One of the insights that came flooding over me watching HBO’s new movie about Temple Grandin is how my day-to-day experience of the world is so perfectly arranged – and limited – by my particular brain and conditioning. What I think I see, what I affix shape and meaning and language to – the particular way I make sense of the world – is also a kind of blindness to anything else.

Grandin, a doctor of animal science and noted autism advocate whose rare ability to explain the condition’s effects changed the way both science and society perceive it, tells us right from the start, “I’m not like other people. I think in pictures. And I connect them.”

An early scene makes the point. Grandin and her aunt drive up to the gated entrance of a sprawling Arizona cattle ranch, and what might appear as nothing more than a pass-through (the gated entrance) suddenly becomes a complex interplay of angles and trajectories, of geometry and relationships, through Grandin’s unique consciousness (and some rather stunning visual effects).

Clearly, there’s a lot more going on than we perceive. For most of us, it’s the gated entrance we see, the instantaneously configured end product of our perception. We lock in on the world-as-objects so that we can move through it in expedient ways.

Grandin sees the configuration process itself – the interplay of past experiences, physical stimuli and their perceptual effects. Just as the gate is more than a gate, Grandin’s mind, her science teacher explains, is like a door that opens up on a whole new world.

Seeing our seeing, and the limitations of our seeing, is useful and important. You might say it is the only way we ever perceive anything “new.”

That’s one of the reasons I found today’s blog post by Altarum Institute’s Stanley Chin so refreshing (“Just How Do We Define a ‘Culture of Health’?”). Rather than provide pat answers and superficial solutions, researcher Chin poses some big questions that challenge long-held and mostly unexamined assumptions about health, health behaviors and health “determinants,” a word he says is itself problematic: “Health is surely not ‘determined’ or cast in stone but is the result of interacting risk factors, environment, genetics, chance, and individual choices.”

The challenge is furthered when we build assumptions on our assumptions. For example, notes Chin, while education is correlated with health, the precise “pathways from educational attainment to improved health status are not clear,” which of course leaves interventions to guesswork. Chin observes:

That the health policy research community does not know much about such pathways, despite decades of work, says something about the data available, the methods used, and the very nature of the problem. Communities and their health are more than just complicated and full of surprises. Formally, they may be examples of ‘complex adaptive systems’ – ecologies with a complex web of feedback loops over time and spatial dimensions. These loops mean that direct causation may be difficult or impossible to demonstrate, that history can be as important as current levels or capacities, and that what we normally think of as the background (context and details of implementation) may actually be the key success factor.

Chin hasn’t cracked it all the way open (yet) – How about deconstructing what we mean by “health”? – but it’s a start in the right direction. A shift in perception might be our best and only hope to get to “the very nature of the problem.”

Here is one of the outputs of an amazing gathering yesterday in Michigan, where community transformation leaders from the east (Detroit) and west (Benton Harbor) edges of the state came together to share stories, aspirations and possibilities for collaboration: article in Detroit News.

The article missed a few facts; what’s more important is the story behind the story, which will continue to emerge through this growing network of leaders. Participation is welcome!

“This initiative is an example of ‘positive deviance,’ an approach to behavioral and social change. Instead of imposing solutions from without, the method identifies outliers in a community who, despite having no special advantages, are doing exceptionally well. By respecting local ingenuity, proponents say, the approach galvanizes community members and is often more effective and sustainable than imported blueprints.

“Unlike a lab experiment or ‘best practices’ transferred from elsewhere, the strategies have already been shown to work in context. As it takes root, positive deviance could instill a new way of looking at hard problems.

“Often, the positive deviants are unaware of the benefits of their habits, and are, in fact, ashamed of them because they violate cultural norms. The approach also works best, ironically, with the most formidable problems, perhaps after other solutions have failed, because the community must be highly motivated to solve the problem.

“In places known for their rigid pecking orders, these interventions often disrupt long-established dynamics. The efficacy of positive deviance…is ‘related to the issue of ownership. The solutions tend to last longer because it’s just human nature that we don’t turn our backs on what we create.’

“At bottom, positive deviance amounts to simple common sense. But that may be what’s most revelatory about it. Instead of throwing money at a problem or devising grand solutions, it urges us to look a little more closely at what’s already happening.” – from “The Power of Positive Deviants,” by Rebecca Tuhus-Dubrow, Boston.com, November 29, 2009

“Why do children love imaginary figures like Santa Claus…? Because they like to pretend. And when children pretend, they are exercising the evolutionarily crucial human ability to envision alternative ways the world could be. In adults that ability is at the core of our very real capacities for invention and innovation.” – Alison Gopnik, author of “The Philosophical Baby: What Children’s Minds Tell Us About Truth, Love and the Meaning of Life”; full story in December 22, 2009, The New York Times.

“Pocket parks — also known as miniparks and vest-pocket parks — are small patches of landscaped nature generally built on vacant building lots or scraps of city land that fall between the cracks of real estate interests… (Thomas Hoving, former New York City parks commissioner) recognized that they offered the city not only ‘lungs’ and a respite from noise, but opportunities for collective action by the surrounding communities whose help he enlisted in reclaiming the land. He believed that the communal act of making these spaces of quiet itself promoted harmony.” – from “City of Earthy Delights,” George Prochnik, Opinion, The New York Times, December 13, 2009.

“Some employers are getting involved in community health promotion initiatives to reinforce their own employment-based health improvement goals… ‘This represents a recognition that employer wellness programs need to fit into a broader community framework,’ said Michael Thompson, principal at PricewaterhouseCoopers L.L.P. ‘It really requires a more holistic effort to change the course of society and employers are playing a major role in getting it started, but they can’t accomplish it without a lot more support from their communities. We need to have the oars pulling in the same direction.’” — full story in Business Insurance, September 14, 2009

Neighborhoods matter to health. Here are two very different approaches to make sure where you live is healthy…

Move to a Healthy Neighborhood: “You’re planning to move, and you’re sure you’ve thought of everything: a good school system, affordable property taxes, a manageable commute. But what about your health? A study published this month in Archives of Internal Medicine found that living in a healthy neighborhood—defined as one that encourages you to ditch the car keys, get moving, and eat more healthfully—may lower the risk of developing type 2 diabetes by 38 percent… Here are some specific things to look for to make your next neighborhood a healthy one.” — full story in U.S. News & World Report, October 28, 2009

Or, Get Your Neighborhood Moving: “Exercise more. Avoid junk food. Such common-sense health advice has proved no match against the temptations of modern life, which have sent obesity rates around the world soaring. Now, government officials in a number of countries are pursing an aggressive new strategy: enlisting entire communities to insulate people from these temptations and make healthier choices easier…. [A] community-based approach to fighting obesity is probably the most promising policy available, experts say. ‘What works is durable, long-lasting changes in habits,’ says Monique Romon, a professor of medicine at Université Lille 2 and the lead researcher of the study on Fleurbaix and Laventie. ‘That’s why community action is so important.’” — full story in The Wall Street Journal, November 10, 2009

San Francisco’s health department is using medical records and epidemiological tools to map AIDS “hot spots,” areas of the city that have the highest intensity of H.I.V. viral loads and are therefore most susceptible to spread of the disease. The effort is groundbreaking in a number of ways.

First, while many communities count the number of H.I.V./AIDS cases in a geographical area, San Francisco uses viral load data – the number of viral particles in patients’ bloodstreams – to track not just where the virus exists but where infection levels are highest and most likely to circulate.

This shift is significant, according to a story in last week’s The New York Times, because it might help officials stop transmission of the disease by focusing on “the deepest reservoirs of H.I.V.” It is like moving from the surface of the water to the water’s depths.

“We’re taking an individual marker and making it a marker for community health,” said Dr. Grant Colfax, director of H.I.V. prevention and research in the city’s Department of Public Health.

Second, the maps provide a credible and actionable fact set that confirms what some had long suspected: In a city with more than 15,000 reported cases of H.I.V./AIDS, the new findings show that the highest viral loads are among African-American, homeless and transgender individuals.

“This scientific evidence supports the community’s notion,” said James Loyce, executive director of Black Coalition on AIDS in San Francisco. He noted that some areas of the city have felt “benign neglect,” suspecting that services were geared to the Castro, where more H.I.V.-infected people live.

“These hot spots are perpetuating themselves, increasing infection in marginalized communities,” said Dr. Julio Montaner, president of the International AIDS Society and head of the division of AIDS at the University of British Columbia. “As long as we don’t deal with that problem, the reservoir of H.I.V. will ensure that we’re promoting the continued spread of H.I.V. in perpetuity.”

Finally, the maps provide something less concrete, though perhaps most valuable: they force us to think beyond previous assumptions and consider completely new possibilities. As noted in the Times’ article, “The city’s decisions on how to act on the new information will be controversial. Officials must decide whether to shift services, create pocketed marketing campaigns or go directly to the individuals with the highest viral load and offer them appropriate care.”

“I think we’re asking the right questions,” said Dr. Colfax. “Now the issue is, What are the answers?” Sometimes the best answer to new questions is more new questions.

This post is a submission to the Hastings Center’s Values and Health Reform Connection, a new group blog on American values and why they matter in health reform.

Our health as a nation continues to deteriorate, in part because we have failed to recognize significant influences that account for more than half of what makes us well or sick. These influences – known as the social determinants of health – are largely hidden and unaddressed by current health management efforts. To create more effective strategies, we need an expanded view of health, what influences it, and what can be done to improve it.

Conventional wisdom says that health is the result of individual behavior, genetics, and medical care. Less recognized, however, is that health is also influenced by a range of social and environmental factors in the places we live, work, learn and play. In fact, research tells us that community influences – such as educational quality, economic and employment opportunity, social cohesion, and access to essential goods and services like food and transportation – are the leading causes of illness.

Left unaddressed, these larger influences compromise the impact of health and wellness efforts. For example, nutrition counseling is ineffective if individuals do not have access to affordable healthy food in their residential and workplace communities.

In our Communities of Health work, we are finding that while people intuitively grasp the idea of social determinants of health when shown the evidence, it is difficult to sustain ongoing awareness and attention on these factors sufficient to do anything about them.

A number of barriers exist. First, it is difficult to break from the prevailing frame, which views health primarily as a function of individual behavior and medical care. The individual-medical model of health dominates our systems, beliefs and language, and is continually reinforced in the way our nation thinks about, talks about and acts on health. And, when health is discussed in a broader context, counter-narratives tend to appear, overwhelming the potential for an expanded view of health.

A second challenge has been demonstrating how social determinants impact specific stakeholder groups. For instance, it has been difficult to draw a direct causal linkage between harmful community conditions and the rising costs of health care paid for by an employer.

Finally, even for those who are motivated to act, specific strategies for addressing the social determinants of health may seem elusive, impractical or insurmountable. As more than a few Communities of Health participants have expressed: “This is like trying to solve world hunger – what do you want me to do about it?”

What we are learning is that nothing changes until people have the opportunity to discover for themselves what matters to health, and what we can do about it together. In short, we must un-learn and re-learn “health” as a direct, ongoing and collective experience of it.

This is happening in a growing number of cities around the country where people are coming together to uncover the broad set of factors driving health and illness in their communities. What they discover together forms the basis of collaborative action among an expanding group of stakeholders – citizens, business, government, education, health and other sectors – who realize the collective strengths, needs, and possibilities inherent in their community.

In some communities this is aided by a data-modeling process – the CoH Index – that maps healthful or harmful conditions by neighborhood. The result is a map of community “hotspots” (red zones) that guides business, neighborhood and organizational communities to the most significant and actionable opportunities to improve health. For instance, by overlaying its employee population on the map, an employer can illuminate specific social determinants that matter most to workers living in the red zones.

While every Communities of Health initiative is unique, each is demonstrating that greater collective awareness and change from within can create a profound and sustainable shift in health for all. In addition to generating tangible action, engaged local participation creates “control of destiny,” which is essential to health. Coming together to consider the health of the community is healthy community.

Can we have a conversation about health if we see it through dramatically different “frames”? How do we arrive at a common frame? Do we need to?

A University of Michigan study found that 32 percent of Democrats believe that social factors — such as socioeconomic status, neighborhood safety and availability of healthy food — play an important role in health, compared to just 16 percent of Republicans. (See coverage by ABC News and Science Blog.) “If you are more liberally minded the ‘neighborhood explanation’ can be motivating, but for people who are more conservative politically, that message can backfire and make them even less interested,” says Peter A. Ubel, M.D., professor of internal medicine at the University of Michigan and director of the U-M Center for Behavioral and Decision Sciences in Medicine. “The same information can polarize people.”

In her dissertation,  Robert Wood Johnson Foundation Health and Society Scholar at the University of Pennsylvania, Sarah E. Gollust, Ph.D., notes that the results challenge conventional wisdom that increasing publicity of the social determinants of health will lead to greater public support for health policies. Rather, advocates who want to mobilize the public might consider disseminating information about both social factors and individual behavioral causes to avoid triggering resistance.

And here we are reminded again that it is context, more than content, that makes healthy conversation possible.