This is a very bad prognostic sign. When change is desperately needed, those who have been responsible for presiding over stagnation inevitably respond to outside diagnoses by saying: “We're doing it already.”

This defensive response is infuriating. It is also a warning that what may be needed is a subtlety, maturity, and a willingness to let people, who may be quite narrow and small minded, take the credit for change and creativity when they have spent 20 years resisting it. It really is one of the most difficult challenges in public health. We need to give more attention to what to do when they say they're doing it already, when it is blatantly obvious that they're not.