A New Parable of the Downstreamers Daniel Jordan, PhD, ABPP, firstname.lastname@example.orgAdapted and Revised From: Ardell, D. (1986). The Parable of the Downstreamers. High Level Wellness: An Alternative to Doctors, Drugs & Disease. Ten Speed Press. Berkeley, CA.
People Were Drowning! Downstream villagers saw the first drowning person in the river many years ago, but they could offer little help. No one knew how to swim, so they organized swim training. Some even got certificates and advanced degrees.
People Kept Drowning! But more drowning people kept floating down the river. Sometimes it took hours to pull dozens from the river, and then only a few would survive. Some drowners even jumped back into the water and were swept away.
People Kept Drowning! The Downstreamers wrote a grant to get specialized life saving equipment. They raised private funds to build a waterside rescue facility. Volunteers staffed it 24/7. They finally got funds for paid staff.
But Things Just Got Worse! The number of victims kept increasing, so . . . They analyzed specific patterns of how people were floating down the river, looked for specific eddies and currents, then modified those water flow patterns to reduce local risks and improve the ability to respond
Finally Things Improved! Outcomes research showed that Downstreamers’ rescues increased from 27.8% to 62.3% in 20 minutes or less, 16.7% are saved in 7 minutes or less! Downstreamers were very proud! They wrote articles, attended conferences, got awards
Downstreamers were Proudof Services and Supports . . . New hospital at the edge of the river, A flotilla of rescue boats ready, Comprehensive plans for staffing Highly trained and dedicated swimmers ready to risk their lives Mental health counselors deal with trauma
Downstreamers are Proudof Services and Supports . . . This has been good for the economy A lot of “good people” have good paying jobs, they also feel productive and useful, fulfilled Downstreamers hold an awards banquet every year They get government honors and grants, newspaper articles
. . . But Some Downstreamers Disagree They believe that people need to take care of themselves They’re upset with having to help people “who won’t help themselves” by learning to swim They say other needs go unmet, and they are being taxed to death for people who arent Downstreamers anyway, send them back where they came from No new taxes!!!!!!
Both Groups Overlook Some Key Questions.Someone finally asks . . .
What’s Going on Upstream??!!Who Keeps Throwing People in the River??!! Are systemic causes getting people in trouble?
. . . a couple of Downstreamers Shift their focus:They ask why drowningpeople are in the river at all
Even Worse: They decide to go upstream to find outwho is throwing people in the river, and even worse than that: They decide to do something about it.
Many Downstreamers GetUpset with the Questioners Some complain that the people going upstream are too radical. If people are drowning, it’s their own fault. Others worry that trying to change things will mean people drowning right now won’t get helped. Their work is important. But: What if drowning people stopped floating down the river?
Many Downstreamers Say These People are too Radical The couple are told they should keep working “inside the system,” thats how change really happens. Don’t make waves, even more people will drown. Theyre told not to make too much of a fuss, it isnt polite, and funders might decide to stop giving grants. The couple say theyre going anyway and start to pack.
The Downstreamers Act! Downstreamers hold a meeting and decide to ostracize the couple. The couple load their car to go upstream. Downstreamers rush the couple, grab them, and throw them into the river. They float away.Problem solved!
And Everyone Upstreamand Downstream Lived Happily Ever After Except for the drowning people of course, and those who wanted to reduce the need.
PUBLIC HEALTH IS . . . A shift in focus: The community, society Serve individuals for community welfare Community is the client Social model not medical model Physical, mental, and emotionalContext MattersWhat is the responsibility of the primary care provider? 改善
HYPOTHESIS IIf we just keep helping people at the individual level, the needs will be the same or worse 10, 20, 100 years from now. 改善
HYPOTHESIS IIThe degree, extent or rate of inequality and discrimnination are the two most consistent predictors of social problems 改善
SIX TENETS THAT MAINTAIN INEQUALITY Elitism is efficient (and efficiency is good) Exclusion is necessary Prejudice is natural Greed is good Despair is inevitable, and is the goal to assure conformity [These conditions are sustainable]Derived from Danny Dorling, Injustice: why social inequality persistshttp://sasi.group.shef.ac.uk/presentations/injustice/ 改善
NASW ETHICAL RESPONSIBILIT Y: SOCIAL JUSTICE & DISCRIMINATIONPursue social change, with and for vulnerable and oppressed individuals and groups: Confront poverty, unemployment, discrimination, and other forms of injusticeNot practice, condone, facilitate, or collaborate with any form of discrimination based on race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability 改善
NASW ETHICAL RESPONSIBILIT Y: TO BROADER SOCIET YPromote general welfare of society, local to global levels, development of people, communities, and environmentsAdvocate living conditions that fulfill human needsPromote social, economic, political, and cultural values and institutions to realize social justice 改善
NASW ETHICAL RESPONSIBILIT Y: SOCIAL & POLITICAL ACTIONEngage in social and political action to ensure that all people have equal access to resources, employment, services, and opportunities to meet basic human needs and develop fullyBe aware of impact of politics on practiceAdvocate for changes in policy and laws to improve conditions to meet basic human needs and promote social justice 改善
NASW ETHICAL RESPONSIBILIT Y: SOCIAL & POLITICAL ACTIONAct to expand choice and opportunity for all, especially vulnerable, disadvantaged, oppressed, and exploited people and groupsPromote respect for cultural and social diversity nationally and globallyPromote policies and practices that show respect for difference, support expansion of cultural knowledge and resources 改善
NASW ETHICAL RESPONSIBILIT Y: SOCIAL & POLITICAL ACTIONAdvocate cultural competence, and policies that safeguard rights of and confirm equity and social justice for all people 改善
NASW ETHICAL RESPONSIBILIT Y: GLOBAL SOCIAL JUSTICEAct to prevent and eliminate domination of, exploitation of, and discrimination against any person, group, or class based on race, ethnicity, national origin, color, sex, sexual orientation, age, marital status, political belief, religion, or mental or physical disability 改善
FUNDAMENTAL CONCEPTPublic health is about helping people find ways to lead healthier lives, in every sense.Public health’s roots tap into social work activism about the betterment of society.Public health standards are divided into three core functions further broken down into ten essential services 改善
THREE COREFUNCTIONSTENESSENTIALPUBLICHEALTHSERVICESSYSTEMMANAGEMENT 改善
More Lower steps can be used to Citizen Control influence higher steps, e.g., therapy Empowerment can be a tool to raise awareness to Delegated Power educate and TEN LEVELS OF Partnership empower people. Education Placation Consultation CHANGE Informing Therapy Modified from, Arnstein, Sherry R. Eight Rungs on the Ladder of Citizen Manipulation Participation. In Cahn, Edgar S. and Passet, Barry A, eds. CitizenLess Participation: Effecting Community Change. New York, Praeger, 1971., p. 70. 改善
Community worker Community workerseeks: raises awareness• To gain acceptance Identify of health and social PRAXIS & by community Felt issues, e.g., help• Listens and Needs community CRITICAL empathises members develop COMMUNITY• Encourages video voice maps EDUCATION: expression of ideas of environ-mental Identify conditions, public EMANCIPA- Community speaking exercises TION FORSuccess breedssuccess. New needs Leaders EMPOWER-identified by community MENTmembers. They Identify root causesdevelop skills and gain of social problems,confidence to Provide e.g.,environmental,undertake new tasks. Supports social, economic, Develop political Community From: Tones. K. Skills Self- (2002) Reveille Advocacy for Radicals! Praxis: Stage of The paramount Reflection and Action: purpose of Establish health Solutions identified, Community education. discussed, and acted on Oxford J. Coalitions Community Action 改 改 善
PUBLIC HEALTH AND COMMUNIT Y TRANSFORMATIONShow up, shut up, and ListenIn other words,therapists have a lotto offer efforts tochange the contexts thatcause social problems 改善
SERIOUS INCREASES IN DISEASES AND ILLNESSESExposure to toxins, pesticides, poisonsAir quality: diesel exhaust, carbon monoxideNoise pollution (leads to decreased academic performance)Water pollutionPerverse incentives: Fast food would not be cheaper without tax incentives to produce those types of products 改善
HEALTH DATA STATISTICS: PART ONEMillions, perhaps billions have been spent on obesity and diabetes reduction and treatment.Have the numerous campaigns to reduce the rates of obesity and diabetes been effective?Time period: 1985-2010 (Note: the CDC changed its reporting methods in 1995) 改善
HEALTH PATTERNSHypothesis: The greater the degree of inequality in a society the higher the levels of virtually every type of social problem, including health problems. Sources Wilkinson and Pickett. The Spirit Level: Why Greater Equality Makes Society Stronger http://www.equalitytrust.org.uk/ The State of Working America Economic Policy Institute: Working Group on Extreme Inequality http://www.stateofworkingamerica.org / http://extremeinequality.org/ 20 Facts About US Inequality Everyone Should Know http://www.stanford.edu/group/scspi/cgi -bin/facts.php 改善
WHAT’S THE BIG DEAL?• In 1974 The Lancet identified obesity as “the most important nutritional disease in the affluent countries of the world.” • Infant and adult obesity [editorial]. Lancet 1974; i:17 -18.• What happened since then? We got fatter.• Worldwide, we’re dying at higher rates and nations are becoming obese.• It’s a syndemic: Obesity, diabetes, asthma, other related diseases are tied together. 改善
A NUMBER OF NEW YORKERS ARE UPSET BY MAYOR BLOOMBERG’S SODA BAN, SAYING THAT IT IS A CHANGE THAT WILL DRAMATICALLY EFFECT THEIR LIFEST YLE. 改善
ABOUT “IT’S JUST ONE SODAx 365 days/year = 15 pounds of body fatSo-called “juice drinks” and“power drinks” are just asbad.They all rot your teeth.Half of Americans’ caloriescome from soda. Half! 改善
ABOUT RESTAURANTS• A typical restaurant portion size is two to three times more than servings should be.• We’ve been conned into measuring quality of food in terms of quantity.• We get far more saturated fat and far fewer nutrients than we should. We’re starving while becoming obese. 改善
ABOUT RESTAURANTS• Kids get hit the hardest: They get twice as many calories in restaurant meals than they need.• This simple fact yields a population of kids that is amazingly obese, will have lifelong health problems, and will die younger than they should.• Our marketing system is killing our kids, and we’re letting it happen. 改善
“SPEC” MODEL: ISAAC PRILILTENSKY Traditional Focus Transformative Focus Deficits-based Strengths-based Reactive Primary Prevention Individual & Family Empowerment Professional-driven Community Conditions Role shift: From “expert helpers” to “critical change agents” Focus shift: From individual to community (context) Power shift: From “providers” to community members Locus of control shift: From victim to empowered actorHttp://people.Vanderbilt.edu/~isaac.prilleltensky 改善
DO OUR CURRENT HEALTH SYSTEMS WORK?No. If they did, we would see successes. “A trap we must avoid, set by the food industry [is] the belief that education is the answer to nutrition problems. The ostensible rationale is that people do not understand nutrition, that educating them will drive up demand for healthier foods, and that the industry will be happy to meet that demand. The hidden rationale is that such programs will have little impact, allowing industry to do business as usual. I can see industry executives jump with glee each time government officials point to education as the answer.” Kelly D. Brownell. http://www.latimes.com/news/opinion/la -op-dustup19sep19,0,1026838.story 改善
RESULTS OF HEALTH EDUCATION1. education has weak effects, if any;2. it drains resources;3. it makes industry seem on the side of consumers; and4. it bolsters industrys hope that government will allow it to self-regulate while government agencies sit on the sidelines.5. It is the “perfect” script for public health failure.• K e l l y D . B r o w n e ll. h t t p : / / www. la t i m e s . c o m / n e ws / op in io n / l a - o p- d us t u p 19 s e p1 9 , 0 , 1 0 26 8 38 . s t o r y 改善
ABOUT INDIVIDUAL BEHAVIORThis epidemic is about more than just individual behavior.Analyzing only individual behavior, assigning blame just to each individual does not explain the stunning change in the pattern of behavior across individuals.Something more than just “individual responsibility” is going on. (But that doesn’t let individuals off the hook!) 改善
QUESTIONSSo why does the US continue spend any money at all on health information and education, obesity prevention, healthy lifestyles, etc., when it clearly does not work?If a similar pattern were experienced in any domain – private business, government, non- profit – what would you advise be done?Follow the money: Who benefits from these realities?The Point: You have to dig deeper. 改善
CONSIDER“If people want to drink 24 ounces of soda, it’s their choice, and nobody else’s business.” Does social, economic, political context have an impact on individual behavior? Are we “free” in some abstract way or does the context in which we live impact our choices? 改善
“CLEAN SHEET” EXERCISEBrainstorming Context: Forget everything you know about health, healthcare, mental health, substance abuse, wellness, systems and programs.Using the core assumption: If you were free to spend a health budget however you could, what would you do? 改善
“CLEAN SHEET” EXERCISE If we were to create a health system from scratch today, how would we organize ourselves and allocate resources, and what would be our community priorities? Work in small groups and develop clean sheet systems of care. Brainstorm wild ideas as well as practical. Choose a policy domain(s) of interest to your group. You can focus on real agencies, your own communities, local entities, state or national policy, your choice. 改善
CLEAN SHEET EXERCISE Try to develop something that you could work toward in your own community. How would you design your approach to developing your plan? Who would you talk to? What procedures would you use to implement your plan? How would you promote it? What community-level indicators would you measure? 改善
CORE ASSUPTION: CONTEXT MATTERSIf we keep doing things the way we do them right now, 50 years from (assuming the world hasn’t imploded) the next generation will be doing exactly the same things we’re doing now.Only the need will be even greater.The more an intervention engages power equalization, the more transformative it will be (Isaac Prilitensky) 改善
DISCUSSIONSmall group presentations.What are the implications of using the NASW standards and to reform the helping professions, health care plans in this case?15 minute small groups, design a broad intervention strategy. 改善