In each of the last two posts I have mentioned Paul Batladen’s famous observation about the output of “systems.” Last Tuesday I wrote:
The great physician and advocate for continuous improvement, Paul Batalden of Dartmouth, has reminded us frequently that “Every system is perfectly designed to get the results it gets.” The results we see as the hospitalizations and death rates from COVID-19 climb, are in large part attributable a system that has designed itself through decades of seeking profit from healthcare delivery while the public clamored for lower taxes, and the budgets for public health were slashed to provide a few shekels of extra money to reduce the burden on taxpayers of providing everyone with a healthy environment, and personal access to care.
Last Friday’s post focused on a “Perspectives” article from the July 30 issue of the New England Journal of Medicine that discussed the importance of health policy by Dr. Eric Schneider. The same edition included an editorial written by Dr. Schneider and two colleagues entitled “Fundamentals of U.S. Health Policy — A Basic Training Perspective Series.” The first paragraph of that editorial quoted Dr. Batalden without direct attribution:
It has been said that every system is perfectly designed to get the results it gets. The strengths, weaknesses, flaws, and complexity of every health care system stem in large part from health policies. The U.S. health care system did not arise randomly but through a series of deliberate policy choices, many of which have come with unintended consequences. Efforts to reform our system over the past century reveal the ways in which Americans think the system has fallen short. They also reveal what we hope our health care system will do for us.
I am not an expert in systems theory, but over the last thirty years it has been a subject of interest for me. In 2008 I had the very great pleasure of spending a day sitting next to Dr. Batalden at a conference at Dartmouth. Not long after that extraordinary day I was visiting Don Berwick at the offices of the IHI which were then located near Harvard Square. Batalden was one of the founders of the IHI, and I noticed that someone there, I assume Don Berwick, had had Dr. Batalden’s wisdom painted on the wall in large letters. There it was as a constant reminder to everyone who worked at IHI or visited, “Every system is perfectly designed to get the results it gets.” For many years, Dr. Batalden has been very interested in quality improvement through the “micro systems” that are organized within a practice, or within a hospital. Hold that thought. We will be coming back to “systemness” after a brief side trip to explain the origin of some of my thinking behind this post.
In previous posts I have mentioned that I am the moderator of my congregation at the First Baptist Church of New London, New Hampshire. The religious history of New London is not like many New England towns where the dominant religious organization was the Congregational Church. New London is not an “old” New Hampshire town. It was established in 1779 by sixteen families from Massachusetts. In New Hampshire, the law at that time required that each town establish a church. Most towns chose the Congregational Church, but at the town meeting in 1787 New London broke the mold and voted to be Baptist. The current church building was begun in 1826 and its sanctuary seats almost 500 people which is an indication of the fervor that existed at that time.
These days religion doesn’t sell all that well in New Hampshire. The percentage of the population that attends church, a synagogue, or a mosque or has any connection to any religious tradition is at an all time low. In multiple studies New Hampshire and most of northern New England have been shown to have the lowest percentages of citizens of any state in the Union who attend religious service or acknowledge an affiliation with any religion. Our church has a historic building and an endowment that is a reflection of the commitment of its members over the many many generations, but like all churches is seeking to redefine its mission and vision in the context of these challenging times. After much discussion between our minister and the church leadership, we decided to read a book together, Healthy Congregations: A Systems Approach by Peter L. Steinke.
We have just begun our discussions of the book, but I was immediately impressed by Steinke’s approach. He began his discussion of systems theory with a quote from Lewis Thomas, MD.
The whole earth is alive, all of a piece, one living thing, a creature.
The quote comes from his 29 essays published in the New England Journal between 1971-73 and collected as a book published in 1974 that you may have read, The Lives of A Cell: Notes of a Biology Watcher. Lewis Thomas and systems theory focus on our connectedness. The previous link is to the 1974 New York Times review of Lives of A Cell that was written by Joyce Carol Oates. As one might expect based on her remarkable literary talents, her review is well worth reading, but I would direct your attention to the point that both Thomas and Oates are making, and toward which I am slowly moving: We are all connected. (Pardon my bolding in what follows.)
“We are told,” Dr. Lewis begins mildly, “that the trouble with Modern Man is that he has been trying to detach himself from nature?” But the revolution in contemporary biology provides us with the knowledge, at times unpleasant, that such a detachment is totally illusory: man is not only completely embedded in nature, he is not definable except in terms of his environment. The earth’s life, far from being fragile, is the toughest membrane imaginable; we are its delicate part, “transient and vulnerable as calla.” Man has only invented in his philosophical fantasies an existence superior to that of “brute nature.” But aren’t we somehow special? Dr. Thomas: “We carry stores of DNA in our nuclei that may have come in, at one time or another, from the fusion of ancestral cells and the link of ancestral organisms in symbiosis. Our genomes are catalogues of instructions from all kinds of sources in nature, filed for all kinds of contingencies. As for me, I am grateful for differentiation and speciation, but I cannot feel as separate an entity as I did a few years ago, before I was told these things, nor, should think, can anyone else.”
Undogmatic, graceful, gently persuasive, these essays insist upon the interrelatedness of all life. But what has been common religious knowledge in the East from ancient times always sounds very nearly revolutionary in the West. All truth carries with it political and moral implications; science cannot be divorced from the rest of our civilization, any more than an individual scientist can be divorced from his participation in the world as a human being.
“Systemness,” interdependence, community, and the inherent worth of every life are subtle threads that I have tried to weave through these notes over many years. I have tried to say in ways that are convincing to individuals and to organizations that we are all part of something larger than ourselves and that if anyone is excluded or has their health compromised by design flaws in the “system” we are all at risk because of our interconnectedness. COVID-19 has taught us that what happens in China makes a difference in Albany, Georgia. What happens in Albany, Georgia and Albany, New York makes a difference in Atlanta and Chicago, and so it goes.
The interconnectedness goes beyond our species and the living world to include our environment. Connectedness and systems thinking are at the heart of the much maligned “Green New Deal.” For over fifty years Stewart Brand, the originator of the “Whole Earth Catalog” back in the 60s, has pushed an awareness of our interconnectedness as occupants on “spaceship earth.” Coal burned in eastern Europe does affect the temperature in New Hampshire. As we slowly cook ourselves in a tradeoff between the downside of fossil fuels and our desire for more and more, we discover that we are imbedded in a huge system where acting as self interested individuals we can doom ourselves and billions more as we unleash violent storms and unintentionally promote zoonosis. Zoonosis, the emergence of new human pathogens that have jumped from animals to human was the process that gave us SARs, MERs, ebola, and now COVID-19. As we sacrifice our environment to our greed, the usual “social distancing” we enjoy from these pathogens is lost as we destroy the habitat of the environment of the usual host. We are slowly learning that connectedness that enables “progress” without concern for systemness has its downsides.
We don’t give enough consideration to the difference between health and healthcare. Health is what is enjoyed when “systems” are in balance. Preventative healthcare, once promoted by the HMO movement, focuses on what I have sometimes called “anticipatory care. ” Preventative practice is our effort to practice a balanced approach to the management of the possibility of disease. Many physicians and healthcare systems find little interest in keeping our individual systems in balance. “Repair care” the treatment of disease and injury in an attempt to restore balance to the system has always been much more interesting and “sexy.” Can you imagine a TV show called “Marcus Welby: County Public Health Officer?”
Health implies systems in balance. We are discovering that we are imbedded in a huge system that is much like those little Russian Babushka dolls. Perhaps the smallest doll is our personal health. The next doll up is our family. Our families are followed by our communities. The health and prosperity of our communities is connected to the stability of our state government. The health of our states is impacted by the nation. The nation can not ignore the whole earth and remain healthy. I will let you take it from there, but I will tell you that the health of an individual is in danger when it is buried several dolls down from an unhealthy doll.
One of the points of the little book that the leadership of my church is studying is that conflicts or problems arise in all systems. Many of those conflicts have external origins. Some bubble up from within. These conflicts can lead to improvement, or they can lead to decline or extinction. Resolution of conflict and reestablishing order require effort. Improvement is dependent on effort, and is facilitated most often by leadership that promotes respect, understanding, and cooperation.
Like it or not, COVID-19 has enrolled everyone riding on “spaceship earth” in a huge global learning project. Unfortunate events that signaled a lack of health in the systems in which we are all embedded culminated in 2016 in the election of a man who has no understanding of the moral fundamentals of leadership and who is incapable of thinking deeply about anything but himself and those closest to him who enable him.
His “executive orders” this week have been called unconstitutional by many inside his own party. Their substance has been examined closely by many experts, and their criticisms are easy to find. Just Google “Trump’s executive orders.” If a specific link is your preference, I recommend John Cassidy’s comments in a New Yorker article entitled “Trump’s Latest Executive Orders Are a Political Stunt.” Cassidy has some good links to other opinions, and he nicely summarized the situation:
…Trump and his staff presented the issuance of the orders as a way to break through the deadlock on Capitol Hill, where negotiators from the two major parties are struggling to agree on a new spending bill. The executive orders “will take care of, pretty much, this entire situation,” Trump said.
Even by Trump’s standards, that was a ludicrous claim. Setting aside the legal issue of whether he has the authority to enact the measures he announced, it is clear that they won’t provide a lasting solution to any of the problems that they were supposedly meant to address. Like so many of the unilateral actions that Trump has taken over the past three and a half years, the orders were designed to garner some headlines and give him a short-term political boost. So far, their main substantive impact has been to create confusion among those likely to be affected.
The president’s history of more than 20,000 less than honest statements and his day to day management of the COVID-19 pandemic guarantees that anything he does between now and the election will create suspicions, not only for the cynics among us, but also for those of us who have come to realize that we are likely never to know the full extent of his enormous inadequacies. Cassidy speaks for many when he writes:
Taken as a whole, it’s clear that these executive orders wouldn’t provide adequate support for the people they were supposedly designed to help; they also fall woefully short of providing the level of support that the economy needs. Through year’s end, “these policies look likely to provide something like $200bn in fiscal relief,” the analysis by Goldman Sachs said. That’s a fraction of the $1.5 trillion that independent economists have said is the minimum sum necessary to prevent a further downturn.
Trump’s economic advisers know all of this, of course, although that didn’t prevent two of them—Larry Kudlow and Peter Navarro—from going on the Sunday-morning talk shows and defending his actions. Far from being a serious effort to prop up the economy, and to help the tens of millions of Americans whose livelihoods the virus has upended, the executive orders are essentially a political ploy.
In case you missed it, the $400 weekly payment to those who are unemployed is not fully funded and will require that the states pay 25%. Since more than a third of states, primarily “red states” where poverty is high, would not join in accepting a 10% share of extending the Medicaid portion of the ACA, what are the chances they will buy into this move? It is an empty box that is wrapped with a bow that he is trying to pass off as a gift, as are the other three “orders.” By failing to give any support to local and state governments the president ensures that even if we recover next year from COVID-19 there will be empty storefronts on the “Main Streets” of America for years to come, and we will have the much desired “reduction” in government that conservatives have talked about since Reagan because many of our cities and towns will be bankrupt and unable to employ teachers, police, firefighters, and other “essential” employees. Oh, and don’t forget to pay your mortgage because that “executive order” was just a “suggestion to study.” Our system is not healthy. COVID-19 reveals enough flaws in our system to keep us in a repair and improve mode for the next fifty years.
I have one final comment on the flaws in our “system” that have been revealed by COVID-19. Have you given much thought to what “essential employee” really means, and who the “essential employees” are? Each defect in our system has its own lexicon of terms with deeper meanings that require some thought to comprehend. In a way they are deceptive, like Trump’s executive orders. We all know that essential employees include doctors and nurses and other healthcare workers. We failed them with inadequate PPE, but we have failed in more dramatic ways the many other “essential employees” that keep things running. I am referring to the people like the ones who deliver our goods that we ordered online, or those who stock the shelves of our grocery stores, or work to maintain rudimentary transportation systems, or collect our garbage, or grow our food, and especially those who process poultry. These people are often from the minorities that our numbers show have suffered the greatest losses to the virus. These low paid workers who have few benefits are really people that we treat more like they were “disposable” than “essential.” Many we even call “illegal,” even as we take advantage of their labor and their lives. ,
So, four years ago many were saying that we needed a businessman to run the country who was tough enough to drain the swamp. What many did not understand was that his swamp included social security, healthcare, education, housing, and necessary infrastructure improvements. He is telling us now that if reelected he will permanently do away with payroll taxes. That is a dog whistle to a base that hates these taxes and that could care less about the elderly and the poor. He is not talking about replacing the part of the social safety net that will be destroyed with something that is more equitably funded. He is describing the road to “Medicare for None.”
There is hope. All systems have feedback loops that function to correct failures if they can’t be avoided. At a personal level most of us are empathetic, have a little “Jiminy Cricket” like voice that tells us when we are off track, and we are capable of embarrassment when our failures are revealed. As organisms, we have immune systems and are capable of healing. At a collective level most of us are capable of “fellow feeling,” and love of those we know. After being sure that we are safe, we have a curiosity about the world and those whom we don’t know, but who are riding through the cosmos on “spaceship earth” with us. “Nations” are a relatively recent extension of “tribe”and the benefits that they extend come with even greater responsibilities to understand and promote systemness and recognize interconnectedness. We don’t do “world” very well at all, but for the last one hundred years since World War I demonstrated we had a problem that could kill tens of millions, we have been trying. We have created the UN with the WHO and UNESCO. We have tried to study and promote the planet’s health through international efforts to address global warming. We have a World Bank. We have a World Trade Organization. We have agreements that support international travel. Commerce is multinational. We are getting there, but we are led by a man who is ignorant of the necessities created by interconnectedness, and who has done his best to harness the ignorance and frustration of others to his own self serving agenda.
The feedback loop that is threatened, but hopefully will not be overwhelmed, is the November election. For systemness and for the future of not only “the least among us,” but for the sake of all of us, we must remove this leader and as many of those who enable him as possible because we are connected. We know that the fluttering wings of a butterfly on one side of the planet does impact the experience of a child half a world away. We are interconnected. Our interconnectedness leads to enormous possibilities for everyone, and simultaneously puts us at all in harm’s way together. Walls around our homes or at our borders will not allow us to avoid what we fear, but will not fix.
Our interconnectedness is the deeper message of COVID-19. It’s not politics, It’s science. Politics can join forces with science to protect us all, and improve all of our lives, or politics can ignore science and leave us all to suffer as is often the experience of anyone who follows a fool and does not understand or believe in our connectedness. There will be more challenges to our wholeness and to our collective future over the next three months. Look below the surface of what you are presented as you search for the truth that can protect us.
