CHAPTER 9 FASD and PROBLEM INTRACTABILITY
9.8. FASD AND FRAGMENTED PROBLEM MANAGEMENT
In applying the ten characteristics of wicked problems, the archival records and interview data provide evidence that FASD is a complex and intractable problem, and that despite attempts to address the problem, little headway has been made. There is no definitive formulation of the problem: information on FASD is vast and yet incomplete, with many questions unresolved. In this research the diversity of responses in the interview data and the scope of key events in the stories of FASD in three countries is open-ended, and this says much about the problem context, endorsed by the claim by Rittel and Webber (1973, p. 161) that the ‘formulation of a wicked problem is the problem!’ If the problem is the absence of a definitive formulation, then the conclusion follows that possible solutions cannot be described or tested and will have unexpected consequences.
The shift in pattern is demonstrated in Figure 2 below, an adaptation of Roberts’ (2000, p. 3) ‘Coping Strategies to Deal with Wicked Problems’. Depending on which expansion strategies are used by originator groups in the initiation stage, different groups enter the problem system. Each has a
different frame of reference which determines their unique and preferred definition of the problem and its possible solutions. The greater the disparity in definitions, the more removed from the initial demands the engagement groups may be. Rather than being understood as a multifaceted problem with many stakeholders representing diverse contexts, the focus of policy shifts, resulting in a fragmented approach.
One of the key challenges to consistently emerge from the research concerns the diagnosis of the problem. There is convincing data to support the notion that the measurable part of the spectrum of fetal alcohol harms – Fetal Alcohol Syndrome – is given priority over other aspects of the condition. A manifest consequence is the inequity experienced by those directly affected by FASD and their
families. While the initiators have made demands for public policy attention to FASD prevention and services for those living with the problem, current approaches still favour medical models to guide government policy. Researchers receive the bulk of government funding, and have used it to focus on
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marginalised population groups and communities in all three countries and to manage otherstakeholders.
Figure 2 FASD problem system: an amalgamation of network approaches to wicked problems and the stages within patterns of public policy agenda-building
This has led to authoritative solutions and over four decades has resulted in limited success in addressing the problem. For governments, this has served to ensure the problem of FASD appears on formal policy agendas in the United States, Canada and Australia, and a shift from an ‘outside’
government to and an ‘inside’ government-initiated pattern of public policy agenda building which has suppressed the problem from the public agenda. Adapted from Figure 1, Figure 2 below presents FASD as a wicked problem, visualised as moving through the four phases of public policy agenda building: initiation, specification, expansion and entrance.
The presence of multiple stakeholders with diverse frames of reference, even within the same attention groups, means that controlling the level of conflict in dealing with FASD is central to issue
management for governments. Conflict has, and will, increase exponentially as more stakeholders engage, but may counter problem fragmentation; the invocation of authoritative strategies follows. Roberts (2000) identified problems as simple, complex and wicked; each is defined by a
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simple problem and by the policy entrance phase is managed with authoritative strategies, proposed in this research to be best suited to the government policy approach: the continued search for scientific and evidence based policy, a problem best guided by medical ‘experts’, and responsibility placed on the individual drinker.The problem of FASD is, in all three countries, contained within a health paradigm which by default is subject to scientific rigour. Unlike other health issues – autism for example –fault is attributed. While autism has a spectrum of conditions and is dependent on clinical diagnosis, it does not target mothers as the source of prevention; nor is it attributed to use of a commodity like alcohol. The incidence of autism is not greater in particular population groups. To recognise FASD as a similar social issue is a conundrum for governments, as policy-making would then require considering FASD in the context of bigger problems like the culture of alcohol use; and commercial and economic interests would further add to the problem’s complexity. The fracturing of the FASD problem into various parts is a
consequence of the zealous reliance on empirical evidence as fundamental to locating a prevention solution, even if in the meantime the impact for individuals living with unrecognised FASD and the burden on parents and families is tragic and ignored.
When a fragmented problem is understood to represent multiple frames of reference, the interests of disparate power bases create a breakdown of the issue into parts which may have single solutions and are manageable as ‘rational–technical approaches’ (Head & Alford 2008). As Roberts (2000, pp. 14– 15) remarks, it ‘seems more productive to be mindful of “taming” wicked problems by a handover to experts or power base for definition and solutions’. If no one is in ‘control … then it is unlikely that the experts and leaders will be able to act unilaterally to define the problems and their solutions’:
The power of those who can articulate and mobilise their preferred definition and solutions has meant a focus on a simple problem model described as a ‘Type 1’ problem (Roberts 2000, p. 1).
Such simple problem solutions assume ‘consensus’ in both problem definition and solution, and a reliance on authoritative types of coping strategies, a reliance on ‘more professional and specialized experts who are assumed to have relevant skills limited in the general public’ (Roberts 2000, p. 1). The consequences are restrictive ‘options for resolution within the narrow scope of professional expertise’, limited opportunities for ‘important issues and considerations’ to be contemplated, and ‘lost
opportunity for learning’ (p. 5). Quantitative approaches to prevention as authoritative solutions are measurable and add to the evidence base. Such approaches obscure the need of families struggling to support those living with the condition in the absence of support services.
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9.9.
SUMMARY
This analysis first attends to the importance of advocacy, leadership and collaboration in bringing the problem of FASD to the attention of policymakers and maintaining policy interest. Differences appear in the informal or formal structure of collaborations and the manner in which respective polities respond. In the United States the problem was first raised in the health science research arena and now falls within the domain of national health institutions which are mandated to report on progress to Congress. Canada differed on two fronts. The collaborative effort came from an amalgamation of diverse representatives who worked with parents, and from the outset strategies acknowledged the challenges ahead and determined that change would happen at a local level with guidance. Key authorities included those who promoted gender as a central feature in prevention planning. In Australia, initial proponents were parents, and little traction was gained until researchers and academics entered the arena.
The interview data reveal a trend towards reliance on the medical profession, recognising consistency in assessment criteria and diagnosis as the key to greater awareness in the future and in securing better outcomes for those living with FASD. What is also revealed in the stories and interviews is
government reliance on the technical authority of key medical professionals and on evidence-based research. There was criticism from interviewees of the failure of the medical profession to inform and educate, to diagnose, facilitate and augment individual case management, and to collect data and participate in research.
While the current pattern is retained, stakeholder needs are compromised. This is not so much of an issue for those in the United States. While American interview participants spoke of defining the ‘D’ in FASD, increased resources and commensurate funding, Canadian focused on better outcomes for population groups: women, children, juvenile and adult corrective services clients and viewed this as attainable with improved collaboration with parents and better service delivery systems. For
Australians, demands were dependent on the individual’s stake in the matter, and were often connected with personal experience. Researchers and medical professionals spoke of the need for continued research, birth parents on their often less than favourable encounters with the medical profession. For carers, the pressing issue was improved understanding, with knowledge of how FASD affects cognition, development and needs across the lifespan.
Through the stories and interviewee data, many stakeholder groups were shown at work. Each
championed alternative solutions and competed to frame ‘the problem’ in a way that connected to their preferred solution. FASD is about unequal power. As Atwood et al. note, it is more often the case that ‘preventive action seems to lag behind the state of public health science’ (1997, p.1603).
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Similarities across the three countries are greater than differences. FASD continues to be framed as a health issue, but when the impact on people’s lives is considered across the lifespan, it is equally a social problem. The technical details concerning the development of brain and body structure means the scientific elite has been sanctioned by governments to guide management of the multiple facets of the problem. This denies opportunities to engage with the diverse knowledge bases that couldcontribute to fuller, improved management of the problem. The harms caused by alcohol are immense and the cost in economic, health and social terms are profound; FASD as a wicked problem is also a political problem. How does a government explain the toxicity of a substance on fetal development and the lifetime implications of FASD to an electorate that loves alcohol? Is this the essence of the FASD problem and its intractability?
There is awareness of the teratogenicity of alcohol and the risk from any alcohol but no definitive definition of the minimal amount that will cause fetal harm. There is advanced knowledge and understanding of how the brain is particularly vulnerable to fetal alcohol exposure and how
impairments impact on individuals across the lifespan. There is also sound knowledge that FASD is not just a health system issue in that the individual living with FASD often has complex needs which translate to financial dependency, unemployment, family breakdown and social isolation,
homelessness, alcohol and other drugs dependencies, incarceration and mental health problems. Hence, there is acceptance that FASD as a problem crosses multiple systems with high economic and intangible costs. This occurs in social and cultural contexts that not only promote alcohol consumption but are reflected in policy positions which deny the breadth of the problem by marginalising the problem as belonging to discrete population groups – high-risk drinking women, Aboriginal and First Nation communities. Consequently, the stakeholder group is expansive and growing – medical and allied health professionals, clinical and non-clinical researchers, parents (birth, adoptive and foster), justice, non-government and government organisations. FASD prevention (raising public awareness, targeting high populations at risk, and targeted intervention or treatment for those who already live with a condition) separates the girl/woman who is drinking and may be at risk for an unplanned pregnancy, who consumes alcohol in pregnancy, from those who are recognised as at-risk or have a diagnosis of a FASD.