Stafford Beer, the British theorist, taught that “the purpose of a system is what it does.” But too often, what it does is not what was intended. If we want our community systems to produce something different, we need to do something different. Consider the story of Betty, a middle-aged woman living on the street.
Betty turned up at a residential food pantry. A woman in her mid-50s, she was withdrawn and wary, but naturally likable when answering questions. A month later, she was found sleeping unsheltered and alone in the rain outside a nearby church. The address she had given was the home where she and her husband lived most of their lives and had lost a few months earlier.
Betty and Joe were quiet, working-class people who fell into debt while Joe fought and lost his battle with cancer three years prior. Following his death, Betty grew despondent and withdrew. Back then, her church was preoccupied with other things and never noticed. She had little formal education beyond high school and rarely worked outside the home. What friends she had drifted away.
She had no health coverage or social service support, and luckily no substance abuse problems or mental illness beyond the severe stress of trying to survive in the cold alone. She was just one of the many invisible people we barely notice as we drive by.
On her third visit to the food pantry, she was “edge of life” sick. The person who came to her aid was a pantry customer living in his car who drove her to the emergency room. A medical evaluation showed that she was in serious condition requiring hospitalization. The working diagnosis was pneumonia, sepsis and impending shock.
Her course was rocky, but she came through thanks to high-quality hospital care and excellent medical staff. Now, she needs outpatient follow up for the pneumonia, as well as for the two lesions unfortunately found in her lung, consistent with metastasis. Three-year-old outpatient records describe the difficulty of getting her to the clinic for follow up of an abnormal mammogram.
The first impulse for many of us is to blame Betty. Why didn’t she call someone to help? Why didn’t she develop more skills and get a decent job? How is it she didn’t know what to do? Why didn’t her church help? Where are her children?
But none of those answers change the reality facing her – and us.
This is not a story about “bad people.” The hospital, physicians, food bank and Betty’s church performed their roles as best they could within the community system in which they operate – a system that doesn’t work the way we think it does.
This is a story of lost opportunity due to the loss of connection. Yet Betty’s disconnect wasn’t her problem alone. Her suffering and the cost of her illness is paid for by society as a whole. Those who are directly affected also suffer in different ways, which creates new problems. The web of relationships in society amplifies those effects, leading to additional problems that can build on each other.
Betty lost her house when medical costs overwhelmed her family because she lacked connection. If she had been better connected, she would have avoided this expensive illness and new morbidity. Likewise, her breast cancer could have been managed three years prior while still in its early stages. Now, post discharge follow-up is seriously complicated and made more difficult by a community system that doesn’t work.
Things we are doing such as referrals, resource lists or improved information exchange are just different ways of doing the same thing – they do not change the behavior of the system and therefore will never result in significantly different outcomes. A different result requires different system behavior, which requires a fundamental change to the way we do things.
This seems counterintuitive to a culture that has long thought it could manage community systems like we manage factories and machines. But communities are complex, self-organizing systems that adapt quickly and easily out-maneuver the slow and rigid control systems of the factory. And attempts to impose hierarchical command and control to adaptive systems also tend to generate the unintended consequence of increasing cost while doing little to improve outcomes.
To change the behavior of the system, we need to change its architecture, refocus its purpose and align incentives around that purpose. We can do these using platforms designed for social determinants of health that are adaptable to complex, adaptive problems like Betty’s. The starting point is a collaborative network of all human services. The network itself becomes the point of entry for problems and the integrating medium of intervention and learning.
Imagine if, when Joe was dying, Betty had been on the radar of a community network that collaborated to help her deal with that transition. Such a network would need few resources to keep her connected and out of the trap of social isolation. She might have found a way to employment or a way to transition from her house to more affordable housing.
At the food pantry, most of the customers have complex problems. Food alone won’t help them address what’s holding them down. They need a more comprehensive solution, one that would help more people avoid Betty’s expensive troubles and get back to living more productive lives.
The same collaboration network would integrate and amplify the work of all. If we began to track dynamics and cost, we would begin to understand more about the whole economy. Right now, most human service agencies are in zero-sum competition for donations from a small group of donors.
We cannot afford disconnected management of complex adaptive problems. The misery and cost this approach creates are downstream, outside the budget cycle and not tracked. They show up in cost trends moving premiums up. This human and financial debt creates a deepening hole in the fabric of society that has led to cascading failures we all feel.
There is hope if we can see from a new perspective. We can improve how the community behaves using scientific advances of the last two decades. These would enable better coordination of human services based on desired outcomes. The technology necessary to do this is already being implemented. What is needed is to see the problems from a more productive perspective.
The price of delay gets higher every day. Today’s systems are producing homelessness. If we want something different to happen, we need to do something different. The place to start is our perspective and how we use the tools available to work together to institute necessary change.
Dr. Michael Rohwer is executive director of Curandi and a member of The Lund Report's board of directors. You can reach him at [email protected].
