Wanted: A Better Metaphor for "Health Systems"

Finding the right metaphor to describe a complex issue is often one of the hardest--and most creative--tasks facing any journalist. Say the words "brain drain" and you feel like you already have an idea of what the issues are--rich countries poaching nurses and doctors from poor countries.* But say the words "health system" and most of us draw a blank about what the phrase means or why it's important.

I know that's the case for me. I started my Malawi project thinking it was about the "brain drain" of nurses. But interviews with Michael Clemens, Fitzhugh Mullan and others convinced me that was only a piece of the puzzle. I needed to widen my focus from what rich countries were doing to lure nurses away to conditions within Malawi that pushed them to leave.

It's about more than just money. You have to look at the state of the entire health system--from conditions in the hospital to how long it takes patients to travel to a clinic (or for a health worker to come to them) to medical opportunities for professional development to individual workers' own hopes and dreams for their children's future.

Ruth Levine of the Center for Global Development suggests the metaphor of the human body to describe a "health system" and likens the physical infrastructure to the bones, the workforce to the muscles, the supply chain to the circulatory system, etc.

Bill Hsiao of Harvard told the Nieman global health fellows his working metaphor is a car. It needs to have enough money (gas in the tank) to run but your basic Tata Nano can get you from point A to B in India for a lot less than a Rolls Royce.

Following up on the automotive metaphors, others have likened health systems to the network of highways that crisscross any major developed country. Imagine trying to move a truck full of lettuce from California to North Dakota on dirt roads vs. six-lane highways and you get the picture. In one case, the produce spoils before reaching its destination. In the other, it seems perfectly unremarkable that you can mix a salad year round.

Don't think we have hit on the right metaphor yet. (Metaphors that need a lot of explanation kind of defeat the purpose.) But more and more of us are working on it.

If you have any suggestions for metaphors to describe health systems, please post them in the comments below.


* More recently, folks like William Easterly have pointed to another view--health workers emigrating to make their lives better and maybe send some cash home in the bargain.