Why the System Isn't Broken (and How to Change It Anyway) / Meghan Bausone / Episode #258

Hi, my name is Megan and this is the service design show episode 258. >> I think a lot of us got into design because we want to solve actual meaningful problems. But somewhere along the line, reality sets in and you end up spending most of your day navigating office politics and clearing out Jira tickets. How do we actually break out of that loop? Hi, my name is Mark Fontine and welcome back to the service design show. Our goal here is to figure out together how we can design services that work for people, for businesses, and of course for our planet. Today's guest is Megan Bzon. Megan has one of the most interesting backgrounds I've come across. She's actually started out studying midwifey before making her way into design. She's also a fountain pen specialist and apparently mastered the yo-yo just to survive a painfully boring job. But recently, she earned her doctorate in design. And her research was just published. As you'll hear, she takes the highstakes world of maternal health and uses it to question the very foundation of how we work as design professionals. We talk about why just throwing more money at a broken system never actually fixes it and how to find the real leverage points for change. But the part that really got me was when we started talking about the first week of Megan's doctorate program. She got asked a simple question about whether human- centered design is actually always the right approach and it completely shook her professional identity. So, if you are struggling to find the deeper meaning in your current role, this conversation is a great way to reframe how you look at your daily job. Let's jump into the conversation with Megan and I'll be back at the end to wrap things up. Welcome to the show, Megan. >> Hi, Mark. >> I'm as always excited for these conversations. Uh you have a very interesting background. you bring a lot of um unique knowledge to uh to the podcast this time. Um let's set the stage before we jump into the specifics. And when I was reading through your notes, uh what sort of emerged for me was um the idea that we as design practitioners, as professionals, um maybe often feel boxed in, stuck within specific um what's the right word? Limitations or constraints. uh and try to adopt ourselves to working and creating impact within these constraints. Um but I feel that you have a perspective on what these walls are. Um >> how to make them visible and maybe even at some point uh let these walls and not even break them down but sort of let them dissolve. So that that's that's a long intro. Um I'm curious, do you see walls in the design practice? And if so, what are the walls that we should be mindful of? >> Yeah, I think walls are a big part of the design practice. And I think having an awareness of them makes you a better designer, not even needing to break them down, just even being aware that they're there. Uh and knowing how to navigate around them and sometimes maybe if you can get through them. Um but it but it's definitely part of the project to understand what the the walls and limitations are. Um I think really savvy and experienced designers are able to know what the limitations are and work within it. And I think in some place you know in some companies and some projects that's like a very valuable thing to just you know be able to navigate that. Um I think it's also part of the systems view of problems. you know, if you're trying to solve a problem and you work somewhere and you have technical limitations or funding limitations or time constraints, um that's all part of the the holistic view of what you're working on. So I I think problem or limitations are part of the problem you're trying to solve, right? >> Yeah. Uh absolutely. And uh without limitations, design would be a lot less uh interesting. But I think the issue where what that we want to explore today is that when these limitations or constraints um force us into positions where we um act as uh what's the right word uh like solving Jira tickets or being very uh pushing buttons across screens um like following uh requirements and procedures and implementing things rather than sort of the promise uh that was made to us when we got into design and that is yes >> the promise of actually being able to do impactful meaningful uh and fulfilling work right then those limitations and constraints become an issue >> yeah so can I I use this as an opportunity to just say you know before I became a designer. I was really passionate about maternal health and I studied midwiffery and I I got a lot of exposure to a a world where there's a lot of politics, there's a lot of problems. Um, you know, it's a very complicated, it's very messy, and there's like real, you know, human lives at stake, right? So it's just a very intense different kind of atmosphere than what you're describing where we're marking Jared tickets done or understanding technical requirements and that sort of thing. So um when I became a designer and I'll I'll skip over some parts. I I became a designer through my my pathway in u maternal health to um graphic design. I worked on a publication um and and that's how I decided to transition. and I knew I wasn't going to actually become a midwife for lots of reasons. But then I did that for a little while and then I decided to get my masters in user experience design. And I thought like to your point like I was going to be a designer that solved problems that I was going to be really you know hit the ground running in my career and this was going to be like the end all be all. I was gonna, you know, be able to dig deep and really make big changes for companies, for end users, you know, redesign services. And I I did um I feel like I had some successes, you know, in that. But I I also found that instead of becoming a really good designer, I became really good at managing requirements and understanding these technical limitations and sometimes just the organizational politics, right? culture and the power dynamics of the places that I worked. And um so my my ability to solve problems actually started to become more about that >> and less about whether or not I was designing things deeply to solve problems for for the people who I was trying to solve them for. And uh that's how I ended up wanting to take it further beyond just saying like oh I'm a UX designer. I have this masters in UX. I want to solve problems. I want to keep digging deeper. >> Okay. Yeah, let's take a pause here because >> some people might say that okay um when you actually get good at managing requirements, navigating the politics, you've won like you're there. You're you're doing great work. Uh but apparently there was I don't know something happened in your trajectory in your journey that made you go h this isn't what I signed up for this isn't enough. So can you take us back to that moment? Yeah, I mean to be clear like I still do that part of it and I do think that is a valuable skill set to have but I just feel like there are a lot of problems that aren't being addressed because they aren't being framed in that way or or maybe they are only being framed in that way and never being approached from a very deep level. Um, I don't know if there was I I think it was just a lingering desire actually to go back into addressing maternal health problems and knowing like there's no app, you know, there's no startup concept. There's nothing that's like this one, you know, one on oneizefits-all kind of, you know, disruptive concept that's going to fix maternal health. um in in the and and I should give some context just really quick because I know some people may not be as you know interested in the maternal health um crisis in the United States as I am but just for for the listeners to know the US has the highest maternal mortality rate of high-income nations in the world um disproportionately impacts uh women of color, black communities, indigenous communities um and and we also have a growing number of maternity care deserts. Um, so these are rural, mostly rural, but in some cases urban counties where there's no access to maternity care services. So we have a really bad situation here. And like I said, there isn't just like, you know, an app that's going to solve it or some kind of quick technology that I can help project manage, you know, to get something done, right? So the the problems are inherently a lot deeper. sounds important the work that you're doing but that to me still doesn't fully uh explain um you you you mentioned that there was an itch a sort of lingering desire um >> a lot of I I think a lot of us have some sort of lingering desire but what sort of tipped you over the edge to say >> I'm going to get a doctorate degree in design >> yeah um I mean maybe just my my own personal sort of um you know drive to to take things further. I actually had before I I got into design I also was considering getting a PhD in medical anthropology and I'm glad that I didn't do that. No offense to anybody who you know it may be an anthropologist who is listening. I have a lot of respect for for anthropology but I I'm very glad I decided to focus on design instead of that. But I I think I just always want to keep asking why and I want to take things deeper. And I think in some cases, you know, that's not always welcome where you are, you know, employed. Sometimes they're just like, Megan, stop asking why and just finish the prototype or make the diagram or, you know, finish the project. Don't we don't need to go that deep. So, um, you know, I think I had kind of a just an overpouring of of desire to to be in a space where I could keep asking why and to to be able to research something that was really meaningful to me. So, that's why I decided to keep going um and and to get the doctor of design. >> Yeah. >> All right. So, we're in a situation where um you're employed, you're doing UX work, you sort of uh slowly but surely develop the skills to actually navigate the system. Uh and in that process you realize that navigating and managing the system um isn't getting you closer to contributing to the world that you want to see and the solutions that you really care about. Right? Is that a good summary? >> I think so. Yeah. I think that and just also helping for myself to understand how to understand bigger problems than you know like how to actually frame I don't even know if framing is a good world word but just to to to see it at a higher altitude or or have a holistic understanding of what's going on. Um I I think you know even for myself back then when if somebody had asked me like why why do we have this maternal health crisis in the United States I would maybe be able to come up with a few things that I felt like were contributing factors but um not like a holistic understanding of what what is really causing it. And I think what I try to do is to build the skills or to to learn the skills to be able to understand problems like that and maybe not just maternal health but to be able to contribute to other wicked problem areas as well. How do you I how do you manage uh to to grasp and to sort of make sense of such a big issue or challenge like maternal health without overwhelming yourself because that might be like it's it's great when you're working on a Jira ticket because the the scope is really defined. You know what success looks like. um what you're describing is like the the polar opposite where like there there isn't a solution, right? You're just working uh to you're contributing to a system where you can improve things but never fully solve them. >> How do you cope? How do you manage what Yeah. What did you learn about the process? Well, I think understanding the problems helps you cope with that you can't solve them, which is it, you know, it's a small consolation for for basically feeling like powerless to do anything um in the face of such big um big issues. But I think one one big takeaway from my explorations is that, you know, it's not it's not one person's fault. like there's not, you know, some evil mastermind that's controlling things, that's making things awful. Um, it's a lot of of the system is designed, you know, to produce the outcomes that it it's designed to produce, right? Like it's it's producing what it's set up for and there's a lot of people involved who are just part of that system who are doing what that system is informing them to do, right? Um, and so there's really not any kind of blame that you can lay. And then, and then you have to take a step back and say, well then how do we change a system where there isn't just like somebody we can go talk to, somebody we can ask to step in or intervene or change what they're doing? That's not exactly how it works. So, um, you know, I needed to get to the point for myself that I felt like that, um, you know, I I could not have not have hard feelings about the system not working the way that it does. And just think really practically about now that we have this bigger view. How do we actually go from this, you know, totally high out there outer space basically altitude of looking at this and zoom down in and find areas where we can actually make change. And I think measuring the impact of those changes is really about that whether or not we've impacted human lives, right? Or or saved lives. um you know so I I'm not sure if I if I answered your question. >> Yeah, there aren't any answers. They're just explorations like you said. So, but you did mention something very interesting. How do you >> um how do you sort of keep working in to improve the system without blaming the system? >> How did you like was there did you have a breakthrough? Was there anything in particular that helped you sort of cope with that feeling? Because I think a lot of us listening sort of um there is a some sort of a being a victim uh of the system and sort of throwing your hands up and saying like >> I'll never be able to change anything because XYZ whatever whatever. >> How do you get over that? >> Well, I mean I definitely get angry about the system sometimes. It's not like I feel totally emotionless towards the system, but I I don't think it's helpful to blame it or to say, you know, it the system is I mean, a lot of people say, "Oh, the system is broken." Well, it's not really broken because it's doing what it's designed to do, right? Um and I think uh if you if you think about that aspect of systems and you disagree with the outcomes of the system, maybe what you're finding is that you actually don't align with the goals of the system. And then you're like, well, who who created the goals of the system, right? And maternal health is, you know, you might assume that the goal of the system is to have healthy outcomes, right? You don't want people to die. You want people to to go through the processes, you know, pregnancy, birth, uh you know, these types of things and to to be healthy and on on the other side. Um but then if you look at it as part of the greater health care system, the goal that's not actually the goal of the greater health care system. The greater health care system is all cost reduction and profit maximization and you know that sort of thing, consolidation, privatization. These are all things that are goals of that greater system. So when you're like the maternal health system's broken, you're actually saying I disagree with the goal. Doesn't that didn't that make you sad when you sort of um >> Yeah. >> accept it or like were you able to accept I I don't know how do you feel about that right now? >> It didn't it doesn't make me sad because I feel like it gives me something more to go off of in trying to identify what kind of change that I can make to the system. the more that I know about the system, the more that I can have traction. Like if you're climbing a cliff wall and you're looking for like the next thing to grab onto to to hoist yourself up to the top, um learning more about how things work and understanding that, you know, there are these underlying goals or or principles of the system actually gives us more to work with. >> Yeah, I I think you mentioned leverage points at some point. uh in in your notes. I I want to get into that, but there's something else that I'm sort of getting from your story and that is also that um >> you have to maybe reframe or rethink or reflect on your own position within this system. We're going to use system a lot. I'm I'm going to do a trivia question on how often we mention the word system in this uh episode, but um did did you get a different perspective on the role that you play like the position that you have as a design professional? Yeah, I mean I think our our position influences a lot like you know I I think I come from a pretty interesting position because I have this you know background in maternal health already in midwiffery and midwiffery is already kind of a uh depending on who you're talking to um you know sort of an outcast in the system. So I sort of came in already biased like you know I think minifree has a lot to do with what possible solutions could look like. Um, and that's unique to me, but I think all designers have things, right? Um, things in their own position or their own beliefs that are going to influence how they want to approach a problem. And, um, you know, I think we also do we we try a lot to skirt around our position. I think that's a very antiquated view of how we we approach things and solve problems. It's sort of this like positivist like scientific view that like we are this unbiased, you know, nonhuman element in the in the problem solving or in the research where we're not really we're we're we're producing very unbiased results. But I think um my position definitely makes me biased and I actually think that in this case it might cause me to think of ways of solving the problems that maybe other people won't think of. So maybe embracing your position and saying like here's why I'm uniquely attuned to this particular situation is actually a powerful stance. Like don't run away from my unique position, you know, or your unique position. Um actually think about how it influences the way you might design for the problem. Yeah, we've had some conversations recently about u about this topic and bringing um your whole identity, your your whole heritage, your whole background. uh was a really interesting conversation with Nano Sullivan who works in New Zealand uh this university where >> sort of the indigenous knowledge for instance uh how do you integrate that but that's sidetrack uh check out that episode if you haven't done so already but um was that like was that also uh a journey of discovery for you that you had to get comfortable with actually bringing your own biases Or were you always comfortable bringing your own bias? >> No, I mean I think I came from the the position where I was trying not to be biased and and actually I referenced this um my transition into design and there was a a publication. It was a nonprofit publication that I started um my my design path through uh that was called Squat Birth Journal. Don't look at it for the design. The design's really bad. They had the visual design. Yes. Yeah. I did the layout, you know, in in design and I learned a lot about that um before I actually we were just bootstrapping. I mean, we were just trying to get it out there. But um but you know, I think we we were really conscious. It was an open forum publication where we were trying to take people's voices from from the field. It was um you know called like the radical birth journal. And we we had articles from doulas and midwives and people across the um these fields um you know there was visuals and poems and essays and interviews and anyway we we were trying to so hard to incorporate everybody anybody and and rightfully so. I mean, everybody, you know, needs to have this platform, this outlet, but I think we were really um the editorial team, like we were all, you know, for the most part like white women who were super passionate about this and we were feeling very um pressured to make sure that we were, you know, pulling ourselves kind of aside and out out of the spotlight. And I and I had a lot of, you know, one of the reasons why we stopped making the publication was because we received, you know, crit criticism sometimes like we weren't doing enough to incorporate this this group or that group and this group and we were just like, well then maybe everybody needs their own publication or and I don't think that's the right answer. So, um I think well everybody can have their own publication. Everybody can do whatever they they need to do. But if you're a designer and you're trying to solve problems for different types of groups of people, right? Maybe recognizing like here's who I am. Here's my positionality. And um you know, maybe I'm not the best person to know exactly what you need. I'm not going to tell you what you need, right? Like we're going to we're going to co-design. We're going to you know have participatory design. We're going to work together or I'm going to listen to you or whatever. But it's I'm not I'm not solving the problem for me, right? Like but I am also bringing my positionality to this conversation. Does that make sense? >> Yeah. So um if I'm hearing you correctly um initially you had a stance that I think a lot of design professionals have where we try to portray objectivity and we sort of try to be the facilitator um not bring in any um biases u but rather try to be the translators of needs and desires fears of the people we're designing for. Um nowadays it seems that you integrate embrace uh your background your your passions your your own thoughts and ideas about what the world should look like. Is is that a again is that a correct summary? I do, but I also am very very passionate about every community needs a solution that works for that community. And that's where I feel like the maternal health problem is very um it's a very good case study I think for lots of other types of problems where we need to think about how a localized solution is going to work uh in and in in a scalable way. So in maternal health um you know part of the problem is that people have been disconnected from community supported um or community centered sources of care. So before hospital birth became like the dominant way of having a baby in the US, we had community midwives and that worked. You know, everybody knew them like they they delivered everybody's babies. Um they were respected, revered uh and then they were ultimately eradicated essentially from the system to use sort of a strong word but they policies were implemented. they were removed and that's where we saw a lot of the formation of the maternity care deserts coming from because um resources were lo were were centralized in hospitals and then you had to travel there to go there rather than having a midwife who would come to you in the middle of the night who would you know go through the creek on the on the horse up the hillside you know to get to these rural areas and who would know exactly who's about to have a baby any minute in their community and would be really tapped in right and I I think you know not to get too far into my own my own physician's belief about like how we would uh actually solve the problem. But going back to a community centered model, a resilient model for midwiffery is is about communities having somebody or people in that community who are like them, who understand them, who are them um filling these roles. And you know as a designer if I were going to implement a solution or try to solve for that problem um you know I a large part of that solution would have to be these are these are your your people and I can't tell you who they are what you need from them right um so so that part of my position can't like inform that part of the solution right >> so where um where do where do you come in like where does your position ality come in in the design process. If you uh have the uh stance that every community needs a solution that works for them, which I think a lot of us will agree to >> where where how does your own positionality manifest in the design process? Well, I think it goes back to my experience working with midwives and and um you know, going to community births, going to people's homes and witnessing birth and having those types of experiences. That's not everybody's ideal solution. Some people are like, "Well, you're not going to solve the maternal health crisis by telling people that they need to have a baby at home." And that's not my goal. But I do have this sort of underlying pretext or this underlying understanding of like that that can work that does work for some people and there are aspects of that model that could be framed or modeled for other communities or you know scaled more broadly. So I think my position and I I I guess some people listening may be like well having experience in midwiffrey isn't really like part of your position but when you work in maternal health there are there's a lot of tensions between medical health professionals and midwives especially community midwives or home birth midwives um that work outside of hospitals. So it does kind of become something you have to say well it's like well I support this model of care. Some people don't. Some people think that the answer to solving the maternal health crisis is leveraging, you know, robotic um arms that will help. And this is actually happening in some places. Um they're using, you know, robotic arms controlled by people in other states to conduct prenatal exams and to um you know, to do ultrasounds and that sort of thing. and and that's some people's idea of the solution, but I think that I personally feel like the maternal health crisis has to do with relationships. I think we need to have stronger relationships and I don't think people are going to form those relationships with robotic arms. >> So that's that's that's my position. >> Some people in Silicon Valley will probably disagree with you. Um. >> Sure. >> Yeah. So what does that mean for what does it mean for design? It's that this is a very broad question but like uh if you look back at how you look at design today versus maybe five or who knows maybe 10 years ago. >> Yeah. When I decided to get the doctorate and I knew I wanted to do some kind of research in maternal health as my core focus of that program. Um, I was leaving that, you know, I'm a UX designer, I'm a product designer, you know, I do service design or whatever. And I I was living in the land of Jer tickets and feeling like I had really mastered that. I mean, we talked about all that. And then I started this doctoral program and I mean it was like the first week um I I went to the um the introductory like symposium where they have speakers and and there was this one speaker her name is Upali Nanda and she's an architect and she said something I don't remember exactly what she said but something along the lines of you know how do we decide that we need need to do human- centered design? Why are we centering things around humans? Maybe there's other ways we need to be doing things. And just her questioning human- centered design, which had become like a cornerstone of everything I defined myself as a designer on. Um, and then having that sort of go like poof, like maybe human- centered design isn't the answer. Maybe we're thinking about this wrong. I was sitting in that call and thinking am I actually a design am I a designer or am I just like I don't even know what what I've gotten myself into. I don't even know if I'm a designer. Um, and I and throughout the the program studying maternal health and having these questions about maternal health, having that positionality of like this, you know, experience in midwifery and um incorporating that into design, there were a lot of moments where I was like, is this design? Is this a design problem? And I think actually what happened was I came out of that program and was like, "Hell yeah, this is design and I can do whatever I want to do with design principles and with design theory." And and I think sometimes people think, you know, maternal health is too abstract or not a cool enough problem to solve for or whatever. And and they're kind of like, okay, you know, that's just Megan's passion. But no, it is a design. We're This is real design. This is real. These are real design problems. >> Listening to you, it sounds like you had some limiting beliefs about what design was and wasn't. >> Yeah. Yeah, I did. I did. >> What were the limiting beliefs? Well, I I think you know I I thought that design really needed to be um super applied in in ways that was came from my experience of like hey you know I I launched um you know a startup beta in like you know nine sprints and we had x amount of uh you know signups or you know we increased the onboarding flow um by x% of traffic or whatever like I just I think I was really looking for very very tactical and applied ways of of looking at design. Um I had also never really had conversations with other design disciplines uh you know in architecture um in in industrial design and I didn't understand that we have a lot of overlaps of how we solve problems and how we can understand what it is that we're trying to do why we're trying to do it. the design research and the theory parts of it are all the same across all these different disciplines really. Um, and we can borrow a lot from each other in in the course of my reading all these design theory materials. I got the most I think out of some articles that I read, some research that I read that came from architecture. I it blew my mind. I had no idea that someone who's like a UX designer could read a a research, you know, case study from an architecture. And I was I broke my highlighter. I was highlighting so much of that paper back because I actually still I still do print things and actually use a highlighter. Um it's my way of processing information. But uh I yeah I so I think the limitations were really in my head around performance and finding really tangible problems to solve and saying like you know we crossed the line with this thing and I I mean then going into maternal health and being like there's no there's no sprints we're not crossing the line on anything necessarily not not at this level you know >> what did um I I agree and if If you look at the people I'm trying to invite here on the podcast sort of I'm hoping to show that design is a lot more than um the sprints and the tangible artifacts that that we output and it's much more about >> a way of thinking being doing um mindset approaches. Um, was there anything in particular that you felt liberated you from that uh quote unquote old way of thinking about design? Because you mentioned that there was a moment where somebody uh in your first week shared or posed a question like is human centered design even the right thing to do? Did you have a similar experience when it comes to feeling liberated? Hey, I I can do whatever I want with design. >> Yeah, I I think it was in in choosing like the first couple of research topics that I was interested in in approaching. I think the first one I chose was looking at like really scoped into the process, you know, some sort of process of interaction between um healthcare provider and a patient. And and I was like, this isn't right. like I felt like I had put on, you know, a a an outfit that was like too tight or something. I was like, "This is weird. This is limiting. Like I don't actually this isn't answering the question that I want to answer in the course of this program." And I kept just, you know, stripping away layers of that limitation and saying like, well, no, I don't need to look at this individual super scoped process um because that's what I'm used to. I don't need to look at specific examples of technology. And I kept just getting bigger and bigger and bigger until I got to the point where I was looking at the whole system. And then we might, you know, talk about leverage points, but I I was looking at the system through these leverage points um that are posed by Danella Meadows and her ultimate leverage point for how to make change in a system comes down to paradigms. there's really not a lot bigger than you know looking at things from a a paradigmatic lens. Um and so that's where I ended up >> for for us who sort of are uh limited and haven't read the book yet. >> Yeah. >> Leverage points paradigms help us out here. >> Okay. So Danella Meadows is a brilliant environmental scientist who was writing a about how to understand a system and it's it's very generalized. So if you even if you don't know anything about environmental science, it's it's for anybody. I think you can apply it to all forms of work, all industries, all problems that you might be looking at. Um how to understand the dynamics of a system. But then what's really unique and interesting about her work is that she poses that there are these leverage points based on her analyzing understanding many systems um from and she ranks them from the least powerful to the most powerful. And at the bottom end of the least powerful ones are things like numbers and parameters like we need to put something more into the system. We need to you know increase the flow of something or the output of something. Um in in maternal health I a lot of times I think about this as like funding. We need to like put more money in or take more money out or you know reallocate or it's all about these little data points these numbers. She calls that section of leverage points rearranging the deck chairs on the Titanic because she just feels like it's not very effective. And that was actually very liberating for me to be like, hey, the answer to the problems according to Danella Meadows or the way that we're going to change the system is not through money. It's not going to be increasing funding. We can throw a lot of funding at a problem but not have the right solutions funded and then end up not, you know, we're burning through that. They're just numbers. It's rearranging deck chairs on the Titanic, right? And then, uh, she goes up, you know, in leverage to, um, I'll skip a few to, uh, you can read it in the book. There's some great visual diagrams, too. um information flows and the way that we communicate as a real source of exchange through a system. And I think this one's really really important for maternal health, but also for lots of other problems. How we receive information, how accessible is the information, who controls the information. Um that's extremely important for being able to enable any kind of change in any kind of system. Empowering the stakeholders, the players of the system to be able to make decisions based on information extremely important. Uh and then there's the structure of the system that has a lot to do with resiliency. Uh she talks about um the that a system that is resilient that is able to form or reform its own system. um is is a very powerful mechanism for change. It's just not a very easy thing to do. And then beyond that is paradigms. So the most impactful ones are paradigms. And that's how we understand the system, how we justify how it works, why we participate in it. and and then her most ultimate one is really understanding that paradigms we all have paradigms and and trying to transcend them and find those limitations like we've been talking about and pushing beyond them right like I might have a paradigm >> so what's limiting belief >> to um uh to make this uh concrete >> what is the existing paradigm around maternity health >> oh this is such a big question actually um I don't know if we'll make things more concrete paint. >> Uh that's right. >> But there Okay. Okay. Yeah, we can try. Um so >> in maternal health there are a few there actually are few paradigms. It depends on and now we're getting into definitions because I think actually the way you define systems and define paradigms are also uh you know up for question or in play, right? Yeah. >> Yeah. So um there is actually a medical anthropologist named Robbie Davis Floyd who uh came up with a framework for maternal health paradigms in the western world and I I use that sort of tenatively you know leverage that as part of my research but to distill it down uh there's a core paradigm um it's it's really the technocratic paradigm we we use that word technocratic to and we use it um and apply it to a lot of different concepts basically that processes are like mechanical, right? And we use technology to streamline and make them better, easier, faster, more efficient, cheaper, whatever. Um, technology is the answer, right? And the the core and dominant paradigm in maternal health in the United States and elsewhere, uh, now more and more and and across the Western world and beyond is that we are using technology to to streamline the processes. And and this this goes one thing I think is so fascinating about maternal health is that it's not just like the exchange that we have the services we receive in a hospital. I mean there's there are processes that are happening. There are physiological physiological processes that are happening, right? There's hormones and you know when you're in in labor there's sequences of events, right? There's a there's a physiological process that's happening and then on top of that you're receiving services. there's processes that are happening in your exchange at a hospital with a provider or with a midwife in your home or whoever you're working with. Um, so so there's, you know, this paradigm that is applied kind of to all of these things. And the technocratic paradigm really reshaped the maternal health system in the early, you know, the turn of the century and when hospitals became more dominant. In 1900, most people had babies with midwives at home or at a birth center or like a you know maternity hospital usually run by like nuns or um you know uh that sort of thing. And then and then they started to have these hospital-based technologically advanced types of procedures where they were using twilight sleep um you know medications that made you not feel the pain or remember your experience. actually I think you still felt pain but you didn't remember um they were using forceps they were you know performing epziottomies C-sections these sorts of things it became very technological it became very streamlined so that's the foundation that's the the the the paradigm that's underlying but there's something more interesting um I think that that's pretty well documented I feel like there's a lot of people who talk about that who write about that who understand it and but when I did my research I found there's something else on top of it. It's not a paradigm. I would actually call it an ideology. Um, has anybody on your show talked about managerialism? >> I don't think we have. No. >> Okay. >> At least not in the term. >> Yeah. So, managerialism as a term, I guess, you know, you could probably imagine what that is, what that what that would mean. But what what I found in my interviews with people who work in the field. So I did a a study with people who work in maternal health in a rural area. I was trying to understand what the paradigms of their specific you know how they understand the system around them. What are their paradigms? Um and what I found is that they actually kind of mix paradigmatic views. Nobody's really technocratic or there's the other two paradigms holistic humanistic. Um they're they're kind of mixing them all together. It's a very like pluralistic, right, as you navigate your everyday in the system. But one thing that they described that was across all of them, their doulas, you know, physician, midwives, um that they are all experiencing the same kinds of financial burdens, the same kinds of policy restrictions, um all of these things that have to do with the the rules and, you know, the financials of the system. And I was hearing everybody say these things and it's not about my my particular beliefs about how I should deliver a baby or how babies should be born or where they should be born or what the environment should be like. It's like I need to pay my bills and malpractice insurance is extremely expensive and I don't I'm not given the scope of practice rights that I need to be able to deliver the care that I need to deliver or you know I there's nobody else providing backup for me so I'm burning out. there's all these things. And so listening to them and thinking, is this another paradigm? And really racking my brain about like what what is this called? What is this term for what they're describing? And that's where managerialism came in. And it sort of hit me like it's the management of these systems. It's the management of these organizations. Again, going back to what we were talking about, there's nobody to blame. There's no specific person that you can say that person is making these bad decisions. It's people who are like hey we need to focus on cost reduction. We need to focus on profit maximization. We need to focus on um you know how we set policies, why we set policies. You know these sorts of things. And I I I do think that type of decision-m can be a a conduit for discrimination or, you know, for um creating, you know, gate being gatekeeping and that sort of thing. That's kind of beside the point. But what what I'm trying to say is that managerialism trumps all of the paradigms within the maternal health system. It controls everybody regardless of what their beliefs of how the system should work. um are does that make sense? >> Yes. So um and the way you're describing this this definitely I I think this is the dominant paradigm across many industries fields practices that this is at least in the western uh or the global north as I recently heard it >> this that yeah so I think this this applies to to a lot of people. Exactly. >> How does that not um uh sort of paralyze you? >> This is Yeah. So it it it feels really big and it does to your point. It it affects everybody. It's all all causes. It's all crisis crises um that are influenced by managerialism. I think it is our core ideology, you know, in the in the world um today at that level, right? We feel very restricted by the system. If we think this is what when I said that the definitions of systems and paradigms are sort of at play. It pushed me to realize in in understanding that managerialism is such a dramatic force on this system that how we define the system may actually be a way that we enable ourselves to find new leverage points or opportunity for innovation. So if I say, you know, how do you fix the maternal health system and in your mind you feel or you see a system that is hospitals and insurance companies and you know burnt out healthcare providers and people not being able to pay their bills and duelist throwing their hands up and saying I quit because I'm burned out. I can't do this anymore. And that's the system. Um then yeah, it's it's pretty paralyzing. But if you think about the system like hey what would your ideal maternal health system be going back to my own personal view like if we had community centered resilient care and we started to reframe hey what if the system isn't about the managerialism. It's not about the the flow of money. Let's just pause that for a minute. We're not going to completely ignore that that exists. But what if we need to reframe our understanding of the system based on what it needs to be, which is these relation relationships? It's relational. The system needs to reflect how we want it to actually function and what we want the outcomes to be. And then we can figure out how to find an opportunity to create those types of ways of making the system work. And when you had this realization that it's about relationships and that it's uh it's a different way of looking and prioritizing things in the system, where how do you then start? Where do you know which which lever to pull? >> Yeah. Well, then I look at the the leverage points. Um I actually think reframing the system is something around the leverage point of of structure of understanding how a system can become resilient. We know that the maternal health system if your goal is actually maternal health like you want to reduce the maternal mortality rate you want to increase access to services the system that's currently in place does not serve that goal. So that system is not going to work for that. So you really do have to create a different system. You have to reframe the system entirely and figure out how to make it resilient and to support that goal. So that's a leverage point all on its own. But I don't like yeah again just that alone that realization might feel overwhelming and paralyzing like you're up against an established system that um works to some extent for some goals >> like >> you're not going to build a parallel system or are you? >> I don't know. I guess we'll find out. Um well so I do think that there's there is some opportunity here because there are maternity care deserts. There are areas where there there aren't services. The system is not participating there. It's not available there. >> So there are areas where what else is there? >> Uhhuh. >> Do you know what I'm saying? And one of one of the questions that I had in this in the course of my research is when when is the system truly gone? And that's actually what made me sort of have to reframe my understanding of the system. If there's no hospital nearby, there's no system in your area. There's no one administering services. Is the system gone? If there's a midwife that lives nearby that can drive to your house that can check on you, that's that's a system, right? Maybe there's a doula who's a nonmed person who has a lot of information, a lot of resources, and can tell you where do you need to go? who do you need to call is that person does that represent a system maybe uh is even to the extreme when we're looking at these the physiological processes I mean people are going to have babies and those babies are going to be born whether or not there's anybody there or any systems there at all so is there is is there a system always there >> even when there's no quote unquote you know managerialist giant system there. >> Yeah. Yeah. It's interesting because um you mentioned the word desert. To me, it almost feels like a green field because the places where um >> a system isn't yet dominant or deeply rooted or established or in this case probably the the managerial paradigm is seeking profit maximization. And if those areas aren't um yet captured by that system, that leaves that that provides a gap that provides an opportunity to a vacuum to put something in place that suits that specific community better, right? >> Yeah. Exactly. And because who else like who is going to come into that community and put it in place there? Nobody's coming from the outside >> to do that. Nobody's, you know, this the the communities need to figure out a way of of building that resiliency, you know, of establishing what kind of services that they need. >> And one of somebody who I interviewed who is a community midwife talked a little bit about cooperative housing models and cooperative food, you know, grocery store type models and was like, well, maybe there's something in that. But really, when big corporations aren't interested, that's where little seeds can sprout. That's where new ideas can come into play. I think that could be truly innovative. But there's also a model that already existed for this before >> the managerialist, you know, hospital system took over. >> So, it's not like we even have to go that far to look at models that worked. And we also have other countries >> that still have models that are working that are different than ours. So, >> you know, it's not such a stretch to think that the system could be radically different than it is right now. And I think a lot of people actually want a radically different system. They recognize we need it. Um, so I do have hope. It isn't totally overwhelming. I think that the pieces will need to come together otherwise, well, we'll just have to. I feel like it's in our human nature. We have to figure it out. >> Yeah. And there are opportunities to experiment uh set up new systems and see what happens. It's it's like it's the existing paradigms aren't all consuming. There are always people communities left out of the existing systems and those might be the best starting points, right? >> Yeah. And there are grassroots organizations. There are community midwives. There are, you know, individual physicians and providers that like buy a an RV or a bus and they're driving around and they're trying to reach these areas. I mean, there are people out there who are trying to do things. It's not like there aren't a lot of people who are trying to contribute to solving this problem because there are and there's a lot of great ideas. It's just >> how do we make it >> sort of more scalable or or create frameworks for it that can be easy to just pop up in places? Let's try to tie this back to how we started this conversation where design feels boxed in maybe invisible walls. We're uh navigating politics. We're checking off Jira tickets. Um and now we're talking about experimenting with new systems. For someone who's listening to our conversation right now and maybe is a little bit overwhelmed and sort of sees their day-to-day reality, like what would you say is a meaningful helpful first step to get out of the um feature implementation mindset attitude approach. >> Yeah. Well, I think identifying the walls, like we talked about, seeing the walls, just knowing that they're there, and then thinking about the kind of design work that you would do if there weren't walls there. If I were approaching the problems that I'm looking at now with the limitations that I had when I was worried about project requirements and you know funding requirements, I would have very very different ideas about how to solve these problems than I do when I have >> put those aside. I know that there are always going to be, you know, if we're if we're going to come up with real tangible solutions, we're probably going to at some point face there are there are funding requirements. There are technical limitations. There are things that we need to consider as we're implementing those solutions. But that's that's right at the point where we're trying to launch something. How do we get to the point where we know what to launch? And and backing all the way up to let's look at the paradigms. Let's look at the system. Let's look at where we most need leverage point action before we get to the point where we're trying to push something through to the other side. >> Yeah. So the limitations of um profit uh the limitations of uh uh time uh which um like is just just made up. If we don't start there and we actually start where we think how can we create the most impact, how can we create value? What do people actually need? And and sort of like you said, defer those other limitations and and trust that they'll figure themselves out along the way that will probably lead to very other different interesting ideas, solutions, yeah, services. >> What are the risks to thinking outside of those limitations? So really there aren't any. I mean you just there are lots of risks I think to staying within them and I think designers could come up with a lot like to your point different solutions that we don't know we don't even know could exist >> uh by by releasing. >> Yeah. >> Interesting. Yeah. All right. So, um I hope people have been uh keeping score of how often we said uh system. I noticed that I used interesting uh at least a dozen times uh during our call. Um Megan, before we wrap up, we like to end on something to chew upon, to think about after this uh episode. What's a question that you'd like to leave us with? How does reframing the system, whatever system you're looking at, how does reframing it give you a view into what else can be done than what you've considered before? >> And on that note, uh we're going to leave everybody to go for a walk, take a shower, do whatever they need to do uh to let this question marinate. Um Megan, uh this hour flew by. Um somehow it's so fascinating uh to see where design can go and what can come to design if we uh let go of our limiting beliefs of what this needs to look like or what it what others tell us to look like. So thanks for coming on sort of opening uh our broadening our horizons with your perspectives. >> Thanks for having me. It's been a real pleasure. This conversation really stuck with me for a while, especially the idea of finding deserts, those overlooked spaces where massive profit-driven systems haven't completely taken over yet. It's a great reminder that if a system feels way too big to fight headon, you don't necessarily have to. You can start just by going to finding a quiet corner and start planting seeds there instead. Huge thanks to Megan for coming on and checking our designer ego just a little bit. If you've enjoyed today's conversation, you can do me one big favor. Click the like button on this video and leave a short comment if you haven't done so already. Not to feed the algorithms, but to let me know whether or not we are on the right track by addressing topics like this. Finally, before we part ways, please take a moment to reflect and most of all celebrate that by joining us today, you've directed your attention towards learning and growing as a professional. So, from everyone who you are going to impact through your work, thank you for making the time and taking the commitment. My name is Mark Fontine and I look forward to having you with us again for a new conversation on the service design show. Take care and see you