Healthy AI?

On Tuesday, this week my colleagues from S23M and I attended the HINZ Conference (Health Informatics New Zealand) as part of Digital Health Week NZ. We conducted an Open Space workshop entitled, “Trust building, thinking, and learning to create an inclusive culture of innovation and collaboration.

First, let me tell you what Health Informatics is? According to Wikipedia: Health Infomatics

is information engineering applied to the field of health care, essentially the management and use of patient health care information. It is a multidisciplinary field[1] that uses health information technology (HIT) to improve health care via any combination of higher quality, higher efficiency (spurring lower cost and thus greater availability), and new opportunities.

As you might imagine in this space there is plenty of frothy talk about innovation, technology and all the buzz words that goes with it i.e. apps., robotics, Internet of Things, medical devices, and of course AI, and machine learning! In fact, one of our colleagues, Dr Hament Pandya was part of a panel workshop, “AI in Health: Beneficial or not?”

For those of you with your bullshit radar up you might not be surprised to know that our workshop on trust, learning, innovation and collaboration was one of the few sessions related to the soft underbelly of technology – us humans! Our company, S23M, consists of a diverse bunch of people who have backgrounds in technological decision making and problem-solving, however, the technology plays second fiddle to our focus on creative collaboration and human-scale knowledge sharing.

Problem Statements

In the HINZ workshop we formed two self-selected working groups to discuss problems that the participants all face in their day to day experience in the NZ healthcare system. Team A focused on change and the barriers to innovation and creativity in general. Team B considered the characteristics of an inclusive innovation and collaboration culture. Listed here are their problem statements.

A. How to initiate change: Analysing constraints and overcoming cultural inertia

  1. Teaching, learning, and change in a capacity constrained environment
  2. Challenging the executive team to understand change and the cultural context needed to support business as usual as well as innovation initiatives
  3. How to get management to open up to bottom-up disruptive change; how to get traction
  4. How to maintain an inclusive culture of innovation in a context where teams have limited technological literacy and where technology is not seen as an important driver of improvements
  5. Managing people’s response to change
    B. Describing the target: Characteristics of an inclusive culture of innovation and collaboration
  6. What is the best environment to nurture innovation and psychological safety
  7. The role of language; avoiding slogans (Deming)
  8. Encouraging a collaborative mind set and culture

I participated in Group A who considered the constraints and cultural inertia that prevent change – or as I saw it – how to overcome bias against creativity? In simple and gross terms we identified the barriers and then discussed suggested solutions to how to initiate change amongst the Executive Leadership teams in healthcare? This was an interesting problem statement in itself because it is usually the senior leadership teams who assume that the barriers to innovation exist amongst the worker bees or users (middle managers, technicians, clinicians, nurses and patients).

The Barriers

  1. Fear of unearthing the truth
  2. Fear of looking stupid
  3. Already receiving biased “information” 
 via the official hierarchical reporting lines
  4. The power differential that weakens 
 the weight of alternative perspectives
  5. Lack of courage, lack of education 
 and genuine experience with co-design
  6. Groupthink
  7. Perceived lack of resources 
 (the logic of “time = money”)

I have focused here on Group A’s 4th barrier to change as it relates directly to psychological safety and creativity in the context of healthcare at the NZ DHBs. Reports of suicides and bullying at the DHBs makes this an urgent issue that Open Spaces can help to solve through creative collaboration.

4. Power Differentials

Healthcare in many countries has a fundamentally hierarchical power structure with 3 silos that have their own power pyramids i.e. administration, clinicians, and nurses. Specifically, we discussed the power differential between those in the administrative ELT (Executive Leadership Team) within NZ DHBs and those stakeholders or initiators of change on the front line. It all depends on the porosity of the layers in organisations and the ability for knowledge to flow freely without regard to org charts, power politics and formal reporting lines. The ability to freely raise issues and come up with suggested improvements depends on the perceived psychological safety of those who are motivated to speak up.

For example, the ability of a nurse to observe a problem or error in the treatment of a patient and feel uninhibited and free to discuss this with a senior clinician who may have overlooked the problem. In her book, The Fearless Organisation: Creating Psychological Safety in the Workplace for Learning, Innovation, and Growth, Amy Edmonson tells an account of a young nurse in a Neonatal Intensive Care Unit and her recent training in the use of a medicine used to promote lung development in high-risk babies. The young female nurse observed how an older male clinician had failed to order a prophylactic surfactant and he had left before she had summoned the courage to ask him why. She had witnessed the specialist berating another nurse the week before for questioning his orders. There was no psychological safety in her work environment and despite there being a high-risk of the death of neonatal twins, in this case, she did not feel safe to speak out.

“Psychological safety was by far the most important of the five key dynamics we found. It’s the underpinning of the other four.” Julia Rozovsky, “The five keys to a successful Google team.”
Edmondson, Amy C.. The Fearless Organization (Kindle Locations 507-509). Wiley. Kindle Edition.

If a young nurse did not feel brave enough to speak out about a potential life-threatening omission then it is hardly surprising that many in NZ DHBs have difficulty making innovative suggestions to those at the top of the administrative pyramid about none life-threatening improvements to other processes. At the HINZ workshop we discussed within our working group small projects that had succeeded and how members of the ELT had noticed and asked how it had happened.

The group concluded that it was important to find “Champions of change (sponsorship) that are equipped with a sense of ownership and a mandate to market the need for change.”

What we have noticed at S23M with other clients and in other industries is that before an organisation can begin to start engaging more stakeholders in innovation, than just a few high up the chain of command, they must first establish psychological safety so those close to the action can also offer up ideas. The ability to start establishing these safe zones is dependent on trust that is hard-won and easily lost. S23M offers Open Space workshops that allow neurodiverse individuals to come together to freely exchange knowledge and come to a mutually agreed understanding of the problems before them.

Hierarchies are significant barriers to the free flow of knowledge and sometimes even raw information. Health informatics has a bias towards explicit knowledge collection, storage and retrieval. This is the easy side of information technology and is the overwhelming focus of Big Data and data analytics. Health informatics encourages technological solutions that favour explicit data records over knowledge which stakeholders find is difficult to articulate. Before we go on it is important to define the difference between the two words information and knowledge. According to the Oxford dictionary:

information – noun:

1)  facts provided or learned about something or someone: a vital piece of information.

2) what is conveyed or represented by a particular arrangement or sequence of things: genetically transmitted information. • Computing data as processed, stored, or transmitted by a computer. • (in information theory) a mathematical quantity expressing the probability of occurrence of a particular sequence of symbols, impulses, etc., as against that of alternative sequences. 


late Middle English (also in the sense ‘formation of the mind, teaching’), via Old French from Latin informatio(n-), from the verb informare (see inform).

knowledge – noun

1. facts, information, and skills acquired through experience or education; the theoretical or practical understanding of a subject: a thirst for knowledge | her considerable knowledge of antiques. • the sum of what is known: the transmission of knowledge. • information held on a computer system. • Philosophy true, justified belief; certain understanding, as opposed to opinion. 

2. awareness or familiarity gained by experience of a fact or situation: the programme had been developed without his knowledge | he denied all knowledge of the incidents

3. archaic sexual intercourse. 


Middle English (originally as a verb in the sense ‘acknowledge, recognize’, later as a noun): from an Old English compound based on cnāwan (see know).

You may wonder why I have highlighted the computer definitions here? The reason is that at the root of a successful plan to change complex social organisations such as DHBs and the healthcare system, in general, we have to emphasise not the human-machine-human communication chain but the human-human understanding which precedes any transfer of health informatics or raw data. Simply put, information can be regarded as explicit data that is easily recorded in the form of databases; written documents; images; recordings etc.

What our working group discussed was the intransigence of DHBs and the disconnect between those in positions of power and those who are in touch with problems first hand. Their tacit knowledge of the problems offers real insights into possible solutions and can contribute to creative collaboration leading to innovations. The co-design of those solutions can engage all stakeholders and thereby testing every aspect and step in the user’s journey.

Tacit knowledge, in contrast to information, is the contextual narrative or justified belief that gives the information structure based on the individual’s experience and learning. Explicit knowledge can be recorded and is one step removed from the information. In contrast, tacit or hidden knowledge, also known as deep smarts, is what Michael Polanyi explained as ‘what you know but cannot say’ and is the basis of all knowledge. In other words, tacit knowledge comes from years of experience, observation, and practice. It is a full sensory collection of interconnected pieces of data and information that defies simple algorithms and protocols that a computer may process. Tacit knowledge and domain expertise allow humans to solve wicked problems and abstract knowledge from experiential smarts and apply them to novel circumstances. This is true intelligence and is a million miles away from neural nets, machine learning, and AI.

It is common for unchallenged bias to be buried beneath mountains of Big Data and for algorithms designed to simplify information and meaning to never reveal the confirmation bias of the programmers who wrote the algorithm in the first place. The AI researcher and academic, Robert Elliott Smith, warns of these algorithmic biases that are being built into employment, medicine, policing, and even dating and financial services. In his book, Rage Inside the Machine: The prejudice of algorithms and how to top the Internet making bigots of us all. He wrote:

“One example is Google’s algorithmic job ad placement, which offers higher paying jobs to men than to women. Even more disturbing are ‘predictive policing’ algorithms that are now being used in law enforcement to determine areas where crime is likely to occur and ‘re-offending risk’ algorithms now being used as a part of sentencing. In both those cases outcomes have been shown to have a severe bias against people of colour. However, perhaps the most concerning phenomena is the influence of algorithms on people’s online communities, an arena where the hopeful vision of a utopian Internet has taken a seriously dystopian turn.”
Smith, Robert Elliott. Rage Inside the Machine (p. 11). Bloomsbury Publishing. Kindle Edition.

Smith, an AI insider, warns us that there has been a rapid colonisation of language surrounding human cognitive functions as computerisation and digitisation gives the impression that the computer is analogous to the human brain and that our cognition works almost identically to that of a computer. AI has colonised the word intelligence as statistical analysis of large data sets confirm assumptions based on the spurious model of IQ and the distribution of a bell curve.

The current fashion of AI and the misnomer of machine learning is misleading medical researchers and policymakers into thinking they are approaching a future when machines can automate diagnosis and make instantaneous decisions about our health based on questionable assumptions around the cost-benefit analysis. Machines cannot learn when they can not experience emotions or make decisions based on human understanding and senses. If we do not heed these warnings we will perpetuate unhealthy AIs and misanthropic bedside manners.

Food for Thought part 2

You can read Part 1 Food for Thought here.

Two days before the Zero Carbon Bill passed into law a Guardian article stated: “The world’s people face “untold suffering due to the climate crisis” unless there are major transformations to global society, according to a stark warning from more than 11,000 scientists.”

“We declare clearly and unequivocally that planet Earth is facing a climate emergency,” it states. “To secure a sustainable future, we must change how we live. [This] entails major transformations in the ways our global society functions and interacts with natural ecosystems.”

There is no time to lose, the scientists say: “The climate crisis has arrived and is accelerating faster than most scientists expected. It is more severe than anticipated, threatening natural ecosystems and the fate of humanity.”

Two days later on the 7th Nov. 2019, the New Zealand government passed into law the Zero Carbon Bill, more formally known as the Climate Change Response Amendment Bill. It passed by an almost unanimous vote of 119 to 120 MPs. According to Spinoff, James Shaw the leader of Labour’s coalition partner, The Green Party, and Climate Change Minister had this to say in parliament.

“Some things are too big for politics, and the biggest of them all is climate change. The intent of the Zero Carbon Bill was, is, and always should be to elevate climate change policy beyond petty politics and partisanship, to transcend and transform a problem so wicked and so stuck that we have made virtually no progress on it in the 30 years we have been aware of it, in spite of the very best efforts of many, many good people. Climate change policy has been a political football kicked up and down the field, and frequently into touch, by changes of government and, in fact, changes within governments. This unstable policy environment has prevented progress and sent contradictory signals, which has stymied decisive action until this, the 11th hour and 55th minute before midnight.”

It is undoubtedly a significant achievement and milestone but before we congratulate ourselves it should still provide us with Food for Thought. Since 2009 the National government and the farming lobby successfully delayed action on agricultural GHG emissions for ten years. The new coalition government of the Greens, Labour, and NZ First promised to do something about agriculture and climate change. However, the passing of the Zero Carbon Bill has come to mean there is zero carbon consequences for agricultural GHG emissions as they are awarded a hiatus of another 2-5 years. This is despite the fact that the sector contributes the largest single percentage of New Zealand’s GHGs @ 48%, and the next closest is Transport @ a distant 20%.

The political compromise in the Zero Carbon Bill sets the methane interim requirement to reduce emissions to 10% below 2017 levels by 2030, and reduce gross emissions of biogenic methane within the range of 24% to 47% below 2017 levels by 2050; all other GHGs including nitrous oxide would have a net emission reduction to zero by 2050. According to MyClimate “Net zero emission means that all man-​made greenhouse gas emissions must be removed from the atmosphere through reduction measures, thus reducing the Earth’s net climate balance, after removal via natural and artificial sink to zero. This way humankind would be carbon neutral and global temperature would stabilise.”

When the government is asked why it has not gone further on setting more aggressive targets for methane they reply because methane (they don’t mention nitrous oxide) is a short lived GHG and within 50 years it disappears and so the amount in the atmosphere will have stabilised. However, that only applies if methane levels no longer continue to rise! It also ignores the fact that methane converts to CO2 when it degrades so it contributes to the cumulative heating caused by carbon dioxide.

The Interim Climate Change Committee report makes an important point. “The warming caused by methane is not as short-lived. The warming today will still be felt several centuries from now as the climate absorbs and redistributes the heat trapped while the methane is in the atmosphere.”

To stress this point methane may only have an approximate 12-year half-life (meaning within 12 years there will be half the original amount and in 24 years a quarter etc.), but within the first 12 years it has a Global Warming Potential (GWP) of 80-104 times that of carbon dioxide and in 100 years a GWP of between 28-32 times, and remember that CO2 is not nothing but is causing most of the global heating of the planet.

A Catastrophic Update

In October 2018 the IPCC shocked the world with it’s updated report for policy makers. “One of the key messages that comes out very strongly from this report is that we are already seeing the consequences of 1°C of global warming through more extreme weather, rising sea levels and diminishing Arctic sea ice, among other changes,” said Panmao Zhai, Co-Chair of IPCC Working Group I.”

The report stressed the urgency of action to reduce all GHGs and that included land use. “The report finds that limiting global warming to 1.5°C would require “rapid and far-reaching” transitions in land, energy, industry, buildings, transport, and cities. Global net human-caused emissions of carbon dioxide (CO2) would need to fall by about 45 percent from 2010 levels by 2030, reaching ‘net zero’ around 2050. This means that any remaining emissions would need to be balanced by removing CO2 from the air.”

Every little bit counts and that certainly means a reduction in powerful GHGs that come from our food production such as methane, and nitrous oxide. This is all a question of time and urgency, therefore, it is hard to reconcile kicking agricultural emissions down the road when immediate action will have immediate results at a time when it is most urgent and needed. According to New Zealand’s Interim Climate Change Committee “One thing is clear – New Zealand must take action to reduce agricultural methane and nitrous oxide because these gases form such a large proportion of our national greenhouse gas profile. There is often less focus put on nitrous oxide – but this is a potent and long- lived gas and must be a part of efforts to achieve a net zero target.

The major cause of these GHGs is our farming systems that includes monocultural animal husbandry and cropping, intensive water use in dairy; heavy fertilizer use; water quality degradation; and concentrated effluent with methane and nitrous oxide consequences. The ICCC stressed that these GHGs cannot be exempt and “Whatever the target relating to methane ends up being, we know that we need to reduce emissions. It is time to get on with the job…Continued delay is not an option. It is critical that we get started now.” (2018)

The IPCC is warning that even limiting global warming to 1.5° C will cause catastrophic death of coral reefs, forest fires; and sea level rises that will inundate low lying islands and coastal communities. The impact of just 1° C of heating has already resulted in the death of coral; ice cap melting; sea-level rise; extreme weather; droughts; heat death; increased poverty and starvation; species extinction threats and mass migration by climate refugees.

The Independent reported on the secretive planning by Shell and BP.

“Oil giants Shell and BP are planning for global temperatures to rise as much as 5°C by the middle of the century. The level is more than double the upper limit committed to by most countries in the world under the Paris Climate Agreement, which both companies publicly support.”

“The discrepancy demonstrates that the companies are keeping shareholders in the dark about the risks posed to their businesses by climate change, according to two new reports published by investment campaign group Share Action. Many climate scientists say that a temperature rise of 5°C would be catastrophic for the planet.”

New Zealand may only contribute 0.17% to CO2 equivalent emissions, however, most of our citizens expect to make a contribution to climate change mitigation and the improvement of the stewardship of our environment. New Zealand is, however, surprisingly in the top 5 countries of total GHG emissions per capita in the OECD (2014).

  1. Australia – 22.4 tonnes per capita
  2. USA – 21.55 tonnes per capita
  3. Canada – 20.51 tonnes per capita
  4. Luxembourg – 19.59 tonnes per capita
  5. New Zealand – 17.98 tonnes per capita

Source: OECD –

Catastrophic Carbon Bombs

Catastrophe has already hit as the job is made much harder by a perfect feedback loop. Cattle ranchers and farmers have been given a green light by the Brazilian government to increase the slashing and burning of the Amazon to make way for cattle grazing. As a result not only does the Earth lose 3 football fields a minute of oxygen-producing forest but the carbon that was sequestered in the trees is released in a gaseous explosion of carbon dioxide, and methane from the biomass. What is more, deforestation leads to lower rainfalls and places like the Amazon may reach a tipping point where the ecosystem will no longer support regrowth.

New South Wales in Australia is today bracing itself for fires that are officially designated a ‘catastrophic fire rating’. One observer who witnessed the dark red and smokey skies called the scene apocalyptic.

As I have pointed out in my book Worldbending: a survivor’s guide: “We live in apocalyptic times, not in any religious sense, but rather of our own making because we have physically and irretrievably damaged our world. John Hall explains that our apocalyptic outlook is not new, it is a belief that has a long history. In our past, the coming of the apocalypse may have caused us to look to the skies for the signs of the end, but in recorded history, despite catastrophic natural disasters, our planet, and our species have survived. Hall explains the historic meaning of the apocalypse is rather than the actual end of the world, the apocalypse is typically “the end of the world as we know it,” an extreme social and cultural disjuncture in which dramatic events reshape the relations of many individuals at once to history.” (Hall, John R.. Apocalypse: From Antiquity to the Empire of Modernity (Kindle Locations 182-185). Wiley. Kindle Edition).

Some have questioned the Australian government’s commitment to climate change mitigation. They signed a target of 26-28% reductions in emissions by 2030 which some have criticised as insufficient for the world’s largest coal exporter. The UN has reported that Australia was not on track to meet its commitment. According to the BBC, the PM of Australia, “Mr Morrison told the UN last year that Australia was doing its bit to address climate change, and “balancing our global responsibilities with sensible and practical policies to secure our environmental and our economic future”. However, the Deputy PM referred to those who reference the role of anthropogenic global warming in the NSW fires the ‘ravings of inner city lunatics’!

And there you have it the arguments given by just about every politician worldwide, and repeated again in New Zealand. Our political system suffers from an addiction to ‘growth economics’ and GDP modelling that even calculates disaster recovery as a positive uplift in GDP. And yet, it is growth-economics based on fossil fuels and faster consumption of resources that has contributed to the parlous state we are currently in.

The Australian fires are a catastrophic lesson for us here in New Zealand. Fires will follow the droughts brought on by global warming and are becoming increasingly the new normal from California, to Siberia, Greenland and New Zealand. Recent fires in the US were caused by powerlines and resulted in massive power outages as the power was cut to prevent more fires. This resulted in the bankruptcy of the utility giant, Pacific Gas & Electric, and is one example of the unintended and unexpected consequences of the Anthropocene and global heating. Another example is the Dunedin fires that could cause three-quarters of the city’s main water supply to be unfit for human consumption due to ash and toxic fire retardant. What this indicates is the systemic fragility of our infrastructure and our lack of imagination when it comes to planning for what promises to be a very uncertain future. This is the theme of Worldbending and why I focus on creativity and looking at the world through new lenses. Our survival is contingent on our ability to adapt and change to unprecedented scenarios.

Farmers for Climate Action

As climate change is now happening right in their back yard some conservative Australian farmers have become climate change activists. Farmers for Climate Action are a lobby group that wants action from a government headed by climate change deniers and they reached out to their own farming network to find out where farmer’s stand on climate change? 80% of 1,300 farmers expressed their concern about climate change. Another farmer pressure group against coal miners and gas drillers, Lock the Gate, which formed in 2010, ‘felt they had no legal rights, so they decided to lock their gates to coal and gas companies’ from entering their properties.

New Zealand politicians and co-operative agriculture leaders such as Federated Farmers could well find themselves out of step with more and more farmers who are suffering from droughts, water access, crop decline and stressed and dying animals due to heat exhaustion.

Increasingly consumers are moving away from poor farm practices that exacerbate global heating through GHGs emissions and environmental pollution from effluent and fertilizer runoff. While there has been a huge increase in customers in Asian markets I remain sceptical about the long term prospects for dairy and even the possibility of future aversion to dairy due to cultural and environmental perceptions. There was a recent announcement that America’s largest milk producer, Deans, has filed for bankruptcy due to declining consumer demand for milk, and as reported by and animal-welfare concerns have also contributed, as more shoppers seek out non-dairy alternatives.

Oat milk, for example, saw US sales rise 636 per cent to more than US$52 million (NZ$82 million) over the past year, according to Nielsen data. Sales of cow’s milk dropped 2.4 per cent in that same time frame.

Political and economic excuses for doing little with respect to agricultural GHGs are shortsighted as it is quite clear we have a decade or less to avert disaster, and yet the 2 bad boys, methane and nitrous oxide, that range from 80 to 300 times more potent at heating the atmosphere than carbon dioxide, are left alone for another 5 years by political compromise. Both methane and nitrous oxide could in the near future come under the microscope as human activities that increase the natural baseline of these GHGs become more critical. There are 50 gigatons of methane trapped in the permafrost in the Arctic that could explode into the atmosphere as the ice continues to melt at a faster rate than expected. What that will mean is that methane will become a significant problem for global heating. Nitrous oxide has also been identified as more important than previously thought. At the end of 2012, it was calculated that nitrous oxide and methane may contribute as much as 25% of California’s GHG emissions. The point is that these very potent GHGs that have been downplayed by the Zero Carbon Bill may suddenly headline and that could force sudden change in the IPCC reporting and subsequent advice from our own Climate Change Committee. The result could be shock legislation and more extreme pain for farmers. Delay in dealing with changes to New Zealand’s farming system will simply mean that more needs to be done in less time – in other words, the crisis will become more extreme.

In a statement published in the journal of BioScience, (and reported in the Guardian), on the 40th anniversary of the first world climate conference, 11,000 scientists from 153 nations endorsed a statement written by dozens of scientists. The lead author, Prof William Ripple of Oregon State University said he was motivated to write it because of the extreme weather he had observed. “The scientists say the urgent changes needed include ending population growth, leaving fossil fuels in the ground, halting forest destruction and slashing meat-eating.” Why we must be focused on the total picture and not just carbon dioxide is that we simply do not know enough about Earth System Science and that we could see a sudden phase change forced by a relatively small addition of methane, nitrous oxide, hydrofluorocarbons, carbon dioxide or all of the above interacting with the hydrosphere, biosphere, atmosphere and lithosphere. As the scientists pointed out “Despite 40 years of global climate negotiations, with few exceptions, we have largely failed to address this predicament. Especially worrisome are potential irreversible climate tipping points. These climate chain reactions could cause significant disruptions to ecosystems, society, and economies, potentially making large areas of Earth uninhabitable.” A domino effect could take any hope of mitigation out of hands at any point.

We have to move on from the political election cycle and think about what we can personally do – lobby government, the Federated Farmers, and stop eating dairy and meat. This may sound radical but time is literally running out and just because we like to eat certain food and consume an unsustainable lifestyle. Food is, after all, a cultural ritual and the one certainty we have about the future is that our culture is likely to change rapidly and without any sense of predictability. We are about to all become firefighters if we run out of water, oxygen, and a cool summer breeze. Worldbending will hopefully give you some further food for thought.