Hunter-gatherer human nature and health system

International Journal for Quality in Health Care 2005; Volume 17, Number 6: pp. 541–545 Advance Access Publication: 20 June 2005

10.1093/intqhc/mzi060

Perspectives on Quality

Hunter-gatherer human nature and health system safety: an evolutionary cleft stick? JEFFREY BRAITHWAITE Centre for Clinical Governance Research, University of New South Wales, Randwick, New South Wales, Australia

Abstract

Keywords: cooperation, evolution, health systems reform, human nature, hunter-gatherers, iatrogenic harm, medical inquiries The recent archaeological find of a new human-like huntergatherer species which lived at the same time as us until around 13,000 years ago [1] is a stark reminder that Homo evolved to exploit various niches. Dubbed ‘the hobbit’ [2], Homo floresiensis is thought to have shrunk to pygmy size under the evolutionary pressure of living on a small island with no predators or limited resources [3]. Both hobbits and modern humans are adapted to clearly defined problems in their environments. This prompts an uninvestigated question: what are the implications of our shared hunter-gatherer past, and our evolved nature, for the health system?

What we are evolved for Some of the adaptation problems hobbits and modern humans share are common to every living organism [4]. They include the need for sufficient food and water; for protection from potential harmful predators or a harsh environment; to mate or otherwise pass on genes; and to raise offspring to continue the line [5]. Fall short on any of these criteria, and the individual fails. If widespread, the species faces extinction [6]. The notion of adapting over time is at the heart of natural selection [7].

Because of the social nature of humanity we are naturally selected for another set of problems, rooted in the Pleistocene [8]. This second set recognizes that 99% of Homo sapiens’ history, and all of Homo floresiensis’, was spent as hunter-gatherers. This suggests that humans are adapted not for modern institutional life but for an ‘environment of evolutionary adaptiveness’ (EEA), which involved millions of years of exploitation of wooded savannah grasslands by small kinbased bands using stone-tool technology [9]. This collaborative process generates evolutionary payoffs such as shared risk, and groups to rely on in tough times, but poses other adaptive problems because social complexity concomitantly increased. This required substantial social understanding and a big brain to process it. Seeking social rank is a general tendency of primates, and for humans, exchanging social, material, and intellectual resources for survival became prominent [10]. Successful behaviours in what became an increasingly intricate political milieu include what evolutionary psychologists call ‘theory of mind’ [11] or ‘mind reading’ [12] and philosophers, ‘intentionality’ [13]—the ability to understand your own mental state (first-order intentionality), and infer from behaviour or similar circumstances that of others (second-order

Address reprint requests to Jeffrey Braithwaite, Associate Professor, Director, Centre for Clinical Governance Research, Faculty of Medicine, University of New South Wales, Sydney, New South Wales 2052, Australia. E-mail: [email protected] International Journal for Quality in Health Care vol. 17 no. 6 © The Author 2005. Published by Oxford University Press on behalf of International Society for Quality in Health Care; all rights reserved

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The stunning archaeological find of a new species of human dubbed the hobbit, formally named Homo floresiensis, is a reminder that humans and hobbits are evolved for transient lives, subsisting in an environment radically different from that of contemporary societies. Although the problems facing health systems are well documented, few scholars have taken an evolutionary-level approach to understanding them. By considering the nature of humans as adapted not for modern societies but for hunter-gatherer existence, and examining what humans were evolved for, new light can be shed on contemporary behaviours exposed by the medical inquiries into what is going wrong in acute health systems. Investigation of two of these inquiries shows how health professionals under pressure typically default to tribal behaviours, have recourse to hierarchies and engage in turf protection routines. Those who have conducted studies into iatrogenic harm or presided over the medical inquiries have argued that culture change is the solution to health care’s ills. This is likely to be much harder to institute than some people realize, especially given our underlying hunter-gatherer nature. This is an evolutionary cleft stick that has not been factored in by those optimistic about health sector reform. The implications are that we need a deep understanding of human nature in addressing health system problems and to recognize that profound culture change is more challenging than many believe. Paradoxically, it is when humans are faced with seemingly intractable problems that a collective way forward might emerge.

J. Braithwaite

intentionality). Even deeper mental skills emerged in later human groups as the brain’s computational power increased, such as guessing what others think in relation to your own interests and in relation to other parties’ interests, and so forth [14]. The social brain hypothesis argues [15] that humans now have considerable capacities to read behavioural and facial cues, anticipate others—and deceive [16]. So we were selected for negotiating with others, trading goods for advantage, collaborating with close tribal members, and nurturing individuals, often on a transactional basis (you scratch my back, I’ll scratch yours). We were also selected for keeping powerful people happy, second guessing rivals, identifying external others who might constitute a threat, protecting our own patch, and outwitting and defeating enemies [17].

Human nature in contemporary health care

Perspectives from two inquiries The inquiries show how human nature is expressed in times of difficulty. We can take two examples and through them see

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Tribalism, hierarchies, and turf protection What do health care behaviours of this kind mean in evolutionary context? We may never know the full story about hobbits or penetrate into the crevasses of their psyches. But we can, through our own observations of people in health systems, studies of errors, and transcripts of the inquiries, move to fathom health sector behaviours. Subtle trade-offs are made whenever humans calculate benefits and costs of cooperation [25]. Undoubtedly this was so for our ancestors and modern hunter-gatherers. Hunter-gatherer survival is predicated on individual alliances


How are these evolved characteristics displayed in contemporary health settings? We observe them every day in the health system. Clinicians and managers work to earn a living to feed, clothe, and house themselves and their families. They seek identification and protection via organizational and professional groups. They like novelty and challenge, both occupationally and through social interaction. Careers are valued and are pursued persistently across decades. Health sector employees execute most of their work socially, mediated through language, symbols, and technology. We call the vehicles they employ to do this meetings, case conferences, and consultations, the key symbols they generate and draw on we know as information and evidence, and the technologies they use to complete their tasks are things such as computers and clinical and diagnostic equipment. When this comes together well, it can be uplifting. In the modern health setting, the evolved cooperative nature often comes to the fore, and ingenuity has enabled health professionals to attend to base problems like subsisting and generating income to satisfy their own socioeconomic needs and wants by working with colleagues, thereby satisfying others’ health needs and wants. The tenor of the clinical endeavour— attending to people in their time of illness or health need—is a highly noble pursuit, likely to create a sense of satisfaction for both patients and staff. Yet there is a dark side. There are now sufficient studies [18–20] and inquiries into hospitals [21–23] to show that established systems cause iatrogenic harm to hundreds of thousands of patients worldwide [24]. It is here that we can catch glimpses of behaviours that have evolved for our personal or group protection that may not lead to an optimal health system. Analyzing these behaviours in an evolutionary context facilitates a deeper understanding of why things go wrong.

people in survival rather than collaborative mode. The public inquiry into paediatric cardiac surgery (PCS) at the Bristol Royal Infirmary in the United Kingdom brought to attention significant problems [22]. The summary of the final report stated that ‘There was poor teamwork…relations between the various professional groups were…poor. All the professionals involved in the PCS service were responsible for this shortcoming’ (p. 4). Later, the report indicated that ‘The teams were not organized primarily around the care of the patient, they were not cross-specialty nor multidisciplinary, and they were profoundly hierarchical’ (p. 198). In Chapter 12, the inquiry found there existed an environment ‘which fostered a sense of “them and us”…in which people were not likely to be approached by colleagues, especially “junior” colleagues who might have concerns’ (p. 169). For the Bristol inquiry members, there were multiple other social and organizational barriers ‘to the sort of open communication which should characterize the management of a unit or directorate in a large hospital’ (p. 169). This resonates with closed-shop behaviours, with people engaged in turf protection, and lack of collaboration and communication across organizational silos. In a government investigation into poor quality of obstetric and gynaecological services at King Edward Memorial Hospital (KEMH) in Perth, Western Australia [23], the inquiry members noted that ‘KEMH is a…close-knit community [that] had been subject to sustained criticisms for some time…the Hospital’s culture was not supportive of staff members who were critical of its performance…these concerns are likely to have been magnified as a result of the treatment, following the establishment of this inquiry, of senior KEMH staff members who had openly questioned the quality of care provided by KEMH. The ostracisation and eventual departures of [the chief executive and legal counsel of the hospital] and others were seen as illustrations of the influence and power exercised by a section of the medical community which did not support the inquiry or its objectives. Specifically, these incidents were also seen as warnings to those who were contemplating disloyalty as whistleblowers’ (sections 2.2.17 and 2.2.29, p. 43). We can readily see the clinical clans protecting their own and marginalizing non-clinical managers. Under threat of an inquiry, and throughout its conduct, individuals battened down the hatches and professional groups closed ranks and fought against the criticism and scrutiny of the inquiry.

Hunter-gatherer human nature and health system safety

The challenge of culture change Those involved in studies of iatrogenic harm or the inquiries have argued for the remedy of culture change of health service organizations. The Bristol inquiry reports mentioned the words ‘culture’ and ‘cultural’ 191 times and the KEMH inquiry 62 times. Although many people may be striving to enact such changes, practices, attitudes, and values can be entrenched, and changing them may be more difficult than supposed [27]. Humans have evolved behaviours to protect and position themselves over many millennia, and these are deeply structured into the social fabric of modern society and its institutions. The health system reflects these characteristics. Especially when intimidated or vulnerable, people will tend to default to well-worn behavioural repertoires, regress to a struggle for individual survival, and intensify relationships within their primary groups and coalitions for support. Organizational-wide or health system-wide cultural change will be hard to achieve. Some may wish to argue that modern humans are special and through civilization, education, intellectual, and technological advancement can overcome, or have transcended such myopic inwardness. Others will doubt this. They can point not only to evidence beyond the tribal behaviour of groups exposed by the inquiries, but also to our failure to provide adequate aid to scandalously poor ‘strangers’ in Africa [28], our willingness to demonise foreigners (and go to war with

them) [29], and our propensity for crime against others [30]. Taken together, these might be seen as indicators of five million years of adaptiveness for personal and small-group protective safeguards at the expense of others. If culture change implies that we have to alter our fundamental human nature, this will likely be astonishingly hard to realize.

The evolutionary cleft stick This leaves us in a catch-22, cleft-stick situation. We may be at an evolutionary point at which we are smart enough to design the health systems we inhabit today, but not smart enough to solve the sociological problems of working together which those systems demand. And, if this analysis of the inquiries is correct in exposing an evolutionary-level problem, the solutions may not be measured in organizational, or even historical, but evolutionary time. Can we rapidly change health system culture to be less hierarchical, less tribal, and more inclusive? Can we in a sustainable way leverage the potential we have to work collaboratively against professionalized silos or entrenched hierarchies? The inquiries assert we must, but evolution says not readily. The oft-misinterpreted Richard Dawkins in his book The selfish gene elegantly said ‘Be warned that if you wish, as I do, to build a society in which individuals cooperate generously and usefully toward a common good, you can expect little help from biological nature. Let us try to teach generosity and altruism, because we are born selfish’ [31]. Many organizations may be trying to encourage generosity and altruism but evidence of the effectiveness of designer cultural change in health service organizations, as in other industries, is weak. Homo floresiensis’ story is an instructive metaphor. Although this species outlived many others including, by about 10,000 years, the robust European group we have come to know as the Neandertals, hobbits are thought to have become extinct by a devastating event, probably a volcano eruption [32]. There is no adapting to such circumstances. One simply ceases to exist. It is possible to discern at this point three pathways for the health system, none of which provides a ready set of solutions to the difficulties we are facing. Firstly, we could wait out the evolutionary timescale and see if evolution shapes us into a more socially collaborative species. Secondly, we could try to do radical change—the organizational equivalent of a volcano-like approach to change health system culture, i.e. one that ineluctably sheers away existing unwanted behaviours, inappropriate posturings, and poor practices. Thirdly, we can continue with the present course, which is one of continuous effort to induce cultural change. Option one involves too long a gestation period without any guarantee of success. The risk of option two is if we try to engender too radical a change which might seriously impair the very health system we are seeking to improve. The problem with option three is that our evolved nature keeps getting in the way.

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and judicious collaboration. Although this is a complex area of evolutionary study and contemporary sociology, what is clear is we also have significant propensity to protect our own turf and treat external others badly, especially when threatened. We need only look at what happened to the whistleblowers in both the Bristol and KEMH cases. They were ‘inadvertently’ left out, gossiped about, ostracized, and generally castigated. It would be surprising if this did not occur, as there is clear survival and group bonding value in such response patterns for those maltreating the whistleblowers. This is not a plea to justify such behaviours but a plea to understand them. Health professionals, despite what has been optimistically written about multidisciplinary teams, tend to flock together in clinical tribes [26]. Clustering like with like and mistrusting, even shunning those who are different from us, or who represent harm, is a powerfully evolved tendency. It helped humans as a species in a great diasporic spread to get from the African savannah to the wide range of habitats populated today. Moreover, these inquiries remind us that humans ubiquitously stratify in hierarchies. There are both logical and unconscious pressures to do so. Every intern and early career nurse experiences this. Yet tribes and hierarchies often close down productive interaction—say between managers and clinicians, within and across professional subgroups, between juniors and seniors, and between clinicians and patients.

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A way forward?

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The inquiries into health system failings have made two categories of recommendation. One proposes that health sector problems are system issues, requiring team-oriented, collaborative approaches (the systems-collective-culture-change approach). The other centres on finding those at fault, seeks to hold them accountable, and insists on individualized punishment or mandated retraining (the seek–find–discipline imperative). Neither seems sufficient on its own, and they may conflict if both are attempted simultaneously. This is well known to organizational theorists as the ‘bottom-up versus top-down’ problem. We may come to realize that we do not really know how to achieve the profound cultural change the inquiries are calling for, given the timescales at issue, the patterns of resistance, and our evolved nature. It might also dawn on us that punishment, used too freely, is a blunt instrument and risks driving clinicians away. It may be cold comfort but at least, when we look at what is needed from an evolutionary vantage point, we begin to make explicit the surprising scale of the problem. Paradoxically, it is then that we may begin to find a collective way forward, and when human cooperation might come to the fore. This is notable in human history. A calamitous predicament is apprehended, and people pull together. Cases in point include the Battle of Britain in Summer, 1940, America’s response to the 9/11 terrorist attacks in New York in 2001, and the international community’s answer to the devastating tsunami on Boxing Day, 2004. A telling question, but one that remains open, is whether the work exposing health care’s harmful ways via the safety inquiries and studies of iatrogenic harm could come to constitute a crisis, real or perceived, and help galvanize people in a similar way into urgent action. In the meantime, the contradiction of the evolutionary cleft stick we are in might give us all pause for thought in the absence of any crisis stimuli, or sure, agreed remedies to what ails acute health systems in the twenty-first century.

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Accepted for publication 26 May 2005


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