When I first started working at the health department, one of my first tasks was to bring the influenza surveillance system up to speed. It used to rely on reports from a few physicians here and there, lab reports from the state lab, results from outbreak investigations, and investigations of child deaths associated with influenza. That was it. My work for my master’s in public health was all about influenza surveillance. I managed to stitch together an effective influenza surveillance system in a rural setting as my “culminating experience” to get my master’s degree. So I used what I learned then to expand and enhance the influenza surveillance system in Maryland. The only things standing in my way were the mental models of the people whose approval I needed.
What is a mental model?
No, not a fashion model with “issues”. (Source)
A mental model is, in essence, a “world view,” a “bias,” or a notion of how things work. Before we knew that the Earth went around the sun and that it also rotated about its axis, the mental model of the universe was that we were the center of the universe and that everything else travelled around us. Of course, we eventually learned the truth and the mental model of the universe changed for nearly all of us.
The mental model I had to contend with at the health department was that the old way of doing things was good enough. So we didn’t know exactly what strains of influenza were circulating and where, so what? Well, by 2008, nearly 100% of all H1 strains of influenza (the pre-pandemic H1 strain) were resistant to oseltamivir, a popular antiviral. Knowing what strains were circulating would give healthcare providers the information they needed in order to decide whether or not to prescribe the antiviral. To achieve that, I wanted to recruit clinical laboratories from all over the state to report the number of rapid tests for influenza they performed, how many were positive, what type they were positive for (A or B), and then have them submit a sample of their specimens to our state lab so we could know the strains. But, again, the old was was “good enough.”
It took some time to convince the bosses that my plan was good and that it would help us track and even predict how the flu would behave in the state. Eventually, they agreed, and the system expanded to include about 30 clinical labs all over the state. Then, the next year, just in time for the pandemic, I suggested using the internet to track illness in people who would otherwise not go to the doctor, people who were not too sick but still sick enough to miss work or school. Again, I ran up into the mental models of some of the bosses, but I had learned from the previous year’s experience that I had to bring evidence of something similar working in other places. Lucky for me, Australia had a lot of success with a similar program.
Without a doctoral degree, I had to do battle with a lot of mental models at the health department. Now that I’m getting that doctoral degree, I’m having to do battle with other mental models, but that’s for another post later.
We encounter mental models that stand in the way of progress and solutions all the time. In some countries, women are not allowed to be functional parts of society, so what can we expect with regards to women’s health in those places? Very little. It’s an uphill battle. Same goes for places within our own country where the mental model of issues like poverty, teenage pregnancy, obesity, etc., is that people are just being irresponsible and that their environment had nothing to do with it. (This is the view of far too many policymakers, sadly.) To get at these problems, we need to change mental models. That is a monumental task.
Think about it, the first scientists to say that we were not the center of the universe were tried (some executed) and shunned from their societies for the rest of their lives… For stating the truth! If I go to Capitol Hill right now and tell lawmakers that they’re doing it wrong, they’ll kick me out. (Those who stand on Mt. Olympus hate being told that they’re capable of human mistakes, in my opinion.) People in power and authority will resist change at any cost. In fact, the old saying about bureaucracies is that they exist to keep the status quo, and not much more.
So how do we get things done? How did we pass seatbelt laws and smoking bans when it comes to public health? Well, it wasn’t instantaneous. Scientists have been telling us about dangers from time immemorial, but it took a change at the social level — a change in the mental model of the majority — to get things done. Now, if someone lights up on a plane or in a crowded restaurant in Maryland, the rest of the crowd will want that cigar or cigarette snuffed out.
And then turned into glorious art. (Source)
It happens, but it takes time. Sometimes, it takes too much time.
We’re seeing it happen right now with the Affordable Care Act. The mental model is that healthcare is a product that people must buy. If you’re rich, you get better healthcare. You can afford a better provider and get better care. If you’re poor, it sucks to be you. You’re left with maybe emergency room care or going to some charity that will hire some kind-hearted provider to look after you. If you have health insurance, great for you. You may get some of what the rich can afford, though maybe at the quality and accessibility of what the poor can only dream of. If you don’t have health insurance, why don’t you get a job, you hippie?
Of course, it’s much more complicated than this. There are plenty of fully-employed people who cannot afford healthcare, or they live in parts of the country where access is lacking. (Yes, there are places in the most powerful nation where there are not enough providers and health services to go around.) And the ACA is not the end-all, be-all of all things. Much work is yet to be done in other areas.
And, of course, you all know about my continuing battles with people whose mental model is one of anti-science and lack of reasoning. But that’s for a later time too.
What to do, then? We can start by crossing our T’s and dotting our I’s. Nothing hurts a project like getting something wrong. A delay can kill anything you’re working on. A bad apple ruins the batch. You know what I’m talking about, right?
Next, make the policymakers, or the ones in power who you need to convince to get something done, make them think that it was their idea all along. How you go about doing this effectively depends on what you’re trying to do. Some people are very gullible, even if they’re in charge and are supposed to be leaders. Others are skeptical of every little type of change. You’ll have more of a problem of playing Jedi mind tricks on them.
All in all, remember to expect a lot of resistance to change, and even more resistance from those who are insecure and see you as a threat. That second scenario is far too common in these times of economic uncertainty. If some young “whipper snapper” comes along and shows to have promise, the “old guard” will not let you into the “inner circle.” Their mental models will be cemented. So get ready to bust some concrete.
René F. Najera, DrPH
I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
About History of Vaccines: I am the editor of the History of Vaccines site, a project of the College of Physicians of Philadelphia. Please read the About page on the site for more information.
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