Wad-if-I-don-wanna? Sometimes, when he wants to push on his parents a bit, my eight-year-old son asks that question, in a whiny, smirky sort of way. I can react with frustration. I can try to assert my sense of power, and take away some of his. Or, I can smile back at him, and play along: OK, so you tell me. What happens now?

In his New York Times column today, David Brooks considers what would happen, on a grand scale, if one of our greatest intrinsic motivators was gone. “The value of the thought experiment,” says Brooks, “is that it reminds us of the power posterity holds over our lives.”

He writes:

Anything worth doing is the work of generations — ending racism, promoting freedom or building a nation.

 

Without posterity, there are no grand designs…no high ambitions…no sense of peoplehood, none of the untaught affections of those who are part of an organic social unit that shares the same destiny.

 

Instead, we are blessed with the disciplining power of our posterity. We rely on this strong, invisible and unacknowledged force — these millions of unborn people we will never meet but who give us the gift of our way of life.

Here we find the better story, one that goes to the heart of Communities of Health. Change, if there is to be any, relies on people’s innate sense of contribution — our “untaught affections” for each other.

We invite people to consider for themselves what matters most, and to begin to see and act more consciously toward the future they wish for. We have no prescription. No power to assert. We ask a simple question: Does the health of the community matter?

The “disciplining power of posterity” may not get my son to clean up his Legos. But what we find together in the conversation might be more important.

“We tend to view obesity as a consequence of individual choices, but it’s clear that the environment is a major contributing factor,” says William Dietz, director of the CDC’s Division of Nutrition, Physical Activity and Obesity. “Place matters. Where people live, work, learn, play and pray affects their nutritional and physical activity opportunities.”

Next week, public health advocates, government leaders and obesity researchers will meet in Washington, DC, for a three-day Weight of the Nation conference sponsored by the Centers for Disease Control and Prevention and the Robert Wood Johnson Foundation.

Among the topics: What government can do to make streets, schools and communities conducive to healthy choices.

We encourage participants to go beyond strategies for fixing current conditions, however. For real change, we must also consider what led to these conditions in the first place. Without a fundamental, ongoing re-examination of how we got to where we are, we are likely to return to the same place again and again.

A “healthy environment” is one in which people come together to continually consider and act on what they most care about.

Social determinants language has made its way into the health reform bills passed by the House and Senate committees. Nearly hidden beneath the myriad details of health coverage for all are a few notable provisions that are (quietly) calling for:

• Investment in community health infrastructure;
• Support for evidence-based community interventions;
• Use of health impact assessments;
• Focus on health disparities;
• Emphasis on public health and prevention; and a
• Broader, multi-disciplinary approach to national health policy and metrics.

(See social determinants highlights and bill comparisons by American Public Health Association and Kaiser Family Foundation.)

While we are encouraged, we also know this is a long way from officially (and vociferously!) declaring social determinants as a national priority. Most concerning is the relatively limited attention these particular provisions are getting in news coverage and the public discourse.

Without broad-based, ongoing awareness-building that reframes (see previous post) our understanding of health and what determines health, provisions like these are too easily discarded as pork rather than essential long-term investments in a healthier nation. We got a whisper when we need roar.

A few years ago, we had the opportunity to sit down with Malcolm Gladwell and share some early ideas behind Communities of Health. We said that it was time to change the conversation, from managing the cost of care to improving health. This was the only way that the health care industry and our nation would break free from the current paradigm and begin working together toward a more meaningful, lasting impact.

Gladwell cited the example of seatbelt use, which failed to take hold through improved convenience, laws and marketing, and only succeeded when it was ”reframed” as an issue of child safety and it became the job of us adults to wear ours when we asked the kids to wear theirs. He said that such a shift in thinking was always necessary for significant change, and he thought that ”health” might just be a big enough reframing to bring together parties across a fragmented health system for a unifying purpose.

In searching for solutions—whether for a new product or for national health care reform—we tend to focus on fixing what’s wrong (cost), rather than sustaining what’s right (health). This preoccupation with pathology is limiting, keeping us in narrow, endless cycles of repair, while overlooking a greater source that already exists. As social scientist, Dennis Sandow, says:

Attempts to change people are no longer relevant means to creating a better world. I have found that social systems which generate social, biological, and financial well-being are commonplace in networks of ordinary people.

This is a spontaneous social order arising from the emotion of love, in which ordinary people are creating extraordinary value…where everyone in the network considers everyone else in the network a legitimate contributor.

 

It is not change, but conservation that we should attend to. Conserving the emergent social systems of well-being…will bring forth a new visioning process through which we can generate the future we wish to live.

A good example is presented in the first chapter of Gladwell’s latest book, Outliers, which tells the story of Italian immigrant town, Roseto, PA. Researchers studying this “tiny, self-sufficient world” in the early 1960s were astounded to find that, at a time when heart attacks were an epidemic in the United States, Rosetans had just half the national rate, with virtually no one under 55 showing any signs of heart disease; in fact, the death rate from all causes in Roseto was 30%-35% lower than the norm.

To investigate, University of Oklahoma professor and physician, Stewart Wolf, and sociologist John Bruhn gathered a group of grad students to go door to door, talking to residents and taking medical histories. The anomalies could not be explained by good diet (fat accounted for 41% of Rosetans’ calorie intake), lifestyle (Rosetans smoked heavily and many were struggling with obesity), genetics (relatives living in other parts of U.S. did not share the same remarkable health), or geography (death rates from heart disease were three times higher in the two closest towns to Roseto).

“What Wolf slowly realized,” writes Gladwell, “was that the secret of Roseto wasn’t diet or exercise or genes or the region where Roseto was situated… The Rosetans were healthy because of where they were from, because of the world they had created for themselves.”

The researchers found that “the Rosetans had created a powerful, protective social structure capable of insulating them from the pressures of the modern world.” For instance, “how the Rosetans visited each other, stopping to chat with each other in Italian on the street, or cooking for each other in their backyards… extended family clans that underlay the town’s social structure… homes (with) three generations living under one roof… the unifying and calming effect of the church… twenty-two separate civic organizations in a town of just under 2,000… (and) the particular egalitarian ethos of the town, that discouraged the wealthy from flaunting their success and helped the unsuccessful obscure their failures.”

Roseto shows us that the real value in studying outliers is not to pinpoint what’s wrong (like watching for defects coming off an assembly line), but to help us notice what’s right, especially when it’s obscured by the prevailing frame. Gladwell writes:

Living a long life, the conventional wisdom said at the time, depended to a great extent on…our genes…the decisions people made—on what they chose to eat, and how much they chose to exercise, and how effectively they were treated by the medical system.

 

Wolf and Bruhn had to convince the medical establishment to think about health and heart attacks in an entirely new way: they had to get them to realize that you couldn’t understand why someone was healthy if all you did was think about their individual choices or actions in isolation. You had to look beyond the individual… You had to appreciate the idea that community—the values of the world we inhabit and the people we surround ourselves with—has a profound effect on who we are. The value of an outlier was that it forced you to look a little harder and dig a little deeper than you normally would to make sense of the world.

Just as important, as Dennis Sandow reminds us, is learning to conserve what makes us well. We first read about Roseto in an article by Harvard social epidemiologist Ichiro Kawachi, who writes:

As young people began to move away to seek jobs in neighboring towns and the community entered the mainstream of American life, the social taboos against conspicuous consumption began to weaken, as did the community bonds that once maintained the town’s egalitarian values.

 

The unforeseen consequence of improved material well-being and, probably more important, rising socioeconomic disparities was that the incidence of heart attack in Roseto caught up with neighboring towns within a span of a decade.

In our Communities of Health gatherings, we use a form of appreciative inquiry to uncover—and conserve—existing community conditions that are sources of health and well-being. Together, we ask:

• What’s working well around here?
• What conditions have allowed this happen?
• And, how do we create more of these conditions?

These are questions worth coming together for. They reframe our sense of what’s good and what’s possible, and point a healthy way forward.

There is undoubtly some sub-text at play that makes the current health care reform debate, with it attendant polemics,
more than a curious sideshow. Afterall, these are all highly intelligent people, and the views held on all sides are held with conviction. But the debate seems locked in a context it’s participants are unwilling to confront. So Wendell Potter’s forty minutes on Bill Moyer’s PBS show Friday offered a depressing picture of the greed motivating the health care system, greed driven by a fanatical obedience to Wall
Street.

In his 1776 pamphlet, Common Sense, Thomas Paine writes: “Society promotes our happiness positively by uniting our affections.” This is in contrast to government, which he says is “a necessary evil,” to restrain our vices, create distinctions and control, and punish when we go astray.

Paine gives this example:

…let us suppose a small number of persons settled in some sequestered part of the earth, unconnected with the rest, they will then represent the first peopling of any country, or of the world. In this state of natural liberty, society will be their first thought. A thousand motives will excite them thereto, the strength of one man is so unequal to his wants, and his mind so unfitted for perpetual solitude, that he is soon obliged to seek assistance and relief of another, who in his turn requires the same. Four or five united would be able to raise a tolerable dwelling in the midst of a wilderness, but one man might labor out the common period of life without accomplishing any thing; when he had felled his timber he could not remove it, nor erect it after it was removed; hunger in the mean time would urge him from his work, and every different want call him a different way. Disease, nay even misfortune would be death, for though neither might be mortal, yet either would disable him from living, and reduce him to a state in which he might rather be said to perish than to die.

 

Thus necessity, like a gravitating power, would soon form our newly arrived emigrants into society, the reciprocal blessings of which, would supersede, and render the obligations of law and government unnecessary while they remained perfectly just to each other; but as nothing but heaven is impregnable to vice, it will unavoidably happen, that in proportion as they surmount the first difficulties of emigration, which bound them together in a common cause, they will begin to relax in their duty and attachment to each other; and this remissness, will point out the necessity, of establishing some form of government to supply the defect of moral virtue.

This has me thinking today, some 233 years later, about what it might take to see the opportunity that remains before us. I wonder, when are we most perfect as a society? In what places, at what times, and with whom do we find ourselves uniting our affections? What calls us, like a gravitating power, into society?

And, how do we remain perfectly just to each other?