People-Centred Health and Deep Adaptation
Asiya Odugleh-Kolev is a technical officer at the World Health Organisation, and a member of the Holding Group of the Deep Adaptation Forum. This article was first published by the Initiative for Leadership and Sustainability, University of Cumbria, and was written after she participated in the Sustainable Leadership and Deep Adaptation short course, offered by the University of Cumbria.
As the COVID-19 pandemic challenges both health systems and whole communities around the world, the matter of how we help each other maintain physical, mental and emotional health in the context of social distancing is a hot topic of conversation. People are realising that one cannot be separated from the other. They are all deeply interconnected and contribute to our health and overall sense of wellbeing. In fact, the restriction of traditional ways of being with others has focused attention on precisely what we have lost – the quality and nature of our participation in relationship, whether at the family, community, organizational and societal level and how we give and receive. Where these relationships have been healthy and functional, we have mourned their loss. Where these relationships have been dysfunctional and toxic, the result has been an increase in violence.  I am convinced that as humanity is challenged more by all kinds of disruptions and disturbances, belonging, community and our ability to relate will become more important. To meet that challenge, we need more creative approaches to health, that integrate all aspects of who we are, moving beyond the limitations of some of the current medical orthodoxy.
My work at the World Health Organisation’s Integrated Health Services Department, is concerned with how we take a whole-person whole-system approach to community engagement and how such an approach can support health services become more resilient and people-centred so that health care environments are capable of contributing to the health and well-being of their own workforce and the populations they serve. This work is essential to break down silos created by standard medical knowledge. I have seen how disconnected a health system can be from itself and the needs of the communities they serve. Whether working in Sierra Leone during epidemics, or in the UK with refugee families, I have experienced and observed first-hand some of the deep flaws in our mindsets and healthcare systems. Content and process are routinely separated which in turn creates multiple blind spots in health service planning, delivery and experience. In fact, the integration of the promotion of health in our everyday interactions through human connection and relationship building is the exception rather than the norm in every country I have visited.
Why is this the case? Like other sectors, health has been shaped by its historical legacy and shored up by disciplinary silos across the sciences that impede collective learning and sense-making. It is not what we know but how that knowledge is applied to address real world problems that still challenges us. Our healthcare systems were originally designed to diagnose and treat disease. They were driven by the eradication of infectious diseases that were prevalent at the time hence the focus on technical solutions such as vaccines, anti-biotics and water and sanitation programmes. The consequence of such a system has been to reduce people to body parts and minimize investments in the social determinants of health. A lot has already been written by others about the need to evolve from a bio-medical mindset – especially as more people find themselves in a period of sustained uncertainty and disruption. The irony is that the need for more socially-based interventions are coming from the natural sciences. Imaging and diagnostic tools that have allowed us to peer inside our brains and bodies and the work of scientists on gene function and expression are all reinforcing the critical connection between the mind, the body and lived experience. The neural architecture and algorithms that humans need for navigating life and making sense of the world are laid down in early childhood. Consequently, as a species we know an awful lot about what contributes to building healthy individuals, families, communities, schools, and workplaces. yet that knowledge is not being translated into supporting the adaption and evolution of our systems of human organization and governance across all sectors.
It has been estimated that it takes roughly 17 years or longer for research to become integrated and mainstreamed into the health sector, with most innovation taking place outside of formal health systems.  Furthermore, science itself is only just catching up with indigenous knowledge and ways of knowing about our interconnectedness. I have often said that we need to acknowledge the science of common sense. Indigenous knowledge and ways of relating and living has been built over thousand of years of observation. Research has shown that lack of social connection is a greater detriment to health than obesity, smoking and high blood pressure, and that genes impacted by loneliness also code for immune function and inflammation.  According to the Stanford Centre for Compassion and Altruism Research and Education, “strong social connections boost immunity and lengthen life. People who feel more connected to others have lower levels of anxiety and depression, higher self-esteem, and greater empathy for others. They are also more trusting and cooperative, and others are therefore more open to trusting and cooperating with them. In other words, social connectedness generates a positive feedback loop of social, emotional and physical well-being”. 
We don’t need a medical degree to understand how humans are born to bond and wired to connect, and human relationships are the primary social “building block” of community. Yet the breakdown of extended families, the increasing isolation of caregivers and the stress people are exposed to through social adversity and life events deeply affect their ability to connect and to form and sustain healthy relationships. Understanding this complexity is important for develop more systemic interventions that help individuals and communities to cope and to thrive. This means connecting the dots between different disciplines, including brain sciences and the relational sciences, and the social and emotional contexts in which clinical and technical work gets done. When it is carried out with this intention, community engagement can become a transformative process and a mechanism to reorient public sector institutions, starting with health. Institutions and places of work have to become the new “relational schools” of the present and future.
The need for the medical systems of the world to evolve beyond the limitations of a standard medical mindset feels important to me personally. I was born into an oral society in East Africa where relationships define who we are and our culture. Relationship and connection are in my DNA. But early childhood trauma also taught me what disconnection and isolation feel like and what the long-term consequences can be to someone’s development. It has taken decades of self-reflection and inner work to learn how to feel safe in my relationships so that I can contribute to mutually empowering relationships that are interdependent. For instance, during my work with refugee communities in the UK, I found it much easier to help others find their voice than to express my own needs and preferences. It has been a painful yet joyful process that has brought me to my knees but also enabled me to celebrate significant success.
I share with you my own journey because an aspect of the standard medical mindset which needs to change has been to downplay our own humanity, beyond the important oath to do no harm. I remember one of my directors telling me over a decade ago that public health has traditionally played the role of Cinderella to medicine. However, COVID-19 has demonstrated that individual and population-based approaches are inseparable. The pandemic has also focused attention on the needs of the health workforce and there have been increasing calls on the need for compassion at all levels with a particular emphasis on health leadership. This means tackling chronic work overload, acute staff shortages, workforce attrition and retention as well and dealing with relational crises. This was before the virus appeared and in a COVID world will require a different kind of investment. For example, roughly 54 million people experience workplace bullying in the US, and healthcare organizations have the highest incidence of bullying across all sectors. Studies from Europe show that half of all doctors report symptoms of depression, exhaustion, dissatisfaction and a sense of failure, compromising patient safety and service quality, and contributing to medical errors.   Lateral or horizontal violence in nursing is also described as a “persistent occupational hazard within the global nursing workforce”.
There is no magic bullet when the problem is the confluence of multiple factors to create a culture that needs radical self-love and a reorientation to purpose. Namely, a hierarchical structure, patriarchy, silos, and outdated, fragmented medical curricula and methods of professional training. When asked, health system changemakers have often described the culture and leadership of health systems as being one of command and control and highly masculinized. Given that 50-75% of the global health workforce are women, the brunt of caring and front-line delivery of health services falls on those who do not have a voice at the decision-making table and are unable to have their needs heard.
The phrase “physician heal thyself” echoes through the ages, and into the corridors of the World Health Organisation. Because we cannot encourage a shift to more people-centred approaches across the world, if we do not explore what this means for our own lives and work. Therefore, I am an active member of a Change Agent Network to transform our own culture and ways of working. I am also collaborating internally and externally to promote innovation in research to address gaps in evidence for community engagement, while learning from changemakers around the world about how they are leading successful change at different levels of the health system. As part of this work, and my own desire to expand and deepen my own leadership practice, I discovered the Deep Adaptation movement. Here I met people who were either experiencing or anticipating societal disruption and even collapse, and responding by emphasising the opportunities for holistic transformations of self and society.
This is important, because there are increasing indicators that we must take the possibility of greater societal disruptions seriously. In my experience, the transdisciplinarity needed for our health systems to address precursors to societal disruption and collapse remains at the stage of initial ideas. Deep Adaptation provides a framework, among others aligned with profound transformation of self and society and inspiration to go further in that work. It also offers a framework for how we can have a different quality of conversation within our organizations.
It may seem very bleak to some, especially who have had no experience of societal disruptions in their recent cultural history. Yet, given my own life experience, I have some faith that out of a situation of growing health stresses and disruptions, we can start to connect the dots and there can be the opportunity for the health sector to begin to renew its purpose and meaning alongside similar efforts in the education sector. To become partners in collective action to heal our organizations and reintegrate physical, mental, emotional and social health – as in WHO’s definition of health.