The revolutionary power of network thought- a Scientific American Blog to share (not mine)

from the SA blog- “Network thinking lets us scientifically understand the world around us as one of connections that shape observed phenomena, rather than as one where the intrinsic properties of people, genes, or particles determine outcomes. Like previous scientific revolutions, the network revolution also has the promise of reshaping our basic commonsense expectations of the world around us, and may allow us to recognize that we are not a basically individualistic, asocial, and quarrelsome creature that comes in bounded linguistic, ethnic, racial, or religious types, but a social species linked to one another by far-reaching network ties.”

My short take:
This piece takes some elementary ideas from network analysis and packages them for the the less than convinced linear thinkers. Again, we system thinkers are again pleading for openness to this paradigm. Maybe such blogs (and even my book, can break through the complacency. The revolution lies in accepting our relational reality and approaching its discernment in systemic fashion. Period.


For your consideration- Chapter 2 from my book is freely available here

Chapter 2 from my book found posted here as a pdf and on the Springer International website

Chapter 2 of my Systems Thinking and Policy Book


My book is now available on the Springer site!

My book now available at . This method will require library license. Paperback and e-book coming soon for the rest of us. Please spread the word of

(Anti-) Smoking, Complexity and U.S. Public Law 111-31

Using The United States’ The Family Smoking and Prevention Act (Public Law 111-31) as an example, complexity is inherent to anti-tobacco policy and how unexpected factors emerge once such a divisive policy is enacted. Passed during President Barack Obama’s first administration, The Family Smoking and Prevention Act (Public Law 111-31) became the most sweeping regulatory support in combatting a leading cause of preventable death in the United States that have been scientifically linked to tobacco use. The Family Smoking and Prevention Act did not take away access to tobacco to consumers of age. Tobacco is sold legally, under the continued regulatory oversight from the Federal Food and Drug Administration. Newly ‘strengthened’ regulatory powers supplied by this act works to ensure the “safest” possible tobacco products sold to U.S. consumers using the most ethical forms of marketing to the public. Safe is certainly used loosely here. The sale of tobacco as ethical is another question. But tobacco is legal to use for those of age to use the product. What is allowed from a regulatory standpoint by this Act is targeting sales, marketing and distribution channels.
Upon maximization, the virtuous goal is to optimize the desired benefit of tobacco control policy, thereby saving lives and improving quality of life from morbidity and mortality related to tobacco use.

“This legislation will not ban all tobacco products, and it will allow adults to make their own choices…We know that even with the passage of this legislation, our work to protect our children and improve the public’s health is not complete.”, President Barack Obama during the signing of the Family Smoking Prevention and Tobacco Control Act (2009)

“Deliberate or orderly steps are not an accurate portrayal of how the policy process actually works. Policy making is, instead, a complexly interactive process without beginning or end.” (Lindblom & Woodhouse, 1993).

President Obama’s statement illustrates the depth and limitations of the powers of policy and portends systemic mess that could possibly ensure even under the most noble of intention. From his statement, we can take away that the following issues are central to the prescript of the law.

1. Increasing regulation of a legal product, in this case, tobacco.
2. Blocking tobacco advertisements from children within a specified distance of schools and parks.
3. Making flavored tobacco distribution illegal. Menthol is excluded from this ban.
4. All harmful chemicals must be fully disclosed to the smoker along with graphic fear appeals on the labelling.
5. Public Safety overrides autonomous actions of the consumer. Some elements of the society, such as children, require higher ethical safeguards which require the power of policy behind it.
Is an advertisement on the way home from the park that falls outside of the banned quadrant acceptable? By the letter of the policy, it is allowed. Is it ethical at the point of exposure to the ad or to the mere possibility of exposure to the marketing? Menthol is exempt from federal ban. Menthol would be a gustatory nightmare that does not leave a smoker’s breath or lungs minty fresh. I would rethink a pint of vanilla bean and menthol ice cream, but the immense popularity of the menthol flavor in tobacco does not require a sugar cone. It requires demand. Do we have enough room on the carton? It is going to have to be microscopic font and some gory images.
I am a never-smoker but that reality does coat my social and intellectual observations of the “smoker”. When I have stood behind someone purchasing tobacco, I have marveled at the specification given by the customer when requesting a cigarette. The customer recalls with exact precision of the colors on the box, the shelf location, and the nature of acrid, intoxicating smell wafting from the creases of the box.

Nope…Yes, the box right there on the second shelf next to the Ultra non-filtered. I want those menthol non-filtered buy one, get one. It will be debit card. And a lighter.

Cigarette smokers have been found to have very high levels of brand loyalty (see Dawes, 2013). The smoker knows the brand, down to the flavor, even recalling the specifications of the box that they want. At times, perhaps another perceived equivalent cigarette will do just this once and buy a comparable brand if the requested one is not available (Dawes, 2013). For others, not having their brand is a game breaker. Dawes (2013) in his analysis of U.S. cigarette consumer panel data uncovered the strong power of perception in cigarette branding.
1. A smoker that purchases high end cigarettes most likely will not lower the expectation of the quality perception by buying a generic brand.
2. If there is a female aesthetic on the box, men will not bite at all even when the call of nicotine gnaws. They will look for a cowboy or something testosterone driven in marketing appearance.
3. Price point does matter.
4. If you want overwhelming consumer loyalty, market to a smoker.
(Dawes, 2012)
But is packaging the end of the story? It is only one of parameters churning.
Voluntarily taking the smokes off of the shelves is a different animal altogether. What if a pharmacy decides to no longer sell tobacco which in 2014 was being tried? The smoker may choose to patronize a competing pharmacy that still sells the desired product. In order to offset the loss of sales in tobacco, what other measures will be set in place by the corporation to keep the smoker in their pharmacy a happy customer for other durable goods or leverage opportunities to bring in more new customers to offset the effects of losing smokers’ business? From a public health standpoint, good job for removing tobacco. From a business standpoint, will that smoker decide to move his prescriptions to a rival pharmacy? From a system dynamics view, a business move that diminishes returns is a negative feedback while increasing returns is positive (see Sterman, 2000). While there are standalone pharmacies that only dispense medication, many pharmacies double as quick convenience stores. A smoker is a goldmine. There will be medications on the horizon, if not filled already, to treat the morbidities related to smoking.
How can the tobacco removal spin work, really? Will the spiel from the CEO announcing the policy to remove the tobacco products lose resonance once the Twitter frenzy ensues farther diluting the intended corporate message. Once a message is viral on social media, the more removed the policy machine becomes and the message becomes more susceptible to distortion and emotion. Does the removal of tobacco tricked to higher prices across all products in order to make up for the projected loss of profit? Does a nonsmoker care about using a tobacco free business if he never bought or consumed the product at that time of service? What effect, in the long term, will removing tobacco from one chain have on tobacco related outcomes? Will other pharmacy chains follow suit? As you can see, these policy tentacles overlap and intertwine.

Dawes, John G., Cigarette Brand Loyalty and Purchase Patterns: An Examination Using US Consumer Panel Data (August 9, 2012). Available at SSRN: or

Lindblom, Charles E. and Edward J. Woodhouse. 1993. The Policy Making Process, 3 Edition.Upper Saddle River, NJ: Prentice Hall.

Sterman, J. (2000). Business Dynamics-Systems Thinking and Modeling for a Complex World. Boston: The McGraw-Hill Companies.



Summerschool on Health Law and Ethics 2014, July 1-11, Rotterdam, The Netherlands

Summerschool on Health Law and Ethics 2014,July 1-11, Rotterdam, The Netherlands



The Erasmus Observatory on Health Law / Institute of Health Policy & Management (Erasmus University Rotterdam) announces the annual Summer school programme on Health law, providing health professionals and practitioners, with an opportunity for intensive training in various aspects of health law and ethics over a two-weeks period, while absorbing the sights, sounds and culture unique to Rotterdam and the Netherlands. The Summer school offers a custom-developed course taught by leading academics in their field.

Questions? Mail to or


Can anything be learned from a Zombie Apocalypse? Maybe…

Let us give Chris Christie’s latest exploits a rest today. I was in a zombie mood today and decided to revisit a CDC zombie initiative from 2011. In the less comedic galaxy of public health, the world also needs saving from premature mortality and morbidity. The rightfully respected CDC made a venture into the “zombie apocalypse”, educating the public about emergency preparedness with a zombie novella. Unfortunately disaster planning leaves much in the public with obvious missteps in policy formulation and execution. Maggie Silver, a contributor to the CDC Public Health Matters blog, had even taken to giving the play by play on how to stay alive based on lessons learned (or not learned so well) based on the popular zombie feast, The Walking Dead (  It is an ingenious leverage of marketing hard to reach populations with health information in light of increasing occurrence of natural disasters ( It has been reported by the Washington Post that Twitter followers increased ten-fold for the unsexy CDC’s Emergency Preparedness division shortly after Silver’s blog went live (Bell, 2011).

The line between influential and conceptual health policy is hazy. On one hand, the CDC policy behind green lighting such novel communication channels may have come from the need to increase knowledge of emergency preparedness (conceptual) in the light of recent natural disasters. But the CDC is also in the business of saving lives. In preparation for all hazards, many deaths and injuries can be averted by knowing what to do before the “zombie apocalypse”, the CDC’s allegory for natural disasters. The blogosphere was chockfull of pundits decrying with the use of the federal money to educate the living on not becoming undead. Dear pundits, zombies are not real. Such a falsehood was not disseminated by Federal Emergency Management Agency (FEMA). The CDC, as the trusted source, would eliminate the chance of a phishing hoax. Zombies did not spark alert on the Public Broadcast System. I did not hear any upheaval as in ,vis a vis, Orson Welles. Branscum & Sharma (2009) reviewed the use of comics in health promotions targeted at children. More often, the comics are not a standalone intervention (Branscum & Sharma, 2009). But from an ethical standpoint, could the realness of the campaign blur the lines between entertainment to inform versus realistic entertainment that “warns”. But let us get this straight. The undead’s purpose in life (generously defined as so) is to make more undead in order to have more slowly shuffling company of the Cesar Romero variety. I have yet to have met a nonliving zombie in my traverses about town. Art can and has been an effective vehicle to slyly introduce health information but care must be taken in assuring that there is no confusion in the public as to its purpose.  

The CDC is working behind the scenes with evidence based public health interventions and is not trying to take over the pedestal of DC Comics. The jury is still out as to the effectiveness of the zombie campaign. In the area of viral impact, The Washington Post reported that social media interest in the zombies crashed the CDC website (Bell, 2011). I argue that this venture into comics (while perhaps not a novella about zombies in every case) has some lessons for the health policy set to see what the other side (promotion) is doing. Should there be a policy set that deals with entertainment for social change (See the work on edu-tainment from Arvind Singhal of UTEP)?

Branscum, Paul; Sharma, Manoj. COMIC BOOKS AN UNTAPPED MEDIUM FOR HEALTH PROMOTION.Source: American Journal of Health Studies . 2009, Vol. 24 Issue 4, p430-439. 10p.


Bell, Melissa. 5/20/11.Zombie apocalypse a coup for CDC emergency team.


CDC Office of Public Health Preparedness and Response.(

Silver, Maggie. (February 7, 2012). Teachable Moments – Courtesy of The Walking Dead on AMC. Public Health Matters Blog. Retrieved on 12-6-13 from



 The Washington Post. From

Some selected work from Dr. Arvind Singhal:

Communication of Innovations (2006)

Organizing for Social Change (2006)

Entertainment-Education Worldwide: History, Research, and Practice (2004)

Entertainment-Education: A Communication Strategy for Social Change (1999)

The Kidney Sellers- A look at organ procurement in Iran with author, Dr. Sigrid Fry-Revere

Dr. Sigrid Fry-Revere, author of The Kidney Sellers

Dr. Sigrid Fry-Revere, author of The Kidney Sellers

If you have been a dedicated follower of this blog, a common refrain has been the complexity inherent to ESRD and organ donation issues. I am honored to share an interview with Dr. Sigrid Fry-Revere (photo above), the Chairwoman and Founder of the Center for Ethical Solutions. Dr. Fry-Revere has enjoyed an extensive career in bioethics and health policy. I recently had the opportunity to ask Sigrid about her upcoming book, The Kidney Sellers, a book that chronicles her journey as the first Westerner to witness firsthand the Iran’s organ procurement system.

Orgcomplexity: Dr. Fry-Revere, thank you for sharing news of your new book with Orgcomplexity. Many may (or may not) be aware of how the need for procurement of organs in the United States. Would you share how bad the organ shortage in US and abroad is?

Dr. Fry-Revere: In the United States there are 100,000 or more people waiting for kidneys. Worldwide 90% of those who need life-saving organs need kidneys. In the United States only 15% of those waiting get a transplant. The rest wait and get sicker and sicker on dialysis and most die without getting a transplant. The longer on dialysis, the less likely a kidney transplant will work even if the person gets one. The average wait in the U.S. is five years.

Orgcomplexity: Why aren’t there enough cadaver kidneys? Is living donation the answer?

Dr. Fry-Revere: Only approximately 1% of people who die in the United States die under conditions where organs can be harvested. Most are too sick, too old, or die too far from the hospital for organs to be usable. Even if every organ that is even conceivably usable were harvested (Presumed Consent), we would only increase our kidney supply by less than 30,000 kidneys, and we need 100,000 or more. Note 30,000 is an optimistic figure because the more marginal the conditions under which a kidney is harvested the lower the conversion rate — the lower the chances that it will be transplantable even if harvested or that the transplant will succeed.The world’s first transplants were with living donors and in the last 30 years in the United States anywhere from a third to half of all kidney transplants were done with kidneys from living donors. For example, the 30,000 assumes an 82% conversion rate, but when the Washington D.C. Transplant Community (where I’m the ethicist for their Organ and Tissue Advisory Committee) makes efforts to maximize the number of organs harvested by harvesting from older and sicker patients, the conversion rate drops by 10% or more. So the yield of potentially usable cadaver kidneys is difficult to pin down.

Orgcomplexity: I have heard about a black market in organs. Is that true? What is the black market in kidneys?

Dr. Fry-Revere: A black market is an illegal market where anyone involved is punishable by fines or jail if they participate and/or there are is no legal infrastructure or laws to deal with disputes when contracts are made. A 2009 United Nations report estimates that 10% of all transplants are illegal black-market transplants with most of the purchasers being from western countries in North America and Europe while most sellers are from developing nations. As a result there is horrific exploitation of impoverished people by wealthy Westerners who don’t have friend or family who can donate and don’t want to brave the waiting list. As a result donors often don’t get the money they are promised, suffer crude and indignant surgical procedures, and often suffer or die for lack of adequate post-operative care.

Orgcomplexity: One might ask why you would want to go to Iran as a subject for your book.

Dr. Fry-Revere: I would rather go to the Bahamas but Iran is the only country in the world with a legalized market in kidneys. I was in Iran for nearly two months. I visited six major cities, each of which had a transplant program. I interviewed kidney buyers and sellers, doctors, the middlemen who arrange kidney sales, and an Ayatollah.

Orgcomplexity: Thank you so much for sharing news of this great work. Could you share how someone might be able to find your book?

Dr. Fry-Revere: The book website is on the CES website. It is due to come out on February 1, 2014 in hardback. All author royalties are going to the SOS (Solving the Organ Shortage) project of the Center for Ethical Solutions. You can visit for more information about The Center and this project. Thank you for this opportunity to reach the systems community.


Interested in Orgcomplexity’s take on ESRD and its systemic issues? Check out the hot links for past Orgcomplexity blogs on the subject!

Disclosure- Orgcomplexity’s founder, Michele Battle-Fisher, is on the Board of Directors of the Center for Ethical Solutions. Michele Battle-Fisher does not profit in her affiliation with CES. Michele Battle-Fisher or Orgcomplexity do not in any way profit directly from the sale of this book.

Taking a Dramatic Eye to the Doctor’s Office Interaction

This was originally published in The Yale Journal for Humanities in Medicine. The reference is at the end…

Taking a Dramatic Eye to the Doctor’s Office Interaction

by Michele Battle-Fisher (reprinted with permission)

…I began to realize that although medical labels had the same shiny surface as my childhood labels, with a luster capable of illuminating the darkness of disease, they also had the same sticky underside. (1)

Physicians by nature realize the humanity in healing. However, physicians do not leave “self” at the door. Not completely blind to social status distinction, this magnified distance in the doctor’s office may be overcome through discourse and a shared appreciation of worth. A very tall order… This sounds far too easy to do. Physicians are asked in each visit of a face-to-face interaction with a patient to optimize the success of each visit under a number of constraints. HMO’s demand this. Patients expect this. Recognizing the immense opportunity each interaction may hold in the health of the patient, the importance of maximizing each communicative discourse becomes more important. Certainly this thesis cries for the existence of a medical home and a history of a continued relationship between patient and doctor. It is hoped that this would not merely be a one-night only performance. If a doctor and patient are so fortunate to have this continuity of care (or less satisfactorily a one-shot visit), using Erving Goffman’s thesis of the person as a drama player with a splash of Butler’s performativity can be applied in ensuring better success in clinical discourse.

Goffman presents “dramaturgy” in human interaction as a theatrical event, with scenes, roles and players (2). There is no understudy for the physician. The doctor knows his or her role. This meeting of doctor and patient is inherently social. Socialization in this case, according to Dramaturgy, is a form of ritualized theatrics (3). Once the patient dons a hospital gown awaiting the physician, he is in the role of patient. This means that a patient may play a character of “patient” with more ease than having her true self scrutinized. The true self is flawed for many, being imperfect and open to ridicule. When discerning of meaning for other’s judgment when other appropriate evidence is unavailable, the doctor must use “signs” given by the patient (4). A silent patient leads to an evaluation of a mute actor by the physician based on the “performance” given. Personalities notwithstanding, the patient actors may be evaluated on the basis of phenotype: be it race, creed, or intelligence (5; 6). Goffman would say that following the dramatic performance of the doctor-patient interaction gives emotional grounding to these social interactions (7). It is emotive. But is it realistic to expect the patient to purge his or her soul and construct a shared morality in this environment?

Goffman reinforces the prejudice permeating in the 1950’s (that still remains) that held shamed characters in comparison to the gold-standard of the normal and nondeviant (8). Goffman made quite clear his demarcation of normal and deviant; through his use of “we normals” throughout the Stigma piece, he casts himself as “normal” (9). The patient only seeks a return to a quality of normalcy. They ask to be fixed. They ask for their old well “selves”. And that operationalization of normal may not coalesce with the physician’s recommendations. It may be wholly unrealistic clinically. Stigma is correlated to self-hood, as society has created stigma to cope with the dissonance- causing gaps in knowledge of others (10; 11; 12; 13). Serving the purpose of validating or invalidating self-worth, the symbolism of language allows us to create a reality from the outside inward. However, individuals may save face by silence or speak mistruths during the medical visit, whereby projecting what is expected from the patient “audience” (14). Stigma works self-reflexively, necessitating a social construction of a private and public self (15).

Case in point, can a patient not be aware of this stigmatization? Raj (16) powerful describes the use of medical labeling by practitioners. Raj (17) presents the case of becoming the diagnosis. To heal and make healthy a patient equates with a similar move to “normalcy”. The presence of disease is not. Physicians are asked to arbitrate what is arrantly wrong with the health of the patient. If only a less severe physical deterrent or public outings (or none at all) of illness were enough for society to avoid stigmatizing. As a label of diagnosis, HIV and Hepatitis then become unwanted albatrosses in the public sphere (18;19; 20).

Goffman certainly believed in a moral right in performing a role in society, explicitly calling for obligation and respect as an actor/performer (21). Whether a moral right or not, must each of us fill the role of “patient”? The body deteriorates making this a nearly absolute possibility. In doing so, each patient and doctor become team members by making manageable impressions and upholding the actors’ covenantal rules of engagement of that particular illness. The acting appearance reflects a perceived status and this will be linked to the quality of the patient and doctor’s performances (22). Judith Butler (23) asserts that performativity deconstructs power and social relationships. How the patient chooses to navigate the discourse may then call for the use of performativity. But I would argue that the medical visit would only allow for a conception of meaning within that staged performance.

A diagnosis innately defines a self as an “other”, someone different from the healthful and productive. The diagnosis does not automatically remove the personal consequences wrought on the patient. Goffman has realized that acting runs the development of social interaction, where the dramatic depiction can ring true or be falsified. Following the dramatic turn with transcendence, as theorized by Goffman, would salvage Jane or the patient when no other solution could be found. When Jane Eyre wrote, “reader, I married him (Rochester)”, she culminated her drama. Will a patient be able to say he divorced AIDS? No, it remains a chronic reality.

Medicine is a profession that is shrouded in a mystique that can make a patient-doctor relationship more complicated to navigate. That is a heavy burden to shoulder. I understand that there are many signs given by patients. Could that person without perceived blemish fully adhere to the medical expectations required of both sides in this possibly stigmatic dyad? I wonder if Percy Blythe Shelley was at all knowledgeable of his stigma as a philanderer. I would surmise not; he simply “was” Percy. Society gave his actions a label. Shelley gained far too much prominence from his love poetry for this to be of consequent. Society’s acceptance of his work, mine included, reinforced his sense of self. Shame was trumped by society’s notions of importance of this literary gift.

I ask what gift is left to the patient in this call of full disclosure. At times the gift of healing is left unopened. Certainly, this disclosure is with absolute purpose of healing. Again, I ask, what comfort is gained in complete personal nakedness when the other part (doctor) does not reciprocate this favor? In order to maintain ethical care, the focus, but shared culpability, should fall on the fellow actor, the patient. Do we reward our patients’ performances? I stress the heightened responsibility of the physician to heed this inequality of circumstance and remain mindful of the supporting cast’s “process”. This process may in turn reaffirm the humanity of the medical care being offered. But isn’t that the point?


(1) Raj, Y. (November 2005). Lessons from a label maker. Annuals of internal medicine, 143 (9), 687.
(2) Goffman, E. (1973). The presentation of self in everyday life. Woodstock, NY: Overlook Press.
(3) Goffman, E. (1973), previously cited.
(4) Tunc, T. (2008). Female urinary incontinence and the construction of nineteenth-century stigmatized womanhood. Urology, 71, 767-770.
(5) Shapiro, J. (2002). Self and other through the prism of AIDS: a literary examination of relationships with patients. Microbes and Infection, 4, 111-117.
(6) Goffman, E. (1973), previously cited.
(7) Goffman, E. (1963). Stigma: Notes on the Management of a Spoiled Identity. Englewood Cliffs, N.J.: Prentice-Hall.
(8) Goffman, E. (1963), previously cited.
(9) Goffman, E. (1963), previously cited.
(10) Goffman, E. (1973), previously cited.
(11) Rintamaki, L., Scott, A., Kosenko, K., & Jensen, R. (2007). Male patient perceptions of HIV stigma in health care contexts. AIDS Patient Care and STD’s. 21(12), 956-969.
(12) Shapiro, J. (2002), previously cited.
(13) Goffman, E. (1973), previously cited.
(14) Goffman, E. (1963), previously cited.
(15) Raj, Y.(2005), previously cited.
(16) Raj, Y. (2005), previously cited.
(17) Shapiro, J. (2002), previously cited.
(18) Klitzman, R. & Greenberg, J. (2002). Patterns of Communication between gay and lesbian patients and their health care providers. Journal of Homosexuality, 42(4), 65-75.
(19) Schafer, A., Scheurlen, M., Felten, M., & Kraus, M. (December 2005). Physician-patient relationship and disclosure behavior in chronic hepatitis C in a group of German outpatients. European Journal of Gastroenterology & Hepatology. 17(12), 1387-1394.
(20) Goffman, E. (1973), previously cited.
(21) Goffman, E. (1973), previously cited.
(22) Butler, J. (1999). Gender trouble: feminism and subversion of identity. New York: Routledge.
(23) Shapiro, J. (2002), previously cited.

Battle-Fisher, M.(Feb. 8, 2009). Taking a literary eye to the doctor’s office interaction. [Electronic version]. The Yale Journal for Humanities in Medicine. Retrieved from

Exploring Built Environments & Social Connection over Bukidnon & Saturday Yard Sales

by Karina Descartin

In the late 1990s, the summer before my senior year as an undergraduate in public health in the Philippines, I volunteered and participated in a summer immersion program through the university’s Volunteer Service Corps. Our group of eight medical and nursing students lived for almost five weeks with indigenous tribe families in the mountains of Bukidnon on the big island of Mindanao, south of Manila. Our task was to design and implement health programs for the small villages we visited. That summer was an entirely different life for us, city kids all. The homes we visited were far (sometimes whole mountains) apart. Walking for hours from point A to B was the norm. Electricity was rare and the physical and healthcare infrastructure was primitive, mostly inadequate to handle the communities’ needs. Extended family groups typically lived together in small clusters of modest homes, which left little room for privacy but reinforced the supportive and closely knit kinship networks that were part of the fabric of life. Local folks looked you in the eye unhurried, offered their best crops when sharing their meals, and embraced us with a warmth that shone through initial shyness. They laughed easily and their smiles lingered. Even during nights when they shared stories of sorrows and fear, I had a feeling they knew they’d be okay. Afterwards, when I returned for my final year at the university, the world looked different. I’d seen first-hand that even in a context of tremendous lack of external resources — and the near absence of the health support systems that I’d been learning about in my classes — the always-present embrace of a whole community built around the connectedness and sharing of family and friends could boost well-being from the inside-out.


When I started to look at the connection between built environment and health, I found Dr. Richard Jackson’s (2012) book Designing Healthy Communities.  As a physician and Master of Public Health studentI immediately connected with the words.

Jackson (2012) wrote that in the context of love and charity as residents of our will, the built environment is a manifestation of our intention and imagination. Further, in the context of genuine giving, he added that we get more than we give from truly “great built environments” (Jackson & Sinclair, 2012). But that great built environment bunkers us away from the din of social activity, what good is a custom home without a community to share it? Sometimes people can move mountains but they cannot move concrete walls without a building permit.

So when Atlanta’s Mayor Kasim Reed said in his TED City 2.0 Talk that “cities are where hope meets the street,” I agree. But I have to add that, often times, hope meets mountain paths and dusty village roads far from the city. Hope does not care whether we settle in on rolling hills or urban sprawl. Perhaps then, we should ask, where does this hope come from? Perhaps it’s not from the city street or rural lane, in particular, but wherever we are. It is our social connectiveness.


We are what we think.
All that we are arises with our thoughts.
With our thoughts, we make our world.
– Buddha
  Christopher Young, Buddha Quotes, 2012

The directed purpose of the built environment depends on our intent. A long time ago, older cottages on tree lined streets had porches. Remember when people actually congregated on that porch to talk and yell at friends as they passed by.  What are we trying to accomplish with strained decks in the back of our homes? Is our current goal to build and connect? Or is it to fortify and defend and isolate (Caldeira, 1996)? Isolation over the long term has been found to be detrimental to health. But when the heart is taken out of meeting friends by chance or making sure that a neighbor is okay today, we have another disease altogether. We have to work harder in establishing co-presence in our networks to actually stare another person in the eyeballs (Kadushin, 2012). What is co-presence in networks, you say? Sometimes people just share the same space and nothing more bonds them. That is known in networks as co-location. But if we hope to assure that built environment will not impede our ability to connect, co-presence is in order. If there is a neighborhood yard sale to unload unused Stairmasters and bound books, this is space with a social purpose for neighbors and bargain shoppers on the prowl, no matter how fleeting the communion may be.

Process and System

Community is ingrained for some (co-presence). For others, they live only in a zip code (co-location).

– Michele Battle-Fisher– Urban Greenspace

Cities of walls do not strengthen citizenship but rather contribute to its corrosion.
– Teresa P. R. Caldeira, Fortified Enclaves

We need open, inclusive exchange of ideas that will breathe fresh new life into this city. We need this. And when and if we get it, then the walls will come tumbling down.
– Dennis Dalton, 
TED City 2.0

Rydin et al. (2012), Lopez (2012), Rao et al. (2007), Kochitzky et al. (2006), and urban planner Gregor Wiltchko suggest that urban planning must be multidisciplinary and collaborative. This is key in ensuring that a common language is spoken among various disciplines and interests involved in defining our environments. Who has actually attended an urban planning public forum? I hear …silence.  Wiltschko further puts this position in perspective— “not so much to design the site or the right area but designing the right process that collaboration can really happen.”  Do you agree?

If we want to build something that best fits competing needs and makes more people just a little bit happier — perhaps allowing that frustrated driver above to get home in reasonable time even while the slow-pedaling cyclist in the next lane gets to enjoy the scenery. It takes more than a clever plan or smart siting by some architect, planner or engineer. This is parallel to Battle-Fisher (2013), Jackson & Sinclair (2012), and Caldeira’s (1996) explicit language of community, openness, freedom, belonging, and possibilities for people.

Cities, built by humans are complex systems (Rydin et al., 2012). In complex systems, health begets health (Battle-Fisher, 2013, April 5). In complex systems, we not only learn collaboration and participation, but we learn balance that is always under the threat of imbalance (Jackson & Sinclair, 2012; Carlson et al., 2012; Jackson, 2003; Mitchell, 2009; Miller & Page, 2007; Lidwell, Holden, & Butler, 2010; Luke & Stamatakis, 2012).

I wandered the streets in my vicinity to capture some of the many ways that intentions and process have manifested in the built environment of this city. Come walk with me to see for yourself…

A redeveloped mixed-use structure alongside a still-active but underutilized industrial building
The Cannery along Third Street, left, is a former factory repurposed as residential lofts and commercial storefronts in Downtown Dayton. The building on the right, roughly from the same period, is still an active (if underutilized) industrial facility.

Mural in Downtown Dayton
The vacant Lindsey Building along Main Street. The building is boarded up with lively artwork that keeps the façade vibrant.

As humans, we create — we build. We may build structures — soaring art or hulking defense. As humans, we are responsive to our internal as well as our external environments. As humans, we have the propensity to connect, to share, to exchange, to receive, to give, to develop, to innovate, to thrive… or to wilt away.


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All photos copyright ©2013 Karina S. Descartin.

Will young invincibles buy (into) mandated health coverage? The Clash of tweets, the brain and English Rumspringa

Here is a quick discussion of how insurance should work under Obamacare-

· The young peoples’ premiums which should theoretically have the lower probability of catastrophic illness should offset the increased utilization of healthcare by the graying Baby Boomers.

· More money from 20 year old, less office visits should offsets visits of Grandmother who will have higher premiums but also more health care utilization.

· Voila! A healthful societal success!

Take this paradox for a spin—

Got some job history, young one? Believe me, it is not enough quite yet to offset the need to get covered now during the start of your economic productivity. For those young people from the most disenfranchised families with a history of lack of insurance and unstable work histories, the decisions revolved around accepting the Medicaid expansion along party lines leaves many kids in a lurch.

Medicaid expansion is concentric to Obamacare. Take the arduous tabulation of “reported” enrollments in the state-based health exchanges shouldered by the Advisory Board Company (ABC). Two weeks after the roll out, the Advisory Board Company (2013) reported that 130,000 people have applied for coverage through the health exchanges across 15 states that offered up the goods (the data).

The proof some say is in the pudding but this pudding is more of a murky gruel. Having applied for coverage does not mean covered right now. Many applications in some states default to being Medicaid eligible, not exchanges in the traditional sense. Some states continue to poo-poo on Medicaid expansion, though my home state of Ohio got on board. As ABC pointed out, nobody has paid a premium let alone a penalty yet. The applicants have only expressed intent to become covered. What happens when a young person decides not paying that exchange premium and take the penalty ruler to the knuckles versus not defaulting on that student loan that cannot remain in deferment?

The invincibles are once again invisible to Obamacare’s safety net. How are we set to navigate them back once the media spin of ACA’s hiccups and the economic downturn takes hold in getting covered? I say that we must account for perceptions of DC Comics-flavored invincibility, modernization of youth culture, social marketing with a dash of brain function for good measure.

Invincibility may couple with increased risk taking within this young cohort. Rice (1996) defined youth culture as “the sum of the ways of living of adolescents; it refers to the body of norms, values, and practices recognized and shared by members of the adolescent society as appropriate guides to action”. It must be said that youth culture is a relatively new phenomenon. Do we forget that children were given adult responsibilities such as child labor that gave them no ability to “find themselves”? Inadequate neurotransmitter levels may lead to impulsivity. That darn frontal lobe has not been kissed with the ability to have a reliable gut instinct (defined as following the adult world rules). Lastly, youth are less able to make connections between experience and memory.

Now if that memory does not trigger an “a-ha, maybe that hit of salvia is not a good idea this time”, what are we left with?

We must account for this youth reality as it is now. The child worker of yesteryear was forced to take an economically derived “adult “identity covered in soot all the while his brain remained woefully underdeveloped. Youth today have been protected from unfair child labor and celebrated autonomy (within reason) so the youth can relish in a period of an English Rumspringa that bleeds into their 30’s. They have a more fair life course. With that newly allowed time of this new life, young people have time to build social networks of friends. This is not a big surprise to parents who have tried to evoke “if your friends jumped off a bridge”. If the social network of friends using their influence to make a belief or action contagious, young people have an affinity to being a part of the in-group. Let’s all bungee over the Colorado together.

One, two, three, hell yeahhhhhhhhhhhhhhhhhhhhhhhhhh!

It is that social influence within networks that works to get people to adopt health behaviors. That is if we frame the intervention to account for these conforming networks (Smith & Christakis, 2008). Yes, they can make up their own minds to take the coverage or the penalty. Will that take that insured baptism in the end? Young people (18-35) still have high rates of risk factors that would really require health care intervention (such as smoking, drinking, serious mental health impairments). It is amazing how the body accumulates the follies and unfortunates of youth in its cells. Unless something is catastrophic (which is in itself not a guarantee that care will be sought), the body does not tell its unfortunate tale for many years to come.

The roll out has done little to entice with its social media machine to make and counter this invincibility point. While the jury is still out, there is a possible untapped potential of using larger- scale social media campaigns to support behavior change (Centola, 2013).The Obama administration fills my inbox until my box “runneth over”. Now is the time to leverage social media to engage health behaviors such as signing up for Obamacare with an empirically sound research design. Maybe these social marketing messages could outshine the latest meme of cats with witty words just long enough to support that conscious jump over to the health exchange website. And the Advisory Board Company will keep the ticker of those jumps.


Centola, D. (2013) Social Media and the Science of Health Behavior. Circulation. 127: 2135-2144.

Diamond, D. (October 16, 2013). More than 130,000 people have applied for coverage through ACA exchanges. Retrieved on October 16, 2013 from The Advisory Board Company Daily Briefing Blog at

Rice, F. (1996). The adolescent: Development, relationships and culture (7th ed.). Boston: Allyn & Bacon.

Smith, K. & Christakis, N. (2008). Social Networks and Health. Annual Review of Sociology. 34: 409-29.