Gretchen Miller: Hello there on Prevention Works, we have in conversation Professor Diane Finegood, one of the world’s leading experts in systems thinking. Diane’s based at the Simon Fraser University in Vancouver, Canada, but she’s also a member of The Australian Prevention Partnership Centre’s International Scientific Advisory Committee. So, we’re thrilled to have her here with us because the Prevention Centre, which of course hosts this little podcast, is all about drawing together a range of disciplines in its lifestyle related disease research. It turns out we are quite the world innovator in that regard. We’ll get to that in a minute. I’m Gretchen Miller. Let’s get started.
Diane, I think it’s important that we start with some basic definitions to come to understand your way of thinking. So, let’s start with a simple breakdown to demonstrate the various categories of problems that you’ve come up with.
Diane Finegood: The easiest way to think about the difference between simple problems, complicated problems, and complex problems, is to think about baking a cake, sending rocket to the moon and raising a child. So baking a cake is relatively simple. Pretty much everybody can do it – follow the recipe and you’re generally successful. It doesn’t require a lot of expertise. Sending a rocket to the moon is a complicated problem. It requires expertise in things like metallurgy and astrophysics. It requires some trial and error because the protocol isn’t always obvious the first time you try it out. But, generally, once you’ve done the protocol and tried it a few times and done some experimentation, you’re going to be successful and most of the rockets you try to send to the moon are going to go.
But let’s think about raising a child. Raising a child, expertise doesn’t particularly help very much. If you’ve raised one child, you can’t necessarily transfer what you’ve learned with that child to the second child. The context matters a lot and the kind of expertise that you actually need is the parental expertise of understanding the context in which that child is being raised. So, fundamentally different to think about sending a rocket to the moon and raising a child. And one of the challenges is that we mostly try to solve complex problems like raising a child by using methods for sending rockets to the moon.
So, we could take a public health problem. Let’s think about vaccination. The problem of actually administering a vaccine to a child, relatively simple. Some kids don’t like it, but it’s just basically, you know, draw up the vaccine in a syringe and administer it. That’s a relatively simple thing to do, you follow the recipe. Actually distributing vaccines to the places where they’re needed, that’s probably a bit more complicated and making sure you have enough vaccine where you need it. But getting a population vaccinated, that’s actually much more complex. And we can see that in the context of today where we thought we had pretty much eradicated measles, but here we have pockets of measles coming back because of the attitudes people have towards vaccination because of false information that they’ve latched onto about vaccination. And so the actual problem of vaccinating a population and eradicating measles is actually a much more complex.
Gretchen Miller: That’s a really interesting example because what you’re dealing with there is illogic, isn’t it? You’re not dealing with rational responses.
Diane Finegood: That’s not the only thing that makes things complex. So there’s a lot of things that matter in complexity or in dealing with complex problems. Relationships matter, trust matters, information matters. All of these things matter. We’ve become a world where we trust sources of information that might not be trustworthy. And so I think the lack of trust that we’ve seen grow in our society for some of our institutions, like government and even the healthcare system, adds to the complexity of doing something like eradicating measles through vaccination.
Grechen Miller: So complicated is something which has a number of steps and you maybe have to get those steps correct to make it work. But nonetheless, there’s a number of steps that you can go through to potentially solve a problem. Whereas complex has unpredictability built into it.
Diane Finegood: Correct.
Grechen Miller: So, I think one of the interesting ways in which this analysis plays out is looking at the way we treat, have various health issues, and we pop them in silos. We find solutions for particular things in very particular ways and this is actually quite problematic and possibly not sustainable.
Diane Finegood: Yes. So let’s think about the challenge of prevention. There are many different things that we’re trying to prevent and keep people healthy and there are many different behaviours that go along with it. The science we’ve been doing for the last several decades is a science based on the idea that all you need to do is work out the causes of a problem to know how to solve it. That just seems to make so much sense and that’s how we do science.
But when you have a complex problem with, you know, hundreds of different causal relationships that that lead to something like obesity – I mean there’s many, many different things that have been associated with obesity. So, when you have something that is that complex and you try to work out the causes, the first problem is it takes you a very long time to do that because trying to isolate out each of these causes and hold things constant and see how this varies, takes a long time. I think there’s a big opportunity cost actually. As a result of that, there’s a situation where you spend a lot of time working it out, and then you think, okay, now I know that physical inactivity, eating unhealthy food, built environments that don’t allow us to exercise, social media, all kinds of different environmental things, lead to obesity. Then we try to tackle each one alone.
So, that’s a problem. If we’re can isolate all these things and think we know the solution, then we have to add up hundreds and hundreds of solutions in order to get to a place where we want to be. The challenge is that there’s also other levels that we need to think about, other kinds of things we need to think about, like people’s deeply held beliefs. What are our deeply held beliefs, for example, about drug addiction – “Oh, it’s their fault” – and we stigmatise people who are drug addicts. That’s not helpful. It makes it difficult to take a harm reduction approach if we think it’s their fault.
Gretchen Miller: And in a wider population, obesity, even though such a large proportion of the population in the West is obese, we stigmatise it.
Diane Finegood: Absolutely. Our stigmatisation of obesity is so deeply ingrained in us that I as an obese person still think a lot of these things about myself and that’s problematic. It doesn’t help me lose weight. I know a lot more about weight loss than just about anybody would because I’ve struggled with it my whole life. So, it’s not that I need more information or I need to be told just eat less and move more. I know a lot about it and I know what it takes for me to lose weight, but that doesn’t necessarily help me solve the problem and I still feel bad about it.
Gretchen Miller: So this is a very personal example of how complex a problem can be, but also how treating that problem is siloed. Let’s talk a bit more about siloing.
Diane Finegood: Sure. When you talk about siloing here, the challenge with obesity is there’s a whole range of different things that we need to change in our society in addition to changing our deeply held beliefs about obese people or people who are overweight and even people who are underweight. You know, each individual’s different. What I need is going to be different from somebody next door to me and across the street from me. The challenges I face are different from other people. And so I need a world where my options are healthy options. I need a world where I can be physically active in the course of going to work. And even those things which I do – I walk 40 minutes to go to work every day – even those kinds of behaviours don’t necessarily solve my problem, but they might solve somebody else’s.
Gretchen Miller: I’m interested in the way this implies that we are constantly reductionist and therefore perhaps we can lead then to why we struggle so much with introducing or accepting that there’s complexity.
Diane Finegood: It’s certainly clear that we’re reductionist on our approach when we still have a deeply held belief that all you need to do is eat less and move more in order to be a healthy weight. That paradigm of thinking is not helpful. That’s the first thing I would say about the challenge and the complexity of the challenge. You know, it’s not hard for us to see in our population of dogs that there are different dogs and different food behaviours in dogs. I’ve had a labrador retriever who you can never stop them from eating, except for not giving them food, right? I also had a border collie once in my life who would, you know, have a few kibble and then walk away from their bowl and leave food in their bowl. So why would we think that everybody has the same drive to eat? There’s just an example of why we can’t treat everybody the same and that different people struggle with different aspects of it and why, you know, we need a variety of approaches to create an environment where the majority of people are able to maintain a healthy weight.
Gretchen Miller: Let’s talk a little bit more about complexity and the milieu in which we find ourselves socially, politically, economically, and the fact that there’s been such an increase in complexity in our lives to the point that we actually have kind of become paralysed. We cannot adapt anymore.
Diane Finegood: The complexity of our world is clearly increasing. Although I don’t have data to show you, we can feel it in our bones, right? And we have so much information coming at us now. If we think about when the internet was developed, all of a sudden we were exposed to way, way more information, some of it valid, some of it not so valid. And I think around that time we’ve sort of surpassed the capability of an individual human to cope with that complexity. So what do we do when we have complex problems? And we’re faced with complexity?
The usual are common responses. Our despair retreat, believing the problem is beyond hope, believing false information because somebody has given us a simple solution to the complex problem that we’re facing. So we latch onto it because we can’t cope in a world which is too complex. We need to simplify that world. And we do it by believing things that may not actually be true. I mean, look at the growth of populism globally, but most populist politicians are giving their publics simple answers to really complex problems. And it’s pretty hard as a politician to actually allow a complex problem to play out in the media, in the world. That’s a huge challenge. And so for us to cope, you know, one of the things I like to say is that for us to survive and do well and to thrive, the capacity we have needs to be well matched to the complexity of the world that we live in. If the world is too complex, then we’re not going to thrive and survive.
Gretchen Miller: And when you say we, are you talking about us as individuals but also us as communities? I suspect both.
Diane Finegood: Absolutely. Individuals, organisations, communities. The same notion applies that the complexity of the world that we live in or the space that we operate in needs to be well matched to our capacity. For years I think in public health we’ve thought, okay, we’ll educate people that’s going to increase their capacity, but frankly I don’t think that’s a particularly strong way of matching capacity and complexity, better to reduce the complexity of the world. One of the ways that our world is less complex is when we trust the people or the organisations around us. So when we put, when we had more trust in our political masters, it was easier to think about, right? It was easier to sort of function.
Gretchen Miller: How does that therefore apply to public health?
Diane Finegood: Well, let’s actually think about measles. We’ll go back to the measles example. I think for the most part, the largest fraction of the public had trust in the notion that if we got vaccinated, we wouldn’t be exposed to measles and it would go away. And that worked really well. And then there were as a paper or two that came out that started kind of the ball rolling to not trust vaccines or that the worry that a vaccine caused autism or some other problem. And certainly if you’re the parent of an autistic child, that is very difficult. That’s a very complex situation. And so if you’re worried that your child might get autism because they’re vaccinated, then you might not vaccinate your child for good, rational reasons. But the fact is that the paper that proved that vaccination was associated with autism was wrong and it was retracted, but somehow it’s not left the public sphere.
Gretchen Miller: This is a psychological sort of struggle that we’re talking about with complexity. What about practical? We really struggle even with the basic practicalities of complex problems, don’t we?
Diane Finegood: Well, certainly the psychological part is the fact that if there’s a hundred different things that contribute to obesity, we feel overwhelmed and we’re just looking for that simple solution. That’s the way it’s played out. And then the practical challenge is, if there’s a hundred different things that contribute to human obesity, then how are we going to deal with all of them? Let’s try to deal with one at a time, and we tend to latch onto those simple solutions and think they’re gonna solve the problem. But you can’t solve the problem. You can make the population less obese or more obese and you can do a bunch of things that contribute to that. But, fundamentally there’s no solution. We need to move in the right direction by changing hundreds of things that support it.
Gretchen Miller: So what we really need then is integration. Can you talk a bit to that?
Diane Finegood: Absolutely. And you’ve gone right to the right place. When I talk about systems thinking, really I’m talking about going away from isolating the parts to integrating the parts and thinking about the relationships that we can build across sectors, across organisational structures in order to work together on tackling challenges. And there’s good evidence that many of the things that we need to do, for obesity, for climate change, and even for things like under nutrition, the same things can be done to tackle all three of those problems. And we need to do that in a way in which we’re working together because we’ll be more efficient and effective at tackling some of the big challenges.
Gretchen Miller: What are those same things that bring together obesity, climate change, and under nutrition?
Diane Finegood: Well, let’s think about physical activity and active transport is a simple example and it’s easy to see how that relates to both climate change and obesity. We know that if you’re more active, you’re less likely to be obese and you’re also less likely to contribute to greenhouse gases. It’s a simple example there where you can see the connections between them. But there’s many of those connections that we need to be making in order to get where we need to go.
Gretchen Miller: So why is it that that traditional scientific approach just isn’t working?
Diane Finegood: So, let’s talk a little bit about what that means, that traditional scientific approach. The example that’s easy, relatively easy to understand, would be how we test and decide on new pharmaceuticals. The way we consider a new drug to be licensed and used is we do what’s called a randomised control trial and we test it against another drug. The best form of evidence that a drug is going to be effective in that scenario is that we do many of these trials in different populations and pull them together in a synthesis to understand what, what’s the one true result, if you will.
But if you think about what’s going on there, what if it worked in one population really well and slightly well in another population and not so well in another population? When we pull together, we get one answer and we’ve lost all the context and the differentiation that might occur in different environments, different people, different things like that. Well, for drugs it’s still a relatively good way to identify safe and moderately effective drugs, but let’s now apply that to something like obesity or chronic disease. There, many different factors play a role in the context in which people live and the environments in which they live. That kind of science where we try to get rid of context and just find out the one true answer doesn’t really work because then when we go back to apply it in different situations, it doesn’t work very well.
And so we’ve gotten rid of the kind of evidence that is actually important when a problem is complex. We have this thing called an evidence based medicine pyramid and it says the best form of evidence is this synthesis of trials. The worst form of evidence is, or the lowest form of evidence, is expert opinion. And yet, when we think about complex problems, it’s the expert opinion of the people on the ground in a particular context that understand that context, that’s important. And so we’ve got the wrong kind of structure for thinking about the science that I would call a reductionist structure. What we need to do is we need a more integrative approach and one that values the kind of evidence that we need.
Gretchen Miller: How would that play out then if you’re a policy maker, thinking about, you know, working up some policy around obesity or drug addiction.
Diane Finegood: It’s a huge challenge for a policy maker. I think we’ve done a good job over the last few decades of convincing our policy makers that they need evidence, that they should be basing their policy on evidence. So they’re starting to ask for the evidence. But the problem is I don’t think we have the right kind of evidence in the literature or the evidence that we need to really help them.
Gretchen Miller: Because it’s been synthesised and reduced down from thousands of studies down to ‘So this is the one answer’.
Diane Finegood: Yeah, that’s exactly right. Now we are starting to implement in The Australian Prevention Partnership Centre is starting to do methodologies and work with policymakers using more integrative approaches, like something called dynamic simulation modelling where they bring a group of policymakers and other stakeholders together to say, okay, what are all these different things that we need to be concerned about? What do we know is related to this particular complex problem and how can we build a model, build a structure that will help us integrate that information into a tool that will help us not only have a common understanding of the problem, but also maybe do some prediction about what would happen if we did this particular intervention or made this particular change.
Gretchen Miller: Dynamic simulation modelling allows you to change individual factors to see how, you know, one community might respond with its particular needs compared to another community with its particular needs. So you might change the age or the availability of public education and see then what might play out, and therefore what you need to do to respond.
Diane Finegood: Yes. It allows you to take all these different things that we know are associated with a problem, mush them together, if you will, and test in the computer potential interventions, potential changes that we might make. But what’s really valuable about the exercise is the bringing together of the people who hold different levers and have different ways that they can work on the problem to develop a common understanding of where they fit in the system. Right? And so no one person has the solution. There’s no one single silver bullet solution to these problems. But when you bring all kinds of different people together who hold different levers, you start to build an understanding that allows the person with this lever to know, yes, I need to do this, but I’m not going to necessarily solve the problem by myself. I also need to work with this person and I need that person over there to work on it. It’s a tool in a way, the simulation modelling is a tool to bring people together to develop their understanding and to be able to talk to each other about how they can work together. That’s that integrative piece that you were asking about.
Gretchen Miller: But isn’t this in and of itself a complex problem because you actually have to get on board a vast array of disciplines from health to town planning to public transport to the availability of different kinds of foods to make this work. It’s a complex problem, right?
Diane Finegood: Absolutely. Addressing complex problems is complex in and of itself. And part of the reason it’s complex is because we tend not to value those things that really matter when you’re trying to address a complex problem. I’ll just tell the story of talking to the director of social policy at the City of Vancouver, who said that the most important thing she can do is be the convener of many different people in many different organisations as it relates to health and to follow their strategy for a healthy city. But in fact, your bosses don’t necessarily value that function. That’s the thing that she can do the best. That’s the thing we need to do, bring people together, but we don’t value those things. We also tend to be focused on our targets, our outcomes, what outcome do we want to have. We need to stop focusing on those things, thinking we can get somewhere like that, and focusing more on what are the changes and things that we can do through building trust, building relationships, all those integrative functions in order to improve the health of the population.
Gretchen Miller: This is Prevention Works, the podcast of The Australian Prevention Partnership Centre. I’m Gretchen Miller, talking with Professor Diane Finegood, and let’s talk a little bit about what’s been going on in Canada and how you guys have been working on bringing things together in this integrative and yet complex way.
Diane Finegood: Absolutely. We’re doing that in Canada. In the province of Alberta, they’ve gotten very good at bringing researchers, practitioners and policy makers together in something called Strategic Clinical Networks. They form a network for something like diabetes and obesity or bone and joint health and because their clinical networks, they’re really focused on the practitioners as a starting place, but they’ve integrated researchers and policymakers into that in order to improve care in our healthcare system. They’ve done a really good job of that kind of work.
Another example, actually, of something that Canada is doing really well is we’ve invested significant dollars in what we call patient-oriented research. We have a strategy from our national funder called the strategy on patient-oriented research and as a result over the last four or five years, really patients are integrated into most conversations about health research and it’s really changing the face of health research in Canada. It’s changing the questions that are being asked. Researchers are beginning to understand what patients care about, what’s important to them, and as a result the priorities for research are changing. Even something as sort of esoteric, I would say, or crazy as figuring out a clinical practice guideline, what are the rules that a clinician should follow. When a patient’s involved, the questions that are asked in the guidelines that are developed are different from those when patients are not involved at all.
It was a strategy of our national funder to get additional resources from a federal government that was really not providing new money for health research that we would focus on patients. And what you can see over the course of about a five-year investment is, everybody’s talking about it, there’s large patient advisory groups in many provinces and associated with research opportunities. Really you wouldn’t think about doing this kind of clinical research or public health research without involving people with lived experience and patients.
Gretchen Miller: Could you reflect a little bit on the Partnership Centre with which you’ve got a relationship, and how some of its research, is actually a model for what you’re talking about here?
Diane Finegood: Well, clearly, in a complex problem where you need people to come together and integrate their efforts, partnership is the name of the game. Like, clearly partnership needs to be upfront and partnership requires building trust and building relationships. And one of the things I’ve been impressed about the Partnership Centre is the effort and energy that they’ve been able to put into building strong partnerships with their policymaker partners, with their other kinds of partners. And so that’s a critical first step to doing something in a more systems thinking, more integrative fashion is to build those relationships.
Gretchen Miller: So when you talk about integrative research, which is not the same as getting all the studies and squeezing them down into one study and one solution, but actually about multiple different levers, one of the things that you pinpoint can be neatly indicated through the use of terminology of engaging outside partners. And I’m thinking now of the words ‘sponsorship’ and ‘partnership’ and why those two words are different and why it’s important that they’re different.
Diane Finegood: We often use the word partnership to describe all kinds of different relationships, but really there’s a big difference between a sponsorship, an alliance of partners and a true co-created partnership. In a sponsorship mode, it’s transactional, it’s usually about giving somebody money and maybe setting some things about what you want from that money. The organisations are not necessarily working together, but you’re just looking for money to do something. And there’s plenty of sponsorships out there and there’s plenty of challenging sponsorships out there as it relates to something like obesity. I don’t know whether you had it here in Australia, but we had pink buckets of chicken in, I think it was in the US, where KFC had a partnership with the Cancer Society and they were selling pink buckets of chicken. How inappropriate can that be? Unfortunately, sponsorships can often lead to these problems. I know there’s also challenges around sponsorship of sporting events by sugar sweetened beverages or tobacco or gambling or any of those sorts of challenges. So those are dangerous, but sometimes they’re helpful. And it all depends on the parameters of that.
At the other end of the spectrum are true partnerships where the two organisations co-create, they work together, there’s a level of equity between the organisations and you enable that opportunity to really tackle a problem in a collaborative and co-created way. When we talk about partnerships, we need to remember that there’s a large spectrum. And the purpose needs to be clear and the rules of the game need to be clear.
Gretchen Miller: What kind of sectors might you get working together in a partnership over a sponsorship? Is there place, for example, in partnering with say a fast food company. Can it be done? Is it a good idea?
Diane Finegood: We do have examples of successful partnership or relationship building with the food industry, but here’s where you do need to be absolutely careful and be clear about whether you have a conflict of interest or maybe a convergence of interest is what I like to say that there’s a, there’s a bit of a grey zone there and we really should be thinking about convergence of interests.
I’ll give an example from Canada. A number of years ago Kellogg’s decided to put pedometers in Special K. They put like a million pedometers in boxes of cereal and we actually built a partnership with Kellogg’s where we actually had on the back of the box the CIHR logo, the logo of our national health research funder, and it said ‘Walk, log on and donate your steps to health research’. So this relationship was built. And then we brought a group of researchers together to say, okay, what can we learn from this sales marketing campaign, which verges on being a social marketing campaign. But the company has huge reach and huge investment in selling these boxes of cereal. So what can we learn? And at the end of a year of doing that promotion, more people had a pedometer from a box of cereal than had purchased their pedometer. But it’s also true that if they had a pedometer and they recalled some of the messaging, like just add 2000 steps, which was one of the taglines associated with the promotion, that they actually were more likely to have walked more in the week prior. And this was a long-lasting effect.
We learned that in fact the huge reach of a company like that can be helpful in a health promotion scheme. But remember, we had to be careful, you know, that particular cereal has a health halo to some extent. It wasn’t a sugar sweetened cereal that somebody might be upset about or be concerned about. And there was an interesting dynamic that played out. I think it was an interesting exercise. It illustrates there are places where we might work together and it would be helpful, but certainly, you know, there are places where the conflict of interest is probably stronger than the convergence, like making pink buckets of Kentucky Fried Chicken.
Gretchen Miller: So, if you’re a policy maker, where do you go to from here?
Diane Finegood: If you’re a policy maker in Australia, I’d probably go to The Australian Prevention Partnership Centre because they’re probably the leading organisation from the point of view of understanding what we mean by systems thinking. They’re also doing quite a lot of work in the areas in the strategies that are appropriate for dealing with complexity, like building trust, developing a shared understanding of a problem, thinking about how different approaches to the problem might actually resolve it. That shared understanding, that trust, the relationships, all of those things are critical to addressing these problems.
We still need to build a stronger evidence base that we can then turn to our policy makers and decision makers and say, here’s the evidence that this is what we need to do in complexity. That’s work that we still need to do. And I would say The Australian Prevention Partnership Centre is helping to lead the way in Australia, but we need to do that worldwide.
Gretchen Miller: Thank you very much. Leaving us with a bit to think about where this needs to go next. Thank you for your time, Professor Diane Finegood. Listeners, you’ll find plenty of information about systems thinking on the Australian Prevention Centre’s website. So do check us out there. Also, share us around, of course. Leave us a review. It really does make a difference.
I’m Gretchen Miller and I’ll see you next time.
About this episode
Professor Diane Finegood discusses why we need a more integrative approach to produce the kind of evidence we need.