In the early 2000s on the Hawaiian island of Oahu, a healthcare group was having trouble improving health outcomes for certain populations of native peoples.
The problem they were trying to solve was not unique – this population of native peoples tended to be obese, have high blood pressure, high cholesterol, and died young – 30s to 40s – from complications of all. The healthcare group wanted to help these native peoples fix the problem.
To paint the picture, you may know the remake/mash-up of “Over the Rainbow/What a Wonderful World,” sung in a soothing manner by a man with a high voice playing a ukelele.
The song is by Bruddah Iz – Israel Kamakawiwo’ole. He died at 38 from complications of obesity – he was 6’2″ and at one point, 757 pounds. He is of the group of native peoples the healthcare group was aiming to help.
The group set up local clinics – they knew one barrier to health was traveling for appointments.
The group set up a nutrition and exercise program – they knew that this population had a high calorie diet and minimal exercise.
They had positive interactions with the patients, who seemed perfectly fine with the new programs. Doctors reported that people would show up to their initial appointments, seem really pleased by the plans they were presented, were very polite, but then would never show up again and didn’t seem to adopt any of the recommendations.
“Why don’t they care as much about their health as we do?” the doctors and healthcare administrators would lament.
“We’re providing all these resources and they’re not even showing up. Don’t they care?”
A year later, the group had seen no progress. Zero change in health outcomes.
Frustrated, they hired consultants to go in and talk to this group of native peoples. They wanted to know why the program wasn’t working.
Why, after positive initial appointments and resources poured into the program, the native peoples just weren’t taking advantage of what was being provided.
It turns out the healthcare group’s problem was two-fold:
- They had not payed attention to the cultural factors at play.
- They had never asked what this group’s health goals actually were.
The healthcare group saw a population with certain health metrics and went in with the textbook plan of what works for all people to lower weight and get healthier – better nutrition, more activity, routine health checkups.
What they had failed to ask first is if the people in this population actually had a desire to change.
This population liked and enjoyed their current lives. They lived in a beautiful location on Oahu. They enjoyed quality time with their family. They didn’t feel as though they experienced much stress. They ate what they wanted and enjoyed. They didn’t have a negative body image around fat. They didn’t think too much about doing anything they didn’t want to do – be that exercise or whatever else.
They were culturally non-confrontational and didn’t want to push back on doctors when the doctors said they should do this or that. They were good ideas, yes. Just not ideas the people of this population wanted to adapt.
They liked their lives and, when they passed away in their late 30s and early 40s, felt as though they had lived a good and full life with the time they had. Those who DID want a different life or different health did so.
By failing to ask the people of this population what they actually wanted, the healthcare group was measuring health problems and outcomes in a very colonial way – entering a population of people, assuming that the group’s goals and intended outcomes were the only possible path.
They failed to consider that their program’s intended outcomes were not the only possible goals. And in doing so, they disrupted a community and poured resources into a program that was never structured in a way it could succeed.
I share this story because of a panel discussion I attended recently entitled “Diabetics on the Margin,” intended to discuss the experience of living with type 1 diabetes (T1D) for people of color.
Unfortunately, a non-T1D endocrinologist on the panel ended up dominating the conversation in a way that showed she clearly hadn’t been listening to her patients or considering their various experiences.
As anyone who lives with T1D knows, every experience of T1D is different, we each respond to medicines and dosages differently, and there is no blanket way to take care of T1D, even without considering cultural differences and issues of access, which are ever present.
Her heart and intention were in the right place, but her ego, her need to be right, and her lack of listening had taken over.
I implore doctors and health system administrators in all fields to ASK more than you ASSUME. Never forget that you are in a field of people, and as much as people do tend to fall into categories, no two people will have the same exact experience of health. It is your job to listen and design programs around those varied experiences, not around monoliths.