Whatever your political orientation, we can all agree that America in late 2020 has big problems. A few years ago, I came across a neat approach to solving really tough problems called positive deviance. This powerful approach deserves a catchier name but that’s what we got. Positive deviance was instrumental in reducing childhood malnutrition in Vietnam, female genital mutilation in Egypt, and hospital infection rates. It’s been used in the business world by a couple of pharmaceutical companies’ sales forces as well as by Goldman Sachs’ wealth management group. However, its use is still tilted towards the nonprofit world.
Positive deviance is based on the premise that spending time studying the roots of a big, hairy problem and then devising solutions is bass ackwards. PD got its first chance to shine in 1990 after being conceived by a Tufts nutrition professor in the ‘80s. In 1990, husband and wife visionaries Jerry and Monique Sternin were deployed by the NGO Save the Children at the behest of the Vietnamese government to tackle the malnutrition problem plaguing millions of Vietnamese children. The Sternins were dropped into a small village in Vietnam’s hinterlands and told they had six months to come up with a solution! A PhD in nutritional epidemiology could spend years studying the situation and still not come up with any workable solutions.
Desperate, the Sternins turned to the few villagers with adequately nourished children (i.e., the positive outliers) to discover what made them different from the other children in the village. What they learned was simple but revolutionary: unlike the malnourished children, the healthy kids were fed the same food as their elders, namely protein-rich tiny shrimp from nearby rice paddies and nutritious greens. This small insight ended up improving and sometimes saving the lives of millions of Vietnamese children.
The Sternins enabled the villagers to help themselves by identifying what was already working in their own community and then expanding these practices’ use. Positive deviance is a great alternative to conventional top-down problem-solving and the paralysis analysis that frequently accompanies it because it goes right to the punchline rather than getting mired in trying to understand a problem better.
Positive deviance and American health
For such a wealthy country, the United States’ average life expectancy is pretty mediocre. The US’s 78.6 years compares with an average of 82.3 years for other developed countries. While better-off American communities have average life expectancies that often surpass 82.3 years, those with less money frequently die earlier from limited access to quality healthcare and poor diets as well as greater environmental and psychological stressors. How to fix these shortcomings? We can either wait for the big wins such as reducing financial and health inequities or we can also work in parallel to get small-bore wins that can chip away at the lower life expectancies of poor and working class citizens.
A few months ago, I wrote a post about how the residents of Flushing, Queens were able to avoid the higher COVID-19 rates bedeviling other less affluent communities in New York. The predominantly Asian-American Flushingtonians took the pandemic seriously very early on, wearing masks and social distancing well before the rest of New York woke up to the threat. Being recent immigrants from Asia or children of immigrants enabled Flushing’s citizens to receive early warnings about coronavirus from relatives still living in Asia and gave them a heightened alertness to the danger posed by pandemics due to their previous experience with several in their home countries. In drafting plans for how to protect vulnerable communities from the next pandemic, I hope the incoming Biden administration takes to heart the learnings from communities like Flushing.
Getting back to life expectancy, we can similarly identify less well-off communities in the US whose citizens’ average life expectancy far exceeds what would be expected given their household incomes. Since considering the entire US is an overwhelming exercise for this amateur epidemiologist, I decided to limit my exploration to Los Angeles County, where there is a wide range of incomes and ethnicities. I identified three modest income communities in the western San Gabriel Valley – Monterey Park (median household income: $54,821, life expectancy 84.2 years according to NYU Langone’s City Health Dashboard) , Rosemead ($44,524/83.7), and Alhambra ($53,195/82.9) – that significantly outperform their economic peers in LA county on life expectancy and hold their own against wealthier communities in the county.
What makes the Golden Trio tick and keep ticking?
There are several possible reasons why the citizens of the “Golden Trio” – Monterey Park, Rosemead, and Alhambra – enjoy such long lives. We can then take these reasons and start to generate solutions to improve the health of residents of other LA County towns, like Pomona, that have similar incomes but shorter average life expectancies.
It all begins with the fact that all three Golden Trio towns have populations that are over 50% Asian-American, with Monterey Park topping the list at 65%. Asian-Americans in general tend to live longer than other groups and the effect is especially pronounced in populations with significant numbers of first-generation immigrants. According to a Psychology Today article, in Asian cultures, diets are healthier than the typical American diet, people are more likely to practice stress management techniques such as tai chi, they get more sleep than we sleep-deprived non-Asians, and Asians often show greater respect for the elderly.
We’ve heard of areas called food deserts, which are sometimes also called food swamps because it’s much easier to procure junk food than a bunch of celery in these places. Even among more affluent cities and town in the US, there are often a shortage of healthful, ethnic grocery alternatives to complement the typical big-box supermarkets. On the other hand, Monterey Park, Rosemead, and Alhambra are food cornucopias with many small Asian groceries besides Albertsons and other big-chain supermarkets. Since these are fairly densely populated areas, healthy food is a mere walk away and doesn’t require a car to get to. The Golden Trio cities and other communities like the modest income one surrounding the New Orleans Food Co-op, demonstrate that nutritious food can be made both financially and geographically accessible. We need to think beyond the “Whole Foods or bust” mentality about healthy eating.
Getting back to stress management, heavily Asian areas incorporate tai chi and martial arts into daily life. I remember going to San Francisco years ago and seeing elderly Chinese women performing tai chi in a park. This provincial boy from Long Island had no idea what I was witnessing until someone explained it to me. The Golden Trio’s parks, aided by the beautiful year-round climate of southern California, host an enormous array of organized outdoor martial arts and other physical activities – no karate academies or yoga studios required although these towns have those too.
I’d be remiss if I didn’t also mention the significant Hispanic populations in these towns. Like their Asian counterparts, Latin American immigrants to the United States also tend to be healthier than native Americans. Although there are many possible reasons why this is so, diet likely plays a role. A 2016 study found that “compared with the US diet, the Mexican diet [i.e., authentic Mexican, not the Tex-Mex we know and love] reduced insulin by 14%.”
I could go on listing other hypotheses why residents of the economically modest Golden Trio enjoy long lives. I asked a friend who immigrated from South Korea many years ago if he could suggest other factors why Asians live longer than the rest of us and he came up with the following possibilities: Asians’ more disciplined approach to life that keeps them away from bad habits like smoking and Twinkie addictions, their emphasis on education, better access to healthcare, lower crime rates in Asian communities, and plentiful community programs.
Knowledge into action
The big challenge is how to put this knowledge into practice in communities with different ethnic and racial makeups. As is so often true, knowledge is at best half the battle in persuading people to change their behaviors. (See doctors and nurses that smoke.) Habits can be awfully stubborn.
I think we can learn from the Sternins’ grassroots approach to change in Vietnam by letting the people that want to change be the center of change efforts. Outside experts’ role should be limited to that of facilitators that assist these homegrown change agents in discovering what’s worked in success story towns like Monterey Park, Rosemead, and Alhambra and then translating these best practices into forms that will work in their communities.
I will leave you with a quote from the amazing, very readable book by the Sternins and Richard Pascale that is considered the positive deviance bible, The Power of Positive Deviance: “It’s easier to act your way into a new way of thinking, than think your way into a new way of acting.”
