philippines. While a “head-brain” approach may have focused on pushing blood pressure monitors or lab tests, our “tentacle-brain” exploration focused our attention on the things that actually matter for patients: the ability to take a walk in the park, to pay for a child’s education, to leave abusive home environments, to feel respected. We have built award-winning service models for diabetes and hypertension with this orientation at the core: the social support group curricula, virtual engagement modules, games, incentives, and measures of success are defined by the patients, not by us.
We need more global health organisations to focus their energy outside the clean lines of health care to re-imagine what health means at a local level
In parallel, we are striving to put the “health” back in healthcare by thinking beyond the traditional walls of hospitals and pharmacies. In Kenya, we are exploring what it would mean to “prescribe” personalised diets and nutrition plans, working alongside patients to plant kitchen gardens and provide other sources of nutritional support. In India and The Philippines, members of our group-based service spend more time dancing, meditating, and engaging in talk therapy than they do learning about diabetic foot or the risk of stroke. In all of our work we are partnering with local NGOs and governments who provide social services to ensure that patients receive refuge in the face of gender-based violence, food in the face of food insecurity, financial support for education and more. Health is a social subject and we have found success in approaching it in a social context.
The time is now
We are proud of our initiatives and inspired by many others like them around the world, although we are also realistic: for now, at least, they remain exciting innovations on the periphery rather than the norm. As the world becomes more complex and interconnected, the “thickness” of the problems we face becomes ever more apparent and our natural “adult-brain” tendency towards simple and efficient solutions needs to expand. We are hopeful that the challenges of this syndemic age can spur new initiatives that may yet achieve a world not just free of human disease, but full of human health.