Health System Resilience (A proposal for the Resilience session)

[lucasg]

This is a runthrough of what we are going to do in the resilience session (join here). Executive summary: we will try to design a health care system that would work in a financial meltdown scenario, which could happen just three days after the conference in parts of Europe depending on Sunday’s elections in Greece. You will rewire health care to make it low-cost, decentralized and peer-to-peer as much as possible. You will be able to count on Lucas’s knowledge of health care systems and on Ben and Gaia’s network analysis skills. Let’s do it!

Health systems are made of people who have knowledge and work through procedures. They use buildings with machinery that uses consumables and energy.

The scenario is that of a financial meltdown. Even if there’s no money, parts of the system stay in place (people, buildings, machinery, knowledge and many procedures). But some things may become scarce (supplies of consumables and fuel) or will have to change (many procedures).

The overall suggestion is we could look at networks for help. Networks could be activated (or created) in order to look at:

• Supplies (energy, consumables): prioritise transport, synthesise some medication locally, repurpose existing physical resources, etc.
• Procedures: networks look at prioritary aims and adapt procedures: solve things at primary care level if hospital or ambulances fail, boil germs if there’s no electricity, etc.

Personally I’ve been looking at Vinay Gupta’s Simple Critical Infrastructure Maps (SCIM) model for a pandemic, which would be a different scenario.

• The model is simply a spreadsheet of “needs” x “levels”.
• One example of “need” is food, and it’s solved at different “levels”; in my personal case, food is grown internationally and brought to me via international-national-local transport. So, if international markets or transport break, I’d have to look elsewhere or grow food locally. (Poor farmers grow their food locally, and use no transport. In a bad-weather crisis, they need international supplies delivered to them. Or they move.)
• Vinay’s model includes “too hot, too cold, hunger, thirst, disease and injury” (for the individual), “communication, transport, workplace and resource-sharing” (for groups), and up to a total of 18 items for organisations and nation-states.

If the health system is a big organisation (really, a network of many organisations), then we want to look at more specific needs, which are covered by existing provision-systems, and if those provision-systems break then we need to look at alternatives (because needs stay with us!).

• In health systems, the basic needs of the individual (shelter/clothes, water, food) and groups (communications, transport) are still there.
• Specialised needs include: "sterilisation", "main groups of meds" (anesthetics, painkillers, insulin, cancerkillers, etc), "communications" (need can be produced by good protocols for local action), etc. Not a comprehensive list, but the rest can be inferred by analogy.
• If the electric grid fails, "sterilisation" can still be done with generators or boiling. If medicine markets fail, we’d be looking at making them locally if we can, etc.

Here’s how I’d suggest we approach the 2.5 hour session:

1. In 15 minutes (or less) I’d briefly explain how (I think) healthcare works using the SCIM model, and together we’d focus on what breaks in our scenario.
2. In 15 minutes, our network experts would look at it from the “network” point of view. I can imagine some things (each person has contact with others within the system), but not others. Together we can flesh it out, learn and contribute to the solutions, so do come!
3. We can then make groups of 3-4 people for each area. Each area would pose a specific subchallenge, and each group would be expected to come up with workable ideas. (If there are many areas, a group might want to do more than one area if they work really fast.)

AREAS:

What are the areas? A hyper-complex system such as “health” can be split up in many different ways. The general focus is “we have people and buildings and knowledge, but supplies may be costly or unavailable”. We think the following might work as “sub-focus areas” for our creative thinking:

• Peer-to-peer diagnosis and treatment. (Even diagnosis of epidemics?)
• Low-cost pharmaceutical products: medicines, prosthetics, etc. (Include water filters, compost toilets, hand washing in case there’s a general break-down and not just health-care is affected?)
• Prevention through life-style changes: can we help each other live healthier lives and enjoy the process?
• Cooperative help when there’s need for transport (or this is part of \#1).

Can you bring expertise to one or more of these areas? Can you suggest more areas? Do you have specific ideas we shouldn’t have to re-think?

WORKABLE IDEAS:

Coming up with workable ideas would be done by looking at two aspects:

• What are the networks involved: what people are closest to the problem? who provides the services now? who could provide some alternatives?
• How would the sub-focus needs be "solved": reinforce the present system if possible, substitute some elements, do a full redesign of the provision system, change some protocols, etc. Here, creative thinking can be applied to the fullest. If you’re a permaculturist, please apply permacultural design principles such as “relative location for mutual service”, etc.

[alberto]

I’m in!!!

Love it. Way to go!

[cbrewster]

Low cost health systems

I suggest we look at countries with effective health systems but which are “low cost” (as a percentage of GDP) as that may give useful insights on how they have managed without having access to certain elements in the international supply chain. Cuba springs to mind as an example.

Some questions of interest might include:

• what is synthesisable at a local level when the supply cain is cut?
• How energy dependedant are health systems in these contexts, i.e. what happens with no petroleum?
• All health systems have mechanisms to allocate resources and decide not to save some people's lives - how would that work at a local level?
• When we speak of networks are we refering to human networks or do we hypothesise scenarios where there is state breakdown but communication infrastructure still functions? In the latter case what does this provide or enable?
• What lessons can be drawn concerning health systems from past crises e.g. WWII or more recently the change from Yugoslavia (effective health system) to the Serbian/Bosnian war zones? How did health systems behave in post-Soviet Russia?

[alberto]

Excellent points

Wow, really good points. The only one on which I feel I have anything to contribute so far is number 4: in my understanding we are speaking of human networks. I would probably try to design p2p diagnosis and trreatment through networks that minimize the reliance on large communication infrastructure - though you can hypothesize that there would be some nonlocal communication, even if lo-tech and with long lags between iterations.

[lucasg]

Medication

“Synthesisable at the local level when the supply chain is cut” …

I’ve asked at my local pharmacy, and a friend who worked upstream in the supply chain. The repeated answer is “not much”.

I asked somebody in my twitter network who is into DIY biotechnology, with a specific question about insulin and he wrote a blogpost saying it wasn’t doable right now, and there were things they could work on in the future - apparently it’s not simple at all.

I guess it depends. Some medications are generics (doable by several makers) and are already doable more or less in a distributed way, say a factory per 40 million people or less. (That would be a way to measure distributedness, no?) But some are really concentrated in a few working hands.

Part of the trouble is that medications themselves have long and winding supply chains, which in some circumstances (a bad pandemic) are thought to be susceptible to disruption. Here, we’re talking about a handful of countries being affected, with “maker countries” probably unaffected, or at least less affected. So the supply would be there, it’s just that you can’t pay for it because you’re suddenly poor. If that’s the case, then maybe some important medications should just be paid for with international solidarity money. How much and how that’s handled, I don’t know.

Medications could hypothetically go into a spreadsheet, with how many are affected, how much they are affected, how much medication is needed (people x doses), etc. After appropriate sorting, the spreadsheet would give us 3 categories: “impossible” (impossible to do here, so we either import them, or we die), “possible” (we need to change how we do things, and we should start looking into “how” as soon as we can), and “done” (we already make them locally, so they are not really an issue).

My guess is most medications go into the “impossible”, but we’d need to ask real experts (world-wide) about “possible” and “done”.

For our exercise, we’d just have to consider the three categories, and asume each is dealt with differently.

If there’s money or if medications are paid for, transport is not the real problem, because these things are not heavy. Let’s go for (I think) high-ish figures, and say 5% of the population need 100 grams of medication a week, that’s … 50000 x 100 / 1000 … 5000 kilograms per million people and per week. A couple of medium-sized trucks per million and per week. Truck classification - Wikipedia

So, factors are 1) production, 2) payment and 3) transport. (Maybe there are others, like quality control, local distribution, etc, but we can work from those 3 factors.)

Just asking the important questions might take us somewhere - if not now, then later.

Just my 2 cents!

[alberto]

Too linear!

Lucas, this is great but it has a small problem: it presupposes linearity. That means, if now we consume X mediation per week each, well, that’s what we need. This kind of assumption defeats the whole point of a resilience exercise, which is built on the incompatible assumption that X medication is NOT going to be there for you. Linearity assumptions are particularly toxic for the resilience crowd since the Club of Rome predicted that we would run out of several major raw materials in the 1970s.

So let’s look at health, not medication. Instead of sleeping pills, prescribe cutting wood or long-distance running, for example (works a charm for me). Can we do it? You are the doctor.

[lucasg]

Past consumption as reference

Actually, we shouldn’t really look at how much medication we’ve been using.

We should look at real problems, whatever that is. The old issue of “silent high blood pressure” vs “obvious need for conversation”.

Could networks filter what matters? I wonder.

[toolosophy]

J. Galtung on Resilience

Very captivating iscussion here.

I may be a little of topic here but I’d like to bring out a few ideas i found in J.Galtungs book “Peace by Peaceful Means”.

He says that the word for “RESILIENCE” in human and social development is “SUSTAINABILITY”. A better term is acual “REPRODUCIBILITY”, capability of reprodcing itself over time by its own resources. This is not only aplicable not only for nature & for societies, but also for the human & the world level.

Diverse components interacting simbiotically, here interpreted as not parasitically but as equitably, is the key.

I would sugest we sould also focus on the things that keep us healty and in good shape on a dayly basis without the need of medicine. [food, living environment, risk factors, etc.]

[alberto]

Agreed!

Yeah, I agree. If you read the report, you will find that one of the sub-groups is on prevention. Prevention should be paramount anyway, but we all know it is not, and in truth health care top managers, ministers etc. care more about treatment, large hospitals etc.

In a financial meltdown scenario, treatment is extremely difficult to deliver, and you just havve to minimize it by boosting prevention instead, just as you suggest.

[lucasg]

prevention and treatment

If someone with chronic bronquitis stops smoking, he (it used to be a “he”, anyway) will still have chronic bronquitis.

We need to do both.

Both without much money, but with lots of other ingredients. which we should look for, and cook well.

[james_beecher]

A few comments

Don’t have time to properly think about this before travelling but a few comments off the top of my head:

1. Financial meltdown? Resilience is about being adaptable and surviving unknown shocks - so wouldn’t it be better to think about the resilience of a health system to a variety of shocks not just one?

2. What are the problems of financial meltdown - we could easily spend (or waste, depending on your point of view) the whole 2.5 hour session identifying these, which would be a crucial stage if trying to design a resilient system to respond to such problems. I’m not sure we’d all agree either…

3. Health? Ok I’m very interested in this, and it would be a key sector - but I feel it’s slightly odd at a conference like this not to leave more room for discussion of what we understand by resilience and how we think it can be  usefully applied as a concept. This level of detail feels like it might suffocate valuable experiences people have had regarding attempting to increase resilience / thinking about how it applies to other sectors / more widely. The way the proposal above looks, the implication is given that technical knowledge of health is required?

4. To me, this whole thing looks more like business continuity planning, rather than resilience, in short.

Sorry - that probably sounds mean, but only because I’m stressed ahead of travelling and don’t have time to comment properly. Happy to discuss more in person if we get the chance. And will engage enthusiastically whatever…

[lucasg]

General and specific resilience

I too think “resilience” is about a variety of threats, not always one at a time. “Interesting threats” (speaking Chinese here) - say climate change, peak oil, bad pandemics, etc - all have a tendency to be locally not-easy to predict, and then fluid when they evolve. So, for example, a financial meltdown can start out bad or worse, and may later conceivably morph into, well, war. If the threat is (or becomes) bad enough, domino effects start to happen, and then it almost doesn’t matter what started it. Resilience that keeps a broad view, but that’s also locally specific, is - I think - the way to go.

Now, we only have 2.5 hours, so I think we need to do like when we eat spaghetti: select where to stick the fork, then spin the fork once or twice depending on how big our mouth is.

If we go for “health”:

1. We could use a strictly limited time to look at a few “worst impacts in vital areas”. No need to cover it all, and no need to agree on everything. But we might “mostly agree” on a few priorities, like, I don’t know, “young diabetics would die without insulin”, “baby delivery and heart attacks still happen”, “what if I break my skull”, “some vaccines are clearly useful”, “we’ll see the effects of current overweight and smoking in a few years”, or whatever it is that we agree on.

2. Then, we could look for ways to serve those vital, persistent needs - the system may break, but the needs stay. (Not with business as usual, because this is not about “saving the grid” but about “staying warm in winter”. Focus on needs, not in old systems.) We don’t need to be experts in technicalities, and I’d personally find it a good secondary outcome if we come up with a list of questions for specialists. But certainly we can use everything we know how to use: networks of people, lateral thinking, permacultural design, and whatever we all bring.

I’m for it, and we’ll see.

[alberto]

Hard choices

Hey James, I hear what you are saying. All of your points are sound, though I disagree with the final one (will come to that in a minute).

We are facing two constraints here. The shape the session takes is very much a function of that.

One: 2.5 hours means we have to choose a subset of a subset of a subset of an issue, or it will be unmanageable. Health care in  a financial meltdown was suggested by Vinay as a means to (1) connect to the upcoming Greek elections (next week they could find it very hard to pay forn their national health service as the public sector runs into a liquidity stonewall) and (2) take advantage of Lucas’s expertise. Now of course, with you and Simone, we have in the session two people who have hands.on experience of permaculture, and the session could be rearranged around food security (for example: how can a 20K inhabitants city in, say, Northern France achieve self-sufficiency in food production?). I am good with that, but then you have to take the lead!

Two: the selling argument. The long discussion following Vinay’s “War” post touched, among other things, onto the difficulty to sell resilience. lote is after all a big governmental setting, so people will be looking at us with a lot of skepticism. We thought it would be a nice chance to hone our skills at pitching resilience as a sound, sensible policy issue. So, tactically we stay away from “zombie apocalypse” narrative and try to impress the audience with our pragmatism and technical smarts.

Now to the point of contention:

No, this does not look much like business continuity planning to me. Reason: we are going to stay clear from linearity assumptions (see my Too linear comment below). Once you do that, you refocus on needs (a very different thing from demand), and the business side of the equation melts away. If the exercise were just about how to float a downsized version of the same system you already have, then of course you would be right. But there is probably no way that’s a defensible approach in a financial meltdown, so we get to be radical and realistic at the same time.

Makes sense?

[james_beecher]

makes sense

Yes - that all makes sense - look forward to discussing it in person, which I find much easier! I’m very interested in health, and in terms of policy rather than practive I am maybe better informed than on food (perhaps, anyway) - but from a anti-privatisation direction, rather than a treatment / resilient-to-emergencies perspective…

I haven’t seen “the long discussion following Vinay’s “War” post touched, among other things, onto the difficulty to sell resilience”, but will seek it out. I’m not so sure about the difficulty ‘selling’ the concept of resilience… it seems to be almost everywhere at the moment (almost as ubiquitous - and approaching the level of confusion over meaning - as ‘sustainable’). I’m not keen on the language of ‘selling’ things either - how about ‘get people excited about’, ‘inspire’, ‘enthuse’, ‘educate’ or ‘teach’ - do we have to use the language of markets and marketing? I don’t want to be a snake-oil salesman for ‘resilience’ as a concept or policy - I want to live in a resilient neighbourhood/locality/community/country/continent/world! Yes, that will involve policy, but more importantly, it will involve people!

[la_gaia]

I’m so in!

I am so in on this, and have been doing a lot of heavy-lifting-thinking about networked approaches to health and a networks understanding to resilience… TBC at the conference

[lucasg]

networks

I’m eager to learn about your findings.

I can imagine information and knowledge flowing to where it’s needed, but it’s very vague at the moment.

I read somewhere that it’s a good idea to have some “silent time” within the session, so that we can each write our notes. That way, each of us enriches the set of useful ideas, increasing originality.

We’ll see, I hope!

[emiliano_fatello]

hey Luca ciao, for me it would be an honour to have a role in this project, because I also wrote somethings as your project, but more of the comunications. sorry if now I don’t write very well or undestrand but  I did an hard trip: I started from stoccolma at 3:00 o’clock, pass for Berlino, Baden Baden, strasbourg by train and the berlino airline lost my bag…

So if it’s possible I would undestrand better the project and the works to do… I wrote something similar but more of the comunications. I thought to improve the priority of the comunications between citizens and istitutions during an emergency in a field (as those of the protection civil) with tecnological toolmand software to install in the field!

the speed it’s all after the first hours of the natural disaster… I saw with my eyes in Aquila and Emilia Romagna!

[lucasg]

Fastly set-up communications

Hi, Emiliano. I hope you’re better rested when you read this.

Communications systems that are deployed quickly are helpful in many (or all!) emergencies, and from what I’ve been reading (Haiti, frontlineSMS, open-source mapping systems, crisiscamp, etc) they are being used more and more in rapid emergencies.

This makes me think about the nature of an economic meltdown. A person becomes unemployed in a day. But for a community the process happens gradually - or maybe there are “jumps” when compensation mechanisms (help from families or from unemployment funds) themselves fail and, almost with a noise, snap broken. So, in fewer words, I don’t really know how quickly this will play out.

In any case, that’s one potential difference between economic meltdown and other crises: speed.

Another difference is how much communication is needed, and at what distance. In a forest fire, it may be enough if a few teams are interconnected by radio. Within the team, communication may happen via voice.

For societal resilience in the field of health, maybe much of the communication that’s needed is within shouting distance? Or much of the communication that’s needed is long-distance? I hope we’ll be able to look into that via the analysis of networks and health.

If there’s not a phone for each person (share!), maybe we’ll need to walk more. Which is healthy if you can walk. Or maybe we need to have the younger ones use their bike and visit the ill. Or some communication is inside a building, if people can talk from window to window.

medic.frontlinesms.com comes to mind …

I’m starting to see this “health resilience” experiment as a point in a hologram: I feel I’ll be learning about other kinds of crisis too.

(But we need to design something, and I don’t see it yet.)

[emiliano_fatello]

union of the visions

Yes Luca, we need more time to speak better of this importants themes! However think that you are speaking in the specific of the health care theme and it’s an important discussion with experts. I worked as volunteer in many emergency field and I saw any problems about the logistic, organizzation and security. But I undestood that the first problem that during a lot in the time is the comunication immediatly after the disaster, the comunication tools for the citizens and istitutitutions to collaborate and restart and rebuilt and also the trasparency of the comunication.

It’s true that there are many instrument active as these you show me in the precedente post and these are ok for the international crisis, but there are many national crisis where the comunication don’t work, the problem it’s worst at local level. For exampke it was a terrible problem for the earthquake in Molise and it was the same in the earthquake in Abruzzo or for the floods in Liguria. the people could not to spaek with anyone: friends, parents, security, policy, istitutions, they are isolated. Then, when the comunications started again there were many problems to administrate the prioritys for the istitutions and also fot the citizens it was a problem to understand the situation and to get the right comunications.

so I thought or I dream :-)  a software system with tecnological tools to install in the emergency filed useful to adminisrtate better the situation and also the security and specially the psychological status of the people. Also only a call of a friend, a think or a specific answer at a request of the peolple it’s very important, I touch with my hand.

So Luca I’m at completly disposition to built anything is usefull for our objectives! I hope that we can meet and learn by the experience and vision of all.

Come on!

Ciao

[emiliano_fatello]

union of the visions

Yes Luca, we need more time to speak better of this importants themes! However think that you are speaking in the specific of the health care theme and it’s an important discussion with experts. I worked as volunteer in many emergency field and I saw any problems about the logistic, organizzation and security. But I undestood that the first problem that during a lot in the time is the comunication immediatly after the disaster, the comunication tools for the citizens and istitutitutions to collaborate and restart and rebuilt and also the trasparency of the comunication.

It’s true that there are many instrument active as these you show me in the precedente post and these are ok for the international crisis, but there are many national crisis where the comunication don’t work, the problem it’s worst at local level. For exampke it was a terrible problem for the earthquake in Molise and it was the same in the earthquake in Abruzzo or for the floods in Liguria. the people could not to spaek with anyone: friends, parents, security, policy, istitutions, they are isolated. Then, when the comunications started again there were many problems to administrate the prioritys for the istitutions and also fot the citizens it was a problem to understand the situation and to get the right comunications.

so I thought or I dream :-)  a software system with tecnological tools to install in the emergency filed useful to adminisrtate better the situation and also the security and specially the psychological status of the people. Also only a call of a friend, a think or a specific answer at a request of the peolple it’s very important, I touch with my hand.

So Luca I’m at completly disposition to built anything is usefull for our objectives! I hope that we can meet and learn by the experience and vision of all.

Come on!

Ciao