Social Innovations
If Nostradamus Was a Philanthropist
The Robert Wood Johnson Foundation created a forecast for the health future of America’s most vulnerable populations over the next two decades.
Nostradamus was a would-be prophet with a knack for predicting catastrophes well beyond his lifetime, half a millennium ago. What people don’t remember is that Nostradamus also worked as an apothecary and physician’s assistant during his early adulthood, trying to protect people from the plague.
As a doctor who has devoted my life to fighting disease and spreading health, I understand why Nostradamus would want to see the future. I too want to know the causes of future suffering in time to do something about them.
Recognizing that crystal balls won’t get us there, the Robert Wood Johnson Foundation employed the art and science of scenario planning to envision the health future of America’s most vulnerable populations over the next two decades. Together with the Institute for Alternative Futures, we mapped a range of possible forecasts, based on questions such as:
- What if the economy as a whole recovers but high unemployment persists?
- What if oil shortages lead to steep rises in energy and food prices?
- What if urban school systems collapse, contributing to spikes in violence and crime?
- What if government debt or continued political polarization means that our leaders respond poorly to these challenges?
- Or, what if a period of hardship and division sparks a countertrend of innovation, collaboration, and compassion?
This exercise is incredibly humbling. And we came away with important insights that help to focus our work going forward.
First, the factors that will have the biggest impact on the health of vulnerable populations will likely come from outside the health care system. In fact, when you look at county health rankings released earlier this month, health care is estimated to account for only about one-fifth of what makes a place healthy.
What will matter most are things like jobs, schools, crime, food, housing, and energy. That has huge implications for health foundations, NGOs, and government agencies, all of which typically look for solutions within, not across, sectors.
Second, social innovation will be even more critical over the next two decades. The optimal approach to take in the face of many possible futures is to develop strategies that will work under a range of scenarios. And such strategies must be firmly grounded in the communities they are to help.
The best solutions will be innovations that help the most people—that is, cost-effective solutions that are practical to adapt and replicate in other communities. Wherever possible, we should seek policy changes that can support implementation and spread. Even better, those solutions will address the intertwined problems—such as health, education, employment, and housing— that affect our most vulnerable at the same time.
Now that we have developed insightful forecasts, we must go beyond the predictive role of Nostradamus and prepare courses of action to build partnerships across disciplines and to help our most vulnerable communities overcome the changes that are certain to come.
We may not be able to predict the future as well as we’d like, but we do have the power to make it better.
James S. Marks, M.D., M.P.H., is a senior vice president and director of the Health Group for the Robert Wood Johnson Foundation. Download the Vulnerability 2030: Scenarios on Vulnerability in the United States report.
Social enterprises are being shaped by cultural and linguistic history, new state approaches to economic and social development, and strategic framing.
All across the developing world, poor parents are investing in low-cost private education for their children—and seeing positive results.
Did American women actually invent social entrepreneurship?
A recent study found that the number of US nonprofits with annual revenues of more
In his latest book, David Sloan Wilson argues that evolutionary theory should be used to illuminate and tackle urban problems.
Jeff Skoll is one of the most creative, generous, and effective philanthropists of his time. And at age 47, he’s just getting started.
Change.org, a five-year-old San Francisco-based startup, has emerged as one of the leading platforms for online activism.
The Entrepreneurial Finance Lab helps identify investment-worthy business people in developing countries.
A Philadelphia study connects green spaces to neighborhood safety.
A new generation of journalists is developing for-profit and nonprofit enterprises to keep citizens informed.
COMMENTS
BY Clem Bezold
ON April 24, 2011 08:33 PM
Hi Jim,
Your sense of the implications of the scenarios is right on target- reversing vulnerability requires approaches that affect all, particularly the poorest.
As part of the team developing the scenarios, i came away with a sense (both my own and several of the experts we interviewed in the project) that increasing structural unemployment (from knowledge technologies in the near term and desktop manufacturing further on in the future) would require alternative approaches to individual and community self reliance - as envisioned in scenario 4, Creative Communities. Energy technologies, food production (including the potentials for aeroponics to allow families to produce some of their food needs in a refrigerator sized box) would be significant. Likewise time-banking and exchanges of personal resources and services will be important. This will require social innovation. In developing/inventing the products and services, and in ensuring that regulation, liability and other policies promote self/community self-reliance opportunities.
Clem
BY Bob Olson
ON April 25, 2011 07:21 AM
I think Jim’s analysis is spot on: the health of vulnerable populations will be shaped more by developments outside the health care system than by changes within it; social innovation - and technological innovation too - will be more important than ever; and the best solutions will be innovations that help the most people - and are very cost-effective.
I think all these points are relevant to the issue of how foundations can be most effective in today’s political climate. Sadly, we’re in a situation today where talk about “social justice,” “helping the poor” or providing assistance to “vulnerable populations” actually turns many people off. This is especially true of the white working class, the group that was overwhelmingly Democratic before 1970 but now has shifted to the Republican party and created a new conservative center in American politics. It is also true of numbers of independent voters who have been struggling in this period of economic hard times. These people are not callous and uncaring, but their underlying beliefs differ from those of many liberals. In particular, they continue to believe that America is a “land of opportunity,” so they are less inclined than liberals to link poverty with social injustice and more inclined to attribute it to a life of impulse and a lack of personal responsibility and discipline. As they see it, they’ve struggled hard to stay in the middle class in a situation where a few false steps can mean a fall into poverty. They’ve had the self-discipline to keep working every day, often in jobs of deadening repetitiveness; to keep marriages and families together; to devote time and money to helping their children get ahead. They’ve earned what they have, and they don’t like the idea of their tax money being taken from them and given to people who haven’t earned it. This outlook underestimates the barriers to upward mobility for many people in our society, but it is a social and political reality that has to be taken into account as we work to help populations vulnerable to ill health.
Strategies that can skirt these objections are those with exactly the characteristics Jim mentioned: practical, cost-effective social and technological innovations outside the health care system that can be adapted and replicated in many communities and that help create better conditions for most people, not just for vulnerable populations. Put another way, many of the best strategies for reducing vulnerability may not aim directly at vulnerable populations but rather at broader ways to create economic opportunities and improve the quality of life at the local community level.
BY Jerry M. Kaiser
ON April 25, 2011 11:03 AM
Who would not agree with Dr. Marks that “The best solutions will be innovations that help the most people—that is, cost-effective solutions that are practical to adapt and replicate in other communities. Wherever possible, we should seek policy changes that can support implementation and spread. Even better, those solutions will address the intertwined problems—such as health, education, employment, and housing— that affect our most vulnerable at the same time.”
The question is whether the prevailing national consciousness is such that these policies – and solutions – will carry the necessary weight to implement them.
The problem is that “jobs, schools, crime, food, housing, and energy” WILL matter most…and that the driver of the others (“It’s the economy, stupid”) does not, for a variety of reasons, appear to be either healthy or health-promoting.
Without dwelling on history, our Post-WWII “prosperity by default” has ended. Europe has recovered, Asia has developed an industrial base, and manufacturing jobs – the birthplace and lifeblood of the middle class – have migrated East.
At the same time, the demand for energy has produced competition from the new consumers in India and China who can afford automobiles; and, accordingly, rising cost from a weakened dollar and dwindling supply. Much as we’d like, “alternative energy” will not be commercially viable for years…and won’t make plastic, pharmaceuticals, and other petroleum-based products.
Education received attention – and funding – when school-age children had middle-class voting parents. These were either Baby Boom children or children of Baby Boomers. Public education is largely in a deplorable state because it now primarily serves “other” children (Having worked in public education in D.C., it’s no surprise that presidents with school-age children have long placed them in private schools).
And, as goes education, so goes healthcare. When voluntary medical missionaries like Remote Area Medical shift their focus from the jungles of Ecuador to the streets of Oakland, Nashville, and other areas of vulnerable populations, the only logical conclusion is that (a) the system is broken; and (b) those with the power to collectively fix it don’t care enough to do so.
(It’s also interesting to me that one of the champions for the health of working people when I worked at AFL/CIO headquarters in Washington is now the chief lobbyist for the health insurance industry.)
The current political climate reflects a dissolving middle class, an increasing selfishness, and an unwillingness (and increasing hostility) to care for – or about – the needs of others who are “not like us”. The health of our vulnerable populations (increasing in numbers every day) is both a symptom and a result.
We need a healthcare system which will provide healthcare for all, and like deficit reduction, will be supported by the collective sacrifice of everyone.
I’m not optimistic.
BY Jennifer Jarratt
ON April 26, 2011 10:11 AM
There’s no question that we will all have to learn to “think differently” about health, what it is, and how a society can ensure health for everyone. In the US some solutions that work elsewhere are barred from us because our society can’t or won’t tolerate them.
I suggest we put our money and efforts into three areas a) public health, which has probably done the most to improve the overall health of the population over the last 100 years, and 2) using the healthcare skills of those other than doctors, currently underused in today’s system, and 3) eliminating the digital lag in healthcare and dragging our system into the digital era with electronic health records and the sharing of data, which would give us a better idea of where to work and where not.
BY Jim Marks
ON April 26, 2011 11:41 AM
I really appreciate the comments on my blog. A few points in return. First when we think about how important where and how we live, learn, work and play is to health…these factors are crucial to everyone’s health, not just the most vulnerable. Obviously the vulnerable are the most affected and will be most helped by improvements. But we have to have our leaders understand that these factors are important to us all. And that discussions about personal responsibility must take into account that millions of people live in circumstances where social and environmental barriers make it nearly impossible to live healthy lives and make healthy choices.
Bob your points about how many Americans find the “injustice” parts of the arguments hard to deal with as they struggle to keep their head above water are well taken. It is part of our hope that we achieve broader recognition of the importance of issues that extend far beyond medical care. People are indeed polarized on these and many other issues—something we confirmed in research on how to talk about the social determinants of health—but there are practical, far-reaching policies and interventions for which broad-based support can be expected. The economics of health care are causing more and more leaders and the public to recognize that we need to look outside of health care for promising, cost-effective ways to improve health for all. It is time we all realize that having health as something that is assessed in all major policy discussions can focus us on how the decisions of major organizations, including govt, influence the choices we can make and those we do make. Some of these may be in the realm of education, some may be related to parks or rapid transit or agriculture, and yet all can be very important for health.
Jerry It is a discouraging time but I think there is also room for optimism e.g. the recent ACA is much different from the debate in 1994 in that prevention- community and clinical- has a much higher profile. Not prominent enough but for the first time it is in the discussion. Further to reconnect to Nostradamus, if people of his time were told that in the future the average life expectancy would be 30+ years longer, that most families would not experience the death of an infant or young child and the leading causes of death- diarrheal, respiratory illnesses would be uncommon ones in the future, the future would be seen as utopian. Yet that is the situation today. There may be ups and downs but the trend line only supports optimism in the long term. As they say in the stock market past performance doesn’t guarantee future results but….
Jennifer, I am comfortable with your first two points but am skeptical of the third. I am old enough to have heard other times when technology was going to solve our problems only not to see it come to pass. We remain the global biotech leader yet have lost ground relative to other countries in such macro measures of health as life expectancy and infant mortality. So bio-tech has not solved our medical cost crisis nor enabled us to close the gap with other countries. This is for our nation as a whole. Even more concerning is that new effective technology can serve to widen gaps between the vulnerable and others if it is more available to those with means than needs. That said knowing what to apply where makes intuitive sense. Thanks again for your thoughtful comments