We Need a Metaphor for Health Systems. What About the Human Body?

Creating a shared metaphor is a powerful way to make an abstract concept tractable. Just think about how the metaphor of "war" dominates and shapes so much of what we do in public health: the war on cancer, the fight against AIDS, the battle against TB. Metaphors also shape and define the boundaries of how we think about problems and how to solve them. We fight diseases with campaigns, with armies of health workers, with magic bullets. In fact, metaphors are often the boxes (metaphor alert!) that we are asked to think outside of.The contemporary concept of "health systems" desperately needs a better metaphor. Right now, we have a couple of contenders out there. I've seen a puzzle (View image), with five interlocking pieces (financing, human resources, infrastructure, technologies and drugs, and knowledge and information). OK, it gets across the notion of some sort of relationship among the parts, but is static and conveys the (wrong) idea that there's one way to put together the system elements. Health economists occasionally invoke the dominant metaphor in neoclassical economics: The "sides" of demand and supply, and the "invisible hand" of competition. This has a lot of meaning for practitioners of the gloomy science, and leaves just about everyone else glassy-eyed. I have to admit that neither of these metaphors quite do it for me, nor do the growing numbers of boxes-and-arrows diagrams that are cropping up in journal articles and powerpoint presentations. They just make me think, "Wow. That's complicated….I wonder what software they used to make that diagram?" And I suspect I'm not alone in yearning for a useful metaphor, given the inarticulateness that often overcomes very smart people when faced with the question, "What to do you mean when you say 'health system'?"Herewith a modest proposal for an alternative: The human body. - Bodies both consume and, with the right inputs, produce.- They are made up of many discrete subsystems – circulatory, skeletal, respiratory, nervous, endocrine and others; each has a role to play and is dependent on the sound functioning of the others – although one of those subsystems can, if necessary, partially compensate for the shortcomings in another. - They are a combination of material parts, like bones, and hard-to-observe but powerful forces, like signals in the nervous system.- The control system (brain and nervous system) has both involuntary reflexes and the ability to take deliberate actions based on sensory input about the environment and the condition of other parts of the body.So maybe the physical infrastructure of a health system is like bones: it determines the size and reach, and can be molded and shaped but only very slowly. The health workforce resembles the muscles: they are the ones actually doing the work, but only with direction (through the nervous system) and when attached to the infrastructure. The digestive system represents the functions of bringing in the resources from outside and makes them available to the different parts of the system that need nourishment (malabsorption causes endless problems but is sometimes hard to diagnose!). The logistics system for distribution of drugs and supplies is perhaps like the circulatory system. The information system is – or should be – like the body's sensory system, providing a whole set of diverse signals from remote areas, from the gut to the toes, that the brain can interpret and act on. You get the idea.Beyond permitting us to talk about the dynamic and complex nature of health systems in a way that taps into some intuition, the body metaphor could provide useful insights about problems and their solutions. Back to health workers as muscles: Building up muscles takes time, effort and a good diet; once in place, they turn to fat unless they are actively deployed. A partial substitute for building up muscles can be found in deployment of mechanical advantage. It is not much of a mental leap to see the analogy to the problem of the deficits in the health labor force: just building up the number of health workers without ongoing resources and attention to productivity is very unlikely to yield sustained benefits; and creating genuinely labor-saving technologies might be a smart bet.Imperfect though the body metaphor may be, one clear advantage is that it has some meaning to those with medical and public health training, who may be engaged in thinking about health systems but have a hard time interpreting the language of economists and policy analysts. It creates a more level playing field (metaphor alert!) in discussions between those who feel comfortable thinking about abstractions like "stewardship of the health sector" and those who deal with the flesh and blood of health care delivery.So the next time you're in a meeting where a speaker is going on at length about "heath systems," permit your mind to wander a bit, and consider whether and how the image of a body illuminates the topic. Or, better yet, come up with a superior metaphor and send it to us for a future posting!