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Vicious and Virtuous Cycles in Health

Thought Leader: Dave Chokshi
February 23, 2023
Source: JAMA Network
Written by: Dave A. Chokshi

In clinical practice, physicians and other clinicians often come across vicious and virtuous cycles in health. Vicious cycles are negative feedback loops such as when a patient gains weight, causing knee pain, which makes it difficult to exercise, which leads to more weight gain. But there can also be positive feedback loops or virtuous cycles. I think about a patient experiencing homelessness being placed in supportive housing, giving him not only the dignity of having his own space, but also the stability to cut back on drinking alcohol and to care for his diabetes.

Despite this reality, health professionals do not regularly invoke vicious and virtuous cycles in a broader understanding of health. Mental models—simplified ways of figuring out how the world works—are particularly important for creating shared understanding among individuals, communities, and societies. In health, or at least in Western biomedicine, mental models are often linear: systems are organized around episodes of care from evaluation to management. At the population level, health outcomes like hospitalizations are often considered in isolation rather than as part of a broader pattern such as the first tilt into a downward spiral into medical debt or the end of a cascade of unnecessary care. What if mental models of health need to better accommodate vicious and virtuous cycles?

The harmful effects of vicious cycles are often underestimated. Precipitating events like incarceration, job loss, eviction, or violence often set off cycles that are associated with illness, both for the person directly affected, and in many cases for their family members or their community. Similarly, the harms of opioid use disorder extend to the children of people affected by increasing their own risk of developing a substance use disorder or other problems.1

At the societal level, negative feedback loops help to explain some of the most vexing problems from political polarization to profiteering in health care. As people in the US split along party lines, in part because of messaging from certain elected officials and the media, those same officials and news outlets respond by behaving in more polarized ways—further dividing the public. On health care profiteering, Berwick2 has recently written: “The cycle is vicious: unchecked greed concentrates wealth, wealth concentrates political power, and political power blocks constraints on greed.”

Meanwhile, the beneficial effects of virtuous cycles are also underappreciated. Beyond its other health-promoting effects, physical activity leads to better sleep and evidence shows that improved sleep facilitates exercise adherence.3 Public health interventions such as vaccinations, adolescent pregnancy prevention, or lead abatement programs are erroneously seen as one-off benefits, decoupled from economic effects that also have health benefits. For instance, among cohorts of young children, lead poisoning prevention programs are associated with lower health care costs, reduced need for special education, less crime, and higher lifetime earnings.4

Shifting our Mental Models

The COVID-19 pandemic brought forth its own vicious cycles, particularly with respect to negative health and economic effects.5 But it also provided opportunities for interrupting vicious cycles and seeding virtuous ones. In New York City, an unconditional cash transfer program provided $1000 to low-income New Yorkers hospitalized with COVID-19. Whereas hospitalization can often have deleterious consequences for a low-income family due to associated expenses and foregone wages, the cash transfer blunted these effects.

Seventy-nine percent of recipients reported that without the $1000 transfer, they would have had difficulty making ends meet.6 Most importantly, they used the money for food and rent. Other interventions can help support multiple family members in times of duress such as when they need burial assistance or through nurse visiting programs for first-time parents. These programs can help interrupt intergenerational cycles of poverty and illness.

Shifting the worldview around vicious and virtuous cycles also helps connect health with other key sectors, including housing and education. Adolescent health behaviors and mental health are closely tied to educational outcomes and peer network formation in a reinforcing feedback loop. Wong et al7 pointed out how this can lead to school disengagement and dropout, but also how supportive school climates can promote prosocial behaviors that are fundamentally important for health both in adolescence and later in life.

A mental model of catalyzing virtuous cycles could facilitate new avenues for health innovation. Leaders need new ways of implementing solutions for some of the most entrenched challenges such as homelessness, serious mental illness, and the overdose crisis. In my experience as a public health leader, elected officials too often address these issues without recognizing that people are caught in vicious cycles.

For instance, many cities and states have invested in outreach and engagement teams for people experiencing homelessness or suffering from a behavioral health disorder. Although outreach is no doubt important, public officials must pair it with the right destinations for people so they are not just shuttled back and forth among emergency departments, shelters or other temporary facilities, and the streets. In some cases, the destination is an actual physical location, such as supportive housing or an overdose prevention center.8 In other cases, the destination is an intervention that enables a virtuous cycle such as long-acting injectable medication for schizophrenia or buprenorphine for opioid use disorder. Radically lowering access barriers to either type of destination would help reverse these vicious cycles.

In addition, clinicians who bear witness to vicious cycles in patients’ lives may also give voice to the ways that care and compassion beget a virtuous cycle of trust. In an initial clinical encounter, this compassion may mean focusing less on the care gaps, or discrete quality measures prompted by the electronic health record, and more on building rapport so the patient returns for their second visit. Beyond medicine, the focus on relationships is no less important because it is an antidote to disconnection as individuals confront disinformation, distrust, and discrimination. Fostering a collective will through those relationships—a sense of social connection, rather than atomization—may be the ultimate virtuous cycle for good health.

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