Healthcare

My focus has been on determinants of health. These are the causes of chronic illness that regular folks can perceive in themselves and their surroundings.

Perceive — at a minimum that means to recognize, but it also means to understand because seeing is not necessarily believing. You need to believe something is true and meaningful before you’re willing to take risks and action.

(Precisely what you do is the raison d’être of Humaginarium. We won’t go into that here.)

Much study and reflection had brought me to a conclusion that the determinants of health occur in four categories. I believed all causes of chronic illness fall into one or more of these, but I was wrong.

One category of determinant is the somatic, which is basically your physiology and biochemistry. The somatic is what you see in the mirror and in body scans like CT and MRI. If you are one of the gamers entertained by Humaginarium, you perceive very little of yourself that is somatic. Instead there is fantasy, memory, or even nothing at all.

Another category is the psychosomatic, which is basically your thought processes and emotions. The psychosomatic includes the rational mind and imagination. It also includes feelings that have little to do with cognition and more to do with nerves and hormones. Most regular folks perceive the faintest glimmer of their psychosomatic self, though many may live and die for it.

Yet another kind of determinant is the social, which is basically relationships, dependencies, culture and community. Social determinants of health are not of you or another; they are all that occurs between you and others; all that makes us valuable or useful to each other. Politics, which makes many of us sick, is a social determinant of health that most can’t fathom, as usual for the category.

I thought that the final category is the environmental, which is basically the space that supports life. Metabolism is the cardinal difference between living and not living, but nobody knows how or why it started. We only know it cannot happen without an environment that sustains it. There are no martians and there never will be, Elon.

Now I realize there is a fifth determinant of health; a fifth cause of chronic illness that is painfully obvious but often overlooked. It is healthcare, which is basically the medical industry. It is your primary and specialty care, medical devices, drugs, clinics, hospitals and god almighty insurer. I hate to say this about an industry that vacuums up nearly $4 trillion a year from our collective human capital, but most of us do not understand this determinant of our health, no more than the other four. We perceive only the faintest glimmer of what medicine is — even when it’s being practiced on ourselves.

Five determinants hints at an analogy with Peter Senge’s five disciplines for creating learning organizations. Let’s see if it works. Here they are:

1. “Personal mastery is a discipline of continually clarifying and deepening our personal vision, of focusing our energies, of developing patience, and of seeing reality objectively.” Check! That’s what Humaginarium does with and for folks dealing with chronic illness.
2. “Mental models are deeply ingrained assumptions, generalizations, or even pictures of images that influence how we understand the world and how we take action.” Roger that! Humaginarium is changing mental models of health from spectator to change agent.
3. “Building shared vision — a practice of unearthing shared pictures of the future that foster genuine commitment and enrollment rather than compliance.” Our concept of commitment and enrollment is not in an employer health plan, but in the individual sense of well-being that comes with self-actualization.
4. “Team learning starts with ‘dialogue’, the capacity of members of a team to suspend assumptions and enter into genuine ‘thinking together’.” Our program is 1:1 with and for each individual to become more comfortable in their own skin. That looks to me like a prerequisite for thinking with others.
5. “Systems thinking – The Fifth Discipline that integrates the other four.”

The Fifth Discipline is the title of Senge’s book and also an organizing principle of Humaginarium. Though we do not create learning organizations, we use systems thinking and dynamic models of health and healthcare for a far humbler purpose. To create learning individuals, one by one, millions at a time.

These individuals suffer with chronic illness that they do not control. We can’t cure their illness, but we can lessen their suffering by helping them perceive how much power they have, and can get, to live better.

I Saw the Figure 5 in Gold (1928) by Charles Demuth, bequeathed by Georgia O’Keeffe to the Metropolitan Museum of Art in New York. The painting is a mental model that illustrates The Great Figure (1920), by William Carlos Williams:

Among the rain
and lights
I saw the figure 5
in gold
on a red
firetruck
moving
tense
unheeded
to gong clangs
siren howls
and wheels rumbling
through the dark city.

Determinants

Humaginarium addresses the problem of health incompetence, and we do it in a new way.

Not by telling folks how to avoid, prevent and control chronic illness, but letting them figure it out by themselves.

Not by imparting sterile medical information, but empowering them to make choices and decisions that satisfy underlying needs.

Not by picking apart symptoms and treatments, but nudging folks to understand and deal with causes.

Those causes are called determinants of health. According to Humaginarium, the determinants of health fall into four categories:

• Physical
• Psychological
• Social
• Environmental

Physical determinants are tangible properties of the body. Physiology, biochemistry, the tissues that give it shape and weight, the growth and decay manifest in them. Physical determinants can be seen under a microscope, on an x-ray and CT scan, in a DNA sequence. They’re as tiny as molecules swarming the mitochondria, as large as 25 feet of neatly folded intestines hosting trillions of symbiotic bacteria.

Psychological determinants are properties of the mind — conscious and subconscious, voluntary and reflexive, rational and emotional, learned and instinctive. Psychological determinants can’t be seen, yet they can be felt and measured. They’re as fleeting as appetite and rooted as depression. As a professional focus of mind-body medicine, and having biochemical agency, they are psychic fluff that both augurs and stymies disease.

Social determinants of health are properties of lifestyle. Extrinsic, situational, interpersonal rather than organic and evolved, they manifest in customs, culture, class and community as behavioral norms, relationships and traditions that organize and regulate the tribe. Social determinants of health include wealth and poverty, education, race, religion, vocation, zip code and lately ideology. Sex and violence are also big among them.

Environmental determinants of health are both naturally occurring and built — in biosphere and atmosphere, urban sprawls and outback. The water we drink, the air we breathe, the weather that rains on our parade, the ground we frack, the mountains we strip and decapitate, the rivers we pollute, the trees we incinerate. Environmental determinants are palpable yet easy to ignore. They not only cause sickness, but also extinction!

There we have it, four determinants of health by category. There’s a fifth one I haven’t mentioned, the secret sauce of Humaginarium: it’s the determinant of self.

As in, self-determination. An individual’s firm intention to achieve a desired end. Self-determination theory explains out how it works and what it means; conation gives it linguistic pedigree; motivation, grit and ambition haul it into common parlance.

Self-determination is what a person exercises to assert cause, rather than be wrangled by the causes of others. Self-determination can be positive as with Laurence of Arabia, or negative as with Billy Budd. Either way, it is the single most potent counterweight to the other determinants of health that I listed. And of course, it is largely ignored by healthcare and biomedicine as we know them.

As players in Humaginarium develop their own firm intention to prevent, avoid and control the chronic illnesses they meet in our fantasies, it shall happen, they will win, both in game and real life.

But as long as they lack the gumption and inspiration and wherewithal to stand up and fight, it will not happen. I believe that as surely as I believe the sun also rises.

That Humaginarium has found a way to operationalize self determinants at scale, quickly and easily, simply means that the days of the other determinants of health may be numbered. They have ruled and tortured folks with chronic illness enough. Shut the back door. Game on!

From The Little Engine That Could