The following blog entry is the beginning of a series of interviews between the ABIHM and various guest thought leaders. This month, ABHIM Board President, Scott Shannon, MD, interviews Jamie Harvie. Jamie is the Executive Director of the Institute for a Sustainable Future. Jamie was recognized by the Natural Resources Defense Council as a National Thought Leader for his work integrating a sustainable food and prevention agenda into the national healthcare setting. He is a contributor to the text book, Integrative Medicine, 3rd Ed. This month, he was included in Food Service Director, one of the nation’s premier food service publication’s 20 Most Influential List, which also includes First Lady Michelle Obama. Recently, he established the Commons Health Care Network, representing a community of systems thinkers.
ABIHM: Hello and welcome. I recently came across your policy piece, “The Case for Commons Healthcare” in the January edition of the journal, Explore. In the paper and your more detailed Commons Health Care Blog, you weave together disparate issues such as climate change, food, anchor institutions and integrative practices into a forceful argument for a new healthcare framework. Can you distill your thinking about how these issues fit together?
Harvie: Thanks, Scott. It may be helpful to provide some context. For the past 14 years, I worked with colleagues to insinuate an environmental agenda within western medicine. We achieved considerable success. Hospitals have eliminated mercury thermometers and PVC IV bags, stopped incinerating medical waste, and have implemented other environmentally friendly strategies. Yet, there was an unspoken acknowledgement, that though green hospitals are good, wouldn’t the ideal be far fewer hospitals? What if our vision as a society was optimal health, and as a result, lowered or eliminated our need for hospitals? How would we get there? With approximately 20% of our economy invested in our current treatment model, change is difficult, and we are vexed by healthcare reform. But it is even harder to change without a vision of what we might imagine as a new health delivery system. There is a general consensus that our existing model is broken and in transition, but no one seems to know exactly where it is going. A commons healthcare framework attempts to provide some direction; the idea is to create the future health system, instead of fixing the old one. Moreover, it offers some concepts about key allies and drivers that can affect a transition more rapidly when properly aligned. Of course, this model is neither simplistic nor perfect, but it represents a vantage point that will only be strengthened by debate, discussion, and trial.
ABIHM: So can you explain these linkages?
Harvie: Consider key drivers of disease or ill health. We know that our global healthcare system is crumbling under a burden of primarily diet related chronic diseases. The IPCC (Intergovernmental Panel on Climate Change) has highlighted an impending public health crisis because of climate related impacts such as heat stress, infectious disease, and natural disasters. The International Agriculture Assessment, a global report funded by multiple UN agencies, has determined that our current industrial agriculture model has led to a host of social and environmental impacts that jeopardize our ability to both grow food for future generations and maintain social stability. Moreover, the UN Millenium Report describes major global ecosystems at imminent collapse. Hospitals and clinicians in an already overburdened healthcare system will be at the receiving end of these predicted impacts. Our food system represents one third of climate emissions (greater than transportation); healthcare treatment represents about 80% of healthcare climate emissions (versus 20% for energy use). Our industrial food model promotes social inequity and negative environmental impacts. If we want to be healthy on a healthy planet, we will need to look for multiple benefits solutions (and we have limited time to do so). As a result, a health care commons model will necessarily require a “systems” mindset with primary prevention as its focus.
ABHIM: So is this where the commons comes in?
Harvie: This is where we recognize the interrelationship between community and the commons. The commons are what we all share. They are both what we inherit and what we create together. Think of air, water, food, libraries. So at one level, the commons are used to reflect common drivers of good health and to highlight community ownership. Hippocrates, Florence Nightingale, and others have long recognized that clean air, water, and food are at the heart of prevention and good health. They would never have imagined that food (through genetic engineering), water (through privatization), or natural remedies including yoga postures might one day by privatized. But this can extend to the enclosure of research, education and more.
Commons is at root of “community” so it is about rebalancing the relationship between individual and community. This is implied in healthcare reform – more people and resources in the “pool” beyond healthcare delivery. We know that a sense of connectedness, or “community” improves health outcomes. In the UK, where they’ve been giving considerable thought to this, the NHS Roadmap describes a transition from institution led health to community based social and health care. This concept is also central to the health care commons model in which the community takes ownership for its health. It parallels the tremendous work the integrative community has done to educate and empower patients to take control of their own health, just at a different level. Interestingly, the important work that the integrative community is advancing at the clinical and political levels parallels the work of many community and environmental advocates. There is a deep caring, passion, and soulfulness that is woven through these cultures. If we can understand this, and see the connectedness in our work, I believe we can create important linkages, leverage our work and generate more co-creators and catalysts.
ABHIM: This sounds exciting, but what does this mean in practice, for our clinical community? What might next steps be?
Harvie: At the present time, there’s no obvious roadmap, but we can co-create the next steps. It is important to articulate a new primary prevention framework, especially one that works towards multibenefit solutions. Moreover, it must extend beyond clinical medicine throughout the lives of fellow clinicians, patients and communities, such that the interconnections feel obvious. I suspect that many of your Diplomates are already involved in some way. At the heart of your training and practices are the understanding of environmental toxins, clean water, nutrition and spirituality. The broad thinking systems model I’ve been talking about typically feels intuitive to integrative holistic practitioners.
More than likely, the same old institutions are not going to provide the answers. If we invite the same guests to the party we’ll have the same conversations. In the UK, they’ve created DEFRA, a new Department of Environment, Food and Rural Affairs. This is an exciting way to engage new and inspiring discussions. We are beginning to see this philosophy through the establishment of ACO’s (accountable care organizations). We have to remember that we have about 17% of the economy invested in a treatment model. This is a lot of entrenched power that will resist change. So things won’t just “happen”. What will this mean in practice? It will require future health professionals to promote consumption of healthy foods from agro-ecological production models, not only at the patient level, but to be advocates within the community for agro-ecology because this production and management method has the potential to improve social determinants of health, mitigate ecological impacts, and reduce the burden of chronic disease. Implicit in this approach is support for community approaches to resource management. In practice, this means prohibiting GE Foods or requiring labeling, and no bottled water.
Physicians and other staff can call on their hospitals to set up farmers markets, facilitate CSA drop-offs, support food literacy initiatives, or teach cooking skills. Much of the groundwork has already been laid by facilities who have committed to these practices. Clinicians can work with community members and challenge their hospitals to support Baby Friendly hospital guidelines, a hospital commitment to purchase local sustainable food, and to stop selling sugar sweetened beverages. In Cleveland, the community has helped develop a hospitals and universities supported worker-owned laundry. Clinicians can join with community members to highlight social disparities and support economic policies that support safe working conditions and livable wages. These are ultimately connected to socioeconomic health. This is why anchor institutions are included in the Commons Health Framework.
Researchers might also include the development of a multi-benefit research agenda. The Bravewell Collaborative published a wonderful paper, The Efficacy and Cost-Effectiveness of Integrative Medicine. Much of the cost effectiveness was due to a reduced need for pharmaceutical interventions. Because there are significant climate and other ecological/human impacts associated with the lifecycle of pharmaceuticals, we should intentionally highlight and explicitly link these benefits in research back to the health of individuals, communities and the planet. If we understand this, it might help us be more judicious and intentional when pharmaceutical interventions are considered.
At the same time, this model requires taking responsibility at the personal and community levels. Integrative clinicians have been good at “empowering” patients to take control of their health. With ACOs, we’ll start to have a better handle on community based costs of treatment. This transparency may help communities make more informed choices about how and where they invest their “health” dollars. In her wonderful short video, “The Story of Stuff”, Annie Leonard reminds us that much of our consumer oriented economic model is based on making us feel lonely and unhappy. The commons health care community might raise the idea of including a “happiness” index“ as a community health benchmark, and maybe even replace a strict economic indicator, such as the GDP.
The weight of a community driven approach does not have to be shouldered by clinicians alone, though their moral authority is helpful in engaging business and community leaders. In so doing, communities can begin to take ownership of their health resources in the same way that patients are asked to take responsibility for their health. This agenda is really about de-siloing and weaving many areas of policy and practice with community at the center, and shifting power in decision making from the institution to the community.
ABHIM: This is tremendous food for thought. Thank you for sharing your vision and for providing so many useful links and resources for this work.