Column #149. First published in the St. Cloud Times online Nov. 29, 2019; in print Dec. 1
“Wicked problem.”
It doesn’t mean the problem is evil or mischievous or dreadful. It doesn’t mean, either, that the problem is fabulous or cool. (“Wicked” ranges more widely in the thesaurus than any other word I’ve ever checked.)
No, a wicked problem is one at the nub of many interdependent causes. The challenge is to get a clear picture of the problem itself.
I learned about “wicked problems” from a presentation to the American Evaluation Association by my stepdaughter, Dr. Christina Welter, who directs a University of Illinois at Chicago doctoral program in public health leadership. Wicked problems are daily fare in her field.
She takes guidance from Yogi Berra: “You can observe a lot by just watching.” Recognize and acknowledge your own assumptions. Pay attention to others’ viewpoints (which of course have their own assumptions). Practice critiques theory. Power dynamics are revealed – seldom is the playing field level. You learn nuance.
I recently interviewed someone in our area whose job is to grapple with wicked problems.
Dr. David Tilstra, community transformation officer for CentraCare, explained that CentraCare is both instructed and motivated by the “wickedness” of health. What follows, including quotations, is from our conversation.
Health care is responsible for only about 10%-15% of health. Biology and genetics, 15%-20%. Behavior (diet, exercise, social connections) explains another 30%. “The biggest determiner: your ZIP code.” If we are to be healthy, to thrive, the community must come together to assess and address socioeconomic factors.
Together with the public health departments of Stearns, Benton and Sherburne counties, CentraCare is one of 28 members of Communities of Excellence, a shared effort across the nation.
Communities of Excellence is a true collaborative. Members talk with each other at least once a month. They have a mentor, a systems improvement expert who worked for Medtronic for a decade. The fundamental question gets at the wickedness of the problem: “How can you put time and energy and resources into what is not going well, and how can you strengthen what is going well, so that the entire community is improved and is able to sustain that improvement?”
“We start by looking at social determinants of health, such as housing and food access. If you’re a 55-year-old with diabetes who is housed and has a good-paying job, after 10 years of treatment you will probably have good numbers. If you struggle with housing or food access, you will likely have worse outcomes even when the doctors deliver precisely the same care for the same period. The 10%-15% of health that depends on health care is overwhelmed by the 35%-45% determined by environment – that is, by socioeconomic circumstances.”
If the first test of a wicked problem is to get as clear a sense as you can of what the problem is, a second requirement is evaluation. How do you know – actually know – that what you’ve done has helped?
CentraCare and St. Cloud State University have launched a joint initiative to correlate data, to create a scorecard for the area that will measure how we are doing on health, education, jobs and opportunities and quality of life (including housing, transportation, arts, entertainment). “Shopping for a community to live in, what would I want to know? This scorecard will provide some answers.”
CentraCare is well aware of other groups tackling the same or similar wicked problems – such as United Way/Partner for Student Success, Greater St. Cloud Development Corporation, Community Pillars – and is learning from them.
I asked Dr. Tilstra about his own preconceptions and assumptions. “At the start of my career I was science, science, science. This shifted when I was medical director and was asked what we were doing about childhood obesity. Turkey Trots and health fairs were a start, but I soon realized we have to get into people’s lives. We wrote grants for sidewalks, changed the contents of vending machines in schools. We helped alter about 150 policies. When 12-year-olds in the target area were compared with their counterparts from other areas, there was a 30% difference in obesity. We can’t say which policy changes were responsible – the problem remains ‘wicked.’ But the improvement is dramatic.”
Results aren’t quick, but the long-term investment is worth it. You want results? Reward them. “CentraCare reaps benefits. We have contracts that say if we make people healthy (not just provide health care), we’ll actually earn more.”
One big reason this is an appealing place to live: collaboration across sectors, based on relationships, to address wicked problems. It is encouraging that CentraCare has a community transformation officer whose job it is – with community partners – to understand problems and find solutions to make the St. Cloud area – our home – truly healthy, a place where everyone thrives.