Building the World

Voice of the Future 2015: Dr. Manuel G. Chavez-Angeles

Dr. Manuel Gerardo Chavez-Angeles, MPA/ID, Sc.D., Profesor-investigador at Universidad de la Sierra Sur and 2015 Voices of the Future recipient, is heading many important projects including a bi-national program on e-Nursing seeking to research innovative models on e-health.


“The Future of Global Health Systems”

Healthcare systems around the developed world have been in crisis and urging reform. High expenses, aging populations, and growing needs have pushed many systems to the brink. Across Europe, where healthcare systems go back to the 19th and early 20th century, citizens have questioned the future of these systems that have such a deep influence on their well-being. In the United States, President Barack Obama asked Congress to pass important bills to achieve universal health care. In 2010, landmark reform was passed through two federal statutes: the Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (H.R. 4872), which amended the PPACA. Reforms in the U.S. are better known as Obamacare.

With this background, The Lancet created a commission on global health, and published conclusions in 2013. The Lancet Commission revisited the case for investment in health and created a new framework to achieve ‘dramatic health gains’ by 2035, mainly in the developing world. Trying to mimic those same systems that are under stress in Europe and the United States, The Lancet argues for the need to develop them around the world. The goal is to achieve universal health care at the global level. These demands were recently echoed by the United Nations’ Sustainable Development Goals.

At the same time, digital technology poses new challenges. In 2010, Eric Topol wrote: “The lack of plasticity of the medical profession and health care system in the face of new technology and information is about to be challenged on two major fronts in digital medicine: wireless technologies and genomics. These two areas have been characterized by unprecedented innovation and discovery at a breakneck pace. Whereas the 2000s saw the introduction of digital life-style devices, the 2010s will probably be known as the era of digital medical devices. These devices have exceptional promise for changing the future of medicine because of their ability to produce exquisitely detailed individual biological and physiological data.”

So, under this scenario: system reform in the developing world, system expansion in the developing world and technological change at the global level, we should ask what is the future of global health systems. As early as 2003, Otto Scharmer and colleagues were already studying the German health system and looking for responses to avoid the system’s collapse. They looked into the system at Lahn-Dill, a region of 280,000 inhabitants north of Frankfurt, where innovations led by a grassroots organization, including medical professionals, has made fundamental changes to the local healthcare system. The seed of change was qualitative improvement in patient-physician dialogue. If the Lahn-Dill case proves to be relevant to the global agenda, we should look  for ways to work at the grassroots level and the more elementary interactions among patients and health professionals.

For instance, studies estimate that nurses spend as little as 15% of their time on direct patient care. As much as half goes to documentation. In this sense, we should be looking for IT initiatives that help to revitalize the role of nurses and nursing practice at the level of interaction with patients. How could electronic devices be used to get patients and health professionals closer and not the other way around seems not to be a question included in the global health agenda. This poses important research questions on machine-human interaction and human-human interaction. For instance, could we improve health systems through robotics? What are the roles of bioinformatics and digital communications in having a deeper patient-physician dialogue? Those are questions that we should put in our research agenda.


Dean T. Jamison, Lawrence H. Summers, George Alleyne, Kenneth J. Arrow, Seth Berkley, Agnes Binagwaho, Flavia Bustreo, David Evans, Richard G.A. Feachem, Julio Frenk, Gargee Ghosh, Sue J. Goldie, Yan Guo, Sanjeev Gupta, Richard Horton, Margaret E. Kruk, Adel Mahmoud, Linah K. Mohohlo, Mthuli Ncube, Ariel Pablos-Mendez, K. Srinath Reddy, Helen Saxenian, Agnes Soucat, Karen H. Ulltveit-Moe, Gavin Yamey. “Global health 2035: a world converging with a generation.” Lancet 2013; 382: 1898-955.

E.J. Topol. “Transforming medicine via digital innovation.” Sci. Transl. Med. 2, 16cm4 (2010).

Katrin Kaeufer, Claus Otto Scharmer  & Ursula Versteegen. “Breathing Life into a Dying System Recreating Healthcare from Within.” Reflections, Vol. 5. No. 3.


Boiling Frogs, Prisoner’s Dilemma and Small Island States facing Climate Change.

Manuel G. Chávez-Ángeles, MPA/ID, Sc.D.

The last couple of weeks world’s leaders have gotten together in Paris to discuss climate change at COP21. Greenhouse gases (GHG) emission and rising sea levels have received a lot of attention. Small island states put important issues on the table regarding the future and some developing countries endorsed the action agendas of Small Islands Developing States (SIDS).

In order to understand small islands citizens we should understand the economics of a shrinking place. Imagine you live in a small atoll in the Pacific Ocean called Paradiso (not a real name). Paradiso is your country, and you live very happily there. The only problem is that the atoll where you are living is sinking under the sea. You may not know the exact deadline when Paradiso would be completely under water but at some point you, your children or (with a lot of luck) your grandchildren will have to move to some other country in an unknown continent. Also think that habitable land in Paradiso is not going to disappear from one day to the other but is gradually shrinking. Under this circumstance you have to take the decision of when to leave home forever. If you wait long enough your neighbor may leave before you, and you and your family may enjoy staying in Paradiso for as long as one more generation. If your leave earlier, you’ll be letting your neighbor to enjoy that benefit.

So Paradiso’s situation is clearly a prisoner’s dilemma with possible suboptimal outcomes. We can use game theory to better understand the situation:

Fig 1. Prisoner’s Dilemma of Leaving Paradiso.
Citizen of Paradiso 2
Leave Not leave
Citizen of Paradiso 1 Leave -1, -1 -10, 10
Not leave 10, -10 -5, -5


On the game describe in Fig 1, the dominant strategy is (Not leave, Not leave) with an outcome of (-5, -5). Why is suboptimal not to leave the island? Well, we can imagine that as the dry land in Paradiso shrinks, population density rises and overcrowding causes increasing pressure over resources, creating conflicts, violence and eventually death.

So what options do the citizens of Paradiso have? Whatever they do, it is necessary to find the means to create cooperation. Here are some options:

  • Sell to your neighbor: Some citizens of Paradiso may be willing to pay for staying longer at the island. So those leaving first may charge some price to those staying in exchange.
  • Timeshare: Citizens may agree to leave at the same time and create a timeshare property similar to the kind used in the tourism industry. This way, a citizen may enjoy some weeks a year in Paradiso or sell this right.
  • Sell to a third party: Citizens of Paradiso may prefer to leave in exchange for a new home in another country and compensation provided by the international community.

Using game theory to understand the painful dilemma of people losing their home may seem simplistic, but it is helpful to understand the social dynamics we can expect on small island states in the next generation. Coastal regions in other parts of the world may be facing a similar dilemma.

Fortunately we have the science and information to move in advance. Otherwise we’d be like the boiling frog. The premise is that if a frog is placed in boiling water, it will jump out, but if it is placed in cold water that is slowly heated, it will not perceive the danger and will be cooked to death. This story is a good metaphor to portrait the inability or unwillingness of human beings to react to or be aware of threats that occur gradually. In the case of SIS and rising sea levels, we know that “water is going to boil” so is better to look for solutions today in order to avoid been “cooked” in the future.

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