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Cadernos de Saúde Pública

Print version ISSN 0102-311X

Cad. Saúde Pública vol.17  suppl.0 Rio de Janeiro Jan. 2001

http://dx.doi.org/10.1590/S0102-311X2001000700005 

DEBATE DEBATE

 

Emilio F. Moran

Indiana University. Blomington, Indiana, United States of America.


Debate on the paper by David Waltner-Toews

Debate sobre o artigo de David Waltner-Toews

 

 

The discussion by David Waltner-Toews covers considerable ground and is stimulating as a whole. It correctly diagnoses our contemporary problems as stemming from sectoral and disciplinary thinking, with all the inevitable blinders. Indeed, he reviews the frequent failures that result when we mean to do good but fail to foresee the consequences of our interventions at higher or lower levels in complex system hierarchies.

I was particularly taken by his Table 4 of recommendations, which seem to be sensible and appropriate as first steps to health in the new millennium. There can be little quarrel with the author that we need more complex systems thinking or that this approach (together with participation by the populations affected in the process) is likely to lead to better health outcomes. My main critique of the author is that he fails to provide either details on how his Great Lakes Basin program or the Dirk Gently Group are attempting to implement this approach or evidence for improved outcomes from such efforts.

Without evidence for how a SOHO approach leads to improved health and well-being, it is unlikely that its adoption will follow. There are many inherent difficulties in the approach that must be dealt with (and the author only rarely alludes to them): divergent and/or competing interests among sectors of the human community; the free-rider problem; the challenge of building robust institutions based on trust and reciprocity (in a world where these are increasingly scarce); mechanisms for allocating costs in multi-tier systems, etc.

In other words, the sectoral model has prevailed because it makes it easier to manage simple, single-tier systems created to facilitate operations, allocate charges, and produce reasonable results (while ignoring upstream and downstream consequences). The proposed SOHO approach is conceptually more attractive but riddled with all kinds of new challenges for its "managers" or modelers. Particularly if such systems are non-linear and chaotic (as they must be), the uncertainty of outcome in itself is a political challenge for those who wish to implement it. Most human communities are not likely to be receptive to outcomes characterized by uncertainty. The author and his colleagues need to move from the appealing conceptual and diagnostic stage to an operational model if we are to hope for implementation of this idealistic goal in the 21st century. We certainly need alternatives to health and business as usual.