March 22, 2019 — When many people think of design they’re probably picturing a product, like a new smartphone or car. But the design principles that lead to the creation of those products—such as the focus on human behavior or the use of prototyping—can also be harnessed to tackle complex public health challenges.
In this week’s episode you’ll learn how one of the world’s top public health researchers, Ashish Jha, dean for global strategy at Harvard T.H Chan School of Public Health and director of the Harvard Global Health Institute, and one of the world’s foremost design experts, Patrick Whitney, professor in residence in the Department of Health Policy and Management, have teamed up to think about how design methods can be used to address issues ranging from the opioid epidemic to the future of hospitals.
This episode is a collaboration with Harvard Global Health Institute.
Rethinking WHO: Students see a bigger role for frontline health workers (Harvard Chan School news)
NOAH LEAVITT: Coming up on Harvard Chan: This Week in Health…What can public health learn from the design world?
PATRICK WHITNEY: Design doesn’t look for the truth or the perfect answer. Design looks for a better answer than the current situation.
NOAH LEAVITT: In this week’s episode: A leading public health expert and a leading design expert share what they’ve learned from each other and how the principles of design can be applied to address some of the world’s most complex health challenges.
ASHISH JHA: Design isn’t a substitute for what we do already in public health. It’s not a substitute for statistics. It’s not a substitute for epidemiology or economics. It’s a complement to those things, because all of them have their shortcomings. And public health has got to go beyond the shortcomings of its traditional areas of study, and has got to bring in new tools to move the needle further.
NOAH LEAVITT: Hello and welcome to Harvard Chan: This Week in Health. I’m Noah Leavitt.
Ashish Jha was skeptical the first time he heard Patrick Whitney speak.
Jha is the director of the Harvard Global Health Institute and Dean for Global Strategy at the Harvard Chan School. Whitney is professor in residence in the Department of Health Policy and Management at the Harvard Chan School, and one of the world’s leading design experts.
Whitney previously served as Dean of the Institute of Design at the Illinois Institute of Technology, where Jha heard him speak about design’s approach to health problems.
That initial skepticism gave way to enthusiasm—and eventually partnership—as Jha learned how the perspective of the design field could be useful in addressing a range of public health issues.
In 2017, Jha and Whitney taught a class together, Design of Social Innovation which asked students to use design methods to find ways for the World Health Organization to more effectively manage disease outbreaks.
That class is running again this semester, focusing on smart cities.
We wanted to learn more about this partnership between Jha and Whitney—and how lessons from design can be used to address issues ranging from asthma to the opioid epidemic to the future of hospitals.
So, we partnered with Stefanie Friedhoff, the assistant director of communications at the Harvard Global Health Institute, to produce a really fascinating interview with Jha and Whitney.
A key takeaway from the conversation is that design’s value comes from the fact that it really focuses on human behavior—providing insights into better ways to implement a public health program or even just finding ways to make it easier for people to make medication.
But first, Friedhoff started the conversation by asking Jha to recall that first encounter with Whitney—and to explain that initial skepticism. Take a listen.
STEFANIE FRIEDHOFF: Well, thank you again, both, for being here the podcast with us. Ashish, I’m going to start with you. Our topic today is, what can design do for public health. What did you first think when you heard about this idea of bringing a design expert to help with public health problems.
ASHISH JHA: So my first real encounter with design was a few years ago when I had a chance to visit with Patrick in Chicago. And I arrived that morning– I remember it very clearly. And I remember Patrick standing up and talking about approaches a design takes us solving problems. And I would say about 10 seconds into his talk, I started feeling very skeptical. And as he continued, I got more and more skeptical.
And about five, seven minutes, I couldn’t hold back anymore, and I had to raise my hand and ask. And let me explain the skepticism. So much of what I have cared about– what many of us care about in public health– is about bringing evidence, bringing science and data, to moving away from solving problems by saying, hey, how does this make me feel?
I feel like vaccines are unnatural and cause health problems. Well, I understand. But the evidence and the science and data are very clear that vaccines are safe and effective. And so what I initially perceived listening to Patrick was something that felt very effort antithetical to what I think is fundamental to public health. And so I raised my hand and asked him about it. And I hope I did it respectfully, Patrick.
PATRICK WHITNEY: You did.
ASHISH JHA: But that was the skepticism. And I’m an empiricist. Even my little tag line is, an out of evidence is worth a thousand pounds of opinion. And this felt like anti-evidence to me, and it worried me.
STEFANIE FRIEDHOFF: Patrick, how did you experience that encounter and the questions that you got from Ashish there?
PATRICK WHITNEY: Well, a lot of people are skeptical about design because of lack of evidence. You weren’t unable to make the dinner the night before, but David Gergen was in the room at dinner and asked what was the reading we had done as background material for work we had done on helping the aged live more graceful lives in Hong Kong. And my answer was, we didn’t do any reading to begin with. Because there was too much to read about what the funders assumed the problem was, which was housing. It would have taken us a year to read about housing for the elderly in China.
And what we did is interviewed experts, and then went out and met with elderly people. And we rapidly found out that housing wasn’t their big problem. Housing was a problem, but it wasn’t the sole problem. And the last thing they wanted was a elderly ghetto. In working with them and doing day-in-the-life studies, we changed the questions from what housing do they need to how do they want to live. And housing was part of that.
The difference is that empirical evidence is wonderful when you’ve got problems that can be solved in a deterministic way where there’s a right answer. But there’s so many things in daily life that– we don’t have evidence about how people feel about getting older. We don’t have evidence about how people shop when they’re elderly. That those issues can be overlooked if you look at the existing literature.
STEFANIE FRIEDHOFF: Ashish, is it this kind of argument that changed your mind? Or what made you–
ASHISH JHA: As I went through the day– and it’s interesting because even by the end of the day, I was feeling a little less strident, shall we say.
PATRICK WHITNEY: But you were still skeptical when I visited you in Harvard months later.
ASHISH JHA: Absolutely. And obviously I have my skepticism has given way to real enthusiasm. But that journey has been a long one, and has been a considered and deliberate one. I’ll tell you initial crack in my thinking came later that morning. I was watching a presentation of a project that Patrick’s team had done with a professor there where they looked at kids who kept coming back to the emergency department with asthma exacerbations.
And they looked at the fact that– like, look, we know how to prevent asthma exacerbations. These kids and their parents were getting the right information. We had the evidence, we had the science, and yet it wasn’t quite working.
And what they did is they went into people’s homes. They figured out how people were living. They understood why the evidence wasn’t translating. And, of course, it made eminent sense to me that so many public health problems are actually about behavior and about how people live lives and what they value. And just walking in and saying, you need evidence, and this will give you the best scientific evidence– it just doesn’t work. It does for some people, but for very many people, it doesn’t.
Even the vaccine example I use. The evidence is extremely clear, but there’s still people who are hesitant about vaccines, who aren’t quite ready to accept it. And it hit me that this wasn’t a classic scientific problem to solve. It was a human behavioral problem to solve.
And the way that design people thought about these issues seemed to have some importance that we as public health officials often didn’t pay attention to it. And that’s what got me initially thinking.
PATRICK WHITNEY: Staying with the asthma problem for a minute. What the team noticed as they went in was that the problem was holes in the hole where rodents and insects– triggers for asthma– were living. But as far as we could tell, holes in the wall isn’t part of the protocol for treatment prescribed by the NIH. So, in a sense, the medical doctors couldn’t look at it. It’s not part of the protocol.
ASHISH JHA: They didn’t even know about it.
PATRICK WHITNEY: Whereas it was obvious to us one of the first things to do is get some Saran wrap and plug those holes today, and then come back tomorrow and do it with plaster.
STEFANIE FRIEDHOFF: So this is a traditional, I would say, problem in global health. That we provide people with drugs, for example, but then they don’t have enough food to eat to actually absorb the drugs in the way they’re meant to be absorbed. So, if you could, Patrick, talk a little bit about how are you helping people in public health see more of the problem or take a bigger look. How does design help us do that?
PATRICK WHITNEY: Well, in the class, we give them problems that don’t have a definitive right answer. Design doesn’t look for the truth or the perfect answer. Design looks for a better answer than the current situation, and believes that the answer would be better yet if we had a little more time to keep working on it.
It’s a fundamental difference. When you’re not looking for the truth, you can get to better much quicker. So I give these problems to the students. For example, providing healthy, tasty food to people who don’t have enough food in the Boston area. That’s a complex problem, but it’s not a complex problem like a complex problem in physics or chemistry or physiology. It’s a complex problem where you don’t have all the information.
We give them frameworks for dealing with that ambiguity so that they aren’t making uneducated guesses, but they’re making informed guesses. Not based on scientific evidence, but evidence about the project. I think of it as– I don’t know whether this is the correct way of thinking or not, but I think of public health dealing with the– deals with problems with the rigor of the general. Looks at massive amounts of data very rigorously, and to find principles.
Design looks at the rigor of the particular. We look at how people make breakfast. How they send their kids off to school. How they use the atomizer in the morning, or not. One kid wasn’t using the atomizer because his parents didn’t have time to do it because they had to walk him to school because there were gangs in the neighborhood. And they had to trade off– the way the parents said it is, I know this is bad for my kid not to use the atomizer for the long term. But it’s life threatening for him not to be walked to school everyday.
STEFANIE FRIEDHOFF: Immediate life is more important than that, yes.
PATRICK WHITNEY: Yes, exactly.
STEFANIE FRIEDHOFF: Which is a great example also for global health problems.
ASHISH JHA: Absolutely.
PATRICK WHITNEY: So how do you deal with that?
STEFANIE FRIEDHOFF: Yeah. Let’s back up for a moment. Patrick, you are teaching a class right now at the School of Public Health. It’s the second time you’re teaching it. Tell us a bit about who takes this class. Why are the students there?
PATRICK WHITNEY: It’s mostly students from public health. But there are students from Kennedy, engineering, business, tough school public policies has students in it. And there are about 25 or 30 students in the class. And they are accepting the level of ambiguity and the open-ended exploration very well. They’re enjoying it.
Now, it’s fair to say they were given fair Warning before they signed up. But people from a technical background– science or engineering– who enjoy ambiguity do wondrous work in design. Now, maybe the majority of them don’t enjoy ambiguity. But those who do love design.
So these students are having a great time. And they work in small teams on projects, and get small lectures to catalyze those projects. It’s not an issue of me relaying information to them. It’s an issue of me creating a context where they develop their own content and their own answers to the problems.
STEFANIE FRIEDHOFF: Ashish, you just talk to the students in the class. You talk, presumably, to other people at the School of Public Health about why this is important. What are some of the things that you tell them? Obviously, there’s a lot of people who don’t like ambiguity or uncertainty, which are at the core of a lot of these complex problems. How do you help people understand this?
ASHISH JHA: The approach I’ve taken– and it’s been interesting, learning design from Patrick. I’ve started seeing its application in more and more public health problems. Arguably, in almost every public health problem, there is an application of design. And what I’ve done is try to lay those out for people. I try to lay it out in class.
The fact that– just recently, for instance, President Trump announced that he wants America to get to zero new HIV infections by 2030. Well, if you think about the science behind HIV infections, we have great diagnostics. We have great treatments. Policy is mostly good in that we now give people access to treatments. Most people have access to drugs.
And yet our best estimate is that half of people who have HIV in America are on drugs in a way that’s truly suppressing their viral load. 50% efficacy in the context of guy getting all the science right. That’s crazy.
And so then, when you start taking apart why has this been so hard, you realize there’s a whole set of issues where design would be actually extremely helpful. A lot of people don’t take their medicines. And the simplistic and wrong answer is to say, well, those people are not very smart, or they don’t care about their health. No, that’s all wrong. We know that’s wrong.
And there is no one answer for why people don’t take their medicines. Design lets you get into that, and understand human behavior and the ambiguity on the trade-off people make, and gives you new tools to begin to move that needle. We could talk about TB. We could talk about smoking. We could talk about almost every major public health problem. And you end up with all of these elements.
And what I try to convey to your students in class, Patrick, and what I have tried to convey to my colleagues is that design isn’t a substitute for what we do already in public health. It’s not a substitute for statistics. It’s not a substitute for epidemiology or economics. It’s a complement to those things, because all of them have their shortcomings. And public health has got to go beyond the shortcomings of its traditional areas of study, and has got to bring in new tools to move the needle further.
PATRICK WHITNEY: Let me give an example of that. We did a project several years ago at the Institute of Design about people recovering from heart disease, where the recidivism rate is 50%. And when we looked at what they did, they tried to follow the regimen that they were given. And it turns out that eating with one’s family is not a clinical or medicinal experience. It’s a joyful experience, and ties the Family together. So people fell back into their old eating habits and eating habits and cooking habits and family ways.
So what the student did was stop thinking of the problem as something that needed to be treated, but bring the joy back into it. She made a digital cookbook that allowed people to pull ingredients onto their plate. You could see the plate. Size them. You could see the calories and fat going up and down as she sized it.
It expanded the repertoire of meals. Most people eat 15 recipes they repeat, or fewer. This expanded that. Made it joyous. So much so that people who didn’t have heart problems wanted to use it as a cookbook. So how do you flip it from something that needs to be treated to something that works and the joyful side of life? And by the way, the treatment gets better.
STEFANIE FRIEDHOFF: Tell us a bit about how, in practice, you get to these results. I mean, these stories sound fantastic, and they make a lot of sense. But what is the process of identifying that this is the actual problem, or the obstacle that you need to overcome?
PATRICK WHITNEY: On small projects, you start by looking at what the user’s experience is, both good and bad. And think of ways of accomplishing the goals by amplifying throughout the amplification of the positive experiences. On larger projects, things at the scale that public health have had deals with or a hospital deals with, you not only look at user experience, but you look at the organizational strategy, the organization operations, and the offerings, as well as user experience. And you find a new way to create more value for the organization– maybe the hospital– by changing the operations or changing the offering.
And you’re also creating more value for the end user. It’s looking at the whole view of the problem, rather than a slice. Which is what gets us into problems with people who insist we should be using evidence. Because when you look at the whole view, you’ve got too many variables to land on something that’s statistically significant.
STEFANIE FRIEDHOFF: Ashish, there’s a lot of talk in the medical field about how hospitals have moved away from serving the actual patient. It sounds like good design could help with this problem. Is that how you think about it? Is there an application?
ASHISH JHA: If you think about where health care is today– let’s pick hospitals, since you brought up hospitals. An American hospital today looks not that different from an American hospital 100 years ago. There’s new technology, new training, sure. All of that is different. But the fundamental design concept behind what it means to take care of somebody, how you deliver it, all of that has remained more or less the same.
So yes, medicine’s gotten– there’s more money. It’s gotten away from some of its traditional values. But the bottom line is that there are some fundamental aspects of medicine that haven’t changed at all. And what I think is probably the most exciting application– one of the more exciting applications– is to reconceive what is hospital care. How you would design physical spaces for healing.
Right now, it’s designed for convenience of doctors and nurses. And by the way, let me tell you as a person who practices in hospitals, it’s not even all that convenient for doctors or nurses. So one area where I think there is a lot of opportunity for design is to go into physical spaces where people receive care, and think about what we’re trying to achieve in those areas, how we’re trying to promote healing and rest and wellness, and how do you redesign this space. How do you redesign the workflow.
And in that approach, I think there are a few places starting to think about that, but that’s a massive opportunity for design. One of things that I’ve come to learn over the last year is in almost every complex problem we look at, there’s a very big pull for design. And I think certainly health care and hospital care is, for me, near the top of that list.
STEFANIE FRIEDHOFF: What are some other areas that you think are ripe– if you could apply Patrick to three problems, where would his team go?
ASHISH JHA: So, things that have a big behavioral component. Medication non-adherence, as we like to use the term– it’s a terrible term. But when people don’t do what we tell them to do, that is a huge component of moving public health forward. And I feel like that’s a place where design can be enormously useful.
Another area is when you think about things that have a very large structural component. So what do I mean by that? It’s like road traffic injuries. Probably the number one cause of death and disability among young people on the globe.
It’s such a complex problem, and it’s so begging for design. Not because design will solve it. One of things I’ve come to appreciate from Patrick is that design is rarely looking for solutions. And one of his lines, which I love and quote liberally, always with attribution, is he says, it’s better to be approximately right than precisely wrong.
PATRICK WHITNEY: It turns out John Maynard Keynes had that phrase first.
ASHISH JHA: Oh, he did?
PATRICK WHITNEY: But we’ll use it.
ASHISH JHA: OK, I’m calling it a Patrick Whitney phrase. But it’s really helpful because we always are looking for solutions in public health. And what this does is, in things that are complex and structural, like road traffic injuries; very behavioral, like getting people to take their TB meds; very physical space oriented. In those instances, it strikes me that design has a lot to offer– not in solving it, but moving the ball forward in a meaningful way so that people are much better off.
PATRICK WHITNEY: A big part of our design does is it changes the questions you ask, rather than come up with an automatic answer.
STEFANIE FRIEDHOFF: So let’s talk a little bit about the behavioral health component, which has been a part of public health forever. Public health has always been about how do we change people’s behavior. How is design different? And how do you not get in trouble with the people who have been doing this for a really long time?
ASHISH JHA: So one of the things we’ve learned in public health is behavior change is hard. And that’s a first thing that people say. Changing people’s behavior is hard. And it is hard.
And I think we try things, like we give people incentives. Behavioral economics has made, obviously, huge inroads in trying to understand how people make decisions and how they think. One of the things that I’ve come to, I think, appreciate is that economics has certain traditional models of rationality of how humans behave. And every time humans don’t behave in those ways, we think people are being irrational, and then we think about how to basically beat them up so that they can be a bit more rational.
My experience with design– and Patrick, who’s obviously the expert here, may have a different take– is that design takes people where they are. Doesn’t immediately assign a value judgment, like you’re making a bad decision, you’re being irrational, you’re not taking your meds, you’re smoking, you’re a bad person. Gets rid of all that.
Begins with, where are you? What’s going on? You’re making the decisions you’re making. And then how do we help you redesign your life so you make decisions that are better for you? It’s a very different approach.
And I wouldn’t say it’s completely antithetical to what other people have done. People in public health I’ve tried that. I think this just augments and supplements some of those.
PATRICK WHITNEY: And to emphasize one of those points is design will accept that people are irrational, and not try and get them to be rational.
ASHISH JHA: I love that, because–
PATRICK WHITNEY: We are.
ASHISH JHA: We are.
STEFANIE FRIEDHOFF: We are.
ASHISH JHA: It turns out.
STEFANIE FRIEDHOFF: Or also, as your example earlier showed, we might not have the full picture. So we it’s a very rational choice to save your child from being shot, and put the asthma care later if those are your two options. We just may not be seeing both of those.
PATRICK WHITNEY: Yes, absolutely.
STEFANIE FRIEDHOFF: So, Patrick, you’ve had a distinguished career. You’re a renowned design expert and all around the world. You could have picked any field to focus on. Why public health?
PATRICK WHITNEY: Well, there’s the inherent value to society that public health has, which is attractive. But in terms of type of knowledge and type of information, I’m very attracted to the problems. I think of it as design being able to contribute to the behavioral side of medicine. And when you say that, as you mentioned earlier, you land on public health. The nature of the problems have a rational, statistically significant, evidence-based aspect to them, which is– dealing with that is something that design can learn from, and will help design. Having a structured way of dealing with irrational people and incomplete information that changes faster than you can understand it is a way that design can help public health.
STEFANIE FRIEDHOFF: Ashish, has working with Patrick changed how you think about your work? You wear a couple of different heads, though.
ASHISH JHA: Yeah. You know, it’s interesting. Before we started this podcast, I was describing to Patrick that I’m facing a complex problem, which is a talk I have to give where I don’t have a clear sense of what I want to say, what the audience needs to hear. And I described my approach. And he was laughing because I was describing a classic design approach.
I was prototyping. I was iterating. I was trying to get to approximately right. I was living with ambiguity. And there are two points on that.
One is, it’s not like I never did that. I mean, a lot of us do those kinds of things. Sometimes it’s useful to put a name on it. And sometimes it’s useful to know what you’re doing and why you’re doing it because it helps you be more deliberate about it.
And so, for instance, in this specific instance, it’s understanding that I’m taking a very design approach, as I’ve learned from Patrick, makes me feel calmer because I know there’s a process. And I know that with each iteration my own ideas will get clearer. And this approach– so I would say, absolutely.
Whether it’s my research, whether it’s the work that I do as a director of a global health institute, as a leader at the school, all of it has, I think, has been influenced by design. And some of it much more explicitly than I think I appreciated.
PATRICK WHITNEY: What you’ve just described is an interesting switch to what I call the Jack Welch approach to projects, where you identify a project, identify the answer, and then optimize towards that answer. And success in accuracy and quality comes from how closely your end result ends up being to the predicted result, which you described as something completely different. If you have a general idea of where you’re going, and you work your way towards it, having faith you’ll come up with something better and more interesting than what you would have had you [INAUDIBLE] it at the beginning.
ASHISH JHA: Yeah. It’s a little unsettling, though.
PATRICK WHITNEY: It’s easier if you give it a name and remember that you’ve done it before.
ASHISH JHA: Right. It’s definitely been helpful in that way.
PATRICK WHITNEY: You end up turning a corner where what’s unsettling is if your idea isn’t changing as you go. None of us believe that we’re smart enough to have the right idea with 2.0.
STEFANIE FRIEDHOFF: Yeah. And very often it is our hesitancy to go to that uncomfortable place to endure it for a moment to actually see other solutions, or other approaches.
PATRICK WHITNEY: But it’s great when that uncomfortableness becomes fun.
STEFANIE FRIEDHOFF: Yeah.
ASHISH JHA: Yeah.
STEFANIE FRIEDHOFF: So that’s a behavioral change in–
PATRICK WHITNEY: Yes, in us.
STEFANIE FRIEDHOFF: –the researcher and in us. Exactly.
ASHISH JHA: Absolutely.
STEFANIE FRIEDHOFF: So, Patrick, what has surprised you? You came to the School of Public Health about one and 1/2 years ago. This is the second time you you’re teaching design for social innovation.
PATRICK WHITNEY: Well, I remember when Ashish asked me to sit in on a discussion about a research paper you were framing. And what I realized as I was listening was something that taught me something about not just public health, but about design, too.
What you were doing which your team was taking large databases that had been existed for a while and hadn’t been done in relationship to each other. But you were relating them together, and you were looking for insights in them. What struck me is never once did anyone in the conversation suggest that we go into a user’s home and see what an activity was like it was leading to some of this data.
And it occurred to me what designers would do if they were working on that problem is never look at data sets, but would go into people’s home, and make conjectures, and work their way towards a solution. And, to me, bringing those two things together would be good for public health and good for design.
ASHISH JHA: What is interesting to me in watching Patrick is– look, he won’t say this about himself. You’ve alluded to this, but I had the pleasure of chairing the search committee that ultimately led to Patrick’s appointment. Our first ever appointment at the school as a professor in residence. And pretty much across the board, the letters all described him as the leading design scholar in the world. Some people were like, well, maybe he’s one of the top two. But once you’re in the top two in the world, you’re pretty much there.
What’s really impressive about Patrick– and he just did it right now– is, when you become the leading voice in a certain way to solve the world’s problems, you see that as not just one way, but often the best way. And design has a lot to offer the world. And what I have found so generous in his thinking is he understands design’s limitations. He appreciates what public health brings that design doesn’t.
It’s easy enough now, in retrospect, to talk about what design brings and public health can’t. But he’s thought a lot about how does public health influence design. When I’m doing my studies, I’m looking at how to improve heart failure care. No, we don’t go into people’s homes. We look at national Medicare data, we look at policies, et cetera, and try to think about what makes care better.
He doesn’t poo-poo that. He just sees that as a complement to what he’s done. And I think that makes you more effective in talking to people on the public health side. And hopefully it makes us more effective in helping design as a field get better.
PATRICK WHITNEY: Yes. And to illustrate how what you’re describing can be taken to silly lengths, there are papers now in journals– I was handed one two days ago– with titles about why human-centered design doesn’t have all the answers for health care. Well, who on earth thinks that it did?
ASHISH JHA: Right.
PATRICK WHITNEY: And we should find those people, and correct their activities.
STEFANIE FRIEDHOFF: Well, this is the problem often when we feel like we have a new hammer, and everything is a nail. And I think at this point of being excited about having you here, let’s also talk a little bit about what are some of the limitations. Where should people not be confused about problems or ways that design can not be helpful?
PATRICK WHITNEY: There are lots of problems which aren’t behavioral. And there are lots of parts of problems which are not behavioral or related to culture. And when there’s evidence about what to do in those areas, and you’re not venturing into the unknown, fuzzy area of people’s daily lives, you don’t want design to have much say in those problems.
STEFANIE FRIEDHOFF: You don’t want designers to actually make the vaccine?
PATRICK WHITNEY: That would be a mistake.
ASHISH JHA: Yeah, or if you’re testing whether drug A or drug B is more efficacious in a clinical trial, that’s a classic scientific problem where–
PATRICK WHITNEY: Or when you’re looking at those large data sets that your team is looking at, and your question isn’t how do we make people’s health better, but how do we make hospitals, in this situation, operate more efficiently or effectively. Designers might have a little bit to contribute to that, but I can’t think of what that would be right now.
STEFANIE FRIEDHOFF: So, as a journalist who’s covered global health problems for a long time, I was struck by the initial idea of design coming into the picture, because a lot of the issues that I see as a reporter, where I see things at the very end when they try to hit the ground, and when you see the implementation is working, and if an approach is working, you see all the things that people didn’t think about. And you see the cultural mismatch, and you see that bigger picture that you were mentioning earlier where design helps you see the hole in the wall, and not just the immediate thing that you talked about. Which is sort of what got me excited about it.
Ashish, are you thinking about it in those same ways, where we’re like, we have the vaccine, but then we really have the problem?
ASHISH JHA: Yeah, almost every– one of the public health problems– crises– that has really had a very profound influence on how I think about public health problems is the Ebola outbreak in West Africa 2013 to 2015. And here is a disease– we’ve seen it 20-some-odd times before.
It’s a disease where we actually know how to treat people. And in a good health system, the mortality rate should be 5%, 10%, maybe even 0%. And yet we saw what happened in West Africa, where 11,000 people died. And it was a failure on so many different levels. And what was interesting is, in retrospect, it all seems obvious. The issues around trust. The issues around communication.
And so one of the things I’ve often thought about– and by the way, here’s the craziest part of it. There was an entire system designed to counter exactly these kinds of problems. It was very thoughtfully crafted, and then none of it worked. None of it got implemented in the right way.
And so one of things I’ve thought a lot about is how do we make sure these things don’t happen again when they keep happening. And part of it is taking a much more proactive approach to identifying these problems. So, in retrospect, you can say, well, the problem was trust. People didn’t trust the authorities. Sure.
But if we could have prospectively gone in with more of a design approach and understood how people live, and how they felt about different kinds of things, one of the hardest things initially was getting people to change their burial practices. Because that was a major source of transmission. We had to understand why burial practices were important, what they signified to people, and why somebody coming in with a moon suit saying, don’t bury your dead this way, the way you’ve been doing it for thousands of years, may not immediately work.
Those are the kinds of things where I have come to believe that if we can be much more proactive with design, we can make a lot of progress. And so, as Patrick said, no, it’s not the end all, be all. Of course it isn’t. Nothing is. But it’s a very important tool in our– a very important kind of arrow in our quiver now that we have to learn how to use more effectively, how to move the ball forward.
PATRICK WHITNEY: There’s an additional aspect to this that Michelle Williams in the public health school talks about, which is being focused on solutions. And design does focus on solutions. We don’t keep track of the data in our projects. We don’t build a body of information in our projects. One of the things I’m hoping to learn about here is how to do that.
ASHISH JHA: How to build that body of information.
PATRICK WHITNEY: How to build that value of information as we’re doing design projects. But now, for the time being, we’re focusing on solutions. Those solutions are good because we can get to them faster if we’re not worried about the science that might be behind it.
But I also believe– this is a conjecture. But I think– I believe– that these solutions can provide a second base for research in public health. Whereas now, young researchers look to solid bodies of research to build their research on so they’ve got stuff to work with. What if, in addition, there was a base for research which would solve problems, but you didn’t know why they worked? You knew it worked, but you didn’t know why.
You could imagine a group of scientists jumping all over that and rapidly coming up with principles that make sense, because you’re starting with the fact that it worked. When you start with research questions, you may research something and build science, but it’s not leading to something that works.
STEFANIE FRIEDHOFF: Exactly. Ashish, do you want to put that in context for us? The terms implementation science have been thrown around. About a decade ago, we started to realize there was so much implementation, and nobody was actually evaluating– and thus finding out– what works and what doesn’t in global health, and why.
ASHISH JHA: Yeah. So right there, there’s this massive gap between– well, there are two things. There’s a massive gap between what we know is the right answer and what we do. That’s the whole behavioral stuff that we spent a bunch of time talking about. But then there’s also this huge problem of we see people do things successfully– things that work. And we don’t understand why they work.
And so there is this new field of implementation science. And it’s very, I think, early days. There are people, certainly at the Chan School, who are working on this, or people. But I’ve always believed that implementation science is an area where design can be potentially very helpful in getting us understand why did intervention A work, but intervention B didn’t? Because the problem is you do intervention A versus B. A works, B doesn’t. Great.
And then, when you go to scale it, it often doesn’t work out because you didn’t understand why A worked. And so you didn’t know what part you had to have with high fidelity as you went and customized it in other places. And it’s that kind of detailed, messy stuff that we’ve got to figure out, or we end up just not being able to scale things very effectively. because we don’t understand that what’s really critical, and what you are allowed to change and customize. I’m hoping design helps us with some of that work.
PATRICK WHITNEY: Design does that in other fields where they focus on the difference between the product and the touch points of the product. The product can work in some ways spectacularly well. Those are touch points that give the product its identity. And in other things, it doesn’t have to work so well.
Knowing which touch points in the product, or which touch points in a medical protocol, are important is critical.
ASHISH JHA: Well, I’m thinking of a story, and I don’t know if this gets at this. But a bunch of years ago, a guy named Peter Pronovost came up with a checklist for how to eliminate central line infections. These are infections– deadly, very expensive– that develop when people put in catheters into large veins in the body. This is almost only used in the intensive care unit.
He developed a checklist. Atul wrote about this checklist. And it got the infection rate down to zero. And we used to think you could cut the infection rate to a certain some number. Peter’s checklist got it to zero at Hopkins.
And everybody said, oh, that’s Hopkins. you can do it at Hopkins, but you could never do this more broadly because Hopkins is so different. And he went and implemented it in the state of Michigan and across 50 hospitals. And about 35 hospitals got to zero, and stayed at zero. And so that was impressive. New England Journal paper. Lots of excitement.
But what’s interesting is I always wondered what happened to the other 15. And why did 35 make it, and 15 didn’t? 35 seems very impressive. Certainly good enough that your statistics are great and you end up The New England Journal. And what he and others have basically come to discover that took a bunch of years. And a lot of going back is that you had a checklist. The problem with this checklist was that doctors didn’t want to follow a checklist. Doctors are like, I don’t need the checklist. I’m a doctor.
And what happened at Hopkins was Peter Pronovost had tremendous amount of social power because everybody knew him. He was a chief quality officer. They loved him. So when he implemented it, nobody was willing to go up against the checklist, because they were going up against Peter.
When he went to Michigan, people in Michigan– most of the community hospitals didn’t know him. So he didn’t have that same power. He got hospital CEOs to tell their doctors that this is the checklist. And when you don’t listen to the nurse who’s implementing the checklist, you’re essentially going up against me. And in about 35 hospitals, that happened. In about 15 hospitals, the CEO didn’t really communicate that. And then you know what actually happened.
So the bottom line is an implementation of things like checklists is hugely dependent on cultural change, and is hugely dependent on sometimes strong-arming people. Sometimes setting up very clear expectations and boundaries. It’s that cultural stuff that we haven’t paid as much attention to in public health.
And it’s interesting because I suspect that if you had done sort of a design analysis at Hopkins, you could have figured out that part of what led to the success was people appreciated and understood who Peter was. And then you had to figure out how do we replicate and clone Peter and all those other 50 hospitals in Michigan. Can’t clone them. Our technology on cloning isn’t so good. But the point is you’ve got to come up with a substitute. I think we could have predicted that if we had applied design early. We didn’t, and so we had to learn it 10 years later.
PATRICK WHITNEY: But socializing his reputation and even him might have gone some ways to get that up to 40 or 45.
ASHISH JHA: Yeah.
STEFANIE FRIEDHOFF: What did you mean by socializing?
PATRICK WHITNEY: Well, rather than the CEO ordering them to follow the nurse’s statements of the checklist, build the respect for Peter in those docs similar to the respect that he had at Hopkins. If they didn’t know who he was, tell them who he is, and have them meet him. And have a drink with him. Go to a seminar with him so that they had the same respect.
Most people want to do the right thing. It’s the chaos of daily life, whether it’s work or learning or family life, that keeps you from doing the right thing every time you’re supposed to do it. So what you want to try to do is, rather than beat people up to do the right thing, is figure out what they’re doing, and build your protocol and your goals into what they do.
STEFANIE FRIEDHOFF: Well, I was about to ask– this is one of the major criticisms of bringing of a design approach to these types of complicated problems, because it’s easy to design an iPhone and make it very user friendly. It is much harder to get people to do some of the things that don’t fit so much into their–
PATRICK WHITNEY: Yeah, but let’s go back to the student who did the cookbook. That cookbook was so fun to use. It expanded your diet options. It was easier to use than a regular cookbook that people without heart disease want to use it, and people with heart disease were thrilled with it.
STEFANIE FRIEDHOFF: So would you say that you believe that you can get people to– I mean, we’ve seen it with smoking. People have stopped smoking, or a lot of them have.
PATRICK WHITNEY: We should write a book called The Joy of Health. Or The Joy of Medicine.
ASHISH JHA: This is what I was going to say, is– I’m new to design, so I still use very kind of basic examples. But when think back to Steve Jobs talking about it iPhone.
PATRICK WHITNEY: That’s a great example.
ASHISH JHA: He always used that notion of this being a delight. This being something fun to do. This being delightful to do. We don’t talk about delight in public health or in clinical medicine. We’re like, you must take this medicine, or you must cut out salt in your diet.
Boy, life is much, much harder when you have to do a lot of things you must do. Life is a lot easier if you can do things that are delightful to do.
PATRICK WHITNEY: In fact, you’ll only adopt a few things that you must do. And the others are just too much.
ASHISH JHA: Too much. How many must-dos can you do in a day? And the answer is, a couple, and then leave me alone. And what I’ve really enjoyed about watching Patrick think about problems is he takes things that feel like must-dos and tries to turn them into delighted-to-do-these-things.
Look, again, we don’t want to be Pollyannish about this. It’s not going to be super easy. We’re not going to be able to get smoking cessation to be a delightful thing. It’s hard. People are addicted to nicotine. But we’ve got to take a different approach to a lot of these problems. Just hammering people over the head with things they have to do to improve their health just doesn’t work.
STEFANIE FRIEDHOFF: If you were to look at the opioid crisis right now, Patrick, what do you think you would see?
PATRICK WHITNEY: That’s a hard one. I have a wild idea that could well be– is probably wrong– but I’ll try it on you. I suspect that some percentage of the people– think the Midwest, where I’ve just moved from. The opioid addicts there are turning to it because life is miserable.
Their jobs are going away. They’re stopping making cars and are being Walmart greeters. Fraction of a pay, fraction of the prestige. And they don’t see a happy future. Suicide rates are going up. It’s not just opioids as a symptom of this.
There is an organization in Detroit called Recovery Park. They found 80 acres of contiguous land– land contiguous to downtown Detroit– dedicated to food. Two-acre greenhouse. Tilapia farms. Schools for teaching restaurant workers how to be restaurant workers to teach kids how to be restaurant workers. It’s all dedicated to food. Food is one of the joyful things in life.
What if we took the Recovery Park– which is, by the way, named Recovery Park because they employ drug addicts and alcoholics who are recovering. It’s the only people they’ll employ. And the founder of it is a trader who was addicted to cocaine.
What if we took the ideas of Recovery Park and replicated them so there are these people doing something joyful– making food– rather than greeting people at Walmart, or being unemployed. Contributing to society, making a little money. Doing something creative.
I can’t believe that we wouldn’t get some number of people to be eased off opioids. And even if we didn’t, even if the thing failed, we’ve got more jobs in the Midwest, which needs some. Doing good things, and providing more food into the food deserts in so many of those cities. So, rather than studying it, the design approach would be to give it a try. I think it passes the test of not doing any harm, and would be a good thing.
ASHISH JHA: Though I think, as a public health person, I would like to study it. There’s no reason we shouldn’t.
PATRICK WHITNEY: And we would love you to study it.
ASHISH JHA: Yeah, so we can do that, too. Well, just two reflections on this story. First, when Patrick first only about Recovery Park, I think on a Saturday morning. We were having a conversation, and you described this.
And I hung up the phone, and walked into the kitchen, and found my 12-year-old with one of her friends. And they been baking up a storm. They were baking a cake. And I watched the joy that they had. And I have to tell you, my own approach to cooking is, what’s the least I have to cook to get enough nutrition and so I can keep going. I’m probably a bad example of this. But the point is, cooking–
PATRICK WHITNEY: Spoken like a scientist.
ASHISH JHA: –cooking, baking are joyful activities. And we don’t think about joy so much in how we think about helping people live better, healthier lives. We think of joy as some kind of side product and not a means by which you help people live healthier, better lives. And you’ve helped me see that. And you’ve helped me see that when you described this.
The other thing, which I love about how you approach almost every problem, Patrick, is you don’t begin by looking for villains. I find this to be a huge problem in public health, where we often begin by saying, oh, the problem is pharma. Oh, the problem is the government. Oh, the problem is people who won’t take their medicines.
And you don’t begin by saying who’s the villain who is creating this public health problem, and how do I shut them down. You begin by looking at the problem as it is, and saying, how do we make this better. It’s a really useful framework that I think could apply to a lot of public health issues.
PATRICK WHITNEY: That’s interesting. I’d never noticed it, but it relates to something I have noticed, which is our medical system, and even more so our school system, are two of the very few systems or organizations that Henry Ford would recognize if he came back in a time machine, now I look at them. We think of people as material, both kids and patients. We think of processing them. We think of quality checks along the way.
We never think of making them happier. It’s not in the curriculum goals.
ASHISH JHA: Nor in the medical goals. It’s a problem.
STEFANIE FRIEDHOFF: So, fewer villains, more happiness, and more empathy. It’s a great note to end on. Thanks to both of you.
ASHISH JHA: A pleasure.
PATRICK WHITNEY: Thank you.
ASHISH JHA: This was fun.