Arvind Singhal, PhD, is the Samuel Shirley and Edna Holt Marston Professor & Director of the Social Justice Initiative in UTEP’s Department of Communication. He is also appointed William J. Clinton Distinguished Fellow at the Clinton School of Public Service, Little Rock, Arkansas. He specializes in diffusion of innovations, the positive deviance approach, organizing for social change, the entertainment-education strategy,& liberating structures. He has authored 12 books:Health Communication in the 21st Century (2014); Inviting Everyone:Healing Healthcare through Positive Deviance (2010); Protecting Children: Using the Positive Deviance Approach (2009); Communication of Innovations (2006); Organizing for Social Change (2006); Entertainment-Education Worldwide (2004); Combating AIDS: Communication Strategies in Action (2003); India’s Communication Revolution (2001); Entertainment-Education: A Communication Strategy for Social Change (1999). He has also authored 170 peer-reviewed essays.
Gunderson: Arvind and I are in the recording studios at Campbell University in downtown Buies Creek, North Carolina. For background, this is a podcast for Stakeholder Health. The general audience for this are folks who work in the boundary between healthcare and the reality, the very complex reality of community. Most of them in the United States, but many of them have a broader imagination, many of them have broader experiences. The purpose of talking to Arvind is because you lived across every possible imaginable boundary I could imagine, including being faculty at the University of Texas El Paso, which is literally on a boundary.
Singhal: It is.
Gunderson: Look out your window where you work and you can see Mexico and you can see the complexity of the interchange that happens at boundary zones.
Gunderson: You’ve always been someone I’ve thought of as a boundary leader. In this context, when we blew through El Paso partway on our 3-400 mile Winnebago trip looking for what works, looking for the opposite of the dominant narrative of our day, which is convinced that everything has fallen apart and the best we could hope for is to manage the entropic decline of our communities. Everything that you’ve done is the opposite of that so we deeply resonate with the notion of positive deviance.
Gunderson: We see enormous convergence between some of the guiding thought between Stakeholder Health, including probably our most radical of leading causes of life. The other striking thing about your work is its exquisite attention to detail, to the actual practices.
Gunderson: Not making heroes out of those who find a new way but being very curious about what are they doing? You honor the highest virtues and the most nitty, granular practical work that is also virtuous. Let me start, we’ll have about 30 minutes, how in the world did Arvind become Arvind?
Singhal: Well, there’s so many different ways, Gary, of trying to answer the question. I think in part I have to go back to my roots. I was born in a family where my father served as a railroad engineer, which means or meant that given he belonged to a very elite service of engineers, they only took a handful each year to work for the Indian national railway system. He was constantly on the move the first 11 years of my life. He was building track and building bridges and building yards. Arvind had a home where his father had a home but his father always had a home on wheels.
Gunderson: We did not know this. My dad was also a civil engineer for the railroads.
Singhal: Oh my God.
Gunderson: In Baltimore and West Virginia…. We grew up in the same family.
Singhal: We did. indeed. Movement, not just physical movement but movement, was always an inherent part of my upbringing. We know that it’s not just going down a railway track but going to an uncharted territory, living in seven or eight different locations in the first 11 years of my life. Being in a country as India where you move into a different state, a different language, a different set of food habits, a different set of climate and taking it in your stride like sort of a rolling pin or a rolling wheel. I think movement has been an integral part of who I am and that might explain why I have a bachelor’s degree in mechanical engineering and then given writing and speaking and radio was part of something which I greatly enjoyed in addition to physics and chemistry and mathematics. I came to the US 36 years ago to get a masters of arts degree after finishing a bachelor’s degree in engineering in radio, television, and film production. That’s not a path that is a normative path.
Gunderson: Well, you know, Dr. Fred Smith, one of our dear friends, one time I complained to him. I said, “You know, Fred. This guy is not normal.” He said, “Gary, do you have any normal friends?” I said, “No, come to think of it.” He said, “Well, normal people don’t do this kind of work.” You’re the embodiment of that.
Singhal: Well, I certainly feel it has served me well to have a certain sensibility, which is guided by curiosity. That never stops.
Gunderson: Leap to the story that many of our Stakeholder folks would relate to is many of us have unusual backgrounds that have brought us into a field of health. We may have a business card that has the name of a hospital or a public health agency or something health-ish but we’ve been formed in a more complex manner as you described. How did you get to the health? You’re helping eliminate polio. That’s about as hardcore health as you can get.
Singhal: It’s interesting you ask that question because in none of my business cards I have the moniker of health emblazoned on a piece of paper. However, I have found myself very interested in, given the way I was trained, in message production issues. If you have a degree in radio, television, and film production you become very interested in how messages are encoded. Then if you have a PHD in communication theory and research you become very interested in how messages are decoded. So the whole notion of narratives as a way to connect with people—because fundamentally with my interests in social change my belief is that if you want to try to understand a culture you listen to the narratives, you listen to the scripts, and if you are trying to change it then you try to change the narrative and change the script.
In many ways, my interest in communication and my interest in change find utterance in a field that we know as health and health of course very broadly construed, not just health in terms of physical wellbeing, which we know is widely important, a body without polio virus or a body inoculated with a vaccine that keeps the polio virus at bay, but also health in terms of relationship, health in terms of meaning and purpose that stems from people coming together to realize something, which is bigger than their own.
I construe health with that deeper sense of let’s call them the leading causes of life. So many of the leading causes of life as I construe them are relational. You know, kindness or the metaphor is love or if it’s forgiveness. They are all very communicative actions. I’d say that my interest in this was sharpened in 1994 when as a young assistant professor I was invited to be on the technical advisory group of what was a $170 million USAID project called AIDS Gap and it was providing technical assistance to 17 high priority countries, mostly in sub Saharan Africa. I realized that of a 13 members technical advisory group I was the only one who did not have a degree in public health or in medicine.
I was the only person from communication. How did I find myself there? I don’t know. I was struck that … We met in Washington, DC every two months for a period of five years or something like that. I was struck in the very first meeting that while there were a lot of conversations around the table about the virus and what it does to the body, which is important to talk about, but nobody was talking about the relational virus, the stigma, the virus which is, I would suggest, even more virulent than in many ways the biological virus because you can make peace with it but how do you make peace with the way prejudice and discrimination are enacted, which prevents people as you know to go get a test and even if you get a test and so on and so forth. I think my interest was sharpened.
Gunderson: As you know, I have some background at the Carter Center and was friends with many of the extraordinarily courageous men and women who were going to the end of the road and battling polio and guinea worm. There’s a handful of diseases that actually are scientifically capable of being eliminated and that in itself was an audacious thought. But most of the threats to human committee, most of the burden of disease that we suffer, most of the negative pathologies in our work, are not capable of being eliminated in the same way you can eliminate the transmission of a disease. Most of what we’ve got to work with is harder than eliminating an entire category of smallpox or polio.
Right now we’re in the season within the institutions of healthcare and public health in which only recently has the World Health Organization and now pretty much everybody believes that a primary driver of health outcomes is actually socially driven. We talk about social determinants, which I imagine for an expert in positive deviance sort of grates on your language nerve endings right off the bat. Talk to me a little bit about how radically different it is—but what a moment of opportunity it is—that healthcare and public health are embracing the social aspect of the conditions that we’re not just called to engage in an abstract mission but increasingly our reimbursement patterns, our contracts require us to demonstrate competence in engaging the social factors of disease. How much of that is getting the story right? Go right back to the power of the narrative.
Singhal: Well, maybe I’ll respond to that with a little story, with a narrative. I distinctly remember when I offered the first class on positive deviance at the University of Texas at El Paso 10 years ago. It remains I think to this date the only full-length semester-long course that we teach on the positive deviance approach. Of course, the fundamental premise of the positive deviance approach that we live in a highly complex world where you cannot really take care of things with a technical solution like a vaccine or… You know, the problems that we face are far more complex with a whole host of underlying causes that are intertwined and just trying to sort of unsort them or sort them will be very difficult.
The story to me sort of brings it home in a humanistic way. I had a student in class and you may have heard this story. Her mother had died of breast cancer when she was very young. She in the class for her class project said, “Dr. Singhal, I am very interested in positive deviance approach because, gee, I live in a community, the Hispanic community, where we know that the cancer screening rates for women when it comes to mammograms or pap smears, which are technical ways of addressing issues of prevention, are very, very low.”
She fundamentally asked a question which had never been asked before. You see how social processes come into play as we code her question, the research question, and the answer she found. The question simply was: are there women in El Paso County in a particular zip code which is the poorest of poor zip codes, which basically means there are people of low socioeconomic status who may not have medical insurance, who when it comes to health-seeking behavior, are not the ones who are going for mammograms and cancer screenings.
Yet for some reason despite those factors, social factors, demographic factors, local factors that put them at the highest of high risk, were there any women who actually had had a few cancer screenings in the past few years. Of course, those are the deviants. The positive ones, because they’re not the norm. The norm is if you have those characteristics you’re not tested. The answer that she found, what were the characteristics of those who actually did get cancer screening tests when they shouldn’t have because they are not the norm, was that it had nothing to do with them but it had everything to do with their daughters.
Singhal: Because their daughters knew about HPV, they were the ones who had smartphones, they were the ones who knew that they would need to take care of their mother. When the mother fell sick they would tell the mom, “Mom, you’re going to go for this cancer screening test. It happens at this clinic at this hour when the test is offered free and you’re not going alone. I’m going to go with you. I’m going to drive you because I know exactly where to take you. Guess what? We are not going alone, just you and I. I’m going to take Aunt Emily…” The whole social support.
Gunderson: Part of the obvious magic of that story is this was not a relationship just between an asymmetry of generational technical knowledge. It was a relationship of love.
Singhal: Absolutely. Of care, of compassion, of looking into the future and saying, “I am protected by HPV. I know the significance. I have access to a smartphone and information where I can take my mother, whom I deeply love and care, and my aunts and create the conditions for them to be at a place where they can easily be but aren’t.”
Gunderson: You could do poetry about this but you do data about this.
Singhal: Yes. This is all data-driven because the question that she asked was completely data-driven. Are there women, women as a measurable variable, in El Paso County, that’s a measurable locale, who are let’s say above the age of 40, that’s very measurable, who belong to a Hispanic Latino community, that is very measurable, who live in a certain zip code, that’s very measurable, who have had two cancer screenings in the last three years? That’s very measurable.
Gunderson: It would be pretty easy to play out the delta between those who … I’m getting to the cost issues and just the utilization issues that would come out of the difference between when someone is screened and not just the tragedy in the lives of their life and those who love them but the systems that bear the cost of delayed care.
Singhal: Absolutely. We are not talking individual. We are talking about … In this case, of course, it was a few women coming out of a class project but if you look at the implications programmatically of what this means it means that we spend so much time and effort in our Newtonian world of, if… go to his third law, that if this is the problem, well, an equal and opposite solution. If Hispanic women are not going for testing, well, Hispanic women should go for testing and we direct all our efforts there whereas with the signs of complexity, or the complex nature of social systems, telling us there can be non-linearity and you can do a small little thing here with, let’s say, the daughters of women who are not going, which then can create the conditions for not just that women to go because it’s her daughter but create the conditions for others to go. Once they begin to go what does it do for others, the neighbors?
Gunderson: Would you be bold enough, and I know the answer that, yes, you would be bold enough, but I want to tease you in the direction of evaluation.
Gunderson: Of things that we say have succeeded that we attribute to technical, linear, Newtonian, equal and opposite, fixation solutions. There are multiple health programs who claim to be successes often dealing with highly complex… I’m thinking of all the food-related, metabolic syndrome-related problems. And from time to time will say, “This project succeeded” but it’ll give the credit to a technical intervention when I suspect if you looked at the complex relationality of what was going on in that project you would see things much like that amazing story of the students and their moms.
Singhal: True. I would say, Gary, clearly it’s not one against the other in any way because the mammogram is essential. The pap smear is essential. They are indeed a technical offering, which creates the conditions for people to live healthier lives by virtue of getting screened. What makes possible a pap smear for a woman who will ordinarily never get a pap smear or what makes possible a mammogram is this social web of relationships nudged in a way that it can make things tip. That insight, that narrative comes from using data to figure out who has solved a problem when they shouldn’t have and then amplifying as a strategy, as an intervention the narrative now you know that works because it is locally embedded in the conditionality of those who have actually solved the problem.
Gunderson: I’ve heard you say … Tease this out a little bit. There are many narratives in which the hero becomes the one who is sort of set apart from everyone else’s failures but I’ve heard you say that you need to be careful about making heroes here. Focus on the practices that they’ve discovered.
Singhal: Critical. That has been I would say one of the lessons because ordinarily when I think this whole approach got started the natural tendency is to valorize the one who has solved the problem. Of course, you need to identify those to identify what is it that they are doing. As part of the natural process of asking a data-driven question it will lead you to either an individual or a household or a unit, which is doing relatively better than the others with the same odds or against all odds.
What follows typically, as it happened in the positive deviance approach, is you tend to say, “Look here. Look what they are doing.” That’s fine. I mean, that’s one way. Then of course there’s sort of a natural immune response, “Oh, yeah. They will do it because they are different.” Whereas the key which opens the door is not who is behind the key but the key itself, which means the focus really should be on the behavior. What is it that they are doing that makes the difference? The difference is that it’s the young girl who asks, not asks. She tells, not just tells, persuades because the mom still says, “I don’t need to go.” She says, “No. You are going with me because you’ve got transport and you’ve got Aunt Emilia with me.”
Gunderson: What are the implications? The power of this is that the approach you’re commending is not one of adopting personality traits. In other words, there are some people who are natural positive deviants and those who are not. What you’re really describing is a mythology that helps us do this work. That seems to be the revolutionary edge of this.
Singhal: I believe so. Sometimes I’m asked, “So what does this mean? Does this mean if in El Paso County your positive deviance inquiry shows that young girls play a big role in getting their mothers now can you replicate this?” I think that’s the wrong question to ask. Clearly it’s replicable.
Gunderson: That was the question I was about to ask.
Singhal: Because clearly positive deviance happens in a container that is very local. At the same time I do not think it’s a cop-out because you want to ask the question given in this particular context of El Paso, given the context of the Hispanic Latino culture, you have a daughter who is better informed, knows about health-seeking behaviors, and she’s the one who makes possible for her mother and her aunts to go.
But if you go to another level of abstraction, that’s what theory building is, and you ask the question what is happening here? What you see is what’s happening here is the reason why somebody who would ordinarily not go goes is because there is a nudge that comes from somebody who has some clout and has some clout at a very deep, personal, relational level. You also see that that person takes care of all the logistical issues, which rarely are considered. Transportation, how would she know where to go? Creating the social support.
To me, what is most meaningful is not just that in a local context. You have a daughter who creates the conditions for the mother to go. But to me at a theoretical level it is: who is the one who asks? Who is the one who creates the conditions for the logistics to work them in a way that she knows where to go and she’s taken there and the web of social support, a network that we know is very important when you say, “Why would I go alone? I’d be okay going alone if I’m going with …”
Gunderson: Part of the implication … I’m aware in our work we’re in post-Christendom, post-modernism, post-Industrial, post, post, post, post almost every kind of the social architecture that our society has been formed in all of that is fluid now. The reason you need to back up to the theoretical level is to look with new eyes at the social ecology in which we actually live and say, “Who cares about this person besides someone who has a technical reason to view them as an object to give a mammogram to or vaccinate? Who is in relationship?” The eye is for the relationality in our social systems is the critical step of figuring out how to work.
Singhal: Precisely. That’s where it gets interesting. That’s where the scaling and that’s where the amplification lies. It may not be that it’s a daughter in North Carolina or in India but I think those principles of logistics, transport, knowing where a service is offered, the act of somebody being willing to go along, and the social support that is needed. I think this very pointed, data-driven question in a highly complex world where there’s so many intertwining causes is sorted out by valorizing or identifying first what is it that makes the difference and then a level of abstraction, theory-building if you may, says, “Ah, can we bring relationships, logistics, social support together in a way that it completes a relationship?”
Gunderson: How much theory do you need? I can see those who would be interested and not just in El Paso but across the border at Juarez and Winston-Salem and let’s do San Bernardino and someplace in India and South Africa to see all of those different places. You need some theoretical capacity to see many but what you’re also suggesting is if you care about your own place you need the capacity to have a theory in order to see your own place with new eyes.
Singhal: I believe so. There’s tremendous value even if one, let’s say, was completely atheoretical. Let’s go there. There’s tremendous value in applying this method, which believes that data has value provided you ask a data-driven question that has never been asked before of outliers. That of course has its own theory in terms of the normality and how our fixation, I’m going to use that word, fixation, with normality has in some ways kept us very limited because the normal curve by its very narrative valorizes average, valorizes mediocrity. That’s okay it serves that function if you’re trying to make uniforms and make uniforms that would fit most people. You’re not really very interested in the outliers.
But when it comes to solving social problems valorizing mediocrity is not very helpful. It is helpful to ask the question is there somebody, an outlier, who has solved the problem? Not a negative outlier because that is what we are generally focused in, deviance in a very sociological sense, but one who has solved the problem and they shouldn’t have. Even if you were an interventionist, just using a data-driven mindset without any theory building, I think you would get to a good place. If you can take what you find and create … What does it take for social support, logistics, nudge relational issues to come together? That in itself I think has tremendous value because that can then I think geographically go beyond the local.
Gunderson: Right. We’re about out of time but I want to ask you … You’ve just spent days on a very interesting and I would say deviant university setting. I know a good bit about Campbell. You’ve spent a lot of your time crossing generations. What do you see happening in the younger generation that is positive for you? That gives you hope that we can be different.
Singhal: A lot. I do think that in part, Gary, the problem with—we are still young. As Jim says, we have a lot of generative years ahead—I think one thing which those of us, let’s say, who are somewhat advanced on the variable of age …
Gunderson: That was so very sensitive.
Singhal: It’s a continuous variable and it goes in one direction.
Gunderson: No, no, no. We’re going to edit that out
Singhal: Often if we are not curious enough, if we are not hungry enough, we are incapacitated by our training. What gives me the most hope about young people is that their minds can be shaped. The institutions of higher learning, I have my own beef with them. We are so focused on cultivating habits of the heart. No, sorry. We are so focused on cultivating habits of the head. I ask the question when you begin to cultivate habits of the head where you then begin to subscribe to a certain point of view then you see that trained incapacity comes into play where you begin to look at the world as a nail, if you have been trained as a hammer or as something to be screwed on if you are a screwdriver. I think the greatest hope I see with young people is their innate ability to embrace if we can provide them the enabling conditions to cultivate not just habits of the head but have a sense of curiosity, a sense of humility, which is a habit of the heart. I think that’s where you can begin to go places when ideas can circulate and percolate as opposed to being summarily dismissed because it doesn’t fit a certain paradigm.
Gunderson: We were in an executive meeting the other day. We were at an academic medical center. Someone made the comment about raising up the next generation and I said, “You know, we’ve never been here before either. We are the next generation in this crazy new world of healthcare and public health and social this and that. We’ve never been here either.”
Singhal: True. Yeah, the path I think is one where we can either choose to say, “We are we and you are you” or we can choose to walk together.
Gunderson: Well, I hope your dad would be thrilled to see what you’ve done with your railroad training in making the way smooth for many in these times. We’re going to bring this to a close right now but I know it’s the first of many conversations. I look forward to continuing to be in this work and seeing the convergence between your amazingly powerful theory and the practices on the ground of the people who need that theory. Thank you, Arvind.
Singhal: Thank you, Gary. We are in it together.