A game model based on the Prisoner’s Dilemma and Rock, Paper, Scissors shows how longstanding inequality emerged from the choices made by the region’s health system and Montagnard community. Collaboration is costly but competition and avoidance are worse.
Payoff Grid for the Refugee Health Disparities Game. The payoffs were calculated to produce the kinds of conditions we observe today. Collaborative health solutions require extended contact between parties, a common language and a significant stake put down by each side, loudly announced and for all to see.
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Refugee Health Disparities Game Rules
1. Game consists of two players.
2. One player represents the Montagnard Community, the other the Regional Health System.
3. Each round the players flash one, two, or three fingers corresponding to Collaboration, Competition or Avoidance.
4. Players consult the Game Payoff Grid to see the results.
5. Victory Conditions: Whoever reaches 50 points is the winner.
Player Strategies
Collaboration strategy Players continue to win points as long as they don’t switch strategies.
Competition strategy Players attempt to outguess the other. If both choose competition it leads to stalemate or loss.
Avoidance strategy Players force loss to the other side. The other side can retaliate by choosing the same strategy.
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A GAME MODEL CAN HELP EXPLAIN OUTCOMES created by the interaction of two parties in the absence of complete information. It is also an effective way of demonstrating the psychology of players as they make decisions and see the results. We have some hard data and many stories describing interactions between the Montagnard community and the region’s health establishment. Few of them are positive and most conform to the general plight of the poor compounded by the special circumstances refugees face years after their contact with resettlement agencies end. But it is precisely these special circumstances that suggest that seemingly intractable health problems can be fixed. The Montagnard community is a unique subset of the Asian-American population, refugee population and local Triad population. Montagnards overwhelmingly make their home here in the Piedmont, with the majority in the Triad. Major community celebrations, events, and meetings regularly take place within Guilford County or a few miles outside of the county. Thus it is safe to conclude that the majority of Montagnard health issues that reach the attention of Americans come almost exclusively through members of the Guilford Community Care Network, a consortium of regional health providers whose stated mission is to address health disparities. Historically, area health inequality focused on black-white relations and systemic racism. New census data suggests it is time for the region’s health system to respond to the unmet needs of new populations, people of color and ethnic diversity, refugees and immigrants whose growing numbers will continue to impact every aspect of Triad life.
If conditions permitted we would gather more information, but this cuts to the heart of the Montagnard refugee experience. After some 25 years since their arrival, the American community at large seems to have concluded that sustained outreach is too hard and that costs exceed benefits (limited to what is referred to as “drive-by research”, according to one academic). Our work has shown that’s wrong and we’ve demonstrated effective ways to reach the community through culture, art, history, education, language, family life, business and neighborhoods. Our work is cost effective — cheap. Our experiences with the community have been positive — members were eager to talk, to understand how to best take care of themselves and their children, and to take action. We’ve identified its health advocates, community workers, and medical experts —former physicians and US trained professionals — within a short space of time. We introduced Montagnard former physicians to American physicians at Moses Cone’s AHEC (Area Health Education Center). Having borne the costs of poor health for decades, the Montagnard community is ready to collaborate. Convincing a scattered collection of resettlement agencies, public institutions, government agencies, nonprofits, etc becomes a project unto itself — even while Montagnard health problems continue to pile up and the local economy remains stuck with high unemployment numbers. The stakes couldn’t be higher, as Moses Cone Health System CEO Tim Rice has recently stated (News-Record, Sunday, January 15, 2012).
Game models are one way out of this cul de sac because they can be constructed from existing information. Games are about choices, how conditions influence players’ choices, how players' choices modify conditions that in turn influence choices. Through the transformation of real-life scenarios into a game structure defined by rules, goals and players’ strategies, we can understand how certain choices and their results can generate the kind of real-life, deeply troubling stories we are told daily by community health workers and Montagnard families.
To explain the Montagnard predicament I have combined two games: the Prisoner’s Dilemma and Rock, Paper, Scissors:
Prisoner’s DilemmaCollaboration means each side risks resources to reach its goal. In real life, the Montagnard community goal is good health. The American goal is cost savings (or as one former Montagnard doctor described it, “cheap and fast”). If both choose to collaborate, they win a modest number of points. As in real life, collaboration is hard and expensive and its gains are sometimes slow. But they pay off in the long run.
This is a classic problem in which players anticipate the other's decision. Their rational choice is to trust and collaborate; each player’s temptation is to gamble and take advantage of the opposing player's rational strategy. The choices are gridded on a Payoff Grid (see above).
Rock, Paper, Scissors
This childhood game gives each player three choices. In this adaptation, I rename the choices Collaboration, Competition, Avoidance (elaboration on these terms are found below) and introduce new results featured on a Payoff Grid (above)
Instances of clear collaboration by American and Montagnard sides seem rare. The Congregational Nurse program funded by Moses Cone is one example. Through this program, one nurse is assigned to one of the Montagnard churches for three hours per week. The relationship works well, but the Montagnard population was 5,000 when the program began and is probably approaching 10,000 now.
The question arises if collaboration is the way forward, then why don’t both sides adopt it? One answer might be that to rise to a collaborative level, Montagnards must master English. Mastery is influenced by prior education and is a heavy cost in time for the individual. Conversely, perhaps one or two Americans speak any Jarai, Koho, etc for the same reasons. When it comes to collaboration, it seems English mastery takes too long and Americans expect Montagnards to pay for the services of interpreters and translators in most health communications. Other values Montagnards bring to the table aren’t recognized as valid collateral, including social capital or even prior medical training. As long as Americans believe they hold all the cards, collaboration will be rare.
Competition means one side tries to take advantage of the other. “Competition” seems a harsh term to describe American and Montagnard interaction. It also seems inaccurate — why would Americans compete against Montagnards when they are so clearly advantaged? I think this is best understood when we realize sides compete indirectly against one another, not against each other in the personal sense, but against the other’s goals.
Not free
Free dental care offered over the past few years shows the problem clearly. Hundreds wait in long lines over a two-day period, hoping for assistance. Participants believe they are competing against one another to get to the event early, endure the cold, bring proper documentation and proof of eligibility, stand in line for hours without food and bathrooms, etc. If they fail to get service, they are to blame. But the reality is simpler: Too many individuals are competing for limited resources.
Participants at these events are told services are free but they are not. The hundreds of people who did not receive dental care represent thousands of man hours wasted on lines that achieved nothing. Only a system rich in poor people can afford such lavish inefficiency. A lot of refugee resettlement is premised on this kind of “false game play”, doling out limited resources that carry stiff conditions that often seem to outweigh their benefits. Charity is guaranteed to generate plenty of losers and the Game Payoff Grid in the Refugee Health Disparities Game seeks to reflect that.
Patient non-compliance is the most direct evidence of competition in which individual Montagnards thwart the region’s health system and its goal of reducing costs while improving outcomes by failing to follow courses of therapy, failing to show up for appointments or understand physicians’ instructions (due to poor interpretation, low education) and so on.
Does the Montagnard community compete against the regional health system? In limited ways, Montagnard efforts to set up separate institutions such as health clinics, cultural centers, ethnic community based organizations, etc could be analyzed as deliberate efforts to compete with American agencies and organizations with similar missions — for very good reasons, it turns out. In practical terms they provide an excuse for Americans to exit the scene and minimize support to token levels. In real life, there are few forums for Americans and Montagnards to discuss such matters. For example, only recently has the City of Greensboro expressed an interest in talking to refugee- and immigrant-owned businesses.
Avoidance means one side breaks contact and spoils the other’s gains. Avoiders don’t play fair, they seek to inflict damage to the other side, even when it hurts themselves. In real-life most Montagnards do not actively avoid Americans, but after 25 years they have constructed lives that often minimize contact. Conversely, American interaction is highly circumscribed — limited to public education, emergency response, ESOL classes, caseworker appointments, etc. After 25 years, the Montagnard community remains mostly invisible. The value of our work with the lay community health team lies in the regular contacts with its everyday community members. If they exhibit “avoidance” behavior, it might be caused by so many disappointing experiences like “free” dental clinics and other false promises. But mutual avoidance is a recipe for health disaster. The well eventually get sick, the sick get sicker. Today American-Montagnard relations appear at a low. In just a few years, we’ve heard more than a few reports of unexplained deaths. Even the recent triple homicide seems to have been forgotten by Americans. One American church assisting a family connected with the murders seemed oblivious at the time. Their main effort before the killings and afterward were directed at putting a distance between themselves and the family, which they regarded as a drain on their resources. The longer the regional health system ignores the Montagnard community, the greater the chances it will face a steady increase of emergency visits, severely advanced illnesses, and uncollectible bills.
Conclusion
In real life and in the game model, collaboration is expensive and depends on trust and a level playing field. It is the only way forward for both sides, but opportunities for long term gains are likely to be sacrificed for the moment. Stalemate and loss— failure to acculturate, break social, language and cultural isolation — trend to greater expense and more loss for both sides. American doctors should not be happy with the desultory results after Montagnard patients leave their examination rooms. Very sick individuals who have little to no history of regular health care showing up at Moses Cones’ ER create huge bills that can’t be paid. Already CEO Tim Rice has stated this increasing trend. But in our conversations, some Montagnards don’t even bother with emergency room visits — they are already in debt with past medical bills and stay away from professional help. The national debate about health care reform is part of this discussion, but in the case of the Montagnard community, there are options both sides can agree to take to insure the survival of both. Competition and avoidance are not direct strategies pursued by either side in real life, but the negative effects generated by a bundle of choices and conditions made by both sides are real and cry out for attention.
(See Part 2: Refugee Health Disparities Game: Prospect Theory & Stress)
(See Part 3: Avoiding the Prisoner’s Dilemma)
