Mapping the Historical Evolution of the Lack of Access to Affordable Healthcare in Pittsburgh
Assignment #3: Mapping the Evolution of a Wicked Problem
Carnegie Mellon, Transition Design Seminar 2023
Team Diversity: Luis Garcia, Parrish Andre, Ariba Asad, Mary Priyanka Jacob, Emilie Zhou
Due to the complex nature of wicked problems, it is critical to understand their historical roots to ensure appropriate interventions in the present. In this assignment, we dive deep into several historical events that have allowed us to forge connections to the present lack of Access to Affordable Healthcare in Pittsburgh. This historical understanding of the problem gave us a clearer picture of the social, environmental, economic, political, and infrastructural issues (assignment 1) and the implications for stakeholders (assignment 2). This assignment also helped us expand our view of the wicked problem and its multiple dimensions through a long-time horizon exploration. Finally, similar to our previous assignments, we acknowledge the limitations of this research, as it mainly relied on desk research and would be enriched by other contributions, such as those of historians with a robust grasp of events connected to our problem space.
Mapping Process
We started our mapping process by setting up a historical event as a starting point. As a class, we agreed on initiating our mapping from the industrial revolution, which profoundly affected Pittsburgh’s society. Then, our research consisted of reviewing the literature, blog posts, and imagery of critical events in the historical evolution of our wicked problem. As a team, we first met to ideate on potential directions for our research and then agreed on what to use as a reference to feed our map. Then, we located the collected data in a timeline using the Multi-Level Perspective Framework (MLP) that consists of three levels: the landscape, the regime, and the niche. Finally, our mapping ended with a collaborative exercise of looking for the interconnectedness of the different historical events with dates, imagery, or extra information that expanded our understanding of the wicked problem.
The Landscape
Three kinds of events are mapped in our landscape-level events: wars, pandemics, and important economic events. To understand such large-scale events’ effects on Pittsburgh healthcare, it is helpful to divide them like this.
First, wars tend to shift public focus onto healthcare for the war. Often great medical advancement is made during this period, but supplies and services are in high demand, and vulnerable populations suffer. For instance, in World War II, penicillin was invented to treat bacterial infections, but thousands of civilians still die from the flu each year. Wars typically have this kind of effect. Medicine advances in the field, but at home, citizens suffer.
Second, we have mapped a number of epidemics and pandemics. Having lived through one recently, we know its widespread effects on our healthcare and perceptions. Fear rules the population, resources become limited, and an economic downturn almost always exists. To catalyze these troubles, there is typically a politicization of the medical approach.
Lastly, we noted two important economic events: industrialization and the Great Depression. These are especially interesting in Pittsburgh, a city whose industry harmed public health. With the rise of the steel industry, Pittsburgh health greatly declined. Air and water pollution were dramatic, and people’s bodies suffered as the economy thrived. Pittsburgh had a greater GDP than New York City. In circumstances where the industry declined, like the Great Depression or the 1980s fall of the steel industry, people’s pockets suffered as their environmental health factors drastically improved. This feedback loop is not in effect the way it used to be.
Landscape-level events affect every aspect of the system. They are social, technical, economic, environmental, and political. It is difficult to track exactly how they affect a Pittsburgh citizen. For clearer connections, one must look to the regime-level events.
The Regime Level
The regime level captures the status quo and the collection of existing social norms, beliefs, and practices that influence society at different times. The impacts of events and changes in the landscape level can be seen at the regime level, and what happens at the regime level can also consequently affect the niche level. In our timeline, the regime level highlights developments and organizations that we felt were relevant to shaping the healthcare and insurance industries we have today.
In particular, our timeline categorizes the different phases and common views people held regarding healthcare and how they have evolved throughout the charitable, educational, insurance, and government era. During each era, the social norm and status quo around healthcare shifted as landscape, and niche-level changes occurred simultaneously. In the charitable era, there was no organized healthcare, and people provided care out of their generosity and willingness to help others. However, medical education was given more attention in the educational era as more medical schools were developed and reorganized. In the insurance era, new ideas regarding health insurance provided by other organizations or companies became more normalized as more Americans started buying insurance. The status quo in the healthcare industry was once again changed in the government era when the government became more heavily involved in passing policies, reform efforts, and programs to manage people’s access to healthcare. For instance, notable events during this time include the passing of Medicare and Medicaid programs and the signing of the Affordable Care Act. For-profit insurance companies also became more common as the status quo shifted to respond to changes in the landscape level, such as economic crises.
Our timeline also includes other regime-level events that have shaped Pittsburgh and the existing infrastructures, networks, and practices in Pittsburgh. For instance, the growing presence of the steel industry affected the environment and how people lived in Pittsburgh. Redlining in the U.S. also drastically affected the divisions that would form between people and the types of experiences and services people would have access to. The growth of UPMC and Highmark also restructured the status quo for people in Pittsburgh as they came to dominate much of Pittsburgh’s healthcare system. These events, among many others, represented the continuously changing social norm and reflected shifts in how things were done, especially concerning healthcare.
The Niche Level
New technologies, inventions, practices, norms, and policy proposals emerge in response to what happens at Landscape and Regime level. These innovations are tested at the Niche level, challenging the happenings of the status quo.
With respect to the timeline and in relation to events happening at the landscape and regime level, we have identified multiple events, the presence of which was either a response or cause of an event happening in the other two. The arrival of the Carnegie family in Pittsburgh is a niche-level event, with which multiple other small innovations or disruptions occurred at all three levels. Within the same level, it led to the establishment of the first steel mill in Pittsburgh, which later changed Pittsburgh into the heart of the American steel industry. This contributed to the landscape-level innovation of the Rise of Industrial America, which brought a change at the Regime level in the form of water pollution that gave rise to multiple waterborne diseases. This contributed to the advancements in healthcare research, eg. The polio vaccine development by Jonas Salk at the University of Pittsburgh. This period also marks an increase in job opportunities in the steel and healthcare industries. Today, one out of every five people in Pittsburgh works in Healthcare. Andrew Carnegie also supported the discovery of insulin, a major contribution to healthcare locally and globally. Other disruptions brought in by this niche-level change include bad air quality in Pittsburgh that impacts the health of its residents leading to more niche-level innovations such as the building of the Breathe Project to monitor the air quality of Pittsburgh. The polluted air played a major role in the process of Redlining in Pittsburgh and in defining which neighborhoods were to be inhabited by non-white Americans. These interconnected events define the placement of UPMC hospitals and the communities it serves today.
How each level builds a holistic understanding of the wicked problem
As you can see, each event level is connected to the others. Landscape-level events present the problems facing healthcare. For example, look at a landscape event of the 1950s: medical costs were skyrocketing. The niche level responds to the landscape almost immediately. President Truman proposes universal healthcare in Congress. This never entered the regime, though. What enters the regime is usually a bridge between the more radical niche solution and the landscape-level problem. This tends to emerge sometime after the problem first arises. In this example, newly established paramedic services in the 60s lowered medical costs for many citizens. This, in theory, is how most events between levels interact. The landscape presents a problem, the niche responds, and the regime bridges the two to affect the population’s lives.
The essential step in solving any problem is to find the root cause/source of the problem. In today’s problem-solving thinking, we silo the problem into sections and look to put down fires as they come up. At the same time, this working method is necessary to sustain the regime level and balance the system, tinkering from within the system for permanent solutions and transitioning to a future where the wicked problem is resolved. Our deep dive into the healthcare history of not only Pittsburgh but the US in general brought to light so many local and world events, such as the industrial rise of Pittsburgh, the Civil war, the world wars, and economic depressions; and also health events such as the establishment of the first hospital, the 1854 cholera outbreak, the 1902 influenza epidemic, and the most recent Covid-19 pandemic; that has shaped the landscape of Pittsburgh healthcare as it is today. The most crucial piece of information was in the 1950s when healthcare costs started skyrocketing, and insurance was becoming the norm in the backdrop of many new medical innovations.
Conclusion and next steps
The Multi-Level Perspective Framework truly gave us an opportunity to zoom out from our limited vision of the present and look back at the past to study the transition of healthcare from where it was in 1850 to about two centuries down the line. In fact, from our research, we were able to appreciate Stewart Brand’s six levels of a healthy civilization, as we saw the impact of change in commerce, infrastructure, and governance, on nature, which led to gross pollution, which delivered the city in a cloud of smoke for decades; which took decades to fix, and yet, there are still health scares with the number of pollutants in the air, and lead poisoning because of old piping. The city has also seen a wave of population growth and decline through the rise and fall of the steel and glass industries, which has led to the inclusion of many suburbs under Pittsburgh, some of which are now quite sparsely populated and most probably have undergone conscious or unconscious redlining. The fickle first layer of fashion and art does not directly impact our wicked problem but would definitely filter its impacts through the bottom layers.
The exercise really opened our eyes to systems thinking and how economic recessions, geopolitical wars, lack of governmental control on industries, and outright overuse of natural resources, can affect a region’s healthcare. Especially the growth of commerce and the shift of importance from political power to economic power, crippling a good percentage of the population, increasing the gap between the rich and poor, and making access to healthcare a survival game for the richest. However, all is not lost, as there are currently adequate interventions between regimes to prevent the problem from spiraling out of control. However, the machine needs to be repaired from the inside.
Our group initially had trouble finding relevant information to insert on our timeline. After going through multiple online resources, we narrowed our scope down due to time constraints and vast online information on this topic. We did find it challenging to divide our findings into the Landscape, Regime, and Niche levels, which we figured out after feedback from our professors and internal group discussions. Drawing intra- and inter-level connections was another task that took us some time to grasp, but following the threads of the events on the timeline got us some interesting findings.
Having examined the past, we will now look at the cone of the future to map our way to a future of accessible healthcare for the residents of Pittsburgh. This step is crucial as we move towards solutions with our well-researched background of the wicked problem.
A copy of our mapping exercise can be accessed here.
References
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