Don’t Be a Jerk: To Manage Big Change, Help Preserve the Precious Past

Nov 16, 2012, 12:48 PM, Posted by Michael Painter

Mike Painter Mike Painter

I had the recent good fortune to attend an Institute of Medicine Roundtable workshop on the Promotion of Health Equity and the Elimination of Health Disparities called Leveraging Culture to Address Health Inequalities: Examples from Native Communities.  The Robert Wood Johnson Foundation supported the November 14, 2012 Seattle event.  The meeting was a gathering of American Indian, Alaska and Hawaiian Native health and health care leaders, all talking about health and culture.  They told stories of resilient, strong, vibrant, conquered yet not vanquished people.  Their tales were wondrous and sad—troubling, provocative, sometimes angry, often humorous.  

One might think the IOM was doing a good, almost charitable, thing by shining some precious attention on these people. How nice for experts to listen politely to those stories of past cultures struggling against waves of current change.  Well, it was a good thing—but not necessarily just for the natives.  There was immense, quiet wisdom and power there—for everybody. 

What could this relatively small, nearly invisible population have that the rest of us need?  First, they have an obvious culture that they’re fiercely preserving.  The rest of us have cultures too—and we no doubt have important reasons we tend them or not.  For these people, though, their culture is almost certainly important to them precisely because their conquerors tried so hard to strip it.  Much of that native culture is tied inextricably to health and well-being. To them, healing does not mean treating—it means achieving a balance and beauty among individual, family, community, place, and story.  They talk about things like cultural continuity—cultural preservation—cultural safety.  All those terms are basically exhortations that health and health care efforts nest themselves within the culture of the people they’re attempting to heal.  

Presenters gave example after example of innovative, creative approaches by health and health care leaders that do just that.  A formidable, inspiring South Pacific Island health educator explained how she and her colleagues pragmatically devise diabetes and weight loss programs for islanders with islanders.  A Portland area American Indian educator hilariously told how they used a “walk-through” colon model they call “Kiki” to help their people understand why colon cancer screening might be important.  She thought her people would never accept that blow up model—but the patient representatives thought they would—and the people were right.

There is anger and resentment here too.  Many openly voiced strong concern about “evidence-based” approaches to improving health and care.  Some even described those approaches as a sort of new conquest.  That resentment almost certainly stems from the lack of explicit applicability of much of the evidence to particular groups and populations.  Several, in fact, took that resentment pretty far.  Some scoffed at the notion that anyone would attempt to change current native norms about, for instance, obesity.  Comfort with a heavy body is a cultural norm, they explained, and that should not change.  Just when I was getting swept away with the stories—that resentment brought me up short—made me wonder some—and, to be honest, start to worry. 

Our nation faces innumerable, complex, daunting challenges—not just in health and health care, but also with our nation’s financial health and our education systems—as well as really huge, scary problems like climate change.  One common ingredient with all of those enormous challenges is the need for big, rapid, accelerating change—by almost everyone involved.  Everyone, including the public, the professionals, as well as business and government leaders, all must change.  Also, to meet these many complex challenges, we’re going to need every bit of science, evidence, creativity, and innovation we can muster.  An insistence on cultural continuity or preservation, in that urgent challenge context, could seem retrograde—a hindrance.  It could arguably hold people back from changing at the very moment when we need them to change quickly.  Or am I missing something?

At the meeting, Portland physician Dale Walker offered an insight.  He wisely observed that science and evidence are really only as good as the way they fit into the communities they are trying to help.  Evidence can’t help the people who need it unless those people accept it.  Of course, that is a critical, almost obvious point.  These energetic, hopeful, funny native leaders tackling universal problems locally know exactly what they’re doing.  To manage big change—to tend that big change—we must cultivate it locally.  We should follow their wise lead here—they are pragmatically crafting approaches with and for the people they know so well in order to reach those people in ways that are meaningful and understandable to them.

Early in the day, James Knibb-Lamouche presented his original paper on leveraging culture that the IOM roundtable commissioned.  In his discussion he summarized one point by jokingly recommending a slight revision to the first phrase of the Hippocratic Oath from “First, do no harm . . .” to “First, don’t be a jerk . . . .”  We all laughed nervously about the very idea, the irreverence—I even subversively shot it into the Twittersphere. It was only later that I realized James had a point—one that all pressing for big change should take to heart.

Let us know what you think by tweeting to @pioneerrwjf or @paintmd.