Bottom-up Communication

Pattern number within this pattern set: 
Jenny Epstein

Methods of communicating can be looked at as a continuum. At one end there is “expert” opinion (top down) or an authoritative body giving advice. At the other end, there is information that empowers people and gets people to think independently and creatively (bottom up). The medical establishment in the US follows the expert opinion model. Most Public Health information reinforces this same model. Health information acts on the public, not with the public. Top down communication re-enforces dependency on “expert” medical opinion. Ultimately, preserving the top down approach also preserves the status quo.


Reciprocal information and education should be the cornerstones of medical practice and public health. This idea reflects back to Participatory Design #298 and Participatory Design of Information Infrastructures #115, where involvement of all participants at all levels of study and communication are outlined. In the introduction of a Pattern Language, a process that moves away from professional architects, or expert opinion is encouraged.


When patients come into a medical clinic they are given, at the most, a few minutes to voice their concerns. Medical practitioners are encouraged to limit patient discussion to one problem by clinic managers, the HMO they work for or other business concerns. The easiest way to limit dialog, and thus save time, is to not allow any. The medical practitioner may use language that people do not understand (medical jargon), body language that does not invite dialog, and interruption of the patient’s speech to control the visit.
Expert opinion is the public face of a "formal system", such as the biomedical establishment, which invalidates lived experience or the informal system. The contradiction expert opinion raises is that people need it as much as it distorts concerns. Illness requires more than self-care. Alexander's book serves as a template to balance the need for specialized, professional knowledge and the incorporation of non-expert knowledge. Collaboration, rather than one-way teaching should be the preferred model. Each side should must learn something from the other.
Much public health research and health information follows the one-way model of expert opinion. Research is carried out with little if any input from the population it hopes to improve the health of. The reasons for this are many times budgetary, reflecting the social nature of how knowledge is created. Experts become inadvertently spokespeople for a style or topic of research because of their dependency on institutions. Needs assessments are expensive. Trust between researchers and the lay public is both time consuming and difficult to build. Building an equal partnership requires that control is taken away from the expert. Funding follows the political climate of the times.
Social science research, unlike natural science research, examines intangible relationships. It examines power, meaning and the creation of knowledge as part of a cultural system. It should question the status-quo. Indeed, controversy created by social science research is the mark of a truly democratic system, where expert opinion is openly questioned (1).
In the spirit of Alexander's work, knowledge of health, like architecture, is a collaboration of various types of knowledge both expert and lay, Western and non-Western, abstract and lived.


The purpose of health care information must be critically examined. Public Health information must be honestly assessed as to where and how information was derived and to whom it is being disseminated. It must address the true needs of the public, not the perception of needs by the medical expert. Likewise, health care professionals must examine their attitudes and relationship to the established system to recognize assumed bias. Without a reflexive perspective, health care becomes little more than a commodity and/or social control.

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