Outcomes

What are the outcomes of Diabetes Agonistes?

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.

Scientific

What one observes and what one imagines are mutually reinforcing.

Last week I poured a dollop of health literacy and a gobbet of health acumen into a shaker, and shook. Shaken thus (not stirred), they yield a heady cocktail known as self-determination. Why does that matter? Because the self is the most instrumental determinant of health outcomes. Literacy and acumen each by itself informs and weighs; together they empower.

I always call this cocktail “scientific entertainment,” an oxymoron that evokes what Humaginarium is about. We know what entertainment is: it is art; it is artifice that tells the truth and gives pleasure; it is amusement, enjoyment, fun that replaces what actually is with what might or should be in a world of our own making. Everybody knows what entertainment is because everybody needs it, wants it, pays for and uses it; goes out of their way to get it and feels anxious or frustrated when they don’t get enough. But what about scientific? Most of us use that word without knowing (or maybe even caring) what it means.

Science is knowledge; or more precisely systematized knowledge; or more precisely still, systematized knowledge that results from observation and investigation, and that is consistent with evidence. That last bit is the main difference between science and art. Both generate knowledge, but science is empirical while art is philosophical. No big deal. Many people believe that one is more valuable, practical, truthful, influential than the other, but they are wrong. Not only are science and art equal in importance, but each is incomplete and hobbled without the other. Art and science together are another heady cocktail whose parts may also be enjoyed separately, but why on earth would you?

The usual answer is, because science is hard whereas art is easy. Science is technical whereas art is creative. Science is boring whereas art is exciting. Scientific insight resists and eludes discovery and application, whereas artistic insight just lies there waiting to be apprehended, and is useless. All of these contradistinctions are drivel: they just aren’t true. Yet we organize many civilized endeavors, including health promotion, according to our beliefs in them.

I say “scientific entertainment” to prevent the two concepts from coming apart at Humaginarium. My oxymoron is a frank declaration that empiricism and philosophy are not, or should not be, distinguishable. I push this to the farthest extreme by dovetailing the most erudite of all sciences (biomedicine) with the silliest of all arts (fantasy). For Humaginarium, when it comes to health and well-being, what one observes and what one imagines are mutually reinforcing. Always! I am, therefore I think; I think, therefore I am. (Descartes got it half right.)

You will not find health acumen mentioned by the World Health Organization or the Centers for Disease Control and Prevention in their campaigns of health promotion. Only health literacy. The reason for that is probably because literacy is scientific; acumen is fluff. Consequently, because of this scientific bias, their institutional essays on health literacy are generally unsatisfactory, futile, trivial, beside the point. Humaginarium hopes to improve the balance.

Nor will you find WHO and CDC tipping their hats to the arts as they bow to science, except on very rare occasions. Artists have no seats at the table of health promotion; all of the permanent seats are occupied by scientists and clinicians. Is that right and proper? No, it isn’t; it is disastrous. At Humaginarium we hope to do something about that as well.

Our hopes are not effusions of a company that has a dissociative identity disorder. Humaginarium is not trying to meld things that don’t belong together. We are not trying to be clever by getting funky with subject matter that is essentially technical. We are merely doing what needs to be done to break the cognitive chains that hold down the 98% whom I mentioned last week. Science can’t do it alone.

Or to put it a different way, we are making a heady new cocktail that is greater — far greater — than the sum of its parts. Shaken thus (not stirred).

Market

Healthcare treats health literacy as noise on its uneconomical fringes.

The mission of Humaginarium is health promotion. Yet strangely, there’s no market for health promotion. People aren’t buying it.

According to the World Health Organization (WHO), “Health promotion enables people to increase control over their own health. It covers a wide range of social and environmental interventions that are designed to benefit and protect individual people’s health and quality of life by addressing and preventing the root causes of ill health, not just focusing on treatment and cure.”

The emphasis here is on “individual people,” meaning consumers or patients – those I call regular folks. They are the targets and beneficiaries of health promotion.

The emphasis is also on “control,” meaning medical self-efficacy among those selfsame individuals. Health promotion is not supposed to benefit the healthcare or wellness industries that sell services to consumers. It benefits the people who have or risk illness.

The specific pillar of health promotion that concerns Humaginarium is health literacy. WHO says that health literacy enables people to “acquire the knowledge, skills and information to make healthy choices, for example about the food they eat and healthcare services that they need. They need to have opportunities to make those choices.”

Thus health literacy is not knowledge or skill or behavior, and certainly not health outcomes. It’s merely the ability of regular folks to learn, in order to make sense and use of their own choices.

In effect health literacy is a competence rather than an outcome, and it’s one that never comes naturally. It must be learned, and there’s the rub. Most folks may be educated, but few have even the most basic health literacy. They didn’t learn it in school. They didn’t learn it in clinic. They didn’t learn it from friends and family. They didn’t learn it by surfing the Internet. Why is that?

Well, I know of two reasons. One is biology as a second language. We must dismiss the advertising we’ve seen and remember that healthy choices are not consumer packaged goods in the supermarket. They are expressions and perceptions that employ the semantics of science. Healthy choices are really hard! The second reason is the information itself: the intelligibility and utility and consequences of choices even after you know what the words mean.

For example, you probably know the word bacteria, but what good is that without knowing how certain pathogenic bacteria got into your mouth and throat and lungs; and how they managed to thrive; and what they’re doing there; and how your body is coping with them? You cannot gain health literacy – you cannot become an individual who exercises control – without some level of scientific acumen that makes you aware of things like this going on in your body.

Mundane health promotion doesn’t make you aware in that way. It typically doesn’t increase your ability to understand and use scientific information. That privilege is reserved for denizens of the laboratory and clinic. Consumers get to pay the salaries of those professionals, with taxes and co-pays and health insurance. That’s mostly where their role ends, for now.

Taking a new approach, Humaginarium promotes health literacy by helping folks experience and play with science of the human body, so they can discover their own truth and make meaning personal. Few health promoters have inspired regular folks to believe they can do that. Maybe Humaginarium has found a way.

However there’s a problem. Remember what I said about the market for health promotion: there isn’t one. Humaginarium can’t go selling health literacy where nobody is buying it. We’ll have to sell it where customers are likely to show up and pay.

That isn’t in the healthcare industry, which treats health literacy as noise on its fringes. Healthcare rarely addresses or prevents the root causes of ill health, but focuses on treatment and cure. That’s understandable; it’s how companies create shareholder value. As a healthcare executive once said to me: “We’re not interested in wellness; we make money from illness.”

Thus the fringes of healthcare are littered with low-budget crap like self-help books and infomercials. Humaginarium doesn’t like fringes; we want to be the center of attention. So we turn to entertainment, where there is a huge market of individuals seeking to exercise control: the market for commercial video games.

In the video game market we know we can render scientific health information visually and dramatically, without bewildering language. Not to teach but to inspire many individuals with the experience of discovering and controlling healthy choices. First in enjoyable, escapist fantasy chock full of risky adventure; then with the real and persistent challenges of their own body and life.

Scientific entertainment. Male Nude, with Arms Up-Stretched (1828-1830), by William Etty. Pictured with small polymorphic bacteria which cause pneumonia, genital and urinary infections in stressful situations like this one.