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Tomorrow morning thousands of runners will gather at Eakins Oval, beside the Philadelphia Museum of Art, for the Philadelphia Distance Run. I will not be among them this year, although I ran it last year and, as a lifelong devotee of running and exercise, will undoubtedly feel a twinge of envy as I watch them stream down the Parkway. Running has been woven into my life for decades. I relish the early mornings, the solitude, the camaraderie of races and, perhaps most of all, the peculiar satisfaction of discovering that what once seemed arduous can, through repetition, become almost instinctive.
Over the years, I also became accustomed to seeing runners from an organization called Back on My Feet (https://backonmyfeet.org/) at the main Philadelphia races, namely the PDR, Broad Street and the Philadelphia Marathon.
I found myself thinking about Back on My Feet again recently while reading Nir Eyal’s latest book, Beyond Belief. In an early chapter, Eyal recounts the story of Anne Mahlum, the formidable entrepreneur who founded Back on My Feet in Philadelphia in 2007 and later created [solidcore]. Mahlum was herself a runner, and her regular route took her past a homeless shelter. After exchanging greetings with some of the men she encountered there, she began to wonder what might happen if, rather than simply running past them, she invited them to run alongside her. It was an audaciously simple idea, and the genesis of something much bigger.
What fascinates me about the BOMF story is not merely that running helped people experiencing homelessness and addiction. Exercise is hardly a newly discovered elixir. It is what Mahlum constructed around the running that warrants attention. Her organization did not hand somebody a pair of running shoes, deliver a homily about the virtues of exercise and hope for the best. Participants joined scheduled early-morning runs and ran together. One mile became two, then three. Historically, completing two consecutive runs earned new running shoes and clothes; maintaining 90% attendance for a month unlocked “Next Steps”, with individual assistance aimed at employment and housing. The program today still revolves around regular “Circle Ups”, where members run together, set goals and establish consistency before progressing towards employment and self-sufficiency.
Mahlum, in other words, changed more than the behavior. She altered the environment surrounding the behavior. There was a time and place to appear, a group expecting you when you arrived, an attainable initial goal, tangible evidence of progress, rewards for persistence and larger opportunities unlocked by consistency. The fledgling behavior was not expected to subsist on willpower alone.
Mahlum gave it structure, reinforcement and scaffolding.
There are abundant lessons here for healthcare. Those of us working in marketing and I&A roles across pharmaceuticals, biotechnology and medical devices are fundamentally in the habit-change business. A new medicine or treatment approach rarely arrives on virgin territory. Patients already have routine ways of managing their disease, taking their medicines, accommodating symptoms and interacting with the healthcare system. They have rhythms, expectations and assumptions about what constitutes “normal”. Some have lived with them for years.
Occasionally these habits are ripe for overthrow. An existing treatment may be manifestly inadequate, cumbersome or poorly tolerated; symptoms may be worsening; frustration may already have reached the point where a patient is actively seeking something better. More often, however, the incumbent behavior is neither excellent nor dreadful. It is simply good enough. And good enough is a remarkably tenacious adversary because familiarity confers advantages of its own. The patient knows what to expect, has adapted to accommodate the inconveniences and may regard residual symptoms, side-effects or an irksome regimen simply as part of living with the condition. The status quo may be imperfect, but imperfection itself can become familiar.
The conventional commercial response is to prosecute the case for change: better efficacy, improved tolerability, greater convenience, a different mode of administration. All of that matters. But Mahlum’s experience suggests that furnishing someone with a persuasive reason to behave differently is only part of the job. A patient can be convinced that something better might exist and still never ask about it. Awareness is not inquiry; inquiry is not action; and action repeated once is not yet habit. If the environment surrounding the patient continues to favor the familiar behavior, the incumbent retains home-field advantage.
The more useful question may therefore be: what would have to change around the patient to give the new behavior a fighting chance?
Back on My Feet offers some surprisingly practical answers. Reconfigure the environment. Make the first action conspicuous and achievable. Establish a cadence so the action becomes recurrent rather than episodic. Make progress visible. Enlist other people to reinforce the behavior. Reward advancement in a tangible way. And, crucially, allow success at one stage to unlock the next. Mahlum did not ask somebody to contemplate an entirely different life on Monday morning. She asked him to show up and run.
For patient marketers, the equivalent first step might be surprisingly modest. Notice that the symptoms one has learnt to tolerate need not be tolerated. Talk to another patient who has confronted the same problem. Complete a short assessment. Download a discussion guide. Raise a particular question at the next appointment. Ask whether another treatment is available. The important point is not the particular intervention, but the choreography surrounding it.
This also argues for thinking more broadly about the patient’s environment. Habits seldom reside in splendid isolation. A spouse may reinforce them. A caregiver may disrupt them. Other patients can normalize a new behavior. A nurse may supply reassurance at precisely the moment uncertainty threatens to send someone retreating towards the familiar. Digital tools can provide prompts, track progress and make improvement palpable. Patient communities can turn an unfamiliar action into something that people like oneself routinely do. In each case, the marketer is doing more than transmitting information. The marketer is helping to rearrange the circumstances in which behavior occurs.
That distinction is important. Too much patient communication still concentrates on making the destination attractive. Mahlum’s achievement suggests that changing behavior requires equal attention to the journey: the cues, first steps, reinforcement, community, rewards and small victories that carry someone from I know there is another option to I am going to ask about it, and eventually to this is simply what I do now.
The question is not merely whether patients believe the destination worthwhile, but whether the route has been made navigable.
Mahlum tested many of the same principles in a radically different population when she founded [solidcore] in 2013. I find the connection particularly interesting because I love [solidcore] myself. It is an unusually intense workout, but its appeal is not simply muscular punishment administered on a machine. There is an unmistakable culture surrounding it.
That was deliberate. Mahlum has explained that [solidcore] coaches were expected to learn clients’ names and use them during class. Studios were kept relatively intimate, with roughly 17 machines on average, so anonymity was difficult. If someone failed to appear, an empty machine was visible and the coach noticed. Mahlum described the resulting community quite plainly: “community for us is accountability”. She also hired coaches from amongst [solidcore] clientele and treated the ability to make people feel seen and encouraged as a non-negotiable part of their training.
The resemblance to Back on My Feet is notable. The populations, purposes and economics could scarcely be more different, yet the behavior architecture has familiar components: challenge, repetition, progress, recognition, community and accountability. Mahlum did not merely create things for people to do. She built environments that people wanted to return to.
There is a final element in this architecture which fellow runners will recognize immediately: identity. At some point a person who has started running becomes a runner. The distinction sounds trivial until you experience it. I do not wake up each morning and conduct a cost-benefit analysis of whether running is worthwhile. It is woven into how I live and, to some extent, how I think about myself.
That is a much more ambitious way to think about behavior change in healthcare. Trying something once matters, of course. But the more consequential transition occurs when a patient no longer has to summon quite so much deliberation to do it again. Asking the doctor, taking the medicine, administering the injection, monitoring a symptom, exercising or making some other once-unfamiliar choice gradually becomes part of the fabric of everyday life. The behavior ceases to feel novel or imposed and begins to feel normal. Novelty has become practice; practice has become routine; routine has become habit.
Tomorrow’s runners in Philadelphia will have different goals. Some will chase personal records, some will use the race as preparation for a marathon and others will simply revel in being part of that marvelous, sweating, moving congregation that takes possession of the Philly streets for a few hours. Yet every one of them will get where they are going in exactly the same way: through the accumulation of thousands of individual steps.
Perhaps healthcare marketers should think about behavior change in much the same fashion. We are very good at articulating destinations: better outcomes, earlier treatment, new standards of care. We should be equally exacting about constructing the environment that allows customers to get there.
Mahlum’s genius was not discovering that running is good for people, or even that getting homeless, drug-addicted people addicted to running would be helpful to society. It was in recognizing that a new behavior becomes far more plausible when the environment, goals, community and rewards begin pulling in the same direction. Sometimes changing a habit requires more than making a compelling case for something new. It requires rearranging the world around the behavior until the new thing becomes easier to begin, satisfying to repeat and, eventually, entirely ordinary.
That is how runners cover long distances. And it is not a bad way to change behavior either: one foot in front of the other.
