Habit, custom, and power: A multi-level theory of population health
Highlights
► A new theoretical framework is offered to explain how the many elements included in existing conceptual models function. ► Patterns of behavior can be better explained by cognitive habits, than by rational choice theory. ► When cognitive habits are widely shared within a society, they take on a social ontology as custom. ► Custom evolves toward optimality through a process of natural selection. ► Social, economic, and political power exerts selective pressure for custom to evolve toward the interests of power.
Introduction
Thoughtful introspection suggests that we are thoughtfully introspective. Science says otherwise. An abundance of carefully conducted research now demonstrates that we are imperfect optimizers, slapdash rationalists. The past 20 years have seen an explosion of research in neuroscience, psychology, marketing, and behavioral economics, all of which suggests that our minds are more efficient than rational (Rice & Unruh, 2009). Where the rational choice model claims that behavior is the aggregation of individual decisions, each a thoughtfully deliberative weighing of pros and cons, newer research shows that behavior is not reducible to individual decisions, that decisions have momentum, and that behavior is the accretion of patterns, not the aggregation of choices.
But if we are not careful and deliberative, if instead we are predictably irrational, profoundly influenced by default options, framing, and heuristics, how are we able to make good decisions at all? How is it that, despite it all, most of our decisions are rational, or at least rational-seeming? If we are such bad decision-makers, why aren't we in worse shape? This question has tremendous implications for public health (Ubel, 2009).
This paper lays out an alternative paradigm for human decision-making, a paradigm that acknowledges its debt to rational choice, but is not indentured to it. This alternative paradigm locates the genesis of thought and action in cognitive habits: clusters of cognitions that are triggered as a group by a single cue—much as a musician plays a scale, not a set of individual notes. These cognitive habits evolve over time in response to selective pressure, and can be distorted by powerful individuals or groups (cigarette manufacturers, soda marketers, specialty physicians) who have a vested interest in influencing behavior. This paradigm insists on rigorous integration of research on individual choices with scientific disciplines that model the elements of choice in its neuroscientific underpinnings as well as in its social, economic, and legal contexts. This alternative paradigm is called multi-level theory. It stands in sharp distinction to the pervasive paradigm of rational choice theory.
Multi-level theory is an effort to bring theoretical thinking in the public health upstream (McKinlay, 1975; Pearce, 1996). Upstream from obesity lie diet and physical activity, but upstream from these issues are territories as yet uncharted by public health, contested, and which must be hard-fought: the realm of choice theory and, farther still, social theory. A map of this region is essential, along with a strategic understanding of how this terrain is controlled. Without aggressive intellectual inroads into these areas, public health risks being swept away in the downstream effluvium of forces it cannot apprehend (Krieger, 2011; Mooney, 2009; Pearce, 1996).
Section snippets
Cognitive habits
Suppose that God had given you the task of designing a decision-making machine for his new creature, Adam. You might start by giving Adam some likes and dislikes and a calculation engine that tells Adam to choose the option corresponding most closely to his preferences. His behavior is the collection of these choices, with no correlation among choices other than that implied by Adam's stable preferences. Fig. 1 presents the rational-choice theoretical model.
With this rational machine, Adam can
Evolution
If you are looking for a vegetable whose preparation tries your patience, look no further than the fava. It must be shelled twice, and the bitter inner skin is difficult to remove. Tricks abound for making the process easier, but even with boiling in salt water and plunging into a cold bath, shelling favas is no one's idea of a good time. One San Francisco food writer, lamenting the substantial work it takes to get a quarter-cup of usable beans concludes, “you are so sick of them you'd rather
Power
If, as William Foege has written, “the philosophy of public health is social justice” (Foege, 1987), then the analysis of population health must be the study of power. Indeed, to ignore power would be to ignore the most important determinant of population health—it would be possible, but it would be theoretically impoverished, ad hoc, and boring. As many in public health have argued, rigorous analyses of power are possible (Mooney, 2009; Solar & Irwin, 2010).
Just as neuroscience and psychology
True interests
The invocation of the capacity of power to distort cognitive habits raises the issue of discerning true interests. If a child prefers soda to milk, how can it be determined that this is a choice arising from a distorted set of cognitive habits rather than from his own natural cognitive habits?
To begin, it should be emphasized that “true interests” apply only at a certain level of abstraction. It is reasonable to assert that true interests prioritize health over ill-health, but it would be
Multi-level theory and rational choice theory: a tale of two paradigms
This conceptual apparatus allows our causal maps to be more accurate. There are two frames for decision-making, equally valid, but unequally applicable. The rational-choice model says that we are vassals of fixed preferences, in homage to which we weigh the costs and benefits of each option in our choice set. The habit-custom-power multi-level frame recognizes that our choices and the preferences behind them are profoundly influenced by cognitive habits, which have an ontological existence at a
Conclusion
Conceptual models abound in public health, but conceptual models and theory serve different purposes. While a conceptual model taxonomizes the factors involved in a health outcome, a theory proposes a specific causal mechanism for how these factors work. This distinction is that between nouns and verbs. We in public health have better luck communicating with each and others when we are careful and conscientious in our use of verbs. We now have a good sense of what upstream factors influence
Acknowledgments
The author is grateful to Tom Rice and Dan Bromley for many fruitful discussions, and to the feedback of the Department of Health Policy and Management Seminar at UCLA. Any infelicities are those of the author's alone.
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