Monday, March 31, 2014

Take Me Out to the Chaos!

Research in nonlinear dynamics has demonstrated that cells in healthy hearts seem to behave in a random, complex and unpredictable fashion. Contrary to conventional wisdom, it is this variability, or chaos, that keeps healthy hearts beating normally. Loss of complexity and variability leads to simple and fragile rhythms that put a heart at high risk for sudden cardiac arrest.  

“It is this variability that gives a living, dynamic system, such as the heart, the robustness it requires to cope with change.”
-Ary L. Goldberger, MD – cardiologist, Harvard University

Winter, Baseball, Health, and Chaos
The lack of variability this winter (cold, cold, cold, and more cold) made me ponder the benefits of chaos. A little more variety and unpredictability in the weather would have been welcomed by most Minnesotans. The foot of snow on the ground outside my window the day before Opening Day of the Major League Baseball season helped me finally understand why people wanted an open-air baseball stadium in Minnesota – it assures variability, unpredictability, and chaos.  Same, same, same, is not as much fun. This made me wonder if our health care system is also influenced by the dynamics of chaos.  The more I thought about it, the more I became convinced that baseball and our health care system are prime examples of the power of chaos theory. Let me explain.

My childhood summers were filled with baseball – collecting baseball cards, keeping track of batting averages, listening to Milwaukee Braves games, and playing the game as often as I could. Even though I played baseball almost every day, no two days were alike. Baseball brought me new adventures, new insights, and new challenges almost every day. Baseball was the heart of my summer.

After finishing my morning chores, I would jump on my bike and head to one of the many local ball diamonds. With my baseball glove hooked to the handlebars, a ball in my pocket, a bat in my hand, and a blessing from my mom to “play hard and have a good time,” I would stop by the houses of my friends to recruit participants for the day’s game.

Sometimes only two or three people would be available. At other times 15 or 20 would play.  Regardless of the number, we’d always have a game and we’d always follow an unwritten rule that no one would sit on the bench.  his meant we made up new rules to accommodate the number and skill level of players available. Except for the fact that we used bats, balls, and gloves, our games often bore little resemblance to the official version of baseball advanced by Abner Doubleday. Each day we found new, creative, and unconventional ways to play the game that all of us loved. Each day was wonderfully satisfying and we always looked forward to the next game.

As I got older and became more involved in “organized” baseball, the pick-up games became less frequent – not because of lack of time but because “real” baseball began to put limits on what we could do. In hopes of becoming “better” players we began to pay more attention to the rules that the Little League coaches taught us and work on the “weaknesses in our game” that they had noticed.  The game became a more serious undertaking. Soon the afternoon pick-up games stopped completely and our only baseball time was team practices or games. Since the number of people on the team roster was limited, many of the neighborhood players who hadn't made the team hung up their gloves and moved on to other things. In the process, my circle of friends became smaller and baseball lost much of its variability and spontaneity.

It appears that my experience may not be unique because fewer children are playing baseball today than at any time during the last 50 years. Some of this decline may be the result of increased activity options available to children, but I believe a major reason is that baseball has lost the spontaneity and dynamism that could have kept it fun, robust, and inclusive. Youth baseball has become adult-directed and tied to a set of confining rules so that the variability and innovation needed to survive in our ever-changing world has been curtailed. Baseball has become less chaotic and interesting and increasingly irrelevant to most American children. While baseball still claims to be America’s pastime, that status is now in doubt.

In many ways our health care system parallels baseball. Over the last several decades there has been an increased emphasis on uniformity in health care. Consolidation of health care clinics, providers, and systems has occurred while standardization of disease management protocols has become the norm. Definitions and measures of success have also been standardized and policies have been put in place to facilitate progress toward the desired and defined outcomes. Evidence-based practices are touted as the ideal, leaving little tolerance for spontaneity, individuality, creativity, and variability.

Like baseball’s development system which continues to produce some superstar players, this standardization of health care has also provided some tremendous benefits.  The quality, safety, and value of services have increased and overall health outcomes have improved.  These efforts have helped create one of the best medical care systems in the world and they need to be maintained and expanded.

However, as our society becomes increasingly diverse and complex, we are seeing that the things that most affect health are beyond the scope of “traditional” medical care. The diseases and disabilities affecting society today are influenced mostly by socio-economic and environmental conditions and lifestyle choices rather than health care. Income, economic policies, education, housing, community livability, and social capital are the real determinants of health today. Yet, our health care system with its traditional focus on preventing and treating disease rather than creating health has limited capacity and ability to address or influence these factors. While health care continues to be important, we are learning that its impact on overall health has limitations.

To maximize health, we need a broader approach to health that identifies, embraces, and supports the opportunities to create health in our communities. It needs a bit of disruptive, chaotic innovation that will stimulate complex, diverse, flexible, and dynamic approaches to health. To me, public health’s role in the 21st Century is to bring a bit of chaos (in the non-linear dynamics sense) to our health system.

If we continue to invest most of our resources in disease treatment and management and not in creating health, our health care system will, like baseball, risk becoming somewhat irrelevant – a casualty of its own inflexibility.  Our health system, like a healthy heart, must maintain a high level of variability and chaos. It can only do that by embracing a broader public health context that allows the flexibility to deal with not only the medical determinants of health but the social and environmental determinants as well.

Although we probably can’t do much about the current state of baseball, public health is in a unique position to help stimulate changes in how we create health. By encouraging and supporting creativity, diversity, innovation, risk-taking, and inclusivity in discussions about the social determinants of health, we can maintain a healthy and necessary level of chaos. Changing the current culture and modifying the rules of the health care will be a challenging, chaotic, and rewarding process – one that will most likely go into extra innings. Do you want to play?