What relates public health and the US Army?

A question came up as to why a weblog on "public health" had postings on the US Army field manuals. Good question - stick around for the answer.

Probably the most common misperception of "public health" is to think that the field is about "health care for poor people." In fact, the field is about whatever is out there that is a health threat to the public. That means looking at people thousands or millions at a time, instead of one at a time in a doctor's office or hospital.

So, Homeland Security issues are part of that perspective. Anything that might lead to or prevent World War III is part of that perspective. Reimbursement rates for doctors or hospitals is part of that. The size of your co-pay for your health benefits at work is part of that.

Operations of the US Army and government decision making, especially in crisis situations is part of that. Why was the FEMA response to hurricane Katrina such a disaster? How will the Red Cross, the Coast Guard, ahd the Natioinal Guard work together? Who's doing what to make that better for the next natural or man-made disaster? Those are part of public health too.

Another major difference between public health and routine health care is that public health is less interested in how to fix the person in the ER with a gunshot wound, and more interested in why so many people with gunshot wounds are showing up lately. Inteventions have very little funding, as "prevention" is notoriously hard to sell to the public, so the researchers are forced to keep looking further and further upstream to find "root-causes' and high-leverage points.

What's clear from the Katrina response is that organizational decision making can neutralize or ruin even large quantities of resources or assets on hand. So, the quality of decision making in crises is fair game.

One thing the US Army has specialized in is being a "learning organization". They spend a great deal of time learning by observing what actually works in practice, and they get a lot of practice. General wide-spread disaster response is way less frequent, thank goodness, but that also means that the feedback loop that generates learning is far less powerful.

In short, if public health doesn't learn from the Army's lessons what it takes to respond to a crisis under fire and chaotic conditions, then those lessons will be learned the hard way and millions of people will suffer with more Katrina-type screwups.

In fact, there is some evidence that the whole concept of trying to concentrate decision-making "at the top" of a corporation or the civilian government is a bad idea in general. The visibility of actual reality decreases with each level of administration. There are serious bandwidth problems meaning, in a crisis, there are simply not enough people at the top to make all the necessary decisions if they wanted to and were 100% competent and motivated. There are massive priority problems as people at the top will be instantly preoccupied with "very big questions" and shut off their phones to "lesser questions", such as, oh, whether one particular state or city is at risk.

In short, a case can be made that the Katrina response by FEMA was not an aberration, but is totally representative of any response by any government that tries to concentrate all decision-making at the top, period, regardless who is in power at the time. The problem is a "systems problem", not a people problem. It won't be fixed by replacing Michael Brown in FEMA, or some general in Iraq.

In the human body, for example, touch typing on a keyboard would be impossible if every decision had to be checked with the brain. It takes about 100 milliseconds for a nerve impulse to make it from the finger up to the brain and back, whereas keys have to be struck in the right order as short as 15 milliseconds apart. There is no choice - much of the decision making has to be delegated to the hand.

This is the sort of life-science question that crosses all scales. How do organizations and organisms push and delegate decision-making down to the front, while retaining central control of the mission, and all the while remaining flexible and open to news that the situation out there at the front, on the ground, at the fingertips is not the one everyone thought it was.

The US Army is the best example around of a group that is trying to learn what is actually connected to what, and how it works, based on both academic theory and actual practice.
We can learn a lot from it that can be applied to public health. We better - we'll need it.

Photo by Giampaolo Macorig from Flickr.

technorati tags:Army, learning, learningorganizations, lessons, publichealth, health, organizations, preparedness, disaster, decisionmaking, NIM, management, mindfulness