* RATIONALE

community-centric

A R A T I O N A L E

for improving our nation’s POPULATION HEALTH

and its iconic HEALTHCARE

BEGINNING

all together with

an integrated DESIGN EPISTEMOLOGY.

16.2

INTRODUCTION

“Consideration for others is the basis

for a good life, a good society.”

Confucius (551 – 479 BC)

“I shall pass this way but once;

any good that I can show to any human being, let me do it now.

Let me not defer nor neglect it, for I shall not pass this way again.”

Etiene de Grillet (1773 – 1855)

“The language of citizenship suggests

that self-interests are always embedded in communities of action and

that, in serving neighbors, one also serves oneself.”

Benjamin R. Barber (1939 – 2017)

“I’ve learned that people will forget what you said,

people will forget what you did,

but people will never forget how you made them feel.”

Maya Angelou (1928-2014)

“Never doubt that a few committed people

can change the world. In the end,

it’s the only thing that ever has.”

Margaret Meade (1901-1978)

Before getting started, please take a moment to read again the quotations cited above. As represented by these authors, their views about each person’s lifelong survival are similar to my own. Do you also share their view of life? If so, you’ll probably agree with the next sentence about our nation’s healthcare. The current strategy to reform our nation’s healthcare is unlikely to improve the Primary Healthcare offered for the Basic Healthcare Needs of each resident person of every community. This Primary Healthcare is often ‘difficult’ to locate within a community, ‘difficult’ to use because of its inequitable payment systems, OR ‘difficult’ to trust because of the adverse ecologic and cultural barriers associated with its social interactions.

For truly lasting healthcare reform, any new ‘nationally sanctioned strategy’ must first, begin to promote ‘enhanced’ Primary Healthcare that is equitably available and culturally accessible by each resident person within their own community. Most of the world’s developed nations have their own ‘nationally sanctioned strategy’ to assure the equitable availability of ‘enhanced’ Primary Healthcare for each of their resident persons, community by community. The United States does not.

The deficiencies of this priority also aggravate the failure of our nation’s healthcare reform to improve our nation’s Population Health, especially its social determinants. For this healthcare reform, I use the words ‘nationally sanctioned strategy’ to mean locally initiated, community-sponsored, regionally promoted, and nationally Chartered. And, I use the word ‘enhanced’ to mean that this primary Healthcare should offer enduring, caring relationships as a baseline priority to achieve ‘Stable HEALTH For Each Person.’

Next, please accept my view that healthcare reform should also participate in the improvement of our nation’s social cohesion and its associated poverty. As its most defining character, healthcare reform must become actively connected with a “community by community” promotion of annually sustained, collaborative investments of social capital among our contiguously-adjacent communities. For healthcare reform, these communities would each represent on average 400,000 resident persons. Identifying at least 800 communities that individually pursue a commitment to collaborate with their contiguously-adjacent communities may represent the most important Chartered and regionally promoted strategy for improving each community’s Survival commons, viz., enhanced safety net. I ask you, could this analysis represent the best platform for a steadily progressive improvement of our nation’s Population Health as well as its Healthcare? If possibly so, then please read on.

The remainder of this Sub-Chapter takes about 45 minutes to read. It describes a plan to release the paradigm paralysis that currently prevents meaningful healthcare reform. A 10-15 year, precisely planned, and steadily promoted paradigm reconfiguration will be required to refocus the scientific and humanitarian responsiveness of each community’s social cohesion as well as our nation’s iconic healthcare industry. To release the current paradigm paralysis, the new strategy should begin by slowly building momentum for 3-5 years and then progress more rapidly over another 5-10 years. This reconfiguration strategy should refocus our nation’s social-political-economic priorities to also reduce the poverty underlying its Population Health attributes as well as its Healthcare. To prepare for the long-term phase, the initial focus must begin by improving the social cohesion and primary healthcare for each resident person of every community.

a new DESIGN EPISTEMOLOGY getting started

Using the concept of a Design Epistemology to establish our nation’s VISION for healthcare reform may be the best initial plan for reducing the cognitive dissonance potentially associated with this multi-dimensional paradigm shift. This concept refers to a national paradigm that no longer fulfills its responsibilities for efficiency and effectiveness and needs a new cluster of inter-related definitions as a basis to plan and execute a new set of future GOALS, viz., decrease maternal mortality by 70% and decrease health spending as a portion of our annual GDP from 18% to 13%.

Thirty basic concepts, each defined with integrating terminology, are proposed to inform a goal-directed discussion for enabling a permanently evolving Complex Adaptive System (CAS) to guide healthcare reform with its roots equitably originating within every community. Currently, these thematically categorized concepts lack a widely affirmed basis to integrate their definitions, especially with an intent to form an evolving interconnected implementation strategy by a CAS. Eventually, the thirty concepts will require continuing revision to achieve the precision necessary to persistently improve the level of “Stable Health” for each resident person of every community.

To apply a contemporary philosophical concept, an integrated Design Epistemology for POPULULATION HEALTH and its HEALTHCARE may be the best global discipline for any commitment to comprehend the economic-social-political processes required for improving the resilience of every resident person’s Stable Health. As you will eventually perceive, the 30 concepts inform the basis for implementing a 10-15 year paradigm shift to achieve comprehensively planned healthcare reform. They are thematically categorized for establishing a new, nationally Chartered, semi-autonomous institution, viz., CAD, to guide this paradigm shift for the future. These five Themes are as follows:

COSMOLOGICAL – CLUSTER, DISRUPTIVE PROCESS, * HUMAN DIGNITY, QUANTUM SIGNALING BRAIN, COMPLEX ADAPTIVE SYSTEM, & MANAGING THE COMMONS;
INDIVIDUAL – WELL-BEING, CULTURAL SOCIAL-COGNITION, * HUMAN CAPABILITIES, HUMAN FETUS, PERSON, & POVERTY;
NEIGHBORHOOD – SOCIAL INTERACTION, SALUTATORY GREETING, CARING RELATIONSHIP, FAMILY TRADITIONS, FAMILY CONVOY, & * FAMILY;
COMMUNITY – PROSOCIALITY, SOCIAL DILEMMA, COLLECTIVE ACTION, COMMUNITY, SOCIAL CAPITAL, & * HEALTH; AND
NATIONAL – HEALTH CARE, PRIMARY HEALTHCARE, INSTITUTION, SURVIVAL COMMONS, * SOCIAL COHESION, & COMMON GOOD.

A DESIGN EPISTEMOLOGY for POPULATION HEALTH and its HEALTHCARE

The President Thomas Jefferson Memorial is located on the Tidal Basin south of the Mall in Washington D.C. Inscribed inside the Memorial on its Eastern wall is a quotation from President Jefferson. He said:

“I am certainly not an advocate for frequent and untried changes

in laws and constitutions. I think moderate imperfections had better be borne with;

because, when once known, we accommodate ourselves to them, and

find practical means of correcting their ill effects. But, I know also,

that laws and institutions must go hand in hand with progress of the human mind.

As that progress becomes more developed, more enlightened,

as new discoveries are made, new truths disclosed, and

manners and opinions change with the changes of circumstances,

institutions must advance also, and keep pace with the times.

We might as well require a man to wear still the coat which fitted him when a boy,

as a civilized society to remain under the regimen of their barbarous ancestors.”

Thomas Jefferson (1743 – 1826)

Nestled along with the Memorials honoring President Franklin Roosevelt and The Reverend Doctor Martin Luther King, Jr., I would urge anyone who visits our nation’s capital to plan, at a minimum, a visit to the Tidal Basin. Each Memorial can be easily surveyed during a 2-hour walk. The time really depends on the impact that you experience while integrating the expressions of these three giants within our nation’s heritage. Amid this awareness, one can only worry about the risks to our nation as we now encounter the current turmoil occurring throughout the worldwide community.

Unfortunately, our nation’s own inner turmoil may jeopardize our role among the world’s nations. To promote a sense of urgency, we should acknowledge the wisdom of a noted British historian. Arnold Toynbee, Ph.D. is most widely known for his 10-volume, book set THE STUDY OF HISTORY. (Toynbee 1920) I cite two quotations from Professor Toynbee.

“Of the twenty-two civilizations that have appeared in history,

nineteen collapsed when they reached the moral state

the United States is in now.”

“Civilizations die from suicide, not murder.”

Arnold Toynbee (1889 – 1975)

—————————— C O S M O L O G Y T H E M E ——————————

CLUSTER DISRUPTIVE PROCESS * HUMAN DIGNITY

QUANTUM SIGNALING BRAIN COMPLEX ADAPTIVE SYSTEM

MANAGING THE COMMONS

CLUSTER may be defined as

two or more components that establish a sustainable capability

when the components, uniquely combine as a result

of their attributes, each respectively representing various levels of

synergy among the components,

affinity between the prominent components, and

salutary conditions surrounding these components.

COMMENT Cluster phenomenon might be most recognizable as applicable to the origins of biological evolution. Its technical attributes have been proposed by Addy Pross, Ph.D. Apparently, the underlying challenge required a biological resolution of Newton’s 2nd Law of Thermodynamics, viz., entropy. (Pross 2012)

In the meantime, the use of the term “Cluster Analysis” has become ubiquitous within biologically related research. Strangely, there is no widely recognized definition for a “cluster.” The above definition is intended to be applicable to a wide variety of cosmological, biological, and human dignity phenomena. This definition applies to the frequent application of cluster within this Design Epistemology. A Google citation search simultaneously using “Health” and “Cluster Analysis” revealed an increasing prevalence from #798 during 1980-81, to #2,120 during 1990-91, to #7,700 during 2000-01, and to #47,700 during 2020-21.

DISRUPTIVE PROCESS may be defined for HEALTH as

the origination of Cosmologic, Biologic, and Human Dignity disturbances that co-occur

with diverse intensity, time-course patterns, and ultimately paradoxical emergence

to form a cluster of disturbances which interacts

with a community’s resident persons to uniquely alter the resilience

of each resident person’s self-sufficient survival.

COMMENT Elsewhere, a specific Sub-Chapter for DISRUPTIVE PROCESS attempts to describe the current basis known to encompass the wide variety of associative causes for Unstable HEALTH. Recently new to this formulation, we must come to terms with the complex dimensions of epigenetics. The scientific recognition of this concept as of 2022 is still relatively new. Its complexity will require a new social-economic-political understanding of “poverty” for every nation’s Population Health. Here is a report about epigenetics. In 2020, a multi-institutional research study by the HAPO Follow-up Study Cooperative Research Group was published. For the study’s CONCLUSION AND RELEVANCE, I cite it’s introductory ABSTRACT: “In this multi-national cohort, better-maternal cardiovascular health (CVH) at 28 weeks’ gestation was significantly associated with better offspring CVH at ages 10-14 years after birth.” (Perak et al 2020)

To understand a general recognition of DISRUPTION, its occurrence for industrial business institutions is often associated with the introduction of innovation that might best be described as resulting in unpredictable chaos. I cite (Gans 2016) for this arena.

HUMAN DIGNITY may be defined as

a Homo Sapiens, fertilized ovum that survives its initial gestation

to become a viable Human Fetus who continues to develop after birth

as a dependent person within their family, their home’s neighborhood, and

their community’s Survival Commons to become an independent person

by exploring the dimensions of their uniquely endowed

Human Capabilities as the basis to achieve their own

Intrinsic Value, Moral Autonomy, and Fundamental Equality.

COMMENT Amidst all the other 29 definitions of the Design Epistemology, this one has been the most difficult since there is no historically definable heritage for its presence within a Design Epistemology. To apply another frame reference, I am indebted to the constitutional, legal scholarship that has burgeoned since 1947. While the United Nations was institutionally being formed in 1945, Eleanor Roosevelt convened a large number of international scholars to craft a UNIVERSAL DECLARATION OF HUMAN RIGHTS. It was approved by the United Nations in 1947. It includes a reference to Human Dignity.

Since then, many nation-states and their associated political subdivisions have added Human Dignity to their Constitutional language. There has been an overriding awareness that our Bill of Rights infers the attributes of Human Dignity. To date, only one US State has added Human Dignity provisions to its Constitution. As a US protectorate, Peurto Rico has also.

Since 1947, the Human Dignity concept may be most thoroughly analyzed from the scholarship of Myres S. McDougal (McDougal, Lasswell & Chen 1969), Oscar Schachter (Schachter 1983), W. Michael Reisman (Reisman 1990), Stephen J. Wermiel (Wermiel 1998, 2012), Johanna Kalb (Kalb 2010), Doron Shultziner (2004, 2017), Vicki C. Jackson (Jackson 2004), and Kai Moller (Moller 2012, 2021). The Professor Wermiel essay published in 2012 has a unique title: “Gazing into the future: The 100-Year Legacy of Justice William J. Brennan.” Overall, these authors represent a systematically considered analysis of Human Dignity as a nation’s constitutional concept. The last analysis cited above by Professor Kai Moller informs the potential application of HUMAN DIGNITY to cosmologically enrich this Design Epistemology.

The Professor Moller essay (Moller 2021) carries a descriptive title, viz., “BEYOND REASONABLENESS: The Dignitarian Structure of Human and Constitutional Rights”. With an explicit reference to cosmological dimensions, this Design Epistemology begins with the concept of a CLUSTER. Its use for Human Dignity intends to definably associate three separate but interconnected and broadly recognizable “facets” of Human Dignity. As defined by Professor Moller, they are intrinsic value, moral autonomy, and fundamental equality. They also coincide with the terminology associated with an alternate definition of Human Dignity that originates from the Legal Dictionary at the www.Duhaime.org website. Its terminology is cited, “viz.” within the definition of the Human Dignity cluster that is described below.

“Intrinsic Value”, viz., Self-respect and Self-worth, represents each person’s contribution to their Homo Sapiens species. In that role, each person contributes to the survival of their species, no matter how their contribution could have been measured. As a result of this recognition, each person deserves equitably respectful acknowledgment of their personhood. Therein lies the issues that degrade Humanity as in slavery, social caste systems, poverty from cognitive fatigue, corporal punishment, or the dysfunctional municipal life of too many neighborhoods. The intersection of Human Dignity with the Constitutional provisions for Human Rights can become complex given a view that Human Dignity represents the ultimate source for their authenticity. In addition, this attribute is commonly associated with the cultural traditions of major religious traditions. In a sense, each person’s Cultural-Social Cognition (see below) is a God-given capability to separate each person’s role among all the other Hominids and the worldwide biological community. In that role, each person then becomes responsible for maintaining the welfare of all biological entities including their reproduction.

“Moral Autonomy”, viz., Physical and Psychological Autonomy, would represent each person’s acquisition and subsequent expression of moral reasoning as a basis for achieving their ecological and cultural, self-sufficient survival. In essence, this process is dependent on the options available in their home’s community to acquire and maintain their adaptive skills for survival. Ultimately, each community is obligated to assure meaningful options for each resident person’s survival given their community’s ecological and cultural heritage. Each community will then become faced with the ethical issues associated with childhood maltreatment, suicide, assisted suicide, social isolation, and poverty. Moral Autonomy then implies an obligation to incorporate Moral Dignity into each community’s long-range planning and its social cohesion obligations.

“Fundamental Equality”, viz., Autonomy, would represent each person’s Constitutionally defined Rights and each person’s equal standing for these economic and political rights as compared to any other person. Any restriction or advantage granted to a person must also be proportionate to the circumstances involved. This provision for Human Dignity will require a community by community, communal effort to prevent, mitigate, and ameliorate the inequitable ecological and cultural heritage of their own community’s Survival Commons, viz., enhanced safety net, for each of its resident persons.

QUANTUM SIGNALING BRAIN may be defined as

the biological quantum-based processing of sensory-related, pattern recognition

by a person’s nervous system and its associated Human Capabilities for anticipating

the person’s resilience for adapting their baseline homeostasis and innate temperament

as a Human Fetus before birth and subsequently after birth through late childhood

in preparation for the person to eventually achieve self-sufficient survival during and

after adolescence as a prosocial independent person with moral reasoning.

COMMENT Among the thirty concepts encompassed by this Design Epistemology, a Quantum Signaling Brain for each person is likely to be the most difficult to understand and accept. With the advent of quantum mechanics within the last 100+ years, we now encounter the need to use our “imagination.” The terms paradigm paralysis and paradigm shift continue to appear with the use of new terms, concepts, and dimensions for which any current Glossary or Unified Lexicon may not be intellectually accessible. The best analysis of this paradigm phenomenon would probably be most widely recognizable described by the book THE STRUCTURE OF SCIENTIFIC REVOLUTIONS originally published by Thomas S. Kuhn in 1962. (Kuhn 2012) It is best complemented by the Eric Hoffer book THE TRUE BELIEVER regarding the nature of mass movements. (Hoffer 1951) In a sense, an enduring paradigm is maintained by its own true believers who resist accepting new forms of knowledge.

By understanding the historical evolution of scientific knowledge over time, we now recognize the central role of the human brain and its Cultural Social-cognition as the basis to understand each person’s developmental progress beginning before birth. After birth, each person eventually achieves self-sufficient survival from the continuing acquisition of adaptive skills that eventually includes a cultural array of social interactions, moral reasoning, and their personality. Importantly, to understand the origins of this cultural array, the career-long commitment to understand and describe human development by Michael Tomasello, Ph.D. should inform the knowledge arena for Population Health. Among several books and many research by Professor Tomasello, his capstone book is BECOMING HUMAN – A THEORY OF ONTOGENY. (Tomasello 2019)

For an analysis of the various “quantum” alternatives that could account for consciousness, consider THE ELECTROMAGNETIC BRAIN – ELECTROMAGNETIC FIELD THEORIES ON THE NATURE OF CONSCIOUSNESS by Shelli R. Joye, Ph.D. (Joye 2018) For a recent biological-journal review that is internet open-accessible, consider BIOMOLECULAR BASIS OF CELLULAR CONSCIOUSNESS VIA SUBCELLULAR NANOBRAINS. (Baluska et al 2021)

COMPLEX ADAPTIVE SYSTEM may be defined as

a minimally-nested, cluster of multiple institutions associated with a large-scale,

complex Human Dignity responsibility that becomes established and sustained

by collaboratively recurring, collective action to define and periodically revise

a quantum-informed Visioning Statement and Action Plan

that co-operatively functions at the edge of chaos

to successfully achieve their GOALS.

COMMENT To engage 800 communities of a nation with an interconnected strategy to rebuild our nation’s Social Cohesion with a fragile span-of-control institution involving 8,000 Associates and the Members of their 10 Governance Committees would seem improbable. Even with a chaotic onset initially, a broadly shared commitment to build its social networks, state by state, would ultimately be required. Further analysis and exploration of this concept should begin with the journal essays by Kevin J. Dooley “A COMPLEX ADAPTIVE SYSTEMS MODEL OF ORGANIZATION CHANGE” (Donley 1997); Marguerite Schneider and Mark Sommers “ORGANIZATIONS AS COMPLEX ADAPTIVE SYSTEMS: Implications of Complexity Theory for Leadership Research” (Schneider & Sommers 2006); and Sylvia Grewatsch, Steve Kennedy, and Pratima (Tima) Bansal “TACKLING WICKED PROBLEMS IN STRATEGIC MANAGEMENT WITH SYSTEMS THINKING” (Grewatsch et al 2021). A book written by Danah Zohar describes the quantum perspective for this definition “ZERO DISTANCE Management in the Quantum Age.” (Zohar 2022)

MANAGING THE COMMONS may be defined for HEALTH as

the Design Principles for successfully managing a Common Pool Resource

that would guide the formation of a Complex Adaptive System for allocating

a dedicated portion of a nation’s annual Gross Domestic Product to offer

equitably available, culturally accessible, justly efficient, and predictably effective

Healthcare to each resident person within every community with a national GOAL

to promote Stable Health For Each Person during their lifetime.

COMMENT The acceptance presentation given by Professor Elinore Ostrom on the occasion of her Nobel Prize in 2009 best describes her research for the validation of the Design Principles. A URL for the associated essay can be found at http://www.aeaweb.org/articles.php?doi=10.1257/aer.100.3.641 .

This Design Epistemology proposes a strategy to improve our nation’s social cohesion that will be managed by at least 800 contiguously-designated communities and their locally planned and monitored strategy for implementing enhanced Primary Healthcare throughout their community. Improving every community’s social cohesion as well as its Primary Healthcare will require a collective impact strategy involving each community’s relevant stakeholders as a communityHEALTHforum to collaboratively manage its Survival Commons. As noted elsewhere, at least 800 communityHEALTHforums would be necessary as nationally sanctioned to receive technical assistance. Each communityHEALTHforum would be constituted using county borders as contiguously-adjacent population clusters involving 100,000 to 600,000 (with a mean at 400,000) resident persons depending on population density levels, state by state.

Importantly, another national strategy would steadily develop a financial risk-sharing strategy based on the Design Principles that were defined and validated by Professor Ostrom. The strategy would slowly incorporate all current payers and providers of healthcare in a deeply nested, stop-loss-protected re-insurance system. The system would be implemented with a slowly advancing, annually incremental process. Current pricing and payment systems would be unchanged other than a nationally integrated and enhanced financial monitoring processes that also include any applicable coordination of benefits. As the portion of the GDP devoted to health spending begins to decrease, a strategy to implement universal health insurance would be a consideration.

—————————— I N D I V I D U A L T H E M E ——————————

WELL – BEING CULTURAL SOCIAL – COGNITION

* HUMAN CAPABILITIES HUMAN FETUS PERSON

POVERTY

“WELL-BEING, when defined as a person’s eudaimonia, represents

‘Happiness In An Objectively Worthwhile Life’.” (Badhwar 2014)

COMMENT Professor Badhwar validated this definition with a philosophical analysis using alternate lines of reasoning originating from a diverse arena of authors, viz. Julia Annis, Aristotle, Albert Einstein, Cicero, Victor Frankl, Stephen Hawking, Immanuel Kant, C.S. Lewis, Abraham Maslow, Martha Nussbaum, Carl Rogers, and Amartya Sen, among many others.

As an aside, Merriam-Webster’s Collegiate Dictionary 11th Edition cites 1582 as the origin of the word and defines it as “the state of being happy, healthy, or prosperous.” In addition, the same Dictionary defines “Health,” in part, as “WELL-BEING.” My own bias is that WELL-BEING and a person’s trustworthy perception of their community’s municipal life are inexorably interconnected. Population Health research has shown that “self-reported health” and “trust” demonstrate reverse causality. (Giordano & Lindstrom 2015)

In addition to the above definition for WELL-BEING, a clearly defined definition for HEALTH as the basis to reduce the cognitive dissonance surrounding its use is necessary. This Design Epistemology includes a definition for HEALTH that is focused on how each person’s Well-Being is developmentally sustained after their birth by their uniquely endowed HUMAN CAPABILITIES and its underlying Cultural-Social Cognition.

CULTURAL-SOCIAL COGNITION may be defined for HEALTH as

the cluster of innately expressed

Shared Intentionality, Tribal Social Learning, and Symbolic Learning components

of each person’s social cognition that, when nurtured during their early childhood

by their family’s caring relationships, prepare each person’s prosocial contribution

to the continuing, generational survival of their Homo Sapiens species. (Tomasello 2019)

COMMENT A detailed analysis by Professor Tomasello of the evolutionary progress of the Homo Sapiens species indicated an evolutionarily sudden transition 100,00 years ago that included an expanded set of attributes definable as Shared Intentionality, Tribal Social Learning, and Symbolic Learning. These skills promoted our species’ worldwide migration and its eventual tribal agrarian survival. The eventual transition to larger civic community survival began some 12,000 years ago. (Tomasello & Call 1997)

Shared Intentionality represents “…the ability to participate with others in collaborative activities and shared goals…” (Tomasello et al 2005) In comparison to empathy and its mutual awareness of emotional states of mind, shared intentionality implies a natural predisposition to cooperatively commit to a mutually beneficial outcome.

Tribal Social Learning may best be viewed when occurring among a cluster of 153 persons, aka, a social network. This number is recognized as the mean number of persons within a natural network. (Dunbar 2020) This social network, alias tribe or neighborhood (including “dependents”), then becomes the essential origin from which daily routines involving social interactions are acquired, learned, and continuously revised within a neighborhood’s “social network” and incrementally by its community. The learning micro-events of this process are delightfully described by a somewhat sardonic essay by Erving Goffman: THE NATURE OF DEFERENCE AND DEMEANOR. (Goffman 1956)

Symbolic Learning refers to the knowledge systems for communicating from within a sets of concepts such as for music, language, geography, or mathematics. These forms of information then mediate how a given tribal unit’s cultural traditions and knowledge are then, recorded or memorized and, shared or not shared with other Tribal units.

HUMAN CAPABILITIES may be defined for HEALTH as

a biological cluster of complex control systems for which

each person’s genetic and epigenetically prepared Quantum Signaling Brain

begins promoting synergy between their innate temperament and

baseline homeostasis as a pre-viable Human Fetus;

configures their initial Cultural Social-cognition as a viable Human Fetus

to enable the person’s eventual lifelong pursuit of Human Dignity;

initiates their consciousness at birth; AND

promotes their adaptive skills during

i. the person’s sequentially nested, cognitive development throughout early childhood

when it is nurtured by the close, caring relationships originating before birth from within

the person’s family, its family traditions, its family convoy, and their home’s neighborhood

AND

ii. the person’s situationally socialized, cognitive development throughout

late childhood, adolescence, and early adulthood

to become sustainably self-sufficient after adolescence when

the prosociality of the person’s Cultural-Social cognition begins to merge

the bandwidth fluency of their personality and their moral reasoning while

acquiring the spontaneous immediacy for the use of prosocial norms

to resolve the discordant social interactions encountered daily

within the metropolitan life of their home’s community, especially when

these discordant social interactions also receive timely mentoring

by the close caring relationships originating from within the gatherings

of their family, its family convoy, and their home’s neighborhood.

COMMENT The original conceptual explorations of “Human Capability” are primarily attributable to Martha Nussbaum, Ph.D. and Amartya Sen Ph.D. (Nussbaum and Sen 1993) They have applied each person’s human capability dimensions as a basis to define the aspirational goals for promoting social justice within a social-choice based democracy. This wide discussion has now been somewhat codified by its designation as “the human capability approach.” In contrast, the future of a NATIONAL HEALTH tradition implies that each person’s uniquely endowed Human Capabilities would alone define the Homo Sapiens species as substantially separate from all the other biological species.

HUMAN FETUS may be defined for HEALTH by

its 8-week preparatory stage involving the sudden, gestational presence

of a fertilized ovum of the Homo Sapiens species that

begins its initial development with implantation, germination, and

embryonic phases; followed by

its 32-week fetal stage for integrating the generationally genetic and

epigenetic origins for the endowment of its individually-unique Human Capabilities,

especially when the 8-week and 32-week stages occur in tandem

with close caring relationships originating from within the gestational mother’s

family, their family convoy, and their home’s neighborhood; AND followed by

its birth as enhanced by the pregestational resilience of its mother’s Health.

COMMENT Each resident person of every community should have regular “nudge” reminders that this phase for every resident person’s survival hinges on the unique juxtaposition of multiple complex traditions that convene for every Human Fetus. Family Traditions are required to nurture the maternal “gestational” survival with enduring hope and future confidence, in spite of their physical and emotional risks that are not manageable alone by a “medical model” induced level of survival. This Human Fetal stage begins a quest to gradually acquire a new beginning for its family and their individually communal needs. Its most important transition occurs after 16-20 weeks of gestation when birth viability begins to occur. There are no physiologic resiliency tests available to identify the occurrence of fetal viability.

This stage ends just prior to birth by a rapidly evolving and complicated, reversal of the maternal immune-tolerant gestational status to unduce labor. With birth, the infant is suddenly exposed to a very cold change to initiate a crying response, driven by evaporating amniotic fluids, that likely is necessary to open the respiratory passages necessary to obtain oxygen. The uterine birthing, acquisition of a newborn “splitting” headache has also occurred.

Simultaneously, the person’s mucosal surfaces are being colonized with their own bacterial “biome” to modulate its immune system. And just as suddenly, the Quantum Signaling Brain is awakened by the flood of newly encountered sensory and homeostatic resilience information.

As a result, each newborn dependent person begins to interact with their new environment to achieve many changes, most obviously marked by a doubling of their weight along with a 27% increase in length during the next five months. If you started today at 150 pounds, a similar weight gain would represent a weight of 300 pounds five months later. Remember also, that in 5 months, each newborn will be able to quickly recognize their parents and smile when seeing their face, maybe with a bit of cooing as well.

PERSON may be defined for HEALTH as

a viable Human Fetus that

survives its birth to become an ‘additional’ dependent person of their family;

develops an awareness of the nurturing caring relationships during early childhood that

originate within their family, its family convoy, and its home’s neighborhood

for promoting the initial expression of its endowed Human Capabilities;

ameliorates the discordant social interactions encountered daily after early childhood

within their family’s home and subsequently after late childhood

within their home’s community to merge the person’s personality and

moral reasoning character with their endowed Human Capabilities; and

forms prosocial normative, caring relationships with the persons originating

from within their family, its family convoy, and their home’s neighborhood

to achieve self-sufficient survival as an independent person after adolescence.

COMMENT As anyone might observe, this collection of concepts is sequentially defined, and they could be viewed as overly complicated. In response, the concept of cognitive dissonance needs further recognition. If we are all mutually committed to improving every community’s Social Cohesion by reducing poverty in every community, then we will ALL need to understand how human development occurs. Otherwise, it would be very difficult to prevent, mitigate, and ameliorate each person’s developmental encounters with modest as well as substantially discordant Disruptive Processes. The Poverty definition explains why this becomes generationally important as a result of its epigenetic perpetuation.

Within the Philosophy arena that focuses on a “Person”, I find that the collection of essays written by A.J. Ayer Ph.D. were the most accessible for me during my consideration of the alternate dimensions that are required, see: “THE CONCEPT OF A PERSON and other Essays.” (Ayer 1964) To advance this discipline, it is important to distinguish ‘independent persons’ from ‘dependent persons.’ For daily discourse, the single-word “person” is usually understood as an independent person. This level of complexity is further clouded by each State’s legislation in addition to National legislation for these terms. It becomes ultimately more complicated as each community attempts to manage the freedom of its resident persons that are affected by severe mental illness.

Eventually the issue of Free Will, viz., self-sufficiency, becomes important to consider when evaluating the effects of certain addictions that can degrade any person’s WILLFUL choices. As additionally identifiable in conjunction with Professor Ayer, a sentinel essay written by Professor Harry G. Frankfurt appeared in The Journal Of Philosophy entitled “FREEDOM OF THE WILL AND THE CONCEPT OF PERSON.” (Franfurt 1971) This essay analyses the issue of a person’s Free Will when they are under the influence of mood-altering substances or circumstances. I will defer any related discussion of authenticity to others.

POVERTY may be defined as

a disability affecting a person’s endowed Human Capabilities that occurs

from the chronic cognitive fatigue experienced by the person’s long-standing attempt

to maintain and develop the prosocial adaptive skills required for their survival amidst

the substantial disruptive processes encountered within their community’s municipal life,

especially for the adaptive skills required to maintain a household for themself and,

if any, their family’s additional persons as the basis to provide for their communal

restful SLEEP, good FOOD, dedicated EXERCISE, and courageous MENTORING.

COMMENT Beginning in 1982, the US Census Bureau applied a new algorithm for evaluating the incidence of poverty in each state. Nationally, the annual poverty rate since then has not changed other than a temporary worsening during the years also associated with a recession. For an easily accessible source of state and local areas of poverty, I recommend the NEIGHBORHOOD ATLAS internet site maintained by the University of Wisconsin. I suspect that you might be surprised where they are located in your own community or state. As a result, it is also possible to define a person’s probable longevity by where they live.

The complexity of poverty, especially its epigenetic attributes for generational families, perpetuates its “live and let live” acquiescence within communities. Given this view, any nationally organized program or plan is not likely to resolve the unique ecologic and cultural heritage traditions that have initiated and sustained each community’s lingering poverty. Ultimately, each community will need to identify its own needs that prioritize family support – viz., family leave, and advanced early childhood education – viz., starting at 6 months of age. (Heckman 2013) Thereafter, its crime, housing, jobs – viz., diverse entry-level training, transportation, utilities, primary and secondary education, disaster preparedness, safety-net integrated responsiveness – viz., Survival Commons, and enhanced Primary Healthcare.

Two faculty members at Trinity College Dublin, University of Dublin in Dublin Ireland explored the concept of cognitive fatigue and its effects on moral reasoning. With a research project, they verified the effect of cognitive fatigue on moral reasoning. (Timmons and Byrne 2018) Along with each community’s discordant cultural and ecologic traditions, especially when also associated with low social cohesion, poverty then becomes epigenetically fixed.

—————————— H E I G H B O R H O O D ——————————

SOCIAL INTERACTION SALUTATORY GREETING

CARING RELATIONSHIP

FAMILY TRADITIONS FAMILY CONVOY * FAMILY

SALUTATORY GREETING may be defined as

a person’s regularly renewed, adaptive skill for offering a brief gesture

of Kindness and Respect to every person safely encountered daily

while participating in their community’s municipal life, especially for

* each person recognizably parenting an infant or toddler,

* the eyes of this person’s infant or toddler with a very-brief Smile

* each disabled or possibly homeless person, and

* each person who lives within your Home’s neighborhood.

COMMENT When expressed frequently within your family, its family convoy, your Home’s neighborhood as well as your adjacent communities, the persistent sharing of Kindness and Respect by every resident person builds trustworthy communities. Improving a community’s social cohesion then promotes each person’s healthy survival during the bad times as well as the good times. (Giordano 2016) Importantly, every person needs to steadily revise their adaptive skills for refocusing our increasingly complex society. Remember that social stigmata must never be allowed to disturb our mutually shared expressions of Kindness and Respect. Now, you will understand the serious commitment necessary to perfect the expression of your ‘Salutatory Greeting’ while participating in your community’s municipal life.

Remember again, good neighborhoods become possible for every family when Kindness and Respect are mutually shared among their neighbors, ALL TOGETHER.

SOCIAL INTERACTION may be defined as

a single encounter, or a variously connected series of encounters involving

two or more persons who recognize each other’s shared intentionality

about the occurrence of a situational scenario, assemble for its purpose, and

participate in the situational scenario based on each person’s understanding

of the situational scenario’s likely purpose, rules, and time course.

COMMENT This definition represents a contemporary adaptation of the sociological concept originated by Erving Goffman (1922-1982) who initiated a field of study known as micro-sociology. Briefly considered, Social Interaction refers to those actions within a social scenario that a person initiates with another person who responds in turn. Social Interactions apply to a very large array of human behavior that can be viewed as divided into five categories: Exchange, Competition, Conflict, and Coercion. The use of Social Interactions became a fixture within Sociology following the publication of Professor Goffman’s book entitled “THE PRESENTATION OF SELF.” (Goffman 1959/2008)

Within another similar humanitarian arena, Philosophy uses the term social relations rather than social interactions. With the growing use of social interaction, it seems as if social relation usage has become overall less common. This may be rebalanced by the burgeoning use of Social Relation within the humanitarian arena of social capital, social dilemma, and social cohesion as originated by Professor Elinor Ostrom for the analysis of Common Pool Resource management.

CARING RELATIONSHIP may be defined as

a dyadic social interaction involving diverse scenarios that

begins with mutual respect for each other’s autonomy,

thrives from each person’s steady renewal of their adaptive skills, and

flourishes when the two persons communicate ‘in harmony’ with

warmth, non-critical acceptance, honesty, and empathy.

COMMENT Caring for, by, and about another person seems to be a literary tradition that became entrapped by Carl Rogers, Ph.D. long ago. His research defined the interactional congruence necessary for therapeutic counseling to be effective. Eventually, Rogerian therapy became a recognized skill for which its interactional process reflected warmth (viz., non-possessive positive regard); non-critical acceptance (viz., ecologic and cultural dimensions); honesty (viz., congruent ‘actions, thoughts, and feelings’); and empathy (viz., the most difficult). (Rogers 1961)

What may be new for this definition is the use of the phrase ‘in harmony’: the spontaneous ability of two persons to interact with a spontaneously forming acknowledgment of what the other person may be thinking, feeling, and needing. We all might recognize such an event as occurring with a close friendship or family relationship. There is current research that your brain’s electromagnetic energy patterns may become coupled with another person’s electromagnetic wave patterns to, in some manner, mutually focus each other’s intellectual focus as ‘in harmony.’

FAMILY TRADITIONS may be defined for HEALTH as

a cluster of rank-ordered, adaptive skills expressed by a family’s persons

for promoting their communal survival that is recognizable as:

“1. Communicates and listens, 9. Has a balance of interaction among its members,

2. Affirms and supports one another, 10. Has a shared religious core,

3. Teaches respect for others, 11. Respects the privacy of one another,

4. Develops a sense of trust, 12. Values service to others,

5. Has a sense of play and humor, 13. Fosters family mealtime and conversation,

6. Exhibits a sense of shared responsibility, 14. Shares leisure time, and

7. Teaches a sense of right and wrong, 15. Admits to and seeks help for problems.”

8. Has a strong sense of family in which rituals and traditions abound, (Curran 1963)

COMMENT Dolores Curran found herself as having been appointed to coordinate family education within a Colorado Catholic parish in Denver. With post-graduate education in journalism, she initiated a project to define what is known about how families should function to prepare their children as their enter adulthood. As described in her book TRAITS OF HEALTHY FAMILIES, an extended survey process produced the list above. Now some 60 years later, her book continues to be the gold standard. Written with a warm-hearted hint of Irma Bombeck, it remains current.

When questioned about how many Traits are required to be a Healthy Family, she refused to even study such a GOAL. In essence, her view did not want these Traits to become socially observable currency. She did claim that none of the Traits were absolutely required and that no cluster of Traits was more important than any other cluster of Traits. My own ecological and cultural heritage has roots in an agrarian heritage. As you might expect, family mealtimes were a priority for my own dependent and its independent person, generational traditions.

“Family traditions may be defined historically for the members of a family as their treasured legends and characters, their gathering persons and places, their gathering rituals, their shared past as a link to the future, their positive regard for infants and their elders, and their shared priority to actively attend and participate in their gatherings.” (Curran 1963)

FAMILY CONVOY may be defined as

a micro-social network of persons assembled by a family,

commonly involving 3-4 persons per family member, by whom

each member of the micro-social network maintains a caring relationship

with at least one family member as a mentoring connection that

forms initially with the close, biologically related persons of their family,

the ecological and cultural continuity of its family traditions;

attracts close, nearby residents within the family’s home neighborhood

who share their mutually reciprocating, continuous accessibility;

selects professional persons who offer situational mentoring

for the family members, e.g., for their spiritual community,

Primary Healthcare, or social-political-economic stability;

evolves periodically from the replacement of certain persons according

to the family’s needs for contact frequency, closeness, or prosocial adaptive skills; and

revises the social network’s membership with the occurrence

of a sentinel event that substantially affects the personal Survival plan

of a person within the family. (Kahn and Antonucci 1980)

COMMENT Beginning many years ago, the concept of a personal micro-network as a support and mentoring source of caring relationships continues to be revisited by Professor Antonucci. Some 25 years after assessing the Convoys of an investigational cohort, she assessed the same cohort and its Convoys noting that they had largely remained intact. (Antonucci et al 2020) Presumably, this version of a Convoy for each parent would then prepare their children’s skills for maintaining their own personal or future family’s Convoy.

For this definition, an amalgamated version of a Convoy would accommodate variously close persons for each Family member, viz., god-parents. In a similar vein, the invited attendance at family gatherings might become altered by the event’s social emphasis or Family Traditions.

Take a slow, deep breath before reading the next definition.

FAMILY may be defined for HEALTH as

a cluster of two or more persons that

I. Configures itself with a goal to encourage the broadest expression of each other’s endowed Human Capabilities and to sustain each other‘s survival by the daily immediacy of their communally blended, caring relationships;

II. Institutes itself with shared intentionality within a community for a generational cycle by its ‘originating’ independent person or persons when

A. Two ‘originating’ independent persons express a lifelong commitment to their caring relationship as affirmed by a marriage certificate OR

B. One ‘originating’ independent person who is not married, has a sustainable caring relationship with a dependent person, and accepts custodial responsibility for this dependent person as an ‘additional’ dependent person;

III. Engages their community by offering a Salutatory Greeting to every person that each of the cluster’s persons safely encounters during the municipal life of the cluster’s community, irrespective of any ecological or cultural stigmata possibly represented by either themself or the other person;

IV. Accepts an ‘additional’ dependent person into their cluster, if at least one current ‘originating’ independent person of the cluster has an established custodial responsibility for the ‘additional’ dependent person as defined

A. Biologically through birth, biological child, or sibling OR

B. Legally through divorce, adoption, guardianship, or foster care;

V. Assembles a cluster of family traditions that forms the shared identity of the family’s persons and to guide the responsibilities of the ‘originating’ independent person or persons for their duties to:

A. Establish a household, their Home, for their family within a neighborhood of their municipal or rural community for the purpose of protecting the resilience of each person’s endowed Human Capability,

B. Identify an evolving cluster of independent persons who would function as the household’s family convoy and nurture a caring relationship with at least one household person involving varying degrees of closeness that

1. initially forms by consolidating any pre-existing family convoy persons of the cluster’s ‘originating’ independent person or persons or custodially related dependent person or persons,

2. evolves over time as the cluster’s persons variously participate in the gatherings of the cluster’s evolving family traditions with an intent to enrich its cultural heritage for the cluster’s communal identity, and

3. offers courageous mentorship when requested during a substantial disruptive process affecting the survival resilience of any household person, especially during their adolescence;

C. Promote gatherings of the family members within their Home

1. for a weekly pattern of family mealtimes to promote a communal responsibility for each other’s biological, emotional, and spiritual nutrition to prevent, mitigate, and ameliorate their daily encounters with discordant, social interactions involving modest disruptive processes,

2. for the recurring events involving close persons of their family convoy to enhance the ecological and cultural character of the household’s family traditions, especially in association with the sentinel transitions occurring throughout the household’s generational cycle, and

3. for the episodic events involving persons from within their family convoy who share mutually supportive attributes for the household’s family traditions, especially with those persons residing within the family’s neighborhood;

D. Define a personal Survival plan for each person of the family with a goal to

1. arrange for the daily residential needs of each person’s Stable HEALTH, especially for Restful SLEEP, Good FOOD, Dedicated EXERCISE and Mentored COURAGE,

2. prevent, mitigate, or ameliorate any person’s encounter with a substantial disruptive process, and

3. adapt the residential capabilities of their Home, when required, for the personal Survival plan of each household person; AND

E. Accept an ‘additional’ independent person into their home, if either the ‘additional’ independent person becomes an ‘originating’ independent person through marriage with a sole ‘originating’ independent person of a family OR the ‘additional’ independent person

1. has the authentic consent of the current ‘originating’ independent person or persons that occurs 01 to 28 days before their first day of residence by the ‘additional’ independent person within their Home and

2. has an authentic personal Survival plan, or its next-of-kin approved equivalent, that includes: a. provisions to manage the ‘additional’ independent person’s HEALTH in the event that the ‘additional’ independent person becomes, or is possibly becoming, a ‘dependent person’ who would not qualify as an ‘additional’ dependent person within their Home and b. a notarized Will, power of attorney, and medical power of attorney including its provisions for an advanced directive.

COMMENT If you find this definition somewhat inscrutable, I would respond by saying: “So do I.” Even so, it represents the basis for each person’s future Stable HEALTH. The original formulation for this definition began to evolve in 2005.

The traditions of each person’s cultural and ecologic heritage are now withering under a contemporary barrage of discordant social interactions. More than ever, we all need a very clear basis to reinvigorate the Survival COMMONS of each person’s community. Repeated multiple times, remember that POPULATION HEALTH is ultimately about each person’s family, its family traditions, its family convoy, their home’s neighborhood as sustained by their community’s social cohesion, and the evolving Personal Survival Plan of every family’s independent and dependent persons.

One wonders why there is no clear recognition for a clearly understood and auspiciously shared anthropology about the basic functional dimensions of a family. My favorite dictionary uses just 14 words. Even the occurrence of extended families involving adult-children was identifiable only in a sociologically discrete period of time in the United Kingson by the census-analysis community. Even more unusual, there are now several studies that connect late childhood obesity to the lack of at least 5 family mealtimes weekly during early childhood. One wonders whether or not, the lack of a clear recognition of family dynamics has led to an excessively driven ‘live and let-live’ acceptance about our nation’s obligations to prioritize family traditions. If so, it’s another example of cognitive dissonance that has run amok.

————————— C O M M U N I T Y T H E M E —————————

PROSOCIALITY SOCIAL DILEMMA COLLECTIVE ACTION

COMMUNITY SOCIAL CAPITAL

* HEALTH

PROSOCIALITY may be defined for HEALTH as

a social interaction initiated by one or more persons

in behalf of one or more other persons that is typically based on

caring relationships, a volunteer commitment, and an altruistic purpose

for improving Human Dignity with their shared acknowledgment of

*) certain Principles, such as Autonomy, Beneficence, Nonmaleficence, and Justice;

*) certain Interpersonal Rules, such as Veracity, Confidentiality, Privacy, and Fidelity;

*) certain Ideals of Action, such as Forgiveness, Generosity, Compassion, or Kindness; and

*) certain Social Norms for Collective Action, such as Trust, Reciprocity,

Cooperation, and Idle Talk.

COMMENT During the transition from early and late childhood, each person normally begins to engage their home’s neighborhood and the municipal life of its community. As the encounters with diverse social interactions begin to require a widening array of deference and demeanor skills, each person’s personality and moral reasoning indirectly begins to acquire the spontaneity for maintaining their self-sufficiency. A positive connection with a father helps their daughter manage male encounters. Obviously, the reverse occurs for a mother’s sons. Provided in this Design Epistemology, there is a provision for a Family Convoy to promote contact between adolescent family members and familiar adults. All of this involves prosocial behavior norms (see above). Lost in all of this, we have no means to encourage community-specific, ‘nudges’ to encourage prosociality. Ultimately, Baccalaureate degree-granting colleges might be the best collaborative opportunity to guide/sponsor this priority.

SOCIAL DILEMMA may be defined as

a social interaction involving two or more persons,

commonly occurring as a public-goods scenario with a brief time dimension,

for which one person or a small group of persons choose to acquire

a short-term benefit for themselves rather than expressing the prosociality

that is necessary for all of the persons to receive a long-term benefit.

COMMENT Imagine, three cars slowly arrive at a four-way, stop-sign regulated, intersection at about the same time. The first arrival, not turning, goes first followed by all the other three cars. One of the three might get through, but the other two would need to stop suddenly to avoid a crash. Thus, a public goods, social dilemma has occurred in which there was a conflict between the individual and collective interests among the participants.

Collective Action situations have been studied extensively. The results indicate that participants are more likely to make cooperative decisions when they spontaneously express the prosocial norms of “trust, cooperation, and reciprocity” during the social dilemmas they encounter daily within their community’s municipal life. Improving each community’s expression of prosocial norms, its prosociality, then becomes the basis for the community’s prevalence of “Good Samaritan” acts.

COLLECTIVE ACTION may be defined as

A social interaction involving an initial cluster of three or more persons who collaborate with diverse combinations of ecological and cultural congruence and its prosociality to achieve a Goal to improve their status or the status of another cluster by:

1. formalizing a visioning statement to achieve the initial cluster’s Goal, especially when acting on behalf of one, or more than one, social network;

2. preparing an action plan for achieving the initial cluster’s visioning statement, especially when this visioning statement requires a set of tasks for managing a Common Pool Resource; and

3. delegating the action plan responsibilities to one, or more than one, of the following three options: a. the initial cluster itself, b. another cluster of persons, and c. an incorporated private or public institution selected by the initial cluster.

COMMENT Mancur Olson, Ph.D. wrote the sentinel reference for collective action, viz., its title: “THE LOGIC OF COLLECTIVE ACTION Public Goods and the Theory of Groups.” Importantly, the definition for Collective Action given above describes the importance of a defined Visioning Statement (i.e., Goal, Mission, Principles) and Action Plan (i.e., Strategic Development Plan). It also alludes to alternate types of collective action, as in a collective impact model.

The steady development of collaborative processes, community by community, to manage their own Survival Commons in association with their contiguously adjacent communities is likely to represent a highly diverse set of fits and starts. At least 800 Community HEALTH Forums, each defined by population groups averaging @400,000 resident persons. Each Forum would manage their own community’s Survival Commons, viz., enhanced Safety Net, in association with their contiguously adjacent communities within each State. This Design Epistemology includes a definition for a community’s Survival Commons. Locally initiated and supported by each community, recognized by a nationally instituted sanctioning and technical support strategy. Grappling with adverse, locally entrenched ecological and cultural traditions will require a substantial effort within every community. It is likely to represent the lynch-pin strategy for ultimately improving our nation’s social cohesion.

As a reminder, collective action by itself does not automatically pursue a GOAL that promotes caring relationships and Social Capital. Only one yardstick would accurately measure the Collective Action occurring within a community that augments its Survival Commons, viz., to what extent does each of a community’s neighborhoods contribute their own resident persons to each other’s Family Convoy?

COMMUNITY may be defined as

a cluster of multiple persons, most commonly recognizable

as the persons residing within a municipality’s geographic border

that is usually associated with a unique ecological and cultural heritage,

who participate in more than one social network of the cluster to obtain

certain prosocial benefits from each network’s inter-connected spontaneity and thereby

acquiring a valued awareness about the identity of each cluster’s social network

that is borne out of the social interactions occurring within each social network and

by each person’s cumulative association of these social interactions

with memories of their own ecological and cultural traditions.

COMMENT This definition originated from A COMMENTARY essay written by David M. Chavis and Kien Lee. It appeared in the May 15, 2015 edition of the Stanford SOCIAL INNOVATION Review. It has been augmented to account for the variety of social networks in most communities. The evolution of these social networks that promotes their community’s prosociality then mediates each community’s contribution to their nation’s continuously improving level of Social Cohesion.

For this Design Epistemology, each community is intended to represent on average 400,000 resident persons within the border of each State as primarily defined by county borders and each community comprised of no less than 100,000 resident persons. The community mean-number of resident persons would evolve every 10-15 years based on a national population divided by 800.

SOCIAL CAPITAL may be defined as

the occurrence of bystander immediacy by a community’s resident persons

to apply prosocial norms for resolving the social dilemmas

they encounter daily within their community’s municipal life that

becomes increasingly identifiable among the community’s resident persons

when multi-generational, caring relationships progressively populate

the community’s meso and macro social networks.

COMMENT This definition of Social Capital is uniquely phrased for this Design Epistemology. It reflects an emphasis on the character of the social networks within a community and how they do, or do not, maintain caring relationships among their meso and macro network members. For a uniquely comprehensive bibliography and periodic analysis of Social Capital, visit www.socialcapitalresearch.com . Tristan Claridge initiated his Institute for Social Capital in 2005.

Ultimately, the prevalence of each community’s prosociality and its steady improvement over time contributes to their nation’s Social Cohesion. It is likely that our nation’s locally prevalent social determinants of health will not be resolvable without a nationally sanctioned and locally driven strategy to refurbish every community’s prosociality.

HEALTH may be defined as

a person’s daily experience of Well-Being that occurs when their survival has been

A. Endowed by the perinatal, gestational formation of synergy

between the person’s innate temperament and their baseline homeostasis

to achieve adequate resilience for the person’s survival after birth;

B. Nurtured by the person’s caring relationships originating from within

the person’s family, its family convoy, and their home’s neighborhood

i. before birth with a goal to enrich the person’s eventual search

for the broadest portrayal of their endowed Human Capability

during early childhood as a joyful ‘dependent person’ and

ii. after birth with a goal to eventually mentor the person’s personality, moral reasoning,

and Well-Being for the broadest portrayal of their endowed Human Capability,

especially during late childhood, adolescence, and early adulthood development

while becoming a courageous, sustainably self-sufficient person after adolescence;

C. Challenged by the person’s daily encounter with mild disruptive processes that begins

before birth and occurs as interacting combinations and patterns to cause variably

reversible and either beneficent or maleficent effects on the resilience

of the person’s endowed Human Capability as prevented, mitigated, and ameliorated

by the joyful and courageous caring relationships originating lifelong from within

the person’s family, its family convoy, and their family’s home-neighborhood;

D. Matured by the person’s episodic encounters with substantial disruptive processes

that begin before birth and occur as interacting combinations and patterns

to cause variably irreversible and maleficent effects on the resilience

of the person’s endowed Human Capability

as variously prevented, mitigated, and ameliorated lifelong

by the person’s family, its family traditions, its family convoy, and

their family’s home-neighborhood as well as by their personal Survival plan; AND

E. Sustained by the person’s joyful and courageous caring relationships,

their hopeful family traditions, and the Survival commons of their community

until the sustainable resilience of the person’s endowed Human Capability

is no longer sufficient for the person’s survival as a result

of the person’s lifelong encounters with a disruptive process.

COMMENT MILLMAN, an actuarial consulting company has reported that their analysis of the essential causes of Unstable Health are: Social determinants 40%, Behavioral 30%, Healthcare quality 20%, and DNA Genetics 10%. Healthcare Reform that is solely directed at our healthcare for each resident person’s Basic and Complex Healthcare Needs is unlikely to ever be successful without a simultaneous commitment to promote the locally initiated improvement of its own Survival Commons for each of their resident persons. This commitment must also be associated with a strategy to improve their community’s social cohesion by pursuing a collaborative connection with their contiguously adjacent communities to annually review each other’s Master Disaster Planning Strategy.

—————————— N A T I O N A L ——————————-

HEALTH CARE PRIMARY HEALTHCARE

INSTITUTION

SURVIVAL COMMONS * SOCIAL COHESION COMMON GOOD

HEALTH CARE may be defined as

the preservation of a person’s Stable Health by a specific health service that is

a. recognizable by its designation as a uniformly identifiable unit service

for research, education, or financial reimbursement;

b. provided during an encounter with a professionally licensed person

within a situational scenario of a Caring Relationship; and

c. becomes HEALTHCARE when involving interconnected encounters

over extended periods of time.

COMMENT Both Health Care and Healthcare usually involve many unpredictable professional activities to improve the precision of any encounter. The frequent shifts between alternate, diagnostic hypotheses and their associated deductive and inductive assessment processes require extended periods of study and experience usually involving 5-10 year trends for a physician, especially to acquire the adaptive skills to manage their own Cultural-Social Cognition. It is best to differentiate Basic Healthcare Needs for Primary Healthcare as compared to Complex Healthcare Needs.

a. BASIC HEALTHCARE NEEDS may be defined as the prosocial opportunity for mentoring a person’s priorities for preserving their endowed Human Capability, by offering the following:

i. the equitably available and culturally accessible medical TRIAGE that is telephonically offered to a person continuously for the occurrence of any emergent, urgent, or expectant Health Condition involving a potential requirement for Health Care, especially for a Health Condition requiring a Specialist Physician;

ii. the diagnosis and treatment of *) an urgent or expectant Health Condition possibly representing a disease for which its timely treatment would improve a person’s Stable Health, *) any new or recurring Health Condition possibly associated with a disease for which the person’s Stable Health would be more likely preserved by its timely diagnosis and treatment, and *) any unchanging or uncomplicated disease for which regular reassessment would likely decrease its effects on the person’s Stable Health; and

iii. the periodic reassessment of a person’s overall Stable Health as the basis for determining the person’s priorities for defining a Comprehensive Care Plan to sustain their Stable Health, coordination of this Plan with any co-occurring Complex Healthcare Needs, and provisions for their personal Survival Plan.

b. COMPLEX HEALTHCARE NEEDS may be defined as

i. the diagnosis and treatment of emergent HEALTH CONDITIONS and

ii. the diagnosis and treatment of any new or previously established

HEALTH CONDITION requiring the skills of a specialist physician.

PRIMARY HEALTHCARE may be defined as

the healthcare that each community’s municipal leaders and its applicable stakeholders

promote for their resident persons by establishing the Primary Healthcare Teams required

to serve the Basic Healthcare Needs of their community’s resident persons and

the coordination of these Needs with the Healthcare required

for each person’s Complex Healthcare Needs.

COMMENT This is a very compact definition for which several other definitions are required: HEALTH CONDITION and its subcategories, HEALTHCARE TEAM, medical TRIAGE and its subcategories, and PRIMARY PHYSICIAN. They are further defined at the end of the five Design Epistemology Thematic sections.

The first appearance of Primary Healthcare within a glossary or lexicon would most likely be attributable to a definition established by the World Health Organization in 1975. It ascribes more clearly to an emphasis for Primary Healthcare to honor a nation’s social contract/common good. I quote (WHO 1975):

“Primary health care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation, and at a cost that the community can afford. It forms an integral part of both the country’s health system, of which it is the nucleus, and of the overall social and economic development of the community.”

As our nation continues to survive within the 21st century and its social-political-economic turmoil, the WHO definition for our Primary Healthcare should incessantly remind us that the Health of each community’s resident persons evolves in the context of the worldwide Common Good, viz., Clovid Pandemic. The need to promote international Social Cohesion will not resolve with solutions solely focused on climate change and the pandemic.

INSTITUTION may be defined as

” . . . the prescriptions that humans use to organize all forms of repetitive and

structured interactions including those within families, neighborhoods, markets, firms,

sports leagues, churches, private associations, and governments at all scales.

Individuals interacting within rule-associated situations face choices

regarding the actions and strategies they take, leading to consequences

for themselves and for others. The opportunities and constraints individuals face

in any particular situation, the information they obtain, the benefits they obtain

or are excluded from, and how they reason about the situation are all affected

by the rules or absence of rules that structure the situation. Further, the rules

affecting one situation are themselves crafted by individuals interacting

in deeper level situations. For example, the rules we use when driving to work every day

were themselves crafted by officials acting within the collective-choice rules

used to structure their deliberations and decisions. If the individuals who are crafting

and modifying rules do not understand how particular rules affect actions and outcomes

in a particular ecological and cultural environment, rule changes may produce

unexpected, and at times, disastrous results.” (Ostrom 2009)

COMMENT For improving our focus during any paradigm shift process, one small tradition would offer a substantial level of cognitive dissonance. Population Health and its Healthcare should no longer be identified with organizations. This nuance would then begin to standardize the basic structural character of any cluster of persons who cooperate to maintain a social interaction involving the performance of inter-connected Global Tasks. Global Tasks might generally be recognizable as Organize Systems, Pursue VISION, Build Community, Manage Resources, and Develop Skills.

If you look back at the quotation from President Thomas Jefferson cited above, you will note that it ends with two words, “barbarous ancestors.” And looking back at the definition of an institution by Professor Ostrom, you will note that it ends with two specious words, “disastrous results.” Living nearly two hundred years apart, the character of each person’s Human Dignity would likely have represented two kindred spirits.

SURVIVAL COMMONS may be defined for HEALTH as

the cluster of community capabilities, viz., enhanced safety net,

that each municipal community assembles to protect their resident persons

from the sudden or sustained occurrence of certain disruptive processes

when this cluster of community capabilities is

A. Instituted by their nation’s laws and regulations, that apply to the public and private

institutions of every municipal community at all jurisdictionally nested scales,

to achieve “Stable HEALTH For Each Resident Person”;

B. Enhanced by the daily greetings of Kindness and Respect occurring

amidst the municipal life of their community’s resident persons,

especially when each resident person safely offers

a salutatory greeting to each person they encounter and

each of these persons reciprocates with an appreciative gesture;

C. Offered by each municipal community to its resident persons who each may select,

from among its cluster of community capabilities, the benefits and obligations

most suitable for the needs of their own personal Survival plan within

the ecological and cultural traditions of their home’s municipal community;

D. Improved by each municipal community’s volunteer, resident persons

who become aware that their community’s cluster of community capabilities

has certain discontinuities for which a collective action strategy will be necessary

to resolve these discontinuities with an equitably available, culturally accessible,

justly efficient, and predictably effective action plan;

E. Augmented by the collective action strategies that originate

from within each municipal community’s private and public institutions as well as

its social networks to prevent, mitigate, or ameliorate any ‘newly recognizable adversity’

encountered by its resident persons that is related to a locally prominent discontinuity

among their municipal community’s cluster of community capabilities or

their associated Benefits and Obligations,

especially if the ‘newly recognizable adversity’ represents a deficiency

among the Benefits and Obligations currently intended to

prevent childhood maltreatment, improve social mobility,

reduce social isolation, or disenable poverty;

F. Protected by each municipal community’s Master Disaster Planning Strategy

that is annually reviewed and revised to prevent, mitigate, and ameliorate

certain locally reoccurring disasters and the effects

of their associated disruptive processes that variably impair

each resident person’s ability to maintain a personal Survival plan, especially

by the community’s vulnerably resident persons

who become afflicted by poverty; AND

G. Supported by each community’s reciprocating connection

with their contiguously adjacent communities, and

their nation’s expression of social cohesion when interacting

within the worldwide, marketplace arenas for every nation’s

resources, knowledge, and human dignity.

COMMENT Locally initiated and supported, each nationally designated community would form a Community HEALTH Forum to assure that its own SURVIVAL COMMONS is actively pursued by their community’s public and private stakeholders, at all jurisdictional national, regional, state, county, township, city, and neighborhood levels.

SOCIAL COHESION may be defined for a NATION as

the national expectation among the resident persons of each municipal community

that the resident persons of the other municipal communities are trustworthy and

that the continuing prevalence of these trustworthy persons improves

when each municipal community continually collaborates

with their adjacent communities to enhance each other’s Survival commons

by their reciprocating investments of social capital.

COMMENT Fundamentally, it is possible to construe an analysis that our nation’s steady loss of social cohesion since the Civil War represents the fundamental cause of the stress that we all encounter within our daily lives. The definition above would not be recognizable by most Population Health experts. No matter how it is construed, this Design Epistemology for improving Population Health as well as its healthcare would likely fail without a process to engage every resident person’s own community in a nationally sanctioned self-sustained strategy to rebuild our nation’s social cohesion, community by community.

COMMON GOOD may be defined as

a worldwide compact formed by the cooperative obligation of every nation

to sustain their prosocial social-political-economic, institutional responsibilities

for promoting the broadest expression of endowed Human Capabilities by each

of their resident persons and to sustain the reciprocating exchange of social capital

with their adjacent nations for ultimately assuring the resilient survival

of the worldwide community of persons.

COMMENT The “Universal Declaration for the Common Good of Humanity Project” may represent the most concise, yet comprehensive, statement with a purpose to achieve a nation’s COMMON GOOD. Its origin can be traced to a proposal initiated by the 2012 World Forum for Alternatives in Rio de Janeiro and presented to the 2013 World Social Forum in Tunisia. In addition, the “Convention on the Rights of Persons with Disabilities and Optional Protocol” adopted by the United Nations in 2008 might apply to expand any consideration of the Common Good.

a NEW STRATEGY

Given the heritage of our nation’s healthcare and these thirty definitions, I offer a new view of meaningful healthcare reform. The ultimate character of any new strategy for the reform of our nation’s healthcare will depend on the locally initiated, continuous renewal of each community’s Survival Commons. There are nearly endless priorities that might be identified with this view of healthcare reform. Among these many priorities, I propose that only two priorities are important for true healthcare reform.

First, our nation’s healthcare industry must eventually offer enhanced Primary Healthcare that is equitably available to each resident person within their own community. This health care would strive to offer caring relationships as defined above, thoughts spanning more than 2,500 years. Each community’s collaborative commitment to promote enduring caring relationships between each person and a Primary Healthcare Team should be the essential attribute for this new view of healthcare reform. The ultimate improvement of primary healthcare, community by community, will also require three nationally sanctioned projects. These national projects are necessary to successfully support community-driven healthcare reform.

These national projects are: 1) an evolving comprehensive statement of “best practices” to achieve and sustain the career-long educational preparation of sufficient Primary Physicians for the Basic Healthcare Needs of every community’s resident persons; 2) a set of minimum definitions to use as the basis for the optimal economic reimbursement of enhanced Primary Healthcare; and 3) a HEALTH SECURITY certification process for enhanced Primary Healthcare as the basis for its eligibility to receive optimal economic support.

Second, successful healthcare reform should begin with an assessment of Primary Healthcare, community by community, to assure that it is equitably available to each resident person within their respective community. To support this obligation, each community averaging approximately 400,000 resident persons would support the formation and functions of a Community HEALTH Forum.

COMMUNITY HEALTH FORUM

Approximately 800 of these individual Forums nationwide would each be responsible for their own Community HEALTH Plan as an annual assessment of the equitable availability of its Primary Healthcare and the results of a monitoring process for the efficiency and effectiveness of their community’s healthcare. Eventually, a mature Community HEALTH Plan would have three sections:

a section devoted to achieving equitably available and HEALTH SECURITY certified Primary Healthcare for each resident person as collaboratively promoted by the relevant community stakeholders; this section would eventually be augmented by a community, data-driven monitoring process for assessing the improvement of the community’s level of Stable HEALTH;

a Special Projects section to identify the locally prominent adversities affecting their community’s Survival Commons; this section would also include a community-wide assessment of its current social capital assets and the collective action Special Projects currently in place for mitigating the discontinuities that exist within the community’s Survival Commons, especially for social mobility and social isolation; and

a section to describe their community’s annual review of its Master Disaster Planning Strategy for *) the likely occurrence of predictable disasters as a basis for preventing, mitigating, and ameliorating where possible the effects of these disasters and any unpredictable disasters, *) the applicable preparation in advance of and the recovery efforts immediately following these disasters, *) the community’s connection to their City, County, State, and Federal governments’ disaster preparedness strategies, *) the community’s ongoing collaborative connections with its adjacent communities and the mutual reciprocity of their community’s social capital contributions:

A Community HEALTH Plan offers the best opportunity, annually revised, to highlight certain Special Projects in addition to the usual array of public health needs within each community. The Special Projects might include early childhood education, adolescent development (especially for teenage maternal Well-Being), obesity, mental-health emergency-responsiveness, or homelessness. Disaster preparedness is difficult since the timing and severity of disasters vary considerably. The options available before and after a disaster to mitigate its adverse effects are the most important attribute of these plans. Furthermore, the preparedness for predictable disasters then establishes the basis for managing the community’s unpredictable events.

After a few years, the national character of these 800 Community HEALTH Plans is likely to reflect the diversity of local priorities and their needs. Eventually, they could coalesce on the importance of certain details requiring nationally connected intervention projects. Finally, the benefits of disaster planning are less obvious for predicted disasters than they are for unforeseen disasters. The resilience of each community’s social capital commitment to advance its Survival Commons would be the most profound underlying component for the success of its disaster preparation. This attribute would be enhanced by each community’s collaboration with its adjacent communities.

Each Community HEALTH Forum would be formed to include participation by the locally applicable, community-benefit stakeholders. As ADVOCATES within the overall umbrella of NATIONAL HEALTH, each Forum would participate along with the other nearly 800 Community HEALTH Forums to incorporate the collaborative options that their community’s healthcare institutions have already identified. An underlying theme for each Forum would be its obligation to promote trust, cooperation, and reciprocity among its existing community institutions. Beginning more than 400 years ago, the enduring tradition of locally mobilized volunteerism may be the most important heritage for sustaining our nation’s worldwide autonomy and as well as for the continuous improvement of our nation’s HEALTH.

THREE “Mision To The Moon” GOALs

Unintentionally, the traditions of our nation’s healthcare industry have interacted since 1969 to paralyze its capacity to initiate and perpetuate its own reform. To reverse this paralysis, a supreme national commitment will be required to implement a thoroughly reconsidered basis for healthcare reform. The commitment required for this level of reform should represent our nation’s next, “mission to the moon.” After starting this newly reconsidered “moon-shot,” I propose three very specific GOALs for healthcare reform:

Reduce annual health spending by the equivalent of an incrementally steady reduction from 18.0% in 2019 to 13.0% of our nation’s economy (GDP) within 10 years;
Reduce the annual incidence of women dying from a pregnancy (in 2019) from 20.1 to 6.0 deaths per 100,000 live births, (maternity mortality ratio) within 10 years; and
the ratification by all States of a Charter established by Congress for a new nationally constituted, semi-autonomous institution to achieve these GOALS for healthcare reform within 10 years.

These GOALs beginning in 2023 and ending in 2033 would: 1) reduce annual health spending as a portion of our nation’s GDP by 28%, 2) reduce the number of women dying from a pregnancy by 70%, and 3) achieve legislative by all 50 States for their State’s full collaboration with NATIONAL HEALTH. NATIONAL HEALTH would be Federally funded with fixed, annual cost of living adjusted, annual budget of $1.50 per citizen and have ultimate responsibility for achieving these three GOALS.

Reducing the health spending for our nation’s healthcare will be especially important for our nation to maintain its autonomy within the marketplace arenas for the world’s Resources as well as for its Knowledge and Human Dignity. Continuing our nation’s current deficit spending will eventually achieve a debt per citizen that is the same as it was for Greece in 2011. As of 2019 after 5 years of austerity, their nation was finally able to arrange IMF loans to support their long-term debt without international supervision.

During 2019, total health spending for our nation’s healthcare was $3.92 Trillion. It represented 18.0% of our national economy. Almost all of the other developed nations had spent less than 13% of their nation’s economy on healthcare. Using a benchmark of 13.0% as a goal, the excess health spending in 2019 could be estimated as the difference between 13.0% and 18.0% of our nation’s economy in 2018. This excess health spending for our nation’s healthcare in 2019 would have been $1.008 trillion or the equivalent of fighting 10 Iraqi/Afghanistan wars in 2005, simultaneously! To finish this analysis, the Federal government paid cash for 45% of our nation’s healthcare in 2019, representing $454 Billion of its excess cost. Most importantly, this $452 billion represented 46% of our Federal deficit of $984 Billion in 2019.

GETTING STARTED

The excess cost of our nation’s healthcare represented the largest contribution to the 2019 fiscal deficit of our nation’s Federal government. Furthermore, there is no evidence that the current overall strategy for healthcare reform would substantially improve the overall efficiency and gaps of effectiveness by our nation’s current healthcare. Beginning today, “lift-off” for NATIONAL HEALTH could be 6 months away. Our nation’s autonomy within the worldwide community is at stake. Established by a Congressional Charter for the benefit of our nation’s future, each resident person would eventually recognize the V I S I O N of the new institution by its name. I propose the following visioning statement for NATIONAL HEALTH:

V I S I O N – Stable HEALTH For Each Resident Person

MISSION – To plan healthcare reform

with a continuously renewed understanding of our nation’s

Resources, Knowledge, and Human Dignity

PRINCIPLES – Altruism . Trust . Cooperation . Reciprocity . Excellence

To understand the basic dimensions underlying the future of healthcare reform, I offer a brief history lesson. The history lesson begins with the following question. What is the heritage of our nation that has evolved from the passions of the immigrants who came here from foreign lands? To be sure, many passions motivated the men and women who have historically emigrated and continue to emigrate from their homeland to North America. Among these motivations, three passions probably represent the essential heritage underlying their emigration.

One passion has been a desire to leave their homeland’s authoritarian, autocratic, centralized, and coercive government. A second passion has been a desire to become a citizen of a nation with constitutionally defined and enforced freedom of speech. To be comprehensive, our First Amendment rights also include freedom of religion, print, assembly, and petition.

Since 2001, the world’s continuing and rapidly evolving events represented the beginning of a new era for the worldwide community. This new era clearly represents an evolving threat to each person’s Human Dignity when living in a nation with an autocratic, authoritarian, centralized, and coercive government. According to the NEWSEUM in 2014, only 9% of the world-wide population, who lived outside of the USA, were citizens of a nation with our enforced, First Amendment rights.

The third passion that motivated immigrants was, and still is, the chance to start a new way of life. Starting in 1600, a new way of life was especially prominent for the early immigrants who came to North America and endured life-threatening hardships. Most early immigrants accepted, in advance, the profound and unknown dangers of these hardships. It was a small price to pay for the chance to achieve a substantially and permanently better quality of life. Relocating to North America and leaving “taxation without representation” was, and continues to be, worth these life-threatening risks.

Unfortunately, some immigrants have come to our nation for other reasons. Human trafficking, AKA slavery, has forced and continues to force many immigrants to emigrate for the profit motives of their captors. In 1865, the 13th Amendment to our nation’s Constitution prohibited overt slavery. The forced loss of human dignity for the African emigrants was and continues to be a devastating failure of our nation’s commitment to uniformly honor the human dignity of every immigrant person. The lingering, generational impact for these immigrants continues to haunt the sincerity of our nation’s First Amendment obligations.

Other immigrants have come to our nation only to serve their own predominantly self-centered economic or social values. Finally, our early immigrants forced the Native North Americans to emigrate and, as a result, become immigrants on their own land. Our nation’s legal tradition of assumed property rights drove the forced immigration of our Native Americans. In 1879, Native Americans achieved protection under the law from an Omaha Federal Court decision by Judge Elmer Dundy for Chief Standing Bear of the Ponca Tribe. To achieve this decision, two attorneys had prevailed with a writ of “habeas corpus ad subjiciendum.” The two attorneys were employees of the Union Pacific railroad in Omaha and members of a local Congregational Church who actively affirmed their pro bono commitment.

HUMANITARIAN VERSUS SCIENTIFIC MANDATE

Despite the reasons for immigration, successful survival in North America ultimately required self-discipline, hard work, and altruism – a desire to help others. For nearly 500 years, this dedication to individual survival has been associated with an expectation that each community would function better if its resident persons survived primarily on their own with the assistance of their family despite life’s tragic events. For the 12 million immigrants who arrived in New York City at Ellis Island, any healthcare that was eventually available to them was a privilege based on the economic success of their own survival. The immigrants who passed through Ellis Island represented the ancestors of nearly 40% of our nation’s current citizens when it closed in 1954. They included my grandparents from Sweden.

Between 1850 and 1900, the knowledge about anesthesia and infection control began to evolve. This meant that the benefits of surgery eventually required a specific location outside of a person’s home. Prior to this combination of newly evolving technologies, health care almost always occurred within a person’s home as offered by members of the person’s family and its micro-social networks. Except for wartime or travel away from home, the only persons who did not receive this level of healthcare were the persons without a family, now recognized as homeless.

Almost every community since 1700 began to have rudimentary hospitals for the homeless, currently most commonly identifiable as “nursing homes.” Most of these were community-established by county and city levels of government or religious institutions. With the evolution of surgery, some of these early nursing homes eventually adapted to become modern-day hospitals. Most importantly, the early and eventually profound evolution of life-preserving healthcare beyond the confines of a person’s home removed a powerful means to maintain their family traditions. Specifically, these family traditions were important to sustain the mutually shared commitments within a family and its family convoy to care for each other. Originating slowly following the Civil war ending in 1865, newly constructed hospitals eventually became more common after World War I and especially after World War II.

Along with the shift of healthcare to a location ‘foreign’ to most resident persons, the cultural and ecologic origins of each person’s Health also became exposed to an increasingly complex society. The newly evolving changes involved family-relocation frequency, electronic communication, urbanization, women’s professionalization within the workforce, and urban poverty. A continuing cycle of violence, worldwide and neighborhood by neighborhood, has evolved since the end of WWII in 1945 and especially after 2001. Amid the adaptation to these changes, we have arrived at a time whereby a person’s Family Convoy and their Family Traditions no longer offer the traditional emotional resources for mentoring each person during episodes of unstable Health, especially for women while adapting to a pregnancy.

All of this has led to a diminished commitment within each community to sustain the Stable HEALTH of its resident persons by their community’s Survival commons, aka safety net. Beginning in 1969, the disruptive processes that represent the causes of unstable Health have become increasingly beyond the control of our healthcare industry. Given the vast social and economic changes of the last 150+ years since the Civil War, we have arrived at a level of ecological and cultural turmoil within our world and our nation that is unprecedented by any definition.

PARADIGM SHIFT with PARALYSIS

Beginning in 1969, a rapidly evolving improvement began to occur in the sophistication of healthcare that is now available for Complex Healthcare Needs. Unfortunately, the improved quality of health care for Complex Healthcare Needs has not been matched by a similar improvement in the health care for the Basic Healthcare Needs of each resident person. This change since 1969 means that self-discipline, hard work, and altruism no longer guarantee that health care is equitably available for the Basic Healthcare Needs of each resident person, even for the persons who have achieved economic success. Inequitably available health care for Basic Healthcare Needs can be especially profound *) for any woman before, during, and following a pregnancy, *) for any resident person who is an infant, disabled, homeless, or *) mired by poverty.

By 2009, the poorly recognized imbalance that had evolved between the health care for Basic Healthcare Needs and for Complex Healthcare Needs represents a root cause for the problems within our nation’s health care. Furthermore, the health care for Basic Healthcare Needs has deteriorated without a strategy to assure that Primary Healthcare is equitably available to as well as culturally accessible by each resident person within their own community. The effect of this deficiency has led to severe problems within our healthcare industry, as in its cost and preventable maternal deaths.

The imbalance is partially the result of an inadequate level of financial capital for the Basic Healthcare Needs of each resident person as compared to the financial capital that is available for their Complex Healthcare Needs. It is not the fault of specific resident persons or an organized group of resident persons. It began to occur, more prominently, after Congress authorized Medicare and Medicaid in 1965. Between 1960 and 2019, the portion of our nation’s economy allocated to healthcare has more than tripled.

Unfortunately, the flow of these resources preferentially into the health care for Complex Healthcare Needs has produced a deeply entrenched and pervasive co-dependency between the institutions paying for Complex Healthcare Needs and the institutions offering healthcare for these Complex Healthcare Needs. These institutions are the medical-school affiliated hospital centers and the private health insurance companies. The institutional co-dependency is a contributory root cause of the Paradigm Paralysis afflicting our nation’s healthcare industry.

The Paradigm Paralysis means that the heritage of our nation has produced a healthcare industry that is unable to start or sustain its own reform. Since 1969, this industry has required a new and widely supported institution to guide its reform. Our nation’s agriculture industry has had its Cooperative Extension Service since 1914, and our nation’s monetary policy has had its Federal Reserve since 1913. As a result, our nation’s agriculture industry is the most justly efficient and reliably effective among the world’s nations, by a wide margin, and our nation’s dollar is still the most prominent basis for asset transfer among nations in spite of our nation’s increasing indebtedness. Now, more than 100 years after Congressional approval of the Smith-Lever Act in 1914 for agriculture, a similar institution for our nation’s healthcare industry must begin by promoting Primary Healthcare, community by community, that is equitably available to each resident person within their own community.

In addition, our nation must begin a tradition to establish its ability to re-energize a local ‘collaborative’ heritage within each community. This heritage would sustain a nationwide tradition that recognizes each community’s obligation to promote stable Health for each of its own resident persons. The new strategy should also focus on its resident persons with special needs, especially every infant or toddler and their mother. Thirty years from now, our nation’s autonomy within the worldwide community will depend on the sustainability of each community’s Survival commons to foster the caring and learning generations of our nation’s future resident persons. A newly enriched definition of Health should helps to explain this assertion. It is one of the 23 interconnected definitions listed above.

“GOVERNING THE COMMONS” (Ostrom 1990)

Because of its profound inefficiency, our healthcare industry is no longer affordable within our nation’s economy. A “Tragedy of the Commons” has occurred. The traditions of our national heritage have led to this crisis. Exploring the basis for remodeling these traditions is a central theme for NATIONAL HEALTH. The VINTAGE TRADITIONS Chapter and its Sub-Chapters explore this theme in greater detail. They attempt to explain why the problems are so difficult to define and so resistant to implementing solutions that originate from within our nation’s healthcare industry. Simultaneously, an overall strategy has not originated from within the mainstream of our nation’s private and governmental institutions, at all scales.

Professor Elinor Ostrom points the way with her studies described in nine books published between 1990 and 2010. “Governing the Commons” is the first book in the series. Within this series, she describes an analysis of shared use strategies applied with an intent to preserve a natural resource, such as the freshwater aquifer under the city of Los Angeles, California. Eventually, her studies, along with the research of numerous colleagues, defined the Design Principles that characterize the successful governance by any institution with a responsibility to preserve a common-pool resource. For healthcare, the common-pool resource may be defined as the portion of our national economy devoted to health spending.

NEW CONCEPTS

For lasting healthcare reform, any new strategy should include a continuing search for new concepts that would be uniquely applicable to the future reform of our nation’s healthcare industry. The search for these concepts should not necessarily represent an intent to start a new tradition or to match the institutional heritage of another nation. Among the world’s developed nations, the traditions of our own healthcare industry are unique. Given our own traditions, this proposal for NATIONAL HEALTH or any other reform proposal should refine these traditions rather than replace them. The other developed nations of the world have adopted a variety of models for their own healthcare. They are instructive but do not easily provide a specific model to duplicate for our nation.

The search for concepts that are possibly applicable to healthcare reform by NATIONAL HEALTH has focused primarily on the last 100 years. Within the public arena, I have selected a set of concepts for healthcare reform based on how they would jointly interact for a larger impact. These concepts represent the realms of knowledge from a diverse group of scholars. I propose that taken together they represent a pragmatic basis for the comprehensive reform of our nation’s healthcare. It is described by the NATIONAL HEALTH Chapter and its Sub-Chapters.

HEALTH CARE versus HEALTHCARE — A NEW ERA

Given our nation’s pioneer heritage, the historic traditions of our nation’s healthcare industry have evolved, especially since 1969, into a diverse mix of institutions. This industry has become increasingly unstable since 2011. In 2011, an unexpected number of critical medications were suddenly no longer available. One year later, a failure to maintain quality control standards by a compounding pharmacy in Massachusetts led to more than 75 deaths throughout our nation. This state’s Public Health Department had failed to monitor the quality control standards maintained by the compounding pharmacy. The regulatory failure ultimately contributed to the disaster. Similar disasters involving compounding pharmacies in Tennessee and Texas began to unfold at mid-year in 2013.

In spite of a rapidly worsening incidence of accidental and intentional opioid-overdose related deaths in 2018, our nation’s healthcare industry endured a shortage of an intravenous form of narcotics at mid-year. An underlying observation further mystified the simultaneous occurrence of the death rate and monitoring deficiencies of hospital inventory supplies. The opioid-related mortality incidence was much higher in the States who had implemented a Medicaid expansion policy through Obamacare as opposed to the States that had not implemented Medicaid expansion by 2017.

Next, the opening phase of the National Health Insurance Exchange in October of 2013 was disheartening, at best. And finally, in 2014, the problems with the Veterans Administration represented a recurring theme of institutional leadership problems. This subsequently reached a new peak when it was announced in 2017 that several of their hospitals had lost inventory control of their narcotic medication supplies.

Any reform strategy to promote a broad improvement throughout the diverse institutions of a nation’s large industry must proceed with caution. Improving the daily HEALTH of individual resident persons must be balanced by the evolving continuum of healthcare over time and how it fits together for the seamless health care needs of every resident person. Hopefully, the unstable series of events, noted above over 7 years, was only an isolated occurrence. The evolving reality of the ACA 2010 could worsen this turmoil given its inability to fundamentally unravel the Paradigm Paralysis strangling our nation’s healthcare.

To formulate a new strategy for a carefully defined and implemented healthcare reform strategy, the TRADITIONS Chapter and its Sub-Chapters analyze the essential traditions of our nation’s healthcare. Five of the Sub-Pages propose a solution for specific root causes of the Paradigm Paralysis afflicting our nation’s healthcare. Based on this analysis, the NATIONAL HEALTH Chapter and its Sub-Chapters describe a new institution to be Chartered by Congress. See the OVERVIEW Chapter for further implementation details.

If you appreciate the fundamental value of concepts and ideas as a basis for shaping the future course of events, then you also have a unique perspective for considering the character of our nation’s healthcare. Overall, NATIONAL HEALTH integrates concepts originating from the traditions of thought underlying the social contract for the governance of Western nations. They are sociology, economics, physics, psychology, biology, anthropology as well as medicine.

Let me introduce you to Eric Hoffer, Leon Festinger, Carl Rogers, Thomas Kuhn, Lawrence Weed, Garrett Hardin, Peter Drucker, Steven Covey, Elinor Ostrom, and Michael Tomasello. As a basis for healthcare reform, the cohesion of their concepts as well as the concerns of many persons expressed to me during their personal healthcare represents the essential momentum guiding the conceptual priorities for this healthcare reform proposal.

REPRISE & RECAPITULATE — “The Future As History”

The brief quotation cited above represents the title of a book written by Robert L. Heilbroner. It was printed in 1960. He reviewed the 10-year trends within our nation before 1960 as a basis to describe a view of our nation’s near-term, future evolution. He was substantially correct. The knowledge for assessing future options was known then, as it probably is knowable now, for the immediate future of our nation’s healthcare reform. To view our nation’s heritage during the last 400 years, isolated episodes of supreme commitment and purpose have defined our nation’s history. Remember, especially, the voyage of the Mayflower in 1620, the Declaration of Independence in 1776, the 13th Amendment to the Constitution in 1865, women’s suffrage with the 19th Amendment in 1920, our national commitment to WWII after the Pearl Harbor attack in 1941, our nation’s Mission to the Moon after Sputnik in 1957, and our nation’s sudden awakening to global terrorism after the World Trade Center attack in 2001.

I propose that the knowledge and locally expressed needs for social cohesion are already definable as the basis for the reform of our nation’s healthcare. With a “Moon Shot” level of precision and resolve, fundamental healthcare reform could reduce the cost of our nation’s healthcare from 18.0% of the national economy in 2019 to 13.0%. Remember again that it was 5.0% in 1960. This same strategy could reduce our nation’s number of women who died in 2016 from a pregnancy, from 24.6 to 6.0 deaths per 100,000 living births. The improvement in maternal HEALTH would have prevented at least 700 maternal deaths during 2016, assuming 4 million live births. The analysis using 2019 data remains largely unchanged.

It is highly unlikely that our nation’s current strategy for healthcare reform could achieve these results within the next 10 years, or even come close. Indeed, we must begin by first acknowledging the pervasive paradigm paralysis afflicting our nation’s healthcare. Importantly, this paradigm paralysis increasingly compromises our nation’s autonomy within the worldwide marketplaces for its resources and human dignity. Now is the time for a new strategy to promote social cohesion within each community’s Survival commons, as the ultimate basis for improving the Health of each resident person within every community. There are validated Design Principles that apply to the use of collective action strategies for managing a common-pool resource, as in the portion of our nation’s economy devoted to healthcare.

Since 1960, our nation’s health spending has increased from 5.0% of the GDP to 18.0% in 2019. It represents an increase of 5.0% annually, adjusted for inflation and economic growth, most sensibly explained by Parkinson’s Law. Using the Design Principles defined by Professor Elinor Ostrom and validated by many colleagues, NATIONAL HEALTH would build the widely supported authority necessary to implement the strategies required at the national, state, and local levels for healthcare reform. Its budget should be defined as a Federal expense that is fixed at $1.50 per citizen annually.

Our currently evolving progress for healthcare reform continues to focus primarily on universal health insurance. The Affordable Care Act of 2010 was a magnificent accomplishment, in spite of its deficiencies. Unfortunately, it is actually worsening the level of efficiency within our nation’s healthcare industry. And, it does very little to sponsor the fundamental reforms necessary to achieve equitably available, enhanced Primary Healthcare for each resident person, community by community.

To begin true healthcare reform, it should be locally implemented, regionally coordinated, and nationally promoted. As cited above, former Senator Barber reminds us that “The language of citizenship suggests that self-interests are always embedded in communities of action and that, in serving neighbors, one serves one-self. NATIONAL HEALTH represents a means to achieve a V I S I O N for healthcare reform through communities of action.

Stable HEALTH For Each Resident Person

NATIONAL HEALTH

Improving POPULATION HEALTH and its healthcare, ALTOGETHER

* RATIONALE

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