WHO states that “health promotion enables people to increase control over their own health.” I unpacked their statement for Humaginarium like this: Diabetes Agonistes enables naive adults to increase control over their chronic illness.
Notice the use of that subtle word “enable.” It means that health promotion itself doesn’t control anything. It’s neither a drug nor a dictate. It merely qualifies people to exercise control, on their own, under certain circumstances, if they choose to, until they don’t. Qualifications may be conceptual, rhetorical, even technical skills, fired by greater knowledge and resolve that promotion may catalyze, but not deliver fully baked and ready to use.
In other words, people themselves increase control over their own health; health promotion only gets them started.
This makes isolating the outcomes of health promotion a bit more complicated. Outcomes are changes brought about, differences made, measurable results and impact accomplished. As a program of health promotion, what are the outcomes of Diabetes Agonistes?
They are, in a word, competence. That’s the ability to make and stick to healthy choices. But hold on, how can anybody make healthy choices unless they first understand them? Must they study, randomly guess or even delegate them to others? And how can they stick with choices they made unless they understand consequences? Must they follow rules, be nudged, form habits? None of these sounds like an option for highly effective people.
Stephen Covey famously wrote that highly effective people “Seek First to Understand, Then to Be Understood.” That’s both a rule and a habit, so maybe it’s not an appropriate reference here, but people who don’t sport an orange hue generally agree that no problem can be solved before it’s understood. That ain’t rocket science but it is a foundation of laboratory science and clinical medicine. Seek first to understand chronic illness, then be understood as an individual who has one. Axiomatic.
Still, understanding gets only lip service in health promotion I’ve looked at — and why not? It may seem impossible for regular folks to understand physiology, biochemistry, molecular biology, genetics and other aspects of human metabolism involved in Diabetes Agonistes; but understand they must in order to be highly effective people. Even language that describes metabolism sounds and looks like totemic argot. Can Joe and Ms Sixpack ever become interested in such an obscure and erudite process inside the body, even though the process makes them healthy or sick or ends life prematurely, depending on things the Sixpacks can’t see or touch or make any sense of? Better not to try; just nudge the simple folks to their purportedly healthy choices.
That’s a terrible idea and not because it’s never been tried. It’s always tried. Most health promotion treats understanding as optional, even superfluous, while favoring compliance and adherence. Tell ‘em what you’re gonna to tell ‘em. Tell ‘em. Then tell ‘em what you just told ‘em. If patients with poorly controlled blood pressure or diabetes type 2 got a nickel for every time they’ve been told to eat fewer carbs, get plenty of exercise and take their medicine, they (instead of their physicians) would be seriously rich by now! And yet morbid metabolism is still rampant and there are no signs of abatement.
The reason for that is obvious: instructing and nudging are not replacements for understanding. Seek first to understand means delay those healthy choices until you really know what they mean and then make one that you can — nay will, desire to live with.
The outcomes of Diabetes Agonistes are, in a word, competence. Ours is health promotion that doesn’t look down on people, but looks up to them for thought leadership; that doesn’t ask them to learn stuff they can’t understand, but makes them understand before they realize they’re learning; that doesn’t tell them what to do with their body to be healthy, but asks them what they want to do with their sovereign body and what they actually will do; that doesn’t define physical reality as a biometric paradigm, but kicks physical reality down the stairs and replaces it with wholesale shameless fantasy (wish fulfillment); that doesn’t portray patients as victims, but honors them as warriors and heroes; that doesn’t reward them for passivity, but compliments them for chutzpah; that doesn’t coddle them as though they were morons renting space in their body, but challenges them because it knows they are the smart owners of their body; that replaces nescience with scientific health literacy for actually making healthy choices that also make perfect sense; that allows them to ask why instead of always showing them how, even if it takes a lot longer to get there and the final destination is less than ideally perfect.
I can say this about Diabetes Agonistes because my words are consistent with what WHO recommends: that people themselves (not their delegates) may be able to control their own health better, but nobody nobody nobody can do it for them. Exercising more control without being forced or pinged or supervised or digitally assisted is their responsibility. They can fulfill it only one way: with competence.
As health promotion, Diabetes Agonistes works in the interstices between professional domains of practice, policy and education. This is a no man’s land of nescience. The gap there between knowledge and actual behavior may be infinitesimally small, as it is with virtuoso musicians and professional athletes. They almost always perform well and there is little noticeable difference between what they know, what skills they have, and how they perform. But most of us are not virtuosos of the body. We require tons of practice to get it right even some of the time. Diabetes Agonistes provides hours of opportunities to practice.
WHO continues: “People need to acquire the knowledge, skills and information to make healthy choices.” That’s true, I agree, and Diabetes Agonistes does grow knowledge and skills while presenting information in a phenomenal computer model. That said, WHO left out something very important when it comes to health promotion for people with chronic illness.
What’s missing goes by various names: ambition, conation, motivation, self-determination, drive, grit, passion, courage, resilience. No matter what we call this thing, if we don’t make it a priority, then health promotion is bound to fail (as most of it already does, demonstratively).
Diabetes Agonistes will probably succeed because it never tells people what to do or think. It lets them figure that out for themselves, in playful activities that are utterly, indubitably enchanting.