Newsletter | The Curse of the Systems Thinker

The curse of the systems thinker is that one is always seeing patterns, always searching for the fundamental forces and dynamics that underlie a system and give rise to the peculiar results one sees. One is always – as we like to say in public health – looking upstream, for the root causes – and even their root causes. It’s hard to stay focused on the immediate problems at hand, when there are deeper, more fundamental causes of those problems that are – most perplexing to the systems thinker – so deeply embedded that they are rendered nearly invisible, or at least taken for granted. They are the givens, the fixed conditions that exist outside the solution space.

The health of individuals in the US and in any society today, results from the complex interactions among many systems: there is of course the literal health care system, there are the systems that shape our daily lives, that generate outputs such as food, housing, transportation, education, and infrastructure, and, at deeper levels, our systems of economics and politics, and even the natural systems that make our Earth habitable.

A simple systems thinking tool is the “five whys” interrogation technique, which was developed at Toyota Motor Corporation as a way to identify root causes of defects. The basic idea is for any observed event or phenomenon, ask why it happened, and then ask why the immediate cause happened, and so on. (There’s no reason one has to stop at five – one of the criticisms of the technique is that five is an arbitrary place to stop and can leave you insufficiently deep.) It can also get tricky because at each stage, you might find more than one cause, leading to the need for going down multiple paths. If one had, a la Austin Powers, been asleep for a few decades and woke up to read Adam Clark Estes’s article in Vox “I covered my body in health trackers for 6 months. It ruined my life,” they would do well to start asking a few whys. Estes describes his experience using an Apple Watch, a Whoop band, an Oura ring and a continuous glucose monitor (CGM) to track many facets of his health and his gradual descent into a nightmarish overload of data points, alerts and bland insights. While acknowledging it was sometimes useful and taking pains to note that some tracking can be important to certain people with certain conditions, Estes recounts an experience of way too much obsession, anxiety and panic. Estes does step back and ask “why?” – why is this sort of tracking a thing (and even at the forefront of the MAHA movement)? His primary answer is the failure of the health care system – with a primary case system in crisis and people feeling lucky to get 15 minutes of face time with a doctor each year, it’s no wonder that people want to take health into their own hands. Estes also draws the connection to the new regime of federal health policy leadership, which is both touting these self-tracking solutions and, in the case of the Surgeon General nominee, literally selling them.

So why is the solution to an inadequate health care system the idea that people should use wearables like CGMs, join various fitness services, ingest an assortment of magical ingredients and subscribe to boutique health care services? The answer, implied in Sheila McClear’s article, “The Perilous Spread of the Wellness Craze,” is that these solutions are, um, really big business. Canadian Prime Minister Mark Carney has summed this up rather succinctly: “In America, health care is big business. In Canada, it’s a right.”

Estes, in his reporting on self-tracking, doesn’t explore another possible explanation – which is that it is increasingly hard to be healthy in the US today without using extreme techniques to regulate our behaviors. You know, the argument that’s our bread and butter here at Building H and with which our regular readers are well familiar: that the products and services of everyday life have created an environment that makes it hard to eat and sleep well, get enough physical activity, be social and get outdoors. Asking why that is so leads to the question of incentives that we harp on regularly: that the companies whose products shape people’s behaviors have precious little incentive to do so in ways that create positive health influences and indeed are often incentivized to push for excess consumption (of food, of screen time, etc.). In “Endless growth, endless harm: Facebook is a symptom, not an outlier,” a short essay for Fast Company, University of Cambridge professor Christopher Marquis riffs on Sarah Wynn-Williams’s exposé of Facebook, Careless People, to argue that the deeper issue is the obsession with growth at all costs – one of those fundamental forces that we take as givens. Marquis argues that we need to challenge this invisible assumption:

“Critics often dismiss degrowth as unrealistic or anti-innovation. But what’s truly delusional is believing that the endless growth obsession that fuels companies like Meta can coexist with human dignity and democratic stability. The real question isn’t whether we can afford to abandon growth. It’s whether we can afford not to.”

AI is one area where this question of corporate incentives should give us pause. In "Two Paths for A.I.," New Yorkerwriter Joshua Rothman discusses the "alignment problem” of AI – making sure that AI acts in accordance with human commands and values. The article notes that a key problem is that while there are real risks to create self-improving AI that could theoretically spin out of control prior to having better insight into how these systems would behave, the leading developers are moving forward anyway, which, Rothman dryly notes, seems to suggest “that it’s the A.I. companies that are misaligned.” (This observation echoes Tim O’Reilly’s argument dating back several years that financial markets were in essence a “rogue AI” because of the incentives that required companies to prioritize profit over societal well-being.)

So we arrive at a fundamental question: do we have an alignment problem at a societal level? Do the systems we have created, and which now run in a rather self-propelling manner, act in accordance with our commands and our values? Steve wrote back in the early days of Building H that “Congress never authorized a Manhattan Project to send rates of chronic conditions, like obesity and diabetes, skyrocketing.” Surely a chronic disease epidemic was never a societal goal, but the systems we created produced it. Which begs the question of why we wouldn’t feel the need to do some course correction.

The curse of the systems thinker is that it leaves us battling the deeply rooted paradigms that animate the systems as we know them. To challenge the embedded assumptions – that economic growth is more important than human health and flourishing, that profit is more important than social impact, that the purpose of technology is to provide comfort and convenience in our lives – that lead to the current state of health. As Dan Health explains in his book Upstream, there are many reasons why most people focus their efforts on more proximate, downstream challenges: they are more tractable, they’re more measurable, responsibility is more clearly assigned, and the results are visible sooner, to name a few. And yet, if we don’t tackle the upstream issues – like the alignment between our goals and the operation of our social and economic systems – the downstream problems will continue to proliferate. We choose to work far upstream – not because it is easy, nor, as JFK once said, because it is hard, but because we believe it is necessary.

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