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Originally published in the February 2018 Health Equity Impact Assessment Community of Interest Newsletter
When we think about health equity, we think a lot about language. The language we use to describe various populations is, as always, evolving. One of our favourite resources, Let’s Talk: Populations and the Power of Language (also in French), covers the current landscape well for many groups – but gender isn’t mentioned. Considering how central gender is to many people’s identity, the language we use in equity-related contexts should be as gender-inclusive as we can make it.
We are all “they”
One increasingly popular and accepted tactic is to use “they” in the singular sense. Canada has already adopted “he or she” and its variants (he/she, s/he) instead of the theoretically generic “he”. The singular “they” is the next step towards linguistic gender inclusion. It simplifies sentence structures – he or she should raise his or her concerns with his or her caseworker becomes they should raise their concerns with their caseworker. It implicitly includes not just “he” and “she” but also others who may not identify with either gendered pronoun. Grammar sticklers feeling a frisson of discomfort with this usage may content themselves with evidence that the singular “they” is not new.
“They” has a baby
Gender issues can be particularly tricky when we’re talking about pregnancy and newborn health. It’s easy to fall into stereotypically gendered (and often heterosexist) language in this context. Health Nexus ran an article recently in the Ontario Health Promotion E-Bulletin on the risks of cannabis on fertility, pregnancy, breastfeeding and parenting which demonstrates some of our ideas about writing inclusively about reproductive issues.
One trick, in my experience, is to describe states or functions instead of identities or roles. We can talk about those who are pregnant (a state) instead of pregnant women (an identity) or mothers (a role) for example, as not everyone who is pregnant identifies as female. For example, Tetrahydrocannabinol (THC) crosses the placenta from the pregnant person to the fetus. On the same theme, we can talk about parents instead of mothers. To avoid heterocentrism, we can talk about partners or co-parents or even support people (which includes community supports and anyone supporting a single parent) instead of husbands.
Another trick is to switch to the second person: Being high while parenting can affect how you interact with your child, for example, or if you are unable to stop using cannabis completely, try using less and less often. This can feel overly directive, though.
Even better, we can rewrite sentences to avoid mentioning gender at all: Cannabis use may affect the ability to become pregnant.
As increasing numbers of people shake off the gender binary like an ill-fitting coat, let’s all be glad that – with a bit of thought and effort — English can be flexible enough to be equitable!
Comments closedOntario declared October 15 as Pregnancy and Infant Loss Day very late in 2015, so tomorrow will be the first time this day of remembrance has taken place.
Losing a pregnancy or an infant is a peculiarly difficult form of loss — invisible as all losses are invisible to those outside them, but also with the additional loss of a lifetime of possibility and the very physical sequelae unavoidable at the end of a pregnancy. It’s a monstrous, momentous, unexpected loss, but not a form of loss that we talk about often, although it’s far from uncommon. Perhaps this day of remembrance will help bring the conversation about this form of loss further into the vernacular.
I recently read An Exact Replica of a Figment of My Imagination, Elizabeth McCracken‘s memoir of her stillborn son. She writes about her grief with perceptiveness and clarity and even humour:
“Perhaps it goes without saying that I believe in the geographic cure. Of course you can’t out-travel sadness. You will find it has smuggled itself along in your suitcase. It coats the camera lens, it flavors the local cuisine. In that different sunlight, it stands out, awkward, yours, honking in the brash vowels of your native tongue in otherwise quiet restaurants. You may even feel proud of its stubbornness as it follows you up the bell towers and monuments, as it pants in your ear while you take in the view. I travel not to get away from my troubles but to see how they look in front of famous buildings or on deserted beaches. I take them for walks. Sometimes I get them drunk. Back at home we generally understand each other better.”
It must have been a cathartic book to write, as it certainly is to read.
If you’ve experienced such a loss — as some of us here at Health Nexus have — our hearts are with you, on October 15 and every day.
In Ontario, the Pregnancy and Infant Loss Network (PAIL) offers support groups for bereaved families in many locations, as well as butterfly releases in two cities. See their website for details.
Comments closedOn September 26 I went to a Social Impact Generation session at the Centre for Social Innovation (CSI) on “The culture, passion and how for social innovation”.
I couldn’t immediately remember why I had thought it so important to attend, but it became quickly apparent: several of the guests were from Australia and would talk about TACSI, the innovation lab there, and another guest had been involved in the Kafka Brigade which I’ve always enjoyed.
We hear the word “innovation” a lot in health promotion, often applied somewhat haphazardly, but I was pleased to hear that TACSI’s innovation focus was on system change. They believe all people should have the opportunity to have a good life and to have a say in what that looks like. Health promoters will recognize a close echo of the WHO definition of health promotion in that statement, altough TACSI doesn’t call themselves health promoters.
They see system change developing through four channels:
- Understand the problems and opportunities people experience and built empathy for people and systems. Unpack the assumptions.
- Consider how you design for that truth. What approaches, methods and tools might you use?
- Take a capability-building, mutual-learning approach.
- When the first three aren’t enough, accept that you’re working on a profound systemic challenge. This is the most intangible level, and you’ll need to experiment to shift systems so people can live good lives.
Several points struck me as interesting for health promoters to consider:
- The use of the word “capability” where we would typically use the word “capacity”. I think we may wish to consider using “capability” more often — it’s more easily understood and sounds more active.
- One presenter emphasized that while we are often good at collaborating with people with like minds, to really change systems we need to learn “conflictual collaboration” — that is, to collaborate across difference and disagreement, and to be more comfortable not liking each other.
- All presenters agreed that lots of failures are part of the process in systems change. Innovation labs can be useful, not only as places to encourage ideas and experiments but also as places where people can learn from the failures of others instead of repeating them.
- They noted that idea generation is not an end in itself and doesn’t change the world. You have to act, even knowing that most of your experiments won’t succeed with any rigour. So connect and act!
A video of the evening is now posted.
Comments closed“This world faces daunting challenges–from energy supplies to food supplies, from biodiversity collapse to the freshwater crisis, and, at the root of many of these issues, global climate change. Yet we shrink from confronting these challenges because we don’t like numbers and are more comfortable with beliefs than with rational thought” (loc 46)
Evidence, and being evidence-based, is a major theme in health promotion work right now. Of course evidence is a good thing, but what counts as evidence from a scientific perspective, and what skills do we need in order to evaluate whether it’s good evidence or not?
David J. Helfand’s book (published February 2016) is a good overview of the basics of scientific thinking. Helfand clearly loves science and his writing conveys the wonder and excitement of a scientific perspective.
“Adopting these habits of mind opens up worlds both unseen and unseeable to understanding. It allows us to read the history of the deep past and to predict the future. It provides us with context: our “pale blue dot is but one of eight planets and a few dozen moons orbiting one of a hundred billion stars (many of which, we now know, also have planets) that make up the Milky Way, one of a hundred billion galaxies in our visible corner of the universe. That, far more than a “rainbow in heaven,” is awe-full — it inspires awe.”(loc 232)
Helfand uses relatable examples to illustrate the habits of mind he describes: how much does a rainstorm slow down a baseball? If the US national debt is $1.7 trillion, how much is that per person? Based on a coin-toss rule, who should pay for lunch? The last chapter neatly pulls all the ideas and habits together, working through the example of climate change.
His tone tends toward the curmudgeonly, which I enjoyed tremendously:
“US consumers spent over $3 billion on homeopathic medicine in 2007, obtaining distilled water from which the last trace of such invaluable ingredients as crushed whole bees, red onions, and white arsenic were originally dissolved (a terrible waste of bees in my view).” (loc 3068)
I do worry that he may have pitched the book slightly higher than its ideal audience — those who, as per my first quote, don’t like numbers — might require. But if you made it through high school algebra (whether you remember any of it or not) and understand the basics of how graphs work, the math here shouldn’t be too frightening. There are formulas, but if you’re comfortable enough with the concepts Helfand is discussing, parsing the exact details of each calculation isn’t necessary to follow his argument. It’s the habits of mind and general approaches he discusses that are important, not the calculations in his examples. I’m sure he’d agree, given that one of those habits is “back of the envelope” estimation.
It is, of course, fully referenced and includes appendices with tips and practice questions for each chapter.
Recommended for anyone who’d like to stretch their science muscles or who frowns when someone mistakes “less” for “fewer”.
Comments closedAaron Swartz died three years ago today, but the issue — and yes, ownership of information is a health promotion issue — of who controls what you can post and see on the Internet is most definitely still with us.
For those unfamiliar with Swartz, copyright issues, the open-source movement, and the technical details of his actions, never fear. This book gives not only a thorough accounting of his case but also a history of how copyright came to be as it is and why one might wish it to be otherwise, without being dry or plodding:
“Like a truffle dipped in ipecac, a gift wrapped with poison ivy, Webster’s good ideas were often ruined by their repellent packaging.”
It’s also a tale of complexity and of unintended consequence, of the sort that health promoters will find familiar:
“It is important to remember, however, that the availability and affordability of these pirate editions engendered a book-reading public in nineteenth-century America, which would eventually engender a more mature publishing industry. In this context, what better served America and Americans? To give authors tight control over their works, so that they could profit from their good ideas? Or to build a nation of readers by relaxing restrictions on the flow and dissemination of content? Was copyright a set of social relationships, or was it an inalienable property right? Even after passage of the Copyright Act of 1831, American lawmakers weren’t sure.”
With the rise of the Internet, it’s clear we’re still not sure about how the balance should fall, as Swartz’ case demonstrates.
Swartz himself seemed to me a difficult person, driven and well-intentioned but immature and with a tendency to choose the quick, decisive route over the slow-but-sure. His is a cautionary tale about what can happen when you do too much, too fast, which may provide solace for health promoters and policy advocates frustrated with the slow pace of change.
“I felt like he certainly had sort of the conviction of youth, in the sense that he was convinced that whatever he was doing at any one time — or at least he sort of projected this — he was absolutely convinced that that was the way to go,” his friend Wes Felter said. “And the thing is that most people sort of outgrow that, and I don’t know if he ever did.”
Brewster Kahle, mentioned in the book, gives his gentler view here (video and transcript).
As the free availability of accurate, complete information is of critical importance for people’s ability to make decisions in all areas of life I’d encourage health promoters to read up on information-control issues, and this book is an excellent place to start.
A well-researched, insightful, and human view into copyright law and its various abuses (on multiple sides!) through history, and a fair requiem for Swartz.
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This 2014 book delves into what makes networks tick. How do networks start? How do they stay healthy? How does a network approach to work differ from an organization-based approach? Lots of real-world examples help keep this a very readable book.
The authors divide networks into three categories: connectivity, alignment, and production networks, each with its own characteristics and purposes. (They may also be phases: a single network may go through more than one of these categories over its lifetime.)
- Connectivity networks link people for information exchange and learning.
- Alignment networks link people to help them share ideas, goals, and strategies.
- Production networks enable members to work together for social impact.
A strength of this book is its emphasis on network maintenance as work, and as necessary, highly skilled, challenging, time-consuming work. Often people have the impression that, once they’re established, networks steam on effortlessly towards their goals, but there’s inevitably a great deal of background effort necessary to produce that impression.
So what does the wizard behind the curtain do? This book gives a good overview. Network establishment and maintenance tasks are clearly spelled out; appendices provide useful tools, checklists and resources. There’s even a gentle list of lessons for “network engineers” — funders and others — who wish to launch networks for their own purposes, encouraging them to do so in a supportive versus a directive way.
I appreciated the emphasis on the need for adequate, appropriately-chosen IT tools for network members and on human support for their use:
“Facilitation and coordination at any of the levels we’ve described also require tools for supporting communication among members. A network’s communication infrastructure is essential to the network’s success because it will enable or impede collaboration. …
Whether it’s using e-mail, listserves [sic], or scheduling and collaboration software, there has to be a human touch to help things along. We’ve seen start-up networks in which members had access to commuications software but almost none used it. Some members didn’t want to deal with having yet another website to go to and another password to enter. Some weren’t comfortable with learning how to use the new site. Some tried the site and didn’t find anyone else there, so they dropped it. The lesson seems to be that you can’t just provide everyone with an online communications tool and expect they will start to use it. You have to encourage and support them.”
A note on language: the authors use “value proposition” in an unusual (and slightly distracting) way, to refer to both something that is offered and something that is wanted. It can take a while to parse their meaning as a result. But this is a minor quibble.
Recommended for those new to network work, but the book is also full of useful tips and resources for those already enmeshed in the network way of thinking and working.
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An impressively exhaustive account of the soda industry, its effects on human health, and its extensive efforts to ensure profit triumphs over health concerns.
In this book Marion Nestle painstakingly disassembles, analyzes and documents every possible aspect of the enormous industry dedicated to selling drinks of sugared, flavored water to people across the planet. Beginning with the health effects, moving through marketing (to children, to minorities, to the developing world), and ending with the various flavours of political advocacy efforts, Nestle leaves the reader with a clear picture of how the industry functions. Soda Politics focuses on the USA, particularly in the sections on political efforts, but Nestle keeps the entire world well in view — as the soda companies do.
Health promoters will likely not find anything new in the health-related sections but will appreciate Nestle’s consistent acknowledgement that the health issues to which soda consumption contributes, such as obesity and diabetes, transcend individual lifestyle choices. The startling statistic that sugary drinks comprise fully half of all sugar intake (in the US) shows just how normalized it has become to drink nutritionally-empty calories.
Nestle recounts in detail how soda companies go to extensive efforts to shift attention away from calorie consumption and toward physical activity, and how they create “astroturf” groups (false “grassroots” groups that are industry-created and -funded) to fight any tax, policy, or regulation that would limit soda sales.
Health promoters familiar with tobacco control efforts will note many parallels, which Nestle notes in the text:
“To public health advocates familiar with the actions of tobacco companies, the response of soda companies to obesity seems all too familiar. Soda is not tobacco, of course, and the problems it causes depend on how much is consumed, and how often. But the soda industry’s playbook — the script it follows — is a carbon copy of the one used by cigarette companies to deflect attention from the hazards of smoking.”
Also of particular interest to health promoters will be the sections suggesting activities to use with children, including those highlighting inequality:
“Take your kids to a high-income neighborhood, low-income neighborhood, and a largely minority neighborhood and do some comparisons.
- Which neighborhood makes sodas more readily available?
- Which neighborhood makes fresh fruits and vegetables more readily available?
- Why do these differences exist?”
It’s worth a read (Don’t be put off by the length: the last third is a collection of resources, references, and other supporting material.). While one is left feeling a bit squashed by the enormous industry behemoth of funding and advocacy, Nestle is careful to end on a hopeful note, describing small wins and the momentum those wins are creating. It feels much like the early days of tobacco control — and see how far that has come in the last thirty years! Perhaps thirty years from now Soda Politics will be a curious historical artefact of a strange, bygone world. We can only hope.
Coming in October 2015 from Oxford University Press.
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Food systems and how they affect and interact with human and ecosystem health have been a growing area of concern for health promoters in recent years. In Grow, Stephen Grace explores some community-level enterprises, experiments, and ideas in the context of urban Denver.
After the sudden death of his friend Mostafa, Stephen Grace finds himself searching for connection, happiness, and meaning. Strong associations between Mostafa and the social, comforting aspects of food lead him to Denver’s local sustainable agriculture scene.
While the theoretical notions here won’t be new to anyone already involved in or familiar with community food systems, the specifics of what’s happening in Denver are of significant interest. How can you develop a locavore food scene in a cold, dry, mostly urban environment? It’s an interesting challenge, and Grace digs deeply to find the people and stories at the root of it. Care for the earth. Care for people. Share the surplus.
While small-scale equity is dealt with sensitively, larger-scale equity issues are skimmed over:
Where will all that food come from if it isn’t transported from far-flung places by ship, train, truck and plane? John-Paul answers with one word: “Lawns”.
But what about the many people, disadvantaged and otherwise, who don’t have lawns? And what about the people living in those “far-flung” places? Perhaps that’s another book, but the emphasis on hyper-local solutions in Grow did externalize the rest of the planet. There’s also a tendency in the writing style to tell, not show, which adds a proselytizing tone in spots.
Overall: a thoughtful, hopeful primer on a complex issue, complete with an excellent (and extensive) reference list for further reading.
Comments closedAt the end of April I went to the Apps for Health conference in Hamilton.
From a health promotion perspective as well as from a technological perspective, the entire field of apps for health and wearable technology is fascinating, albeit rather larval. There is a lot going on, but not in sync — it’s a rather cacophonous space at the moment, with no standards and very little interoperability. Everyone is working alone to invent new kinds of wheels. It reminds me of the early days of personal computing. Now, we know ctrl-s (or its equivalent) will probably save your work in most computer-related things we encounter, but it wasn’t always so. I remember pointing out the “save” icon in Word to someone in the early 90s, back when the icon was meant to look like a floppy disk (remember those?), and the person said “Oh, the tv icon? I always wondered what that was for!” To be fair, it did kind of look like a TV.
That’s kind of where health apps and wearable tech are now: figuring out tiny pieces of a big field, throwing a lot of ideas at the wall (in isolation) and seeing what sticks. At the moment there are many ways to represent respiration, for example, or calories or sleep time or stress/emotion. You could spend your whole day counting and reporting things in many single-purpose apps or devices that don’t talk to each other (or to anything else).
What does this have to do with health promotion?
Quite a bit. If we look to the Ottawa Charter’s action areas in health promotion (build healthy public policy, create supportive environments for health, strengthen community action for health, develop personal skills, and re-orient health services) and its three health promotion basic strategies (to enable, mediate, and advocate), it’s clear health promoters need to be paying attention to the possibilities and issues with technology and health.
I’ll divide my comments among the strategies.
Enable
As we move from pure data collection to apps and wearables that can help make decisions and recommendations, health promoters need to have a say in what these decisions might be. Are they healthy decisions overall, for the person and for society? Who is creating the app or wearable and what is their agenda?
There are some excellent apps and wearables being produced right now. For example, at Apps for Health I was particularly impressed with BrainFX, an app produced by several Occupational Therapists for the assessment of mild to moderate brain dysfunctions. Not only does it speed up the assessment process, it removes potential delivery bias, delivers a report immediately, and allows users to contribute their de-identified data for research. OTs benefit from spending two hours to assess someone and get a report instead of twenty hours. Patients benefit from a report that’s immediately available and so can see the specifics of their issues and begin therapy immediately instead of having to wait weeks or months for a hand-written report. Researchers benefit from a steadily increasing collection of nicely anonymous data. Win-win-win.
In the fitness realm, Zombies, Run! and The Walk, both by Six to Start (The Walk was co-produced with the UK’s NHS), are excellent examples of how to add a game layer to workouts for extra fun and reward.
On the other hand, virtually all health-related apps and wearables focus on lifestyle issues, which we know are not the major contributors to health. How can health promoters enable the kind of bigger-picture thinking that could lead to apps and wearables that consider health beyond steps and calories?
Mediate
There are many apps and wearables that aim to help develop personal skills. These are of widely varying quality, and health promoters could help guide people to more credible, reliable, practical apps and to use them in a healthy way. Is it healthy to quantify exactly how many peas your baby ate for lunch and his/her sleep to the nearest second? Or is it healthier to put down the phone and interact with the baby instead? Do we put the might of our words behind self-driving cars, which might reduce injuries, or do we help guide society away from car dependence altogether? Some apps “gamify” health by providing connections to other users based on data sharing — how can we help people disentangle their thoughts about privacy vs. the benefits of access to support? Technology needs health promoters to help mediate the larger issues.
Advocate
Privacy issues in health apps and in wearables are far, far from resolved. At Apps for Health, Ontario’s previous Information and Privacy Commissioner gave an impassioned keynote advocating Privacy By Design. That is, in her opinion (and mine), technology should by default protect the user’s privacy. If they choose to share their information, it should be clear what data is being shared, who it’s being shared with, and why. The corporatization of data and data mining are, I think we can all agree, concerning from a health promotion point of view, and advocating for transparency and Privacy By Design is something health promoters can do.
Security is also something health promoters can draw attention to. I am not at all sure I want my heart rate monitor, my baby monitor, my drug infusion pump or my house (or the power grid, for that matter) attached to the hackable Internet of Things just yet. We need to do some deeper thinking about the implications of the risks involved in connecting everything to the Internet.
Issues of equality and discrimination are key, as well, and health promoters can keep these in the public eye. Whose data is being collected from all these wearables? Well, data from people who can afford smartphones and wearables, so these people are probably from the wealthier end of society. If we’re going to be making policy choices based on collected data — for example, the City of Toronto has created a cycling app to collect information about where people ride to help future infrastructure decisions — we need to spend much more time considering who is included and who is not.
This is evident even from looking at the images that are used of wearable technology in action: wearables are almost always shown on white male bodies. When female bodies are shown at all they are shown either as billboards, wearing high heels and tight dresses displaying the technology in question on their chests or skirts, or they are wearing revealing workout gear. Women’s bodies are depicted somewhat more often in apps addressing mood or stress. In all contexts, however, the women all have long hair and (with few exceptions) are white. What does this mean about whose needs are being attended to with this technology? What kinds of bodies are being considered “normal” and what does this mean on a societal level?
This is very early days, and health promoters have a wonderful opportunity to help guide technology in ways that will be healthy at all levels from the individual to the societal. Feel free to explore my public “wearabletech” tagged bookmarks and “apps” tagged bookmarks and, of course, any other sources that appeal to you. I encourage all health promoters to keep a weather eye on health apps and wearable technology and to speak up whenever you can.
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