What is public health?

What is "public health" anyway?

One way to look at life is the clinical approach: we see a new stream of urban gunshot victims coming into the Emergency Room, and decide to do things like:

• Expand the ER
• Add staff
• Develop a specialty in treating gunshot wounds
• Improve communications between the ambulance and ER

Public health, on the other hand, goes "upstream". We look at that situation and ask "Why are there so many gunshot victims suddenly?" We leave the ER and go look at what is going on in society that is resulting in all these shootings.

Then we ask the annoying question that parents and teachers often discouraged, "Why?", five time more after that to get to the root-cause, and find a place we can intervene that has "leverage". The problems often spring from culture, beliefs, society, industry, economics, and other issues. Unless those are fixed, we're just fixing symptoms and the root problem may get worse.

The illness we are treating is the tendency of society's members to shoot each other, not the wounds themselves. The point is that if we can put out the fire, it will stop the smoke.

These days, the problems hospitals have are more often too many patients, not too few, and the interests of public health and clinical health coincide. If half as many people got shot, or got sick, then the hospitals would have capacity to deal with the others more promptly, and get rid of 3 month delays for surgery. There would be room to treat those we currently leave in the gutter, figuratively or literally, as a society. It would be a win-win.

The current president of the American Medical Association has a specialty in preventive medicine, and understands this overlap -- which has not always been true in the past.

Which one is more important? They're both more important, just on different scales. Life has different levels, and a good solution to a problem will address them all. We need clinical doctors to fix individuals, and public health to fix societies. They both matter.

It doesn't matter which end of the boat we're in has a hole in it -- we need to fix the hole. Right now, there are holes at both ends.

Wade

Should we ask Hugo Chavez for foreign aid?

If the shortage at food banks isn't enough, the New York Times reports today that "Government money short to help poor pay heating bills". Excerpts:

WASHINGTON (Reuters) - About 30 million low-income American households who will need help paying heating bills this winter from a U.S. government program will be left in the cold because of a lack of funding for the program.

The poor, already digging deep to pay for expensive gasoline, also will face much higher heating fuel costs, especially if oil prices stay near record levels.

The government's Low Income Home Energy Assistance Program, known as LIHEAP, only has enough funding to cover 16 percent of the 38 million poor households eligible for the program.

The current $2.16 billion LIHEAP budget in only $300 million more than what the program had when it was created by Congress in 1981. Despite higher energy costs, the Bush administration has proposed cutting the program's budget.

The Energy Department forecasts that household expenses for all heating fuels will rise this winter from last year, with costs for heating oil up 22 percent, propane up 16 percent, natural gas up 10 percent and residential electric bills up 4 percent.

"If it is a typical winter, it's going to be a real struggle for these (poor) households. If it's colder than normal all bets are off," Fox said.

Heating bills will be even higher if the recent jump in U.S. crude oil prices sticks. Oil has soared more than $10 a barrel this month and topped a record $90 on Friday at the New York Mercantile Exchange.

Remember 2005?

See "Chavez ships discounted heating oil to US Families"

At the end of November [2005] , 12 million gallons of discounted home-heating oil for 45,000 poor families and social-service organizations started rolling into Massachusetts from Venezuela. The Bronx also is receiving discounted heating oil under Chavez' program, and discussions are underway with other states that experience cold weather. Home heating oil costs are expected to rise 30 to 50 percent this winter - because of Big Oil's price gouging and restrictions on production, say critics. Despite record-breaking profits in 2005, all the major U.S. oil corporations reportedly refused to participate in similar programs.

I've watched this phenomena in upstate New York for 25 years and know what this means in practice. I don't know the exact numbers, but let's estimate that 1 in 10 of the families without heat rigs up some foolish heat source - an old kerosene lamp, a fire in the sink, a space heater that should have been discarded (or was) years ago. Of those, say 1 in 10 leaves the room unattended or with just children in it; Of those say 1 in 10 actually succeeds in dropping something flammable in the heater or tipping over the heater; of those say 1 in 10 starts a house fire; of those say 1 in 10 results in fatalities.

I'll do the math. How many will die from this policy? 30 million times (1/10) times (1/10) times (1/10) times (1/10) = 3000 lives. This lack of "funding", if those numbers are correct, will result in the same loss of life as the World Trade Center attack, fires, and building collapses on 9/11.

Somehow, the way humans perceive things, the 3000 lives lost in NYC are visible tous, but the 3000 people lost from not funding this heating subsidy is invisible. To those who die, there is no difference. To the families of those who die, there is little difference, and sometimes equal bitter anger.

But, it won't announce itself. You'll just see, here and there, on a regular basis, all winter, in every city in the north, headlines like "Horrified neighbors watch as mom tries to rescue 3 children in fire" and some details about how some makeshift space-heater was responsible.

IN public health we try to go upstream and, like Toyota, ask "Why?" five times.

Why did they die? The fire killed them.
Why was there a fire? Space heater caused it.
Why was there space heater? They couldn't afford to pay for heat.
Why couldn't afford to pay? Government inaction or indifference?
Just spent everything on food or medical costs?
No job.
Why no job? No jobs anywhere. "The economy" has tanked.
Why high cost of food and health care? Much debated.
Why was there government inaction? Because the voters tolerate it.

Why do the voters tolerate it?
Probably due to the number of levels that the consequences are removed from the actions that result in them, people actually don't see what's happening, or don't see it with enough clarity and confidence to change their behavior, given the other louder and more immediate problems they themselves have.
Possibly because they buy the argument that the children who die somehow deserve it for being poor.
Possibly because some human agency was in the middle of this causal chain they blame the parent or grand-parent for bad judgment -- possibly forgetting what their own judgment is like when cold and hungry and in pain and your kids or parents are getting sick and asking you why you can't do something to make it warmer.


Congress fiddles, and children will die. That's what will happen.
We just don't know which ones where and when, and no single incident can be clearly "blamed" on this chain of events, and we, as a society, outside of public health, don't have a way to pull together all these separate incidents and discover that there is a pattern here, a common thread and cause.

It's the same problem we have with smoking. Half of smokers will die of smoking-related diseases. Half. But we don't see it. It happens later, far away, out of sight, with too much in-between for our human eyes to relate the two.

The Battle over Health Care - NY Times

One way we could all "save money" would be to stop putting oil into our cars. Of course, then we would have to deal with the "high cost" of replacing engines, the long waits at engine repair shops, etc. And we could have national programs to cut that cost down by 20% or so. So, we could save the $15/year we spend on oil, and replace it with $1,500 a year in engine replacement costs.

I am hoping that most people would see that the "money saving" scheme above is a terrible idea. What's remarkable is that, when we shift to health care for our bodies, everyone seems to be arguing about reducing the cost of engine replacement and what kind of insurance should pay for it. The idea of preventing the problem in the first place somehow got lost in the shuffle.

In a fascinating editorial today titled "The Battle over Health Care" the New York Times compares candidates platforms and seems something missing. The editors state:

WHAT’S MISSING

All of the plans, both Republican and Democratic, fail to provide a plausible solution to the problem that has driven health care reform to the fore as a political issue: the inexorably rising costs that drive up insurance rates and force employers to cut back on coverage or charge higher premiums. All of the plans acknowledge the need to restrain costs, but most of the remedies they offer are not likely to do much.

Electronic medical records to eliminate errors and increase efficiency, more preventive care to head off serious diseases, and better coordination of patients suffering multiple, chronic illnesses are all worthy proposals, but there is scant evidence they will reduce costs.

Well, I beg to differ. Adding oil costs way less than replacing engines. Preventing disease costs way less than "fixing" it. And yet, of every hundred dollars spent on "health care" in the US, less than $2 is spent on such prevention.

What it seems to me "is missing" is a serious discussion and investigation of exactly why and how we have, as a nation, become so blind to the obvious. And, why is this defect in our national perception resistant to any learning curve?

Since everything decays, including resistance to learning, something must actively be replenishing this social myth. Something like, say, today's NY Times editorial?

I don't want to spend today's column presenting evidence for the value of preventive care, except to note that your sense about oil in your car is correct. Maybe when I get done I'll add links to authoritative sources on preventive care. I've argued that before.

It is an astonishing fact that half of all increases in life expectancy in recorded history have occurred within this century and that most occurred in the first half of the century, before the introduction of modern drugs and vaccines. (Harvard University)

What I do want to do is look at the cultural and psychosocial factors that have created this blindness and that sustain it in the face of overwhelming contrary data.

Off hand, there are a number of contributing factors that spring to mind:

• Clinical health has far better marketing than public health
• Public Health is, effectively, clinically depressed
• Most players on the receiving end of the cash flow don't see the cash flow as a problem.
• Prevention is distant in space and time from the engine-failure event
• It's very hard to count events that would have happened but didn't
• It's very hard to "take credit" for successful preventive maintenance.
• Really good preventive maintenance staff tend to be fired, since "nothing ever breaks, so who needs them!"
• It's very hard for any politician to invest in efforts today that won't bear fruit until a decade from now, regardless how big the fruit is.

We can disentangle these factors somewhat more. Some of them are "perceptual" problems, where even good scientists lack good tools to see, let alone measure, what's called "distal causality" -- that is, causation far in time and space from events, or even harder, an absence of events.

THERE! DID YOU SEE THAT thing that just didn't happen! Just then!
LOOK! It didn't happen again!

Nope, we're not wired that way. Still, people can understand about putting oil in the car. What's different about health care?

A major factor here, generally not considered polite conversation, is a running battle well over a thousand years old between public health and the advocates of prevention on one side, and clinical health and the advocates of heroic acute repair on the other. Those receiving the money tend to argue that they are not biased by this cash flow, contrary to everything known about clinical trials and the insidious effects of bias on judgment. It certainly takes the punch out of arguing that the best "final state" to be desired, socially, would be the degrading of importance of hospitals and doctors or the elimination of both entirely to an era we'd all rather forget when people didn't know how to stay healthy.

I'm not saying that investing in public health would eliminate doctors, but it would certainly refocus them and you'd have to go well against human nature to expect them to be setting up as a national end-goal their own elimination as a respected and rewarded group. So, silence from the American Medical Association on this subject can hardly be viewed as an biased judgment call. And, to be fair, the AMA just elected a Dr. Ronald Davis, a preventive medicine specialist as president, so I suspect they know this change in focus is inevitable and are already reluctantly starting to prepare for it and shift focus to prevention and quality improvement and actually tracking "outcomes." At a recent talk at a Global Health Preparedness conference at the University of Michigan, Dr. Davis emphasized the links between public health and the AMA and his intent to build new bridges between the groups.

Amazingly, however, we don't hear the insurance industry advocating greater prevention efforts. I've inquired about this, and apparently they make money on transactions, not on keeping people healthy, so the corporate bias would be to want more transactions, if you get my drift. They aren't financially motivated to eliminate their source of revenue (broken engines.)

And public health mostly talks to itself, kicking the cat and muttering about how nobody loves them and there's just no point in talking, so have another drink and live with it. Their silence is actually probably due to a lack of funding for good media campaigns, as a result of the last 100 years being kicked across the schoolyard by the AMA and the insurance industry and other beneficiaries of the cash flow. I don't think "clinically depressed" is too strong a term for the state of the field. Most of the improvement in life-expectancy in the last century was due to public health (clean water, sanitary sewers, hand-washing regulations in restaurants, refrigeration, etc.) and occurred prior to the explosion of hospitals, following the Hill-Burton Act, in 1946, as well as prior to the explosion of use of antibiotics.

That, incidentally is a problem now, as antibiotics are increasingly reaching the end of their useful lifetimes, and the long-term result of their use has resulted in "super-bugs" like MRSA and VRE. Suddenly we see "infection control" moving back onto the radar screen, in hospitals and nationwide. We might, gasp, even expect to see a massive media campaign on the concept of washing hands after using the toilet, although if it happens it will most likely be paid for by public health, not the AMA, which still can't even persuade all their own doctors to wash their hands regularly.

Meanwhile, cholera is breaking out in Baghdad I see by the news, since the US blocked the flow of chlorine to public health facilities there, so water treatment with chlorine to kill cholera has stopped - something we just take so much for granted in the US we forget it is there.

So, there are issues with how humans perceive causation, compounded with power politics around a truly huge flow of cash - larger than the defense department, larger than oil. There is a huge invisible effect of bias blinding most doctors, who are generally good and caring people as individuals, to the true magnitude of this problem. (By the time they are done with med school, they're trapped in the system.) Trying to make a living as a "family doctor" in the US today is a losing proposition, totally underfunded as one of the front lines in prevention. So, the nations problems pale in light of the larger, more tangible, personal cash flow problems of just making a living in an insane system gone haywire and dysfunctional.

Public health academics mostly just talk to each other, although that's a common trait for academics in general. There is a dawning realization that no one in government or policy making positions is listening to them any more, and some movement to try to figure out how to have more clout -- hard, since most public health workers in the US are at or near minimum wage since the field is so misunderstood and devalued by the population, in a self-latching loop.
(No cash = no advertising = no cash, etc.)

Meanwhile, since no politician can educate the public against this tide of confusion, and they can't hope to benefit from getting credit now for investing in prevention of future things that won't happen in someone else's term in office, we can't expect much from them.

Still, I did expect more from the New York Times, than not realizing the value of prevention.
At least they could have said "There is scant attention given by us and other media to the overwhelming body of evidence that prevention would save well over half of our health care costs" and done a research piece on why that is.

Probably the last psychosocial fact I didn't mention is relevant there. Prevention would require that people "shape up" and let go of bad behaviors and adopt healthy behaviors - and that would seriously cut into both the profits of some big industries (tobacco, fast-food, alcohol, etc.) and ask people to take personal responsibility for their own "outcomes" instead of the philosophy of "party today and regret it tomorrow" that has become so prevalent.

Again, that could be fixed, but there are strong financial interests in not fixing that aspect of American culture. We still want "mature" to equate to "irresponsible." It may be fun, but other countries with less of that will be eating our lunch soon, and that won't be fun.

GM is blaming its woes on health care costs. According to Harvard's researchers, the largest single cause of bankruptcy in the US is medical bills. Changing who the middleman insurer is for this process will simply change the letterhead on which you get your bill for the engine repairs of yourself and your neighbors, but won't lower the bill.

Nothing will actually lower the bill until we "do less of that" and switch from a repair-mentality to a prevention-mentality. That would be worth about, literally, a trillion US dollars a year, but would require about a billion of that going to revitalize our champions in public health. ( You'd think this would be worth 1/200th of the $200 billion we do choose to spend on the War in Iraq next year in order to make us all "safer" and more secure from bodily harm. )

The fact that we, as a nation, can't do the math and see that trade-off is not helped by today's New York Times. I had hoped for more. I suppose we could dig one more layer further upstream and ask why the Times can't get its own research together anymore.

Meanwhile, looking in our own mirror, on a national scale dawn is coming, the party's over, and the guys with the bill are at the front door. I can't help but notice that neither the grand state of Michigan nor the US Congress has managed to get a budget together for the new fiscal year, that starts in a week. It's the first day of fall and summer is over. Nobody seems to want to face the music and look at the mess we've made for ourselves.

It will be more obvious when the Michigan government shuts down in a week, and the Federal government shuts down in mid-November (judging from prior times they've pulled this stunt.)
Still, it won't do much to improve our image internationally as the guardians of the world's "reserve currency." Or maybe, we've abandoned that role too.

But, here's one suggestion for the UAW - if you guys take on that $50 billion retiree health care obligation that GM is offering you, check out this idea of "prevention" and make friends with "public health." If we can't get the cost of health care in the USA under control, that trickle of patients heading out the door (with their money) to medical tourism sites abroad is going to turn into a flood, and there goes another trillion dollar a year industry outsourced to Asia. Then no Americans will have any money left to buy GM cars, because their medical costs will be hemorrhaging into pockets abroad.

It's like "fuel efficiency". This isn't a local issue any more. It's a global competitiveness issue. If we don't fix it, customers will stop coming entirely. Hospitals need to emulate Toyota and get "lean" about their costs in doing defect-repairs ("health care"), but the whole US needs to get "lean" and stop passing the defects downstream to hospitals and start fixing them upstream at the source, for the very same reason - the economics are killing us.

And, meanwhile, hospitals should consider a different long-term strategy than simply being superb at fixing the defects that are passed on to them by failures upstream in the nation's public health system, as that only institutionalizes the large-scale system structural problem and costs.

Hospitals need to transition increasingly to having positive value-adding roles, not just defect repair roles. They should consider being at the forefront of physical and mental and social fitness, and building our capacity to cope with life and build innovative and thriving industries, not just cleaning up the breakdowns and depression that come from failures in those areas. Then, their success is aligned with our success, and odds of long-term survival of all of us is improved.

Of course, if Hillary Clinton is reading this, remember that one rule of "lean" is that you have to guarantee the employees that, if the cooperate in making things run better, they won't lose their jobs. They may have different jobs, but they won't lose their jobs. Ditto for hospitals - if they participate in reducing their defect management role somewhat and support fitness enhancement programs instead, they need to be guaranteed no one will lose his or her job.

As always, the focus must be on the "customer". And as always, there is a hierarchy of customers, from individuals to families to teams to departments to companies to states to nations. If we do this right, it should be a win-win-win-... etc for everyone. Fit and healthy and innovative employees are what our companies need to thrive, and vice versa.

The job of public health should be to catalyze that win-win transition, and break the "us" versus "them" logjam, of "either" individual fitness "or" corporate fitness. Let's do the "and" solution instead!

Wade

What I learned at Johns Hopkins last week

Well, I saw something completely unexpected yesterday.

I wasn't posting here for most of last week because on Friday I completed a course, "Social and Behavioral Aspects of Public Health", at Johns Hopkins School of Public Health. I thought it was a good course and covered many key ideas, although I did wish it had gone into them in a little more depth.


But, I am a finishing 3rd year student, (my last class! Hooray!). and most of the class had just started two weeks ago, so I could understand the need to not overwhelm people with new concepts. And that's what I thought was happening, but now I'm not so sure.

This is like those scenes in the movies where the music changes and everyone knows that the monster is approaching but our hero and heroine happily play on, oblivious.

During lectures, sometimes we would have a simple summary slide with content such as "Poverty is a carcinogen." We were supposed to evaluate that assertion, tease it apart, sort out what portions were true and how you could tell. This is part of a debate that's been raging for at least 400 years.

Many of these lectures were met with a startling silence by the students, who often had no questions at all. This surprised me as I thought there would at least be a heated discussion. Well, I thought, they're tired from working half the night on their classwork, or don't want to ask "dumb questions."

Still it was eerie to have the professor ask something and the room of 100 or so just sit there.

After the class, in the big blue shuttle to Baltimore - Washington BWI airport, I discovered something I wish I'd known the first day, as it would have totally changed my behavior.

I chanced to ride with another MPH student I recognized and asked her what she thought of the class we'd just had. I hit a nerve. She had thought the class was a total waste of time and money, and put up with it just because it was required. She thought, basically, that the lessons the class taught were stupid, wrong-headed, wrong, soft, politically-motivated, you name it, and she had already discarded all of her notes. She was just livid.

Wow. None of that had come out in class. And, obviously, "my mileage varied." I liked the course and I don't think I'm an easy sell. I'm used to executive education programs where "students", often CEO's of companies, wouldn't hesitate a second to challenge something they disagreed with.

Apparently I had fallen into the common trap of interpreting stony silence as agreement, or consent. In point of fact, it was total disagreement and scorn, suppressed by a need to just complete the required course, hold one's breath, and put up with all this "psycho-babble" for two weeks. (She didn't say "psycho-babble", but could have.)

So we had missed a tremendous teaching opportunity to get this debate and dispute out on the table and have at it. What a great opportunity to get our feet wet on what it means to assert that "A causes B", and how we "prove" things, and what level of skepticism is expected, and what the burden of proof is on someone asserting some new claim, and how to meet that burden, etc.

It would have been a perfect chance to show a snippet of Crime Scene Investigator's CSI TV show where CSI Head Gil Grissom could lecture us all on the need to suspend our suspicions and "let the data talk." We could have viewed a few cases where it was way too easy to believe that Mr. Jones obviously "did it" when, in fact, it was Miss Smith, in the Kitchen, with a lead pipe.

We could have talked about how civilized grown ups in the field disagree with each other's conclusions while remaining cordial and committed to careful ways to defend against being too gullible (a "type I error") or too skeptical (a "type II error").

But, at least for this one student, that chance was missed. She had interpreted this class as just one more of those annoying things in life where a person in authority states or does something stupid and the best thing to do is just shut up and pretend you agree. In fact, silent and sullen obedience is the expected and demanded and rewarded behavior.

I guess it was rewarded here too, because I think she "passed." Hmm.

Way too many years ago, before I had taught in trade school or taught MBA's, a book came out titled "Summerhill", I think. It described a school in England that I actually went to go visit because of the book. The school challenged the prevailing "infectious disease" notion that I can recall quite well:

Courses are something like the measles. They are something you "have", and then, since you've "had it" you don't need to "have it again."

Again, wow. I had thought that concept had died in the 60's. It seems to be resurgent. Or maybe it never left and I'm just finally looking up and noticing it.

Now, I'm the first to agree that I went into undergraduate Engineering at Cornell, after reading C.P. Snow's Two Cultures, because I just couldn't figure out how to deal with classes where the teacher would ask "What did Hemmingway mean when he said X?" and I had no idea what to say next after I offered an opinion and the teacher told me I was "wrong". What the heck? What's with that?

At least in Engineering, if you say something should work and someone else says "No, it shouldn't" you can just both happily go down to the lab machine-shop and build one and just see whether it flies or not. No one ever wastes time talking about the "true nature of causality."

We'd just happily compute what size resistor to put at this point in a circuit without losing sleep over what the meaning was of "resistance" and if we could actually be "certain" that changing the value would have the desired impact on the radio receiver actually working. If in doubt, put in a variable resistance potentiometer ("a pot") and turn the screw to change the value while watching the output on an oscilloscope, and when you got it where you wanted it, Bingo, pull out the "pot"and measure what resistance it was set to and solder a permanent resistor of that size into the circuit and go play volleyball. No big deal.

Maybe it's because I'm looking at social issues more than I used to, or maybe it's because society is changing, but that sort of way of gaining an answer to a question seems to be vanishing as the expected behavior of people.

Without some training and skill in the tools of Public Health, or other rigorous but often qualitative fields, we've reverted back to the Middle Ages where causality is either magical or determined by which "authority" one follows blindly.

Again, wow.

So, if I hold out my pencil and release it, and it falls to the ground, and I ask "Why does that happen?" I'm as likely to hear "God made it move" as "Gravity."

So, hmm. Is this an "either/or" question or an "and" question or what? Personally, I prefer to think that "gravity" made the pencil move, and allow that, if you like, you can add "... and God made gravity." At least with the "theory of gravity" I can write some equations, design equipment, know exactly how fast something will fall, plot trajectories, etc. It's a "theory with meat on the bones" that I can rely on to build stuff that works. I don't get much "predictive value" out of "God made it move."

But, I guess if you never had the math, and never did "get" introductory Physics, and the concept of "potential energy" baffled you, so the equations never gave you any insight or power, then it's pretty much equivalent to you to say "God made it move" or "magic made it move" or "gravity made it move." They're all invisible anyway, right?

I was busy raising children and missed the whole 80's and 90's trend towards cultural relativism applied to everything, including physical laws, so that "your idea of how gravity works is no better than anyone else's" and we should agree to let all three just get along - physics, magic, or God."

Besides, frankly, hey, when you get right down to it, I can't "see" gravity anyway. All I can "see" is the pencil. Your invisible force against my invisible force, it's a tie, right?

All of which gets me back to class. I guess we might need to add an introductory class that we never needed before, to socialize students to an accepted way of challenging assertions and assumptions and accepted ways of meeting the burden of proof without being blindly stubborn or gullible about it. We need to know when and how it's appropriate to raise our hand and say "How can you prove that?" in a neutral, polite, but insistent tone.

As about a zillion (technical term) of my previous posts discussed, a key requirement for a "high-reliability" culture is "mindfulness," which requires the ability and sensed-permission and sensed-expectation that you will surface questions you have, not submerge and suppress them.

If we can't have that discussion first, all the rest of this business with models and hypothesis testing and "p-values" and study design and statistical tests is, indeed, just magical rituals that you have to go through for some stupid legacy reason in order to get published. All this demand for "evidence-based" practice is just a waste of time, then. No wonder students are baffled by it.

Well, we all know the rule that "All Indians walk single-file .... at least the one I saw did."

So, I'm extrapolating to an entire entering class of students from observed puzzling behavior of stony silence and from one accidentally chosen student's opinion in a cab on the way to the airport. That suggests an underlying teaching opportunity that maybe I'm imagining or maybe is real.

How would we decide which it is?

I'm concerned that not a single student challenged the teachings and yet clearly, from this and other conversations, many others I checked with also disagreed -- in complete silence.

Again, wow. And these are all students with undergraduate degrees and at least two years work experience and decent GRE scores. Maybe a third of them are already Medical Doctors. (MD's)

What have we done? Can we trace this defect back upstream and find out where it's coming from? (You can click on this next image to zoom up to a readable scale).


And how can we undo it? And how could we measure our impact and know whether we had succeeded or not?

Those are good Public Health questions that deserve some time on the agenda. They're also major business problems that directly short-circuit techniques like "The Toyota Way" that I've discussed, that require that everyone should work with their eyes open and with permission, and even expectation, that they'll spot things that need to be changed and announce them.

An army of silent, obedient, sullen, blind robot lemmings is not a very solid basis on which to build a competitive economy or a good public health infrastructure that actually works, or an army that works, or anything that works, instead of one that everyone pretends works.

What have we done to our children?

So what? part A of why SLOOPS matter

I get tired of writing "Self-aware, self-repairing, goal-seeking, regulatory feedback-mediated control loops" so I'm going to use S-Loops or "SLOOPS" (all caps) to name those in this post.

Again, I need to meet the burden of showing why all this effort is worth it. Where's the payoff? Where's "the beef?" If this doesn't give at least a 10-times improvement over older techniques or frameworks, it's not worth considering, after looking at "transition costs".

OK. So, let me begin showing why this actually helps. Some theory to start, then some fully worked synthetic examples, then some real data. How's that?

First, recapping, I've said that we need to put on lenses that let us spot proto-life, or S-Loops in the sea of interactions going on around us, within us, and that we're within. Those are where I believe "the action" will be for reasons I went into already. Some are the obvious, named parts of "the Ecological Model" -- cells, tissues, organs like the pancreas, body systems like the endocrine system, families, work-groups, departments, corporations, cultures, religions, nation-states.

Then I suggested that maybe this set of what Marsden Bloise called "curiously laminated" levels of life on Earth isn't really many different living things, but only "one" living thing, in the same sense that our circulatory system or immune system is "one" thing, despite having many parts that are, in the short run, not even connected to each other. White and red blood cells appear at first glance to all be off doing their own things. The "ties that bind" are subtle, and not always some kind of physical binding like glue or cement. The "parts" are not always in a fixed or plastic relationship to each other, like our bodies, and can have "gaps" between them (as do blood cells, or the pancreas and various endocrine control centers in the brain.). They are still, in a critically real sense, "one." They act as "one".

But, this is a funny sort of "one". We're used to billiard-ball models, or rocks. We're taught that "one" plus "one" gives you "two". This kind of "one" has a different math, forget calculus, we've already left the building at "addition". We have "one plus one equals ONE" -- where ONE is larger than "one." But it doesn't stop there, because "ONE plus ONE equals ONE."
and "ONE plus ONE equals ONE." So many cells act as "one" body. And many bodies act as "one" corporation. And many "corporations" act as "one" nation-state. -- but each "one" also includes all the previous, "lower" level "ones" too. So corporations are made of people, but people are STILL made of cells. Corporations are big complex organizations of DNA, in fact.
So is the USA. It has the identity of DNA, and the identity of many immune systems and endocrine systems, and the identity of many "people" and the identity of many "subcultures" AND it has an independent identity too, on top of all of that. It seems infinitely branching, almost fractal. (actually, I think it is symmetric across levels, so it actually IS fractal.)

These identities are context-dependent, scale-dependent variables so we have to be careful what kind of math we do with them, and not just "addition."

In the SHORT RUN, with our SHORT RUN lens on, the levels appear to be "obviously" independent and unconnected, although, sure, they "impact" each other a little. Just like blood stream cells impact each other a little as each does its own thing. But that tells us NOTHING about what we see when we rotate the microscope stage to the LONG RUN, large field-of-view lens -- where suddenly all these "different" things are all connected after all and all coordinated and synchronized at a high level, which is almost (but not entirely) invisible at the lower level.

I gave the example of water molecules -- in the short run, molecular interactions are complex and require advanced quantum mechanics and only supercomputers can predict the behavior of a few hundred molecules at one time.

It's the height of arrogance and folly to try to hope to predict one thousand or ten thousand --- using those tools and that base-point and looking upwards.

But, if you keep on going, you get to the scale of household and city plumbing. Suddenly, people who never graduated from high-school are putting in pipes and faucets and getting "water" to do their bidding, and filling glasses with "water" whenever they need a drink. No big deal.

What was impossibly hard from below, becomes incredibly obvious and easy from above. Same molecules. Same you. Different lens.

So, whether things are "many" or "one" is a slippery concept that may be scale-dependent and time-horizon dependent. Whether interactions are "weak" and "loosely-coupled" or "deterministic" is also a scale-dependent and time-horizon dependent type of variable. We can't use our billiard-ball addition, subtraction, and reasoning on such objects -- they have a different system of math. It's very real and very solid, but it's different than we're used to, so our intuition is just terrible regarding it. Our hunches and impressions tend to be wrong most of the time.

So, bring this back down to Earth and focus, Wade.

OK, yeah, here's the thread. It is an important thing to decide how many semi-living things human beings are "one" with already, right now. If we put the boundary in the wrong place, we will get bad predictions on our "what if " thinking.

In my mind, the proper subject of "Public Health" is not the public misperception of "health care for poor people", or "hygene and sanitation", and is not to maximize the sum of the health status of every person, although both of those are virtuous goals. The proper subject is to take care of the health of the living and semi-living entities that are larger than people, including corporations and cultures and nations, going all the way up to Gaia or "all of us."

The "public" in "public health", in my mind, is ONE living thing, ONE highly complex, fractally organized set of DNA in a fantastically complex dance. Viewed through one lens, it is one planet. Viewed through another, it is separate "countries." Viewed through another, it is 6 billion "people". Viewed by a virus, it is some huge number of cells, waiting to be infected.

It's a system, and not a heap, although both have "oneness." The heap, however, just sits there, and a living system, or S-Loop, is self-aware, self-repairing, goal-seeking, and allostatic. In the heap case, our interventions are on a passive lump of clay. In the complex adapative system case, our interventions are on a living Body that has its own equivalent of an immune system and tissue rejection is a very real possibility. Or the patient could be upset by the injection and punch us in the stomach and stomp out and come back with its friends and burn down the clinic.
It is not a lump of clay. It has huge stored energy and active agents within it. And it has a self-identity, and a goal, and will attempt to keep itself aligned with its current concept of its healthy state.

So, much of this is not news. Public Health knows that you can't just walk into a culture and impose some solution and expect it to "take" and expect that you can walk out again and not have your solution thrown out the window after you. Almost every foundation that funds public health interventions in Africa or elsewhere has already learned that lesson the hard way.

One place where this is news is corporate management theory, and the large interest right now in trying to understand why Toyota, coming from behind with about zero to start with, could walk slowly up to and past General Motors and keep on going. Despite the unseemly screeching about "unfair trade practices" and "unfair cheap labor" and "unfair currency valuation", there is a realization that they're doing something right that corporate America better wake up and figure out and emulate while they still exist.

After reading 20 books on "lean manufacturing" and "The Toyota Production Process" and "Lean Six-Sigma", and attending a weeks training and exercises, I come away with this -- Toyota understands the multi-level living model, and aligns itself with that, and GM still thinks the parts of the Body operate best if they are at war with each other.

Economically, especially if you live in Southeastern Michigan near Detroit as I do, this is one very big deal. This is the dominant thing happening on the economic landscape right now, and it has, surprise!, a huge impact on employment, education, health care, and the health of the states, cities, neighborhoods, families, small businesses, ancillary services, and physical health of the people who live there.

I have trouble imagining how that could NOT be a proper subject for "public health" to attend to, but some don't share that view.

People are not well because their companies are not well. Their companies are not well because they are pursuing a bankrupt, dysfunctional model of human behavior that ran out of steam in the late 1960's, after McGreggor's Theory Y was published -- but the news hasn't hit many corporate boardrooms yet. Why? Because the companies have banded together to maintain a set of stories and myths about why things are the way they are, in which CEO's are "good guys" with "white hats" and labor, environmentalists, unions, lawyers and terrorists are the "bad guys" with black hats. It's a very powerful story, capable of distorting perceptions and selective attention to discount and ignore incredibly strong evidence that the myth doesn't hold water any more.

Well, I have to go. Let me put in a bookmark here. The bad news, from the point of view of activist "people", is that the level of corporations and managmeent a few levels above them seems to be so short sighted that all hope is lost.

My message is don't despair. It's like the water molecules. I'm sure there are idiots and crooks wearing CEO hats, but there are many good people wearing them as well. And, if you get high enough, as with the water and plumbing example, the ultimate investors, the huge funds, the John Templeton's of the world, are not evil people and are not in a frenzy about making 37% return on their money this week before the dude comes with the tire iron to break their kneecap for the loan they took out and failed to repay. The huge investors would be ecstatic to find ANY place to put a trillion dollars that would even RETAIN its value from year to year, or, wow, maybe even grow 1% in absolute real value. China's bankers are sitting on that kind of money and have that very same problem.

So, while the CEO's seem "high up" and out of reach from below, from far above CEO's are hired guns and "a dime a dozen." They can all be replaced, if there is a better way to make money in a sustainable fashion, with less fuss and anxiety and fewer disrupted golf afternoons. Probably entire nation-states can be replaced if they're in the way by the Club of Rome type crowd, or "organized crime" bosses.

Everyone one of them has the same issues, the same problems, the same S-Loop issues to worry about. Every cell, every tissue, every organ, every body system, every person, every company CEO, every Governor or President has the same set of questions they face daily. These are the ones we need to get better at. FIRST, there are the 7 basic steps of the core S-Loop, that I've gone over before.

Yesterday's picture - above. My Capstone picture below.



Second, there is not ONE loop doing this activity, but millions of them, or at least very many, horizontally at each level of the hierarchy of life. Third, there is a whole fractal tree shape of higher and lower level "ones" doing exactly the same activity in their world, at their level, at the same time, interacting vertically. All that gemisch looks only loosely coupled, but I think a deeper investigation will show that, like the body's immune system or circulatory system, the distal parts are really tightly connected after all, in at least a few important ways.

So, we have one huge, fractal tree shaped collection of DNA, all trying to figure out which way is up and how to survive until tomorrow and make it through today. Everyone is working on the same set of 7 questions, over and over.

where to intervene? John Kenneth Galbraith would call them "mental models", but for public health or psychology these days they are "stories" or "narratives" (or myths) that we tell ourselves, tell each other, and make self-sustaining by passing them back and forth so they don't die out. The ones that link up to make an S-Loop will persist and end up dominating.

So, the intevention points are the boxes in yellow then. These are non-tangible "stories" and changing them will change all the very real, very physical parts of the S-Loop located at the right side of the diagram. The IOM had it perfectly -- use "feedback" to inform and reshape the group, and it will become self-working and self-managing and self-righting without any more "guidance" from management. My addition is, use S-Loop feedback, not just "feedback", and your efforts will be 1000 times more self-persisting and have way less "tissue rejection".

Besides, there's a resonant notch there, so it tends to "click into place" or "snap to grid" if you get close to it. It has a familiar heft and ring. We know this place, because it is us.


As T.S. Eliot, in the Four Quartets , said

We shall not cease from exploration
And the end of our exploring
Will be to arrive where we started
And know the place for the first time.

Wade

Remembering our soldiers

Countries still send their youth to fight and die, or come home injured and changed, for causes too often "long ago forgotten."

In the US, memory seems to be very short, and even the returning soldiers from last year are themselves forgotten in corners of Walter Reed, or in our homeless shelters or in cardboard boxes on the streets.

While violence and war seem to be the last resort of those incapable of any higher form of civilization, those who go are often motivated by their understanding of what will protect and serve the rest of us, and deserve our respect. That applies as well to "enemy" soldiers and injured civilians as to our own.

This is one of the most obvious "multi-level" activities of mankind, where "the Nation" is off fighting one kind of war on one level, and armies are fighting a different war on a different level, and individuals and small teams are fighting a third kind of war on a different level.

And, the "causes" of war, or intervention points to stop wars and achieve "just and enduring peace" are similarly clouded by all the factors this weblog discusses, from feedback processes to distant causality and the aggregate impact of many "small things" that we don't realize add up to a dominant force.

I'm reading a book titled "Social Injustice and Public Health", (Oxford, 2006) by Barry Levy and Victor Sidel, which is the textbook for a course I'm taking later this summer. The editors, Levy and Sidel, previously edited two other books "War and Public Health" and "Terrorism and Public Health." Their main thesis is that social injustice underlies these problems -- war, terrorism, and public health -- and that those visible downstream outcomes cannot be resolved until the underlying problem of social justice is solved.

This is similar to the central thesis of the book Peace - More than an End to War, published by the Baha'i Publishing Trust in 1986. Quoting from the forward of that book,

The Baha'i approach to the achievement of peace calls for fundamental changes in all aspects of behavior - individual, interpersonal, corporate, and international - based upon the belief that human beings have an innate capacity for harmony and cooperation,which, unfortunately, has been suppressed by religious fanaticism and the spread of divisive ideologies.

The Baha'i teachings prescribe education for world citizenship, the fostering of effective communication, and the eradication of prejudice. The advocate social reconstruction and administration based on the principle of the oneness of mankind. Each of these behavioral changes supports the others...

While there are many misguided and less noble motivations for warfare, one of the most consistent one, on all sides of any such conflict, is the belief that sacrifice and even death are worth it in the struggle to make a world safe for our children to grow up free of terror, discrimination, disease, and oppression. I suspect no nation has ever gone to war without believing that they are champions of this effort and that they are fighting some version of evil personified. Dehumanization and demonization of "the enemy" is always rampant.

Yet, 50 years later, these people like us that we had perceived as demons are often our friends and allies, and now we've shifted to perceiving other groups as demons.

Surely, our linear minds think, there is someone out there to blame for what is going wrong, and it surely couldn't be ourselves.

One of the most important lessons of "systems thinking" is explained well using a class role-playing simulation of a massive instability in the production and distribution of the alcoholic beverage beer, in MIT Professor Peter Senge's book The Fifth Discipline. Orders fluctuate wildly until companies start failing, but there is, it turns out, no one to blame. The system is to blame. The overall structure of the interactions is to blame, and, literally, every person in the system is behaving rationally and sensibly and no one intends the whole thing to go so wrong.

I can't think of anything more important for people who want to "stop war" or "end violence" to understand than that lesson. Often, no one is to blame, and everyone is to blame, for sustaining a structure that results, inevitably, inexorably, in us demonizing each other, and killing each other, instead of watching our children play soccer together.

The problem is that warfare has always been an inefficient and ineffective method of accomplishing the goal that everyone on all sides wants, ultimately, of a peaceful world with stable, thriving communities, economic prosperity, physical health, and an opportunity to move closer to nature and our particular view of God without being demonized ourselves for doing so.

We all want what our bodies and spirits are designed for and optimized for - social connectivity to each other. We want to belong, and to belong to something larger, and belong to something larger that has noble purpose and that may demand something of us but that sustains our best self in return. When that connectivity breaks down, as all the social epidemiology literature shows, when we become fragmented and disconnected, it is inevitably followed with depression, deteriorating personal physical health on many fronts, sometimes violence, and often death. We were never designed to try to face life alone, and it doesn't work well. Even the cells in our bodies, if removed from our bodies, commit suicide ("apoptosis"), apparently seeing no reason to go on.

This seems to be a deep, profound, and multi-level need, the need to belong, to reassemble all the loose parts and form a fabric, a community, a society, a culture.

One problem is that on different scales, individuals, groups, cultures, and sometimes entire nations and peoples are perceived as "not us" by other people, and efforts are made to marginalize, detach, suppress, or kill them outright - singly, in groups, or in massive genocidal wars. Needless to say, the attitude becomes mutual and self-reinforcing.

From the model I've been painting in the weblog, we may be able to view this in the framework of "regulatory feedback control systems" trying to do what they always do - namely, figure out where their own parts are, reassemble the parts, figure out what parts don't belong, get rid of those parts, and re-stabilize the whole thing in some kind of sustainable shape -- homeostasis in the case of humans, allostasis in the case of other beings or other levels of life, "system stability" in terms of large, complex computing systems and ecologies.

Now, that process is unstoppable and comes with the territory. You can't have Life without that process on every level, from sub-cellular components such as mitochondria to nations. There is nothing wrong with that design. It's a great design. It got us from a sea of hydrogen to the complex muli-leveled beings we are and the world we've built around ourselves and the natural world we've inherited, even if we seem bent on destroying as rapidly as possible.

What is killing us, and resulting in pain and violence at all levels, is not that process, but disorders of that process.

It is quite like our relationship with microscopic organisms known as bacteria. There are millions or billions of different kinds of bacteria, and for the vast majority of them we get along fine. In fact, there are some we literally could not live without, populating our intestines. Even some of the "diseases" that "we" get turn our to be the unintended side-effect of the bacteria themselves getting a disease from the much smaller viruses. We are not, or should not be, at war with bacteria. Coexistence dominates, and there are only a few places where it breaks down, and even those are malfunctions on the pathogen's end. It makes no sense for a pathogen to kill its host, and then have to go find another.

It is, on that scale, a poor business model.

Similarly, the cells of our bodies are not our enemies as humans. Occasionally, one goes crazy and starts ignoring the larger body and grows itself unboundedly, and we call that "cancer", but for the most part the health of our cells and the health of our bodies are fully compatible and, in fact, more than compatible, they are mutually supportive. It's the ultimate win-win solution.

It is, in my mind, a very similar process that we're fighting on a whole different scale with our economies and religions and armies.

Religions have disorders at the entire entity level because they can't resolve clearly what part of themselves is "them" and what part is "other", and we end up with "autoimmune disorders" where one part of the religious body turns on another part of the religious body and tries to destroy it. Sects develop and intersect warfare results. The body religious rips itself apart, to no one's benefit.

Immune systems are great, except when they go wrong. But it is not the concept of an immune system that should be discarded - it is the disorder of the immune system that needs to be repaired. You cannot make a living, sustainable anything without an immune system.

So, our attention then is turned, inevitably, onto how our social immune system makes the subtle but absolutely critical distinction between "me" and "not me", or "us" and "not us". Which thing out there should be preserve and healed, and which thing out there should be attacked and destroyed? This turns out to be a very hard question.

But, it turns out to be a very hard multi-level question, a scale-invariant question, a problem that is instanced on every single level of every living thing that ever was or will be.

In that is our hope, because, even though no one level tells us enough to "find the answer", the fact that all levels have this problem means we can pool data, trade notes, combine our insights from every level into a single master picture and then, I believe, we will be able to simply look at see what to do. It should be obvious, once we get the right viewpoint. It should be unambiguous, because it should be beautiful, simple, elegant, and have "white space" all around it. We should "resonate" with it, because it will be the answer our own body, our own psyche, our own family, our own community needs as well.

So, if we just accept the working hypothesis that "life" exists at every level, and then extend everything we know across levels, it should turn out we already know the answer. The "life sciences" should inform the "social sciences", and vice versa, because we all face the problem of supporting a multi-level mutually compatible immune system and the associated "identity" that the immune system is pledged to defend, at the price of death if necessary.

The expression of this identity at the social and national level can be perceived as "prejudice", when it attempts to divide one part of the human body from another and turns one part of our Body on another in the form of warfare or discrimination or suppression or exploitation.

Put most simply, that can't be good. It is an auto-immune disorder. It turns us on ourselves.

If our health is actually dependent on the health of the people around us and our connectivity to that, which it is, then it seems to follow that we want more of that, not less of it.

As Fisher and Shapiro note in their book Getting to Yes, after analyzing how to stop the Soviet Union and the USA from annihilating each other in a global thermonuclear war, there is a level upstream from the details of "position" where we can look at "interests" and realize that both sides, regardless how much they may hate each other at this moment, actually are made up of humans and actually have common interests - and if we can meet those human interests in some new way, the old "positions" that led to conflict can be released without struggle. The intractable simply dissolves.

This is the sort of thing that Kim Cameron experienced at the Rocky Flats nuclear waste-dump in the work I described yesterday - Making the Impossible Possible. It can work. It has worked. It does work. It will work.

We have a much larger problem than resolving the "Mideast crisis" facing us. The development of nuclear power is widely advertised as "the threat", but it is nothing compared to the threat of biological weapons, which almost any country can already develop. Unlike nukes, that at least mostly stay where they're used, aside from toxic plumes of fallout that will kill everything for the next 50,000 years -- the biological weapons can literally take on a "mind of their own" and decide that they will turn around and destroy their creators, then go on to destroy the rest of human life on the planet. That is not cool.

And, no missile defense shield or "Star Wars" project can stop such an onslaught, once it begins.
Such a thing can be launched, stupidly, by almost any two countries that decide the only way one of them can exist is to destroy the other.

The largest threat to the Homeland Security of the USA, in that light, has nothing to do with nukes or an "axis of evil", but has everything to do with any two countries or cultures or sects of a religion that get it into their heads that they should attack each other with bioweapons, which then spiral out of control around the globe.

There is only one defense for that threat to our lives and our children's lives and the entire future of the human race - and that is to tackle the disease and disorder of our collective immune system that keeps causing "some of us" to abruptly perceive "others of us" as mortal enemies that must be attacked to keep the whole body healthy and operational and to restore "homeostasis" on a larger scale.

As I say, I think we know a lot about regulatory control feedback systems, and we have an unimaginably huge computing capacity on the planet that is mostly used for video games and unused 2/3 of every day while we work or sleep. We have a global communications system with wearable camera-phones and wireless internet. Never before in history has any civilization had such powerful tools to use to tackle any social threat.

The threat is that our collective immune system, on a planetary scale, has not yet been stabilized and keeps mis-identifying parts of our own Body as "enemies" who must die.

It's an issue of who "we" are, at the core, and finding common ground with every other human on the planet -- which shouldn't be too hard in the space age, because we're all standing on the same little ball floating in a very hostile very large space out there.

Through the matter of how our individual and population healths are intertwined on a physiological and psychological and spiritual level, there is no "them" that is not, ultimately,
also "us." "Love thy neighbor as thyself" is redundant, because our neighbor turns out to be another side of ourself.

I recall the day our infant daughter Kelly saw something interesting waving in front of her face and reached out and bit down on it, as infants tend to do. The something was her own large toe.
It took about 2 seconds for this realization to work its way through the system and the shock and horror and pain to "click" and get her to stop biting her own self. Once the issue was "realized" there wasn't a problem in getting her to "disengage."

On a planetary scale we are not just "one people" but also one "meta-organism" with a life on its own level that is higher than our own, and that we share. We have a society and civilization and we have values and "epigenetic" information that was hard won that we want to pass on to our children's children.

It's time to tackle the job of healing that meta-organism's immune system, which will be reflected in the removal of "prejudice" of all types and the partitioning of the world into little subsections that think each other is some kind of enemy agent.

It's not that we shouldn't be fighting a war against bad things and evil, but that the bad thing we need to fight has to be "prejudice" and narrow-minded, short-sighted, selfishness that threatens to kill us all downstream of its own bloody in-fighting.

I think the framework I've laid out, mostly built on Baha'i and Public Health's best teachings, may be a way to approach that problem with new eyes, new tools, and new hope.

If so, maybe all the wars everyone has fought will be finally "worth it" and we can stop the rest of the wars forever, and actually heal this disorder instead of just living with it and dying from it.

Some people have found it strange that I spend a lot of time on a "public health" weblog talking about military leadership and US Army Doctrine. I don't see these as incompatible, and I want to address that question. The US Army Leadership Field Manual (FM22-100) seems to me a marvelous work, even if it now superseded by FM6-22. The description of the doctrine is of a fighting force with tremendous focus on integrity, character, humility, strength, and being a learning organization that learns from every mistake and is agile and not hung up on outdated concepts or models of the battlefield, but can quickly process new information and develop a new model of what's going on. What is not to like there? If there are problems they are from failure to live up to that standard, not from the standard.

Here's a few excerpts from that manual:

1-3: Leadership starts at the top, with the character of the leader, with your character. In order to lead others you have to make sure your own house is in order.

1-7: The example you set is just as important as the words you speak.

1-8: Purpose ... does not mean that as a leader you must explain every decision to the satisfaction of your subordinates. It does mean that you must earn their trust: they must know from experience that you care about them and would not ask them to do something - particularly something dangerous - unless there was a good reason...

1-10: Trust is a basic bond of leadership, and it must be developed over time.

1-15: People who are trained this way will accomplish the mission, even when no one is watching.

1-23: you demonstrate your character through your behavior.

1-56: Effective leaders strive to create an environment of trust and understanding that encourages their subordinates to seize the initiative and act.

1-74: The ultimate end of war, at least as America fights it, is to restore peace.

4-9: Be aware of barriers to listening. Don't form your response while the other person is still talking.

4-20: Critical Reasoning ... means looking at a problem from several points of view instead of just being satisfied with the first answer that comes to mind.

4-24: Ethical leaders do the right things for the right reasons all the time, even when no one is watching.

Such a group is not "the enemy." These aren't the words of people with an objective of hatred and destruction. These aren't the techniques of evil.

The people aren't the problem. The army is not the problem. Individual decisions are not the problem. The problem traces back, up stream, to our collective human immune system. Like Peter Senge's example, even when everyone does the right thing with the right intentions, this sucker breaks down. OK, fine, we've identified the issue, and some tools.

We owe it to everyone who fought to get us this far, preserving the values they understood our future depends on, to complete the job, repair the planet, and restore a vital peace that finally works correctly and doesn't keep veering the car off the road into the trees.

And we owe it to our veterans not to leave them homeless and abandoned. The weapons may have changed, but in a larger sense, we still need to "complete the mission" and protect our future. It's not "their war" and it's already "over here."

It is immoral and twisted to send our children to fight and die to protect some set of values that we are all not involved in protecting through our own daily lives. If these values are not a big deal, then bring the army home. If they are a big deal, why aren't the rest of us working on all the other fronts possible to resolve the conflict and all future conflicts?

"Memorial Day" 2007

Public Health, business, jobs, and profit

All of my theoretical models lead to the same conclusion - the field of "public health" cannot really do their job well until the needs and interests and realities of multi-human meta-organisms are included as well.

In English, that means that we ARE what we are PART OF, which is increasingly clear in public health studies of the impact of social connectivity on physical and mental health.

But it also means that the internal life of corporations, cultures, and nations, as well as the entity called "the public", are all very real systems that behave as if they were separate biological goal-seeking, energy-consuming, adaptive, reactive, self-protective organisms.

It also means that it just doesn't make any sense to evaluate the impact of different interventions in the health of people without, at the same time, evaluating the impact on jobs, employment, and the health of corporations and business and the business community.

The physical health of people in a community or nation is very directly influenced by the "health" of the community or national economy. If the economy or businesses crash, it will show up "under the skin" very rapidly.

The failure of many in public health to have a wholistic approach that includes BOTH people AND corporations reduces the credibility of public health. If there is one lesson "systems thinking" teaches, it is that the word "OR" is vastly over-used. We shouldn't be thinking that EITHER we can serve people OR the public - we need to lead the way in serving BOTH. And, similarly, we need to get corporations realizing that they can't survive if the workforce they draw on, and customer base they need in this country collapse. We need each other. We are each other, in some very real ways, and our respective "health" depends on each other in a feedback loop, either for better or worse.

Similarly, it makes no sense to me that "Republicans" should be fighting for the interests of "business" and "Democrats" for the interests of the "people" - because there is only one, multi-leveled complex life-form on this planet, which includes "cells", "people", "corporations", "cultures", and "nations."

We are all in the same lifeboat. At this point if the people all die off, so do the corporations. If the corporations all died off, so would almost all the people. Get over it.

If we're upset that corporate or national planners don't include "human factors" in their planning, we shoudn't also assume it's because they refuse to -- it is, in my experience, more that they are clueless as to how to do that.

If public health wants to change that equation and interaction, great, pick up that heavy burden and figure out how to include humans in the equations and not make them indescribably difficult to solve. If corporations can get better bottom-line performance by doing better planning including more of reality in the plans, they'll do it, but someone has to show them how that would work and make a convincing case that it does work.

That gets down to that messy problem of "profit." As the Ross School of Business here in Michigan says "Non-profit is a tax strategy, not a business strategy."

Or, as one sister from Trinity Health Care's catholic leadership put it, "No margin, no mission."

Health is intimately tied to growth and life which are intimately tied to "wealth."
That component sub-systems decay and die is a given; what's up for grabs is whether there's a balancing source of regeneration and growth, which requires that actions result, ultimately, in absorbing more energy than is spent in getting there.

In other words, in the larger accounting scheme of life, public health interventions have to "pay off" or they will simply "die off." This is a schitzohrenia that both clinical health and public health seem to have - the idea that making money is intrinsically bad or a dirty concept.

Yes, obsession with short-range, stupid strategies to make money at the expense of life, health, and stability are indeed stupid. On the other hand, there is no such thing as a long-range strategy of losing money each year.

The most important distinction is that wealth, and health, are not zero sum, and are based heavily on interactions across levels of the MAWBA beastie.

Health can, in fact, be created out of thin air.
Wealth can, in fact, be created out of thin air.
BOTH of these, health and wealth, cross-support each other.
Being "rich" and "dead" is not a winning strategy.
Some balance is required.

Public health has an opportunity to teach the principles of SUSTAINABLE GROWTH, which means sustainable rates of return on investment. Business owners hate that venture capital firms and stockholders expect them to operate to maximize profit this quarter, at over 27% a year annual rate, but to keep operating in the long run.
Those are incompatible goals. With the exception of discovering gold or the equivalent, healthy businesses probably grow at 10% or less, maybe as low as 2% per year. If public health would show CEO's how to keep stockholders from jumping ship if the companies invested more internally in people and showed such "small" profits, the CEO's would love public health. Everyone knows this is an absurd demand that's killing off healthy, stable business as "not up to par."

These problems cause each other. People are stressed out because the businesses they work for are stressed out. Businesses are stressed out because they don't know how to tap the healthy creative power of people at a sustainable rate. They are different views of the very same, multi-level, MAWBA problem.

If 30% of the humans died or were seriously put out of commission for 2 months by something like avian flu, at least 30% of the corporations would crash and burn as well, because they are riding very close to the line on being as short-staffed as they can be right now. The crash would cascade, as suppliers of key components failed. The interests of public health and "big business" align when it comes to stopping global pandemics.

This fact is maybe less visible because of the invisiblity of the details of the roles of people on "the bottom" in keeping corporations operating. My guess is, after the last round of layoffs, that more than half the large corporations in the US are vulnerable to crashing and burning if 30% of their Information Technology staff were to abruptly be incapacitated on the same day. All meta-life involves a constant battle between natural collapse and regenerative efforts, which may "look like" nothing is going on and all is "well." Remove those people who are holding everything together, and it will suddenly become apparent that maybe they were doing something after all.

Other areas of "infrastructure" are similar. We have huge reliance on armies of people doing low-visibility or invisible jobs, without which the wheels of commerce would cease turning in a cross-cascade, house-of-cards type collapse.

It is a mistake to think that pulling out the "safety net" has "worked." It hasn't been tested on a full-scale pandemic yet. The effect of having almost 50 million people in the US without health coverage will have the same effect as having a basement filled with gasoline-soaked rags would have on a small house fire. These are things you really do NOT want to give a running start on you.
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(This was originally published 11/21/06 on my weblog "might as well be alive" at http://mawba.blogspot.com)

Multilevel Architectures - Bane or Boom?

Marsden Bloise once described life as having a "curiously laminated quality."

Life on earth does have levels, and they have important mathematical consequences.

In fact, the multi-level model is one we find reasonably familiar and can live with. We structure our corporations and government to have layers and levels, with people one "one level" reporting to people on "a higher level."

Not only are there levels, there are gaps between the layers. It is almost like a quantum mechanical model, where there are legal levels and forbidden zones.

In the world of large-scale enterprise computing, there are officially levels (see the OSI model), where there is a hardware level, a messaging level, an application level, etc. The goal of each level is to function so well that it essentially becomes a perfectly flat, stable platform or metric on which the higher levels can be built. A perfect level "goes away" and "falls out" of the equations.

So, in the best world, when nothing is going wrong, an application such as Microsoft Word can say "save this file!" and, behold, it happens. The application doesn't need to concern itself about the details of what brand disk-drive is in the computer, or how may empty slots of what size are there, or how to chain them together and break up the document into chunks that size for storage and retrieval later.

Or, in business, workers and "the boss" or the next level of management up have a functioning gap between them. The boss doesn't really want to know the details of how something happens, and only wants a simplified, almost cartoon-level sketch, and mostly cares, yes or no, did that happen. The employees see all the details and prefer the boss not "micromanage". The employees have little idea what the boss does all day - so long as reasonable work tasks come down the pike in reasonable order, it's good. The boss has little idea of the complexity of many tasks, or the pains that have to be taken to accomplish them.

On the upside, this makes "management" even possible, because otherwise the world would rapidly become way too complex for anyone to ever comprehend, and the largest business would probably be something like 200 people.

And, if perfectly managed, lower level computer "infrastructure", like plumbing or electrical wiring, should be completely invisible. The thousand upgrades a day, putting in new hardware, swapping out old networks, installing new security patches, upgrading the database or operating system, should all be done "seamlessly" and at most result in a slight slowing down of normal response time.

One downside of this is that it is very easy for the upper levels to mistake the perception with reality. The classic problem in preventive maintenance is that, if perfectly done, all problems are seen coming in advance, headed off, and so "nothing ever breaks" -- and consequently upper management, at the next budget crunch, decides they can lay off the maintenance department because, who needs them, nothing ever breaks! So, they do, and only later discover what it was that the department did.

A second downside is that upper management is shielded from details by multiple layers of oversimplified sketches to the extent that they mistakenly believe that the tasks people at the front, or on the bottom, are actually easy to do, or even trivial. Consequently, it follows that the people doing them are really only one step above morons, and also that failure to do the tasks must be due to not only incompetence, but bad attitudes, because anyone can see the work is trivial.

Thus we have what I call "wicked-II" (wicked two) problems - where the tasks may be enormously difficult, but from above or outside they appear to be simple or trivial.

The immediate consequence of those misperceptions then are that management may decide, in its infinite wisdom, to undertake some new task, or "put in" a new computer system that, from their very limited depth model, should be "easy." First, they seriously lowball the associated work and costs. Then, they interpret reports of trouble from below as being obviously due to incompetence, laziness, or, worse enemy action that demands instant retaliation and disciplining or firing the idiots who resist. Management says "I don't want to hear about problems! Don't tell me you can't do that!" That directive appears to be successful, as complaints drop to zero, until the whole project finally crashes on the rocks the employees were trying to warn management about when they got fired. Management blames the employees for failing to do what they were told to do. And everyone loses.

This model of operation appears to be the norm, and enormously easy to slip into, even if management is trying hard not to. It is what "safety cultures" and "high reliability organizations" have to try to overcome in order to work.

So, we also expect to find, throughout history, a vague awareness of this type of problem and hard-won advice on some benchmarks to avoid falling into that same pitfall in the future - advice typically ignored as old wives tales, so the future generations end up rediscovering the world of hard knocks.

In some ways, this is like the brain-body dichotomy, where our conscious selves are able to think deep thoughts, like what movie to go to, and be generally unaware of all the hard work going on in the body below synthsizing enzymes, digesting food, managing pathogen invasions, etc. It is all too easy, not seeing those details, to take "the body" for granted and neglect or abuse it. And, as with management, complaints can be suppressed and we can continue on deep into fatigue and exhaustion because of higher goals, until some physiological system that was trying to warn us finally collapses. (Recall the old rule of thumb - the time to furl your mainsail is the first time it occurs to you that maybe you should furl your mainsail. Those who forget it as the wind picks up rediscover it after their mast snaps or the boat overturns.)

Similarly, "upper" levels of society are reminded in all religious literature to "remember the poor" and take care of the powerless "below" them. This advice is often neglected for short run gain and long-run disaster.

Similarly, "upper" structures, such as corporations, can easily forget that their existence depends on the lower level existence of a healthy workforce and community, and a stable ecology and climate. Again, industry can take actions for short term gain that undermine the workforce health or environmental stability, with long term catastrophic results. It's very easy to do, and very easy to suppress complaints.

Similarly, "upper" levels of the military, or civilian government, can suppress dissent and ride roughshod over the key needs and observations of their own staff, often without realizing they are doing it. The result is being surrounded by "yes men", being cut off from reality into a fantasy shell, and making terrible mistakes that end up being catastrophic.

The problems listed above are all the "same" problem mathematically. Interlevel communication and the tradeoff between "invisibility / detail hiding" and constant needs that have to be met remains an open problem.

(note: I originally posted this Nov 21, 2006 on my weblog mawba.blogspot.com,
where mawba = "M.ight A.s W.ell B.e A.live", and it got this comment:
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Frank said...

Wade:
A truly great analysis. Are you aware of Macintosh, Moffat, Atkinson's works on resilience and networks? They are going to the High Reliability Organizations conference in Deauville next may (http://www.hro2007.org/index.html ). I find Atkinson book in particular quite congruent with your analyses. There is a link on that page where you can download it: http://www.hro2007.org/speakers.html
Frank H. Wilson

5:42 AM

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