HIV risk taking among homeless teens- The complexity of it for policy

Let us begin with the pressing policy issue of HIV risk taking behavior among homelessness teens to take home this point of social bond (de)construction. In the work of Rice et al.’s (2012) study of HIV risk behavior, homeless adolescents were located within the core (that dense ball of spaghetti in the middle of the network graph), were more likely to be female and were more likely to have been homeless for at least 2 years. The longer the teen, particularly for the young woman, is outside of the family unit, the teens form strong, compact ties with a new “family”. Surprisingly, being on the outside of this tight “family” that is found in the periphery of the network was protective against HIV risk taking. Highly connected, dense core are great for galvanizing information within that group. But a dense group may be more difficult to infiltrate. If the dense ball of teens are passing misinformation and reinforcing risky HIV behaviors, it is best to go your own way. But where can a young person go with such marginalized circumstances?
If the public policy being developed pertains directly to HIV risk taking reduction, perhaps targeting the core network to diminish risk could be a first step. But in the work of being connected to other people, the low risk teens may help each other or could transfer into the high risk group. But policymakers must remain mindful of what systemic changes can flow from targeting that portion of the network. People come and go into each other’s lives. Policy must be mindful that the longer the teen is outside of a traditional household, human connections will be made with the people that they have the most contact with. Could the teens in periphery have formed cliques that supported less risk taking? This may help these teens. Keep the periphery teens supported in their low-risk behavior. In the world of networks, there is something called homophily (birds of a feather). This means more than living in the same place. Above that shared space, the teens are ties together by something stronger: love, support, shared values, shared behaviors (see Feld & Carter, 1998; Kadushin, 2012). In other world, people live by forming bonds wherever they land.
If the policy lumps the new cliques (core and periphery) together, network membership can change over time. Teens that tie together two completely separate networks are called bridges. By theory, the networks would not have connected if not for this new bridge. Often the bridge has enough prestige and power to convince two divergent groups to join forces (Granovetter, 1973). Will the new members from the outside possess adequate social currency to offset the peer influence of the core members? Thus we have complexity. Can one policy that is meant to affect teens as if they share the same life chances and social embeddedness work? Most likely answer is no. While there may be an overarching goal set up the policy, parse out how different attributes of the teens may affect how the proposed policy works.
The longer a teen is away, it becomes more likely that their family will be in the same dire social straits and may not be protective in navigating good social choices and decisions. But the longer a teen is away, human nature requires connection and closeness, a family broadly defined. Being on the outside (periphery) of the homeless core protects against HIV risk-taking. Let us not forget a social purgatory between the instability of homelessness and the perceived caustic environment that the teen desperately calls to escape. The peripherals may be at risk in other ways that may lead to a greater risk of HIV risk taking once the teen is in the core. But if that teen has the ability to persuade those at risk, there is a possibility that the low risk taking of a strong teen could start to cascade low risk attitudes and values. But there is also a possibility that the teen will become enveloped and become high risk himself. It may be too much to ask of that teen to work to overhaul the collectively held value of higher risk sexual practices (Long et. al., 2013).

So in using the research on social networks, I propose systemic factors that should be accounted when attacking HIV among homeless teens:
1. Every homeless teen is not the same and each with present a different set of connections.
2. Being deeply connected in the homeless culture may place these teens at higher risk for unsafe sexual behaviors.
3. Targeting low risk teens on the periphery will require a different intervention to support the low risk behavior.
4. While there may be opportunities to use low-risk teens as “bridges” to the high-risk teens, this should only be done with extreme care and oversight. The bridge is more susceptible to falling into the activities of the core and may suffer from burn-out for the heightened sense that change is on that teen’s shoulders.
5. Watch the movement of teens from the core to periphery (and back again). This movement brings a whole new set of structural realities both for the teen as well as the network.

Social networks are powerful and are often underutilized in uncovering the underlying structure of health policies. But the policy work that we should hold dear must account for the power to combatting ecological gaps and failures, such as the personal and societal failing of just one homeless teen.


Feld, S. & Carter, W. (1998). “Foci of Activities as Changing Contexts for Friendship.” In

Placing Friendship in Context, eds. Rebecca G. Adams and Graham Allan. Cambridge,

UK: Cambridge University Press.

Granovetter, M. (1973). The strength of weak ties. American Journal of Psychology. 78 (9),

Kadushin, C. (2012). Understanding Social Networks. New York: Oxford.

Long, J., Cunningham, F. & Braithwaite, J. (2013). Bridges, brokers and boundary spanners in collaborative networks: a systematic review BMC Health Services Research 2013, 13:158

Rice, E., Barman-Adhikari, A., Milburn, N. & Monro, W. (2012) Position-Specific HIV Risk in a Large Network of Homeless Youths. American Journal Of Public Health. 102(1), 141-147.

NOTE: This white paper is a revision of a blog written by the author. An early version was originally posted on the Orgcomplexity Blog ( on February 28, 2013.


The Ethos of Batman- Human Metachanges in Muscular Motion

Bruce Wayne and his alter ego, Batman, is the epitome of dynamic contradictions.Not unlike Batman’s character struggles, character is built and questioned constantly, often without a law in sight.  Since we are tied to people who talk to each other and make social gestures that have to be recognized, the allegory of the gestures of Batman will be used in the following pages to demonstrate how dynamic systems of trust and relationship were right in front of us all along.

As the alter ego of Bruce Wayne, Batman’s identity rests with his strong sense of citizenship with the inhabitants of Gotham City as well as his fixation for vengeance. After the untimely deaths of Bruce Wayne’s parents, his sole purpose was fixated on righting wrong his way. Heroes or, even more interesting counterparts, the anti-heroes in comics are hyper-real. I, the hero, am good, which is obvious by my fluttering cape with the symbol emblazoned on my pectorals. You, the villain, in body skimming spandex sans cape or even the run-of–the-mill town crook, are not good. The anti-hero is downright malevolent (or perhaps just clueless). The duelists compete in a “language of gestures” (Mead, 1938). To Mead, meaning in the world is made through signals and gestures as a kind of social behaviorism (Mead, 1938). The hero saves the world from ruin. The crowned hero takes a right to the kisser. The miscreant falls ungracefully off the cliff on the outskirts of the city. The physical nooks and crannies around Gotham City are incredibly unexpected and diverse, would you not agree? The hero often appears out of thin air. The villain plunders for power and perhaps less importantly material gain. The hero prevails is immediately absolved for throwing city property at said villain. What brought the hero to that place?

Mead (1938) related this idea of gestures to primarily verbal communication. However this idea can be broadened beyond the spoken word. The superheroes in the bout use verbal and physical fighting so as to “make the gestures (the) same”. The villain gets squashed to smithereens by before mentioned city property then hobbles alone to the dark lair to hatch the next scheme. The higher level of cognitive significance of communicating started with those fisticuffs. But mind you, Batman returns to the dank dark cave…alone to live with consequences of his actions.

 Both hero and villain are tortured in levering heuristics that each in itself could wreak havoc with stability.  Each side of the superhero ethical equations brings undeniable fervor and passion. Bruce Wayne was pushed by a strong drive to avenge. But do superheroes or we mere mortals work primarily off of emotion? Should policy view society as one of rationalized competition for limited resources or one where there is collaboration? For that matter, how should be view “communities of solution” in the same fashion? I do not remember Batman having a brewski in the Arkham Asylum with The Joker. But people tend to demonstrate an allegiance to a side (if only for appearances) to maintain social accord or to leverage advantage.

Any change called metachanges, such as a misplaced physical punch or even a faulty ethical decision, could have major repercussions on the already delicate balance of power. The crooks are transporting from the city dock outdated cathode televisions that conceal booty. Batman swoops down. Good prevails. Bad is defeated for now. But will that Gotham peace last or be the most beneficial in the long term? Does Batman’s moral center waver?  


In part, policy must manage the social and ethical principles linked to the nature of these metachanges. Those in policy game realize all too well that the broader politicized arc is really a generalization of all those metachanges. Those metachanges, some perhaps deemed inconsequential or undiscovered, can have widespread dynamic changes on the larger social system. To that end, tackling these real world metachanges can lead to the large visible health payoff that society requires and expects resolution with their morning coffee. The villain is foiled and all is right in our Gotham until the same burgeoning health concern comes back on the top of the policy docket. Batman found the sweet spot briefly, retreating to his bunker wearing his dented Batsuit to the sage advice of his comrade, Alfred. Policymakers reenter the policy bunker, dodging the heuristics minefield, while shrouded by a porous cloak of political stability. The citizens of Gotham haunt them all in public health while some take a long drag on their cig to calm the nerves. It is back to the drawing board.



Mead, George (1934) Mind, Self, and Society, ed. C.W. Morris (Chicago: University of Chicago Press)

2014 International Conference on Social Computing, Behavioral-Cultural Modeling, and Prediction- Washington DC April 1-4, 2014

Registration is now open for SBP14, the 2014 International Conference on Social Computing, Behavioral-Cultural Modeling, and Prediction.

SBP14 will be held at the UCDC Center, downtown Washington DC, USA April 1 – 4, 2014.

Link to the main conference pages,

*** Please note that early registration deadline is March 8, 2014. ***

Link directly to registration page,


SBP 2014 CHALLENGE – see:

The SBP Challenge aims to demonstrate the real-world and interdisciplinary impact of social computing. The challenge will engage the social computing research community in solving a relevant, interesting, and challenging research problem that will advance the theory, methodology, and/or application of social computing.


Morning and afternoon tutorials are offered on Tuesday, April 1 (included with registration fee):

Morning Session

(1) Modeling a Mobile World


Wendy J. Nilsen, PhD, Health Scientist Administrator, Office of Behavioral and Social Sciences Research/NIH

Stephen Intille, PhD, Associate Professor, College of Computer and Information Science & Dept. of Health Sciences, Bouvé College of Health Sciences, Northeastern University

Donna Spruijt-Metz, MFA, Ph.D, Director, Mobile and Connected Health Program, Center for Economic and Social Research, Associate Professor, Departments of Preventive Medicine and Psychology, University of Southern California

Misha Pavel, PhD, College of Computer and Information Science, Bouvé College of Health Sciences, Northeastern University

(2) Introduction to social data analysis combining R and Python

Presenter: Dr. Jose Manuel MAGALLANES, Center for Social Complexity, George Mason University, and Departamento de Ciencias Sociales, Pontificia Universidad Católica del Perú

Afternoon Session

(1) Multiscale Strategic Interaction with vmStrat Models

Presenter: Dr. David Sallach, Associate Director, Center for Complex Adaptive Agent Systems Simulation (CAS), Argonne National Laboratory;  Senior Fellow, Computation Institute, The University of Chicago

(2) Charting Collections of Connections in Social Media: Creating Maps and Measures with NodeXL


Dr. Marc A. Smith, Chief Social Scientist, Connected Action Consulting Group

For a full description of tutorials, see:

Making sense of healthcare systems using sensemaking and the Price Is Right

Do you recall the “Cliff Hanger” game on the Price Is Right? An overly bedazzled and frantic contestant with the “I spayed Muffin for Betty White” T-shirt has the chance for a hot tub that he never knew he needed. First of all, do we really need a hot tub? With the energy of a roaring audience, the contestant may resign himself and become giddy over the chance for a big algae pool. Each guess that is incorrect causes a flat, one-dimensional yodeler in front of cardboard Alps to move precariously towards the cliff and his impending doom. However, the error in the guess is not revealed until after the cardboard yodeler has moved up the mountain illustrating the deviation of the guess from the correct answer.

Bhermer (1999) spoke of something called “dynamic decision making”. In order for a decision to be labeled dynamic, the cliff hanger decisions are made in “real time” and are dependent on previous actions (guesses). Some factors into the gaming decisions include the initial mechanism used by the contestant to come to the guess, any dynamic alterations made to subsequent guesses, the distance away from the actual price (which is shown in the steps taken by the figure) as well as the distance left from the top of the mountain.

Hodl———–ay–ee-dee -yi—ho.

The show is based on the fascination of the possibility of success, not its realization of success. But what is unique to The Price is Right is that the contestant often calls upon the help of the screaming audience for help in making future guesses, particularly if he failed miserably on an attempt. In the end, there is a system to work through which may in this case be futile for both the contestant and the flat guy in Lederhosen.
The health care delivery system has many stakeholders, with many screaming for attention, not unlike a game show crowd. Each studio audience member works their uvulas in at a frenzy to be picked. But there is an undisclosed system of who can “come on down”. Likewise, Americans across the country have a profound investment with the state of the present health care system, but those voices are not created equal. You must have an acknowledged voice to be an influential citizen. Burke (1966) contends that it is through consensus building that we get meaning. Who is expected to be a part of the deciding consensus? When a reality is deemed in need of repair, communities of like-minded individuals might organize, seeking power through numbers. What cannot be lost in the rendering of “health in America” is the structural reality in which it exists.

In this process of agenda setting, participants may participate in “sensemaking” (Weick, 2005). Sensemaking is based on prior experience that affects our framing of current events. Making sense of a concern within its healthcare context is the crux of sensemaking (Weick, 2005). But too often we divorce decisions from “health” altogether, opting exclusively for emotion and social pressure. Health policymaking, in particular, involves several people each with differing prestige. The powers often listen to the wealthiest and loudest interests. We need to explore sensemaking to separate the chaff from the wheat.
Generally speaking, health policy influences patient services through legislation pertaining to areas such as reimbursement, licensure, and malpractice. Haddow et al. (2007) warns that the fast pace of decision making during such medical crises impedes a true understanding of procedural concerns of such actions. I argue that we often ignore procedure however the procedure comes from collective agreement that is housed within personal and shared values and influences. Society unfortunately fails to grapple with complexity before investing our efforts into a leverage point that give us the most return. The state of gapping disparities in healthcare access has placed a time-based premium on access to patient care, often tying reimbursement to a pre-existing cost-saving market environment. Society unfortunately fail grapple with complexity in favor of a tantalizing newsbyte rather than wisely investing our efforts into a leverage point that give us the most return for limited resources and effort (Resnicow and Page, 2008; Meadows, 1999).
Rockwell (2005) wisely wrote that “if we do not know in detail what the system is doing, we can’t even ask how the system does it.” According to Meadows (2008), “a system is more than the sum of its parts.” I could not state that better than Meadows. Fixing a healthcare “system” requires more than a falsely disjointed approach to its separate elements (which ,in reality, are interconnected). A key to making meaning of health policy is adaptation to the “self- evolving system” as the context of that system dictates and investing where policy will be most salient. Meadows (2008) warned that changing a “mindset” around a system is the hardest change to realize. But the mindset around the healthcare system must first acknowledge the “system” in the truest sense. Policies must be continuously reimagined and we must let go of the resistance in admitting change is even there (Meadows, 2008). We cannot afford to fall miserably off the cliff. We have more than a hot tub at stake.


Brehmer, B. (1992). Dynamic decision making: Human control of complex systems. Acta
Psychologica, 81(3), 211–241.

Burke, K. (1966). Language as symbolic action. Berkeley, CA: University of California

Haddow, G., O’Donnell, C., & Heaney, D. (2007). Stakeholder perspectives on new ways
of delivering unscheduled health care: The role of ownership and organizational
identity. Journal of Evaluation in Clinical Practice, 13(2), 179-185.

Meadows, D. (2008). The Basics. In Thinking in systems: a primer. White River Junction, VT:
Chelsea Green Publishing Company.

Meadows, D. (1999). Leverage Points- Places to intervene in a system. Hartland, VT: The
Sustainability Institute.

Resincow, K., & Page, S. (2008). Embracing Chaos and complexity: a quantum change for public
health. American Journal of Public Health, 98, 1382-1389.

Rockwell, W. (2005). Neither Brain nor Ghost- a nondualist alternative to the mind
-brain identity theory. Boston, MA: MIT Press.

Weick, K. (2005). Sensemaking in organizations. Thousand Oaks, CA: Sage


The suggestion has been made to consult the ReThink Health tools and materials (Fannie E. Rippel Foundation) and what Simudyne is doing with health care simulations (…Thank you Kim Warren

Check this out- “The Secret of Price is Right” -–the-price-is-right–tv-s-most-successful-show-ever–215848146.html

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.

The Talented Tenth? Can I get an amen toward political civility?

The Talented Tenth? Can I get an amen toward political civility?
Michele Battle-Fisher
Orgcomplexity Blog
September 15, 2013
I uncovered with a Bing search one of my early forays into blogging as referenced by “The Essence of Politics” blog hosted by Horadi Brown from October 2009. That reference can be found at My piece, “Has the Talented Tenth already arrived with Obama or is a dream deferred”, was quoted midway through the blog post. I became initiated into blogging while I was associated with the Kirwan Institute for the Study of Race and Ethnicity at the Ohio State University ( The Kirwan Institute Race Talk blog has since been archived (though the organization still blogs under a different means). While I did not start blogging under the umbrella of Orgcomplexity until 2012, my time at the Kirwan Institute and the Race solidified my desire to work in progressive policy. My blog was framed smack dab within the frenzy of “new hope” with POTUS’ first historic election to the nation’s highest office. Today the pundits argue, with chests of puffins, debating Syria, debt ceilings, Tea Party Patriots, of gun permits for the blind, repealing Obama-care and partaking in political gridlock masquerading as “progress” during Obama’s second term of office. So I have read about the bird called a puffin. The puffin’s social organization is the epitome of homophily, finding securing in large groups of like puffins. When said puffin is approached by an intruder, the puffin hunkers in, spreading wings in a display of “I ain’t buying what you’re selling” coupled with a little kicking and wrestling to gain the upper hand. We, political animals, like a good fight not unlike the curious puffins of the colony surrounding the fight to get a little peek at the action. The “new hope” was lent an unfortunate dose of political reality. I thought that it would be appropriate to resurrect that blog today. You may then decide whether there will be “Get out of Jail card” toward political civility.

“Has the Talented Tenth Arrived with Obama or is it a dream deferred?”
By Michele Battle-Fisher, Graduate Research Associate at the Kirwan Institute (at the time of the writing of this piece)
I, along with many citizens, listened with great anticipation to hear President Obama’s speech to the combined Congressional assembly on February 24, 2009. His eloquence was apparent, but I had another issue in mind. How can others in the black community find venues to voice concerns to such a captive audience as he? Perhaps if WEB Dubois were still with us today, he would shout to the rafters “the talented tenth has arisen!” The idea of the “Talented Tenth” espouses that there will be a select number of leaders of color who will serve as the rhetors of the black nation.
They will be articulate.
They will have the best education offered and the capacity to think and express.
They will be given the credibility by others to assume such a position.
Historic election- check.
But though I was moved by the President’s words, I was most moved by the young black student who wrote her letter to Congress and was given a hero’s greeting while sitting next to the First Lady. Poised with the nation’s eyes upon her, she simply asked the legislators that she should no longer be deemed invisible. She, like many other young people, seek hope for a better future but sadly realize that grave injustices still exist that can deter that dream. Yes, she simply asks for parity without the worries of substandard social conditions that could get in her way. I wish her the opportunity to assume her role as a “rhetor” for young people of color, a role she never would have imagined when she penned her letter. This is if she accepts that challenge.

Please reference the Kirwan Institute blog as well as Orgcomplexity when mentioning or reposting this work.

Battle-Fisher, M. (March 4, 2009). Has the “Talented Tenth” already arrived with Obama or is it still a dream deferred? The Kirwan Institute (for the Study of Race and Ethnicity) Blog. Retrieved from
“Fratercula cirrhata- tufted puffin”. Retrieved on September 15, 2013 from

Urban greenspace and health as strange bedfellows

Urban greenspace and health as strange bedfellows
Michele Battle-Fisher
Orgcomplexity Blog
Unpublished manuscript
August 12, 2013

“People are afraid to merge on freeways in Los Angeles. This is the first thing that I hear when I
come back to the city…Though this sentence shouldn’t bother me, it stays in my
mind for an uncomfortably long time.” Excerpt from Ellis, B., Less Than Zero

“Heaven and Hell are just one breath away!”- Andy Warhol

The main protagonist of the novel, Clay, a native of a Godless Los Angeles, has been painted by Bret Easton Ellis as the example of the ills of urban excess—young, bored, over-privileged, well-connected and social deviant. We must merge at some point, interact with other city inhabitants then retire to our urban bunkers for shelter from the madness. It must be acknowledged that he is but one possible archetype of an urban citizen. This Clay of Bel Air does not live the same life or possess the same life chances as a young kid living in “white flighted” Echo Park, Los Angeles. They are one in the same with the city organism (Laubichler, 2013). Clay and the young kid from Echo Park share different lived realities as a city dweller. Each must find his own survival tactic. But each of them is a product of at times forgiving, often constraining complex forces beset on an urban citizen.
Milgram’s idea of a Small World make the world tied in a
network by six degrees. You could possibly have connections in Washington Heights, St. Paul and as well as from a colonias in Mexico City. Our connections may only be around 3.74 hops away as most people on this planet strapped to a Twitter and Facebook account like oxygen masks (Backstrom et al., 2012). But technology cannot solely overcome spatial proximity and intimacy (required by Glaesar) and the need for human and social capital among urban dwellers (“Get Out of Town”, 2011). Our modern world may shrink due to common interest while the physical and emotional resources to house us become more and more constrained (Lemann, 2011). Such constraints can place undue burden on the state of health among urban dwellers. Community is ingrained for some. For others, they live only in a zip code.

Photo 1

Photo 1

Photo 1: Metro North commuter train landing, Cold Spring, NY, 2010
Take for instance Cold Spring, New York. North of New York City along the Hudson Valley, it could be called a semi-urban exurb. I would surmise that the year-round inhabitants want no part of Wal-Mart or “McMansions” and have kept it that way for a good reason (“Et in suburbia ego”, 2011). The “Gap” (photo 1) is quite evident between Cold Spring, a very intimate hamlet of nonconformists (from the Super Creative and Creative Classes described by Florida) seeking tranquility, space and astronomically high priced organic tangerines and those living in the New York City proper with noise, “urban huddle” and still highly priced run-of-the-mill tangerines (Lemann, 2011; “Et in suburbia ego”, 2007). The air in Cold Spring is ripe and healthful. Cold Springers working in NYC as well as weekenders from the city jump the Metro North and begin their vinyasas entering the Valley. Green space is had in Cold Spring without much effort. In Cold Spring, one only has to look outside his door for nature. The community is intimate within the town center. Having your own plot of land goes along his union card as a Cold Springer. Green is in Cold Spring’s DNA.
Green spaces such as the ones in the photos below, serve many important uses: recreation, aesthetic and well as ecological. Why should we make provisions to keep cities green? Cities are known for concrete edifices, technological advancement and fast paces. By definition, such intimacy with nature for the most part has to be created and dedicated for common use within a city. Maas et al. (2006) found that in a Dutch city, there was indeed a positive relationship between having green space and more positive perceptions of health. This relationship was even more pronounced for the urban poor in that study. So those dahlias in the community garden are important to all of us.
The photo below was taken from my friend’s Brooklyn walk-up kitchen window (photo 2). It was a vast sea of greenery, with collective gardens and space maintained by certain inhabitants of the duplex. It brought my intention to my breath. I loved the shops and vibrancy of Brooklyn. But efforts such as this garden illustrates the ownership to the urban center is taking to recapture some organic sources of oxygen.

Photo 2: A Brooklyn walk up with a view

Photo 2: View from the Kitchen window of a Brooklyn, NY walkup, 2010

Photo 3- outside of Brooklyn library

Photo 3: Urbanscape outside of the Brooklyn Museum, 2010
Sometimes a city makes a pointed effort to create green where the people are. NYC is a great example of this movement. Outside of the Brooklyn Museum, the greenspace in this photo (photo 3) may be used as a reading space is maintained by the city, as a congregation space and as a reminder to slow down before entering the city streets again on the trek to the subway.
How can cities bring green into the daily lives of its dwellers? The “e-topias” advocated by William Mitchell of MIT call for all in one places to both live and work (“Et in suburbia ego?, 2007; Zukin, 2010). As a cultural incubator, this would call to act as a citizen within a designated space. Dr. Rossler (2013) notes the importance of creating social contracts (from his video short Creation of Social Contracts) in providing space for each individual for sharing experiences. These “e-topias” may solve the concerns of making daily needs and resources closer and available at the ready. But I take pause. Would these green spaces and living spaces of the “e-topias” be based on a sense of collective, limited ownership (such as restricted use of gardens in London)? Such a proposition may greatly hamper social innovation and sense of larger community outside of its polis walls. It may also strip
the urban cultural character to an unappetizing faint Silly Putty version
of a “city” lacking diversity (Zukin, 2010).
It is quite possible the aggregate benefit of “e-topias” may be offset by increased social and health disparities among those without access. Also, where will the poor and aged live while their homes are razed to make room for this innovation? Will there be a parity of access to these new communities to all regardless of income? But urban centers such as Brooklyn somehow “became cool” (Zukin, 2010). To Zukin, the realness of urban
culture becomes synonymous with “authenticity” to a vision of Brooklyn that
does not pander to the wishes of outsiders. The grittiness and lack of organic
green sources made way for colorful motifs of strength on the sides of
tenements and upstart trendy centers bringing creative culture to the area (Zukin,
2010; Lemann, 2011). Cities need cultural and economic growth for the benefit
of all of its citizens in order to exist and thrive (“A cul-de-sac of poverty”,
2007; Lemann, 2011). What is the social cost to being “cool” or “uncool” particularly for the most disenfranchised?
All photos copyright © Michele Battle-Fisher (do not publish without permission)


Backstrom, L.,Boldi, P. Rosa, M., Ugander, J. & Vigna, S. (January 2012). Four Degrees of Separation. Retrieved on January 27, 2013 from

“A cul-de-sac of poverty” (May 5, 2007) The Economist- A Special report on cites.
Retrieved on January 27,
2013 from http://

Ellis, B. (1985). Less Than Zero. New York: Penguin Books.

“Et in suburbia ego?” (May 5, 2007) The Economist- A Special report on cites. Retrieved
on January 27, 2013 from

Laubichler, M. (2013) Cities and Biological Concepts [Video File]. Video posted to
Lemann, N.(June 27, 2011). Get Out of Town. The New Yorker, 76-80.

Maas, J., Verheij, R., Groenewegen, P., de Vries, S, & Spreeuwenberg, P. (2006) Green space, urbanity, and health: how strong is the relation?.Journal of Epidemiology and Community Health, 60:587-592.
Rossler, W. (2013) Creation of Social Contracts [Video File]. Video posted to
Warhol, A. (1985-86). Heaven and hell are just one breath away! [painting] Pittsburgh, Pa.:
The Andy Warhol Museum.

Zukin, S. (2010). “How Brooklyn Became Cool”. In Naked City: The Life and Death of Authentic Urban Places. New York: Oxford.

Paternalism- what a tangled web

Paternalism- what a tangled web
Michele Battle-Fisher
Orgcomplexity Blog
Unpublished manuscript
August 6, 2013




Back in February 2013, I posted a short tribute to Ronald Dworkin, the famed political legal scholar, upon his passing ( The most salient piece written by Dworkin continues to resonate for me has to be his piece in the Monist, entitled “Paternalism”. I had been exposed to principles of paternalism while a graduate student in African American and African Studies at The Ohio State University. In the African American Leadership course taught my dear mentor, Dr. James Upton, I was asked to lecture as an adjunct to his class of upperclassmen. I stood at a lectern quoting legal scholars while framing paternalism with The Souls of Black Folk by DuBois. Mind you, these students of Afrocentricity often discussed the disparities in racial realities using thinkers such as W.E.B. DuBois and Booker T. Washington. These students advocated through critical engagement. When was the last time health professionals took a step back from our R21’s to do that? I am by no means advocating for a departure from evidence based research (post-positivism). Nope, not me. In an effort to “cast (our) buckets”, Dr. Upton gave me an outlet to further devise a way to explore disparity in a way that suited me…as a scholar. Low and behold, I decided that the way that I would serve society would be as a public health professional in a MPH Program (again as a Buckeye). But instead of being drawn to relative risks as the others, I was hanging on the every word of Dr. Kenneth Steinman. Dr. Steinman had his students dive into Dworkin as a core perspective to understand “public health”, a work that most likely felt foreign to many, but not me. Maybe a little sumthin’ could be learned from a Negro spiritual repurposed by DuBois to emulate “double consciousness” of race or a nice, friendly soft paternalism debate in the light of human fallibility. Just maybe.
Published in 1859, John Stuart Mill penned On Liberty. The basic premise of his work posed the position that the essence of man is to defend the individual rights to think and act for him. According to Mill (1999), action would be wrong when it acts contrary to the greatest happiness for the most people. So how is his stance against paternalism (known as Mill’s principle) counter to the basic tenet of public health? This pareto efficiency is achievable ONLY through the protection of personal autonomy by means of ”protest against external authority” (Mill, 1999). Oops, public health acts through such “external authorities”. In line with utilitarianism,
People, according to Mill (1999), base decisions on “personal preference”. If we in health are to evoke the power to infringe on the personal liberty of an individual, Mill (1999) said that we only have that right when the burden of proof suggests that “preventing harm to others” is the only justification.
What is made quite evident is the warring of the ideals of maintaining personal liberty with the maximization of social utility. What is the acceptable tipping point before we topple too far to the side of autonomy while undermining social welfare? Dworkin (1972) in response to Mill wrote that paternalism “will always involve limitations on the liberty of some individuals in their own interest but it may also extend to interferences with the liberty of parties whose interests are not in question.” Mill sets an unreasonably high threshold for achieving “paternalism”. This certainly is not unusual with such sweeping pronouncements. In light of the impossible achievability of Mill’s requirements, Dworkin (1972) said that what is at work in reality is “impure paternalism”. As impure paternalism is followed, a disenfranchised class’ needs are met by way of subjugating the requirements of an unaffected class (Dworkin, 1972). Someone has to give up liberty so others can gain. But who wants to be the “perceived” loser? If the argument remains as a question of personal liberty, yes, someone will shoot craps. However if the framing of reference becomes that the public’s health will improve which may:
1. Reduce the burden on taxpayers to subsidize services of the underserved in order bring more parity to community.
2. Population based mortality and morbidity may be reversed- If I give a little, I may gain a better quality of life in the end. My insurance premiums are pooled based on the outcomes of all of those insured as a collective. My community will thrive.
It is getting over the immediacy of the personal loss of liberty that stings. We in public health cannot make promises that for each loss of liberty there will be a “recognizable” gain in health status that people may be able sense. People live by the concreteness of their own experiences. Unfortunately, this is often to the disadvantage of public health to get buy-in of impact. But it is perhaps the impurity of human experience that makes the work of public health the most noble of all. It is just so darn hard to lose while “gaining”.


Du Bois, W. (1903) The Souls of Black Folk. Chicago: A.C. McClurg & Co.;
[Cambridge]: University Press John Wilson and Son, Cambridge, U.S.A., 1903;, 1999.

Dworkin, G. (1972). Paternalism. The Monist. 56 (1): 64-84.

Mill, J. (1999). On Liberty. London: Longman, Roberts & Green, 1869;

Suggested reading:
Franklin, J. (1965). Three Negro Classics. New York: Avon Books. I suggest this version which includes the full texts of The Souls of Black Folk & also Up from Slavery (Washington). Elegant foreword by the preeminent black historian, John Hope Franklin, is not to be missed.

Public versus Private Health- stop stepping on my toes

“Public versus Private Health- stop stepping on my toes”


Michele Battle-Fisher

Unpublished manuscript

Orgcomplexity Blog


Note: I originally presented with a lively, unpartnered Bachata dance demonstration to the Complex Systems Advanced Academic Workshop (CSAAW) at the University of Michigan in May 2013. Sorry that you missed it…


We let the words, public health, roll off our tongues with ease. But how often do we take time to understand the ontological meaning of “public”? Discovering “publics” would be quite at home with Aristotle. But how often do health professionals take a moment to give the philosophical less than a fleeting thought. I love political theory but I do not remember any mention of it alongside the analysis of randomized control trials. My discussion of public versus private health opens with a short dance lesson of the bachata, a partnered dance that originated in the Dominican Republic.


How to learn basic bachata with a partner, without getting fancy (accent in 4th count)

Basically, it is “Step-together-step touch” with beats at:

Step 1- step 2- step 3 HIP (accent)

Step 5- step 6- Step 7 HIP (accent)


What is public and what is private, anyway?  “Complexity” can be seen as an exchange and feedback of energies. Those energies certainly can be heat. They could be kinetic. They could be communication based. Or the energies could be manifest as directives and choices of the made of individuals in the public. Public health as a mission seeks to save collective lives from often avoidable premature mortality and morbidity. And those private “lives” that we wish to affect can then be collected together as the “population” of interest, or a public. Okay, now there is a term you can find in a cohort study.


As with an energetic bachata, two partners in close physical proximity enter an agreement to “lead and follow” in order to perform the dance. Like taking a cue from your lead partner to start movements, we also take cues from our social networks. Do we not? Partner dancing requires “real-time coordination between a human leader and follower”, and resembles other decentralized systems with “supervisory control & coordination of agent teams” (Gentry & Feron, 2004). Each partner is an agent who must take cues often relate physically and verbally to move in a hopefully harmonious display. More often than not, there are glitches. One person may dominate another. There is a breakdown operationally in satisfying needs of the network. In the end, the dancers become a small public where each must abide by the rules of gestures of bachata as they are to be performed. Bachata is different from Lindy Hop. There are rules in place to guide the anticipated actions of the partner to actually Bachata. In essence, there is a give and take among all dancers (or even social agents) toward a collective end result of a recognizable Bachata. This is not unlike the give and take of navigating health as a person that is a part of a public. How could this be? While living as a social creature may lack the audible musicality of a bachata song, effective public health action requires that the private sphere be under the watch of the public for the sake of the society as a whole. According to scholars such as Habermas (1989), the “private” sphere is possible when there is no intervention in order to act under his own personal authority. One partner cannot do Waltz steps while the other performs Dominican Bachata. In other words, an entity such as a government or even a bachata partner should not demand to have a say in his status. But this would not make sense for dancing bachata, which is by design a partner dance. Likewise, when we evoke the idea of “public health”, the idea of intervention into the “private sphere” is central to improving the health of the larger public. Some of our private has to give for the sake of the public.





 Gentry, S. & Feron, E. (2004). Musicality experiments in lead and follow danceIn Systems, Man and Cybernetics, 2004 IEEE International Conference on, Vol. 1 (2004), pp. 984-988.


Habermas, J. (trans 1989) The Structural Transformation of the Public Sphere: An Inquiry into a category of Bourgeois Society. Cambridge: Polity.



How malleable is an “ethic”? A dose of system thinking reality

How malleable is an “ethic”? A dose of system thinking reality
Michele Battle-Fisher
Unpublished manuscript
Orgcomplexity Blog July 29, 2013
Before I begin, what do I mean by “ethic”? Ethics are, in the end, a study of moral justification of our actions (or inaction). Most simply put, ethics are a set of moral judgments that can influence and later dictate a person’s or a group’s behavior. This supports for an often overlooked but necessary link to “system thinking” to ethics. When I was chosen as a Visiting Scholar to the Hastings Center ( in 2010, this was the leap of faith that I wanted to make. Medical ethics (or bioethics) has often ascribed to the negotiation of needs and morality as a linear action with no feedbacks, such as doctor/patient (or any other personal coupling). I knew so many ethicists grappling with beneficence and autonomy from this angle. It is a legitimate angle to take. But how do we really grapple with our moral compass? We are social. We are embedded with people, situations and environments which all tug at our ethical decisions every moment that we breathe. I wish to add to these ethical discussions by allowing the lens of systems to shed light on the messiness of ethical negotiation. Some bioethicists may say that this is not ethical work at all. Sure, I am not so interested in the high-brow spheres of “what is good” or “what is moral?” As we engage with our environment, “good” or “moral” compasses change, making such declarations temporally and situational bound rather than universal law or socially proclaimed policy. I call this ethical malleability, whereby a person may “change” his ethical stance to suit his present belief system (Battle-Fisher, 2010). As I wrote in my article published in the Online Journal of Health Ethics (2010), human agency and the ability (though not coercion) to change one’s mind can make even a con a probable yes in the future. The question central for me is good and morality based on social influence and personal proclivity to take a side. In the end, we are linked in networks that influence our stances.
Next, let’s touch on affirming ethics. Does the affirming of bioethics require relevance, novelty or something else altogether? Susceptibility to opinion leaders’ beliefs may be due to resultant centrality within a particular network. There are true power brokers who may sway other enough to influence a choice in ethical decisions. Does this counter the ideal of autonomy? I say no as this malleability serves as a reality check to often unobtainable true autonomy. While we remain social creatures, autonomy will be a striving toward a pinnacle of self-realization. We operate along that journey toward this heightened state of actualization; therefore we are ethically susceptible to malleability. Might an ethic be “innovative” with the ability to diffuse across a network? Could a person change his mind and reverse the “innovation” or is it just a new feedback loop into cycle of innovation with no consequence? For instance if a person has a high measure of trust “closure” plus a high level of “closeness” which makes it easier to find others to influence, imagine the ability to influence ethics under this scenario. Is there really no consequence for not accepting a diffused ethical position posed by influencers (same as opinion leaders)? An ethic can be changed until it is acted upon. Even after it is acted upon, a person may regret that moral decision then revert back and have to deal with the collateral damage of that choice. An ethic is NOT the action but a necessary precondition to action. But we ultimately must pay for our actions so we indirectly pay for our ethical positions in the end.
Have you ever been the lone voice of discordance within a network? What were the situations that you decided to bend to the will of the majority? I implore that the last thing that we should do is blame the person for changing an ethic. An ethic may never necessarily be displayed as a discernible action or even need to be articulated. Must an ethic be communicated to count? Is it something else when discussed (by morphing into a value or norm)? No. Yes. Add in the wrinkle of persuasion and you have a party on your hands. Granovetter (1978) presented a cool idea he called the threshold model of collective behavior. Granovetter (1978) seeks a decision as a binary (such as pro donation, con donation) based on a threshold of others’ participation. Valente (1995) later wrote of the idea of “network thresholds” which should be measured in terms of exposure to “direct communication ties” (degree) but not as a threshold measured for the whole social system. This threshold shows the point where a node will be convinced to adopt. Valente (1995) found that opinion leaders have lower network thresholds; they need the least convincing to innovate. However, these opinion leaders must influence more resistant nodes in the network-those later adopters. But often in health, we do not have enough buy-in of the public. Therefore, increasing the availability of related living organ donors relies on changes in personal ethical systems of the possible donors.
As diffusion is a long-term proposition, is diffusion the best model for ethical deliberation? Someone can change an ethic so perhaps definition of adoption proportion may be less meaningful over the long term. I still see the idea of diffusion spread as important though any conclusions should be taken in light of this time-based restriction. The use of a longitudinal network approach would be the go-to guy. However before any node is mapped, we must discern the nature of the ethic first in order for this network approach to become meaningful.

Battle-Fisher, M. (Dec. 2010). Organ donation ethics: are donors autonomous within Collective

networks? [electronic version] OJHE Online Journal of Health Ethics. 6(2). Retrieved from

Granovetter, M. (1978) Threshold models of collective behavior. The American Journal of
Sociology. 83(6), 1420-43.

Valente, T.W. (1995). Network models of the diffusion of innovations. Cresskill, NJ:
Hampton Press.