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701-32 DOCUMENTS IN THIS PACKET INCLUDE: LETTERS FROM CITIZENS TO THE MAYOR OR CITY COUNCIL RESPONSES FROM STAFF TO LETTERS FROM CITIZENS ITEMS FROM MAYOR AND COUNCIL MEMBERS ITEMS FROM OTHER COMMITTEES AND AGENCIES ITEMS FROM CITY, COUNTY, STATE, AND REGIONAL AGENCIES Prepared for: 06/15/2020 Document dates: 5/27/2020 – 6/3/2020 Set 6 of 6 Note: Documents for every category may not have been received for packet reproduction in a given week. CAUTION: This email originated from outside of the organization. Be cautious of opening attachments and clicking on links. Rebuilding Your City Towards Healthiness: Establish a City Office of Epidemiological Accountability, and Clinics in Every Community of 10,000 People I. Rebuilding the 21st Century City1. Managing Uncertainty2. New Federalism: Useful Community-City Governance for the XXIst Century3. Sustainable City as Regulator and Mediator of Community Health4. The Computerized Community (1970, 2011, 2019) II. US Health & Human Services Challenges5. Planning for the Future: Evolving a U.S. Universal Health System6. Reducing Unnecessary Complications: Nature’s Efficient Complexity vs 20th Century Complicated Bureaucratic Institutions from too much Variety7. The Human Cost of U.S. Health Insurance: Physician Time: 48% computer, 26% patient care:Primitive US Health Insurance vs Sophisticated European Non-Profit Universal Coverage III. US Health & Human Services for the 21st Century8. U.S. Universal Health Care with 40,000 Community Clinics that is better than Private Insurance:The Community Health Clinic: The Central Resource for Community Centered Health & Wellness Clinical Care, Michelle S. Famula, M.D.9. Human Support Services: How to Make the Welfare System Work10. Embracing Long Term Service and Support from a Next Friend’s Perspective11. Create an Office of Epidemiological Accountability at Your Level IV. Making It Work Administratively12. U.S. Universal Health Care: Brazilian Design, Dutch Administration, Daily Accountability: Optimize Primary Care systemwide in every State in the U.S.: 75 FQHC Community Clinics with $25 million annual budget in each Congressional District13. Warm Data14.Present-Future: Stafford Beer’s Viable System Model & disseminated regulation in real time: How to Run a Country or a City15. U.S. Universal Health Care: Budget 2021-2 through 2024-5, The Political Strategy and Implementation Timeline V. The Global Economic Problems16. German Mark Stabilizes the World January 1, 2021: G-Curve: Trump Monthly Hockey Sticks; Biden Election; CCP Dissolves into history 11/15/22; Green New Deal save the World Appendices: Presented to the Berkeley meeting of the Physicians for a National Health Program 1/24/2020, and the Healthy California for All Commission 1/27/2020:#1: Lessons From the Dutch: Health Care that works for EveryoneThe Standard We Are UsingHow This WorksBrazilian Health VSM Twelve Layer Analysis 1.0#2: Harvard’s Getting Health Reform Right: A Guide to Improving Performance & Equity#3: Systems Science Spectacles: London Clinic: Stafford Beer’s Health & Quiet Breathing (1970);Economist January 25, page 16: Letters: Stafford Beer’s Viable System Model #4: Systemic Trauma: The Troubled Prospects for Managed Care in California & the United States (1996) BibliographyJon Li bio This analysis looks at health issues, education, personnel and resources as part of a health system. The United States has the worst health care delivery system in the modern world. The GOP uses free market rhetoric to strangle health services. U.S. health care is overly complicated, expensive, inconsistent, crisis intervention biased, and anti-lifelong health. With Universal Health Coverage, much of the administrative complexity caused by the financing the insurance industry disappears. Because each person is treated as a unique individual with a goal of maximum life long health, the systemic approach maximizes consumer satisfaction, professional fulfillment and resource optimization. We want to design the optimal governmental regulatory information structure at the national, state, regional, city and community level to maximize providing the best and highest level of health care at the community clinic level, and minimize the need for hospitals to the 15% of the situations where clinic care must be backed up. The goal of this process is to bring to life HR 1384 (Jayapal) and S 1129 (Sanders), the Medicare for All Act: Automatic enrollment of all individuals in the United States, cover items or services that are medically necessary or appropriate to maintain health or to diagnose, treat, or rehabilitate a health condition, including hospital services, prescription drugs, mental health and substance abuse treatment, dental and vision services, and long-term care. The bill prohibits cost-sharing (e.g., deductibles, coinsurance and copayments) and other charges for covered services. Private health insurers and employers may only offer coverage that is supplemental to, and not duplicative of, benefits provided under the program. Health insurance exchanges and specified federal health programs terminate upon program implementation, replaced by capped single payer payroll and general taxes with global budgets; local services are managed with community global budgets. I. Rebuilding the 21st Century City 1. Managing Uncertainty How times are changing February was 1929. January Trump peaked: glorying over his victory over Pelosi’s impeachment, the stock market hit an all time high, and the Democratic Party nominating process was chaos in Iowa. Then the novel coronavirus that likes humans became a global pandemic, forcing the continued shut down of the Chinese economy after the Lunar New Year with half the workers home in the rural areas. By mid-March, the global economy is in lockdown in a “mitigation” to minimize the speed of the spread of this uniquely new virus that is exploring its natural human environment around the globe, attaching itself to as many humans as it can, until it is in all of us – just like the coronaviruses that we know about. As a result the global economy is completely shut down for at least two weeks and probably a lot longer, to maximize the chance that the health systems can gain control over this unknown virus. The scientists don’t know what it is, or how it works, so they cannot stop it – they can only watch it and try to minimize the pain of the victims as their immune systems try to figure out what is going on, and win the personal battle. They have figured out the genome, so they are trying all kinds of strategies to develop a vaccine. A vaccine would mimic the coronavirus enough that your body could develop the appropriate response and beat the virus. Economically, we have been here before, in 2008, but the global economy is in a significantly different place now. In 2008, the U.S. economy was riding the housing subprime bubble that W Bush invented. One September Friday, Lehman Brothers was told “NO” from the U.S. Treasury, and the next two weeks were the kind of economic turmoil that the planet is experiencing now. Now, the planetary economy is being transformed in irreversible ways. Many people will lose their jobs, much more than 2008, which was bad. Amazon is destroying U.S. retail, which was previously 50% of the country’s jobs. New York Times columnist Michelle Goldberg, 3/16, “Grieving for My Sick City”: “When this emergency is over, people are likely to emerge into fundamentally changed cities, with economies in crisis and beloved restaurants, businesses and cultural institutions gone for good.” The new global economy has four strata: 1) the new internet economy, 2) the traditional 20th century economy that died last week, 3) the newly unemployed who are resilient and emergent, and 4) society’s bottom quarter. 1) The New Internet Economy is the 21 st century (look at the calendar, the century is already 1/5th over): people who have been telecommuting for years and are in the new reality, dealing with disruptions in real time. Last week was no different for them than previous or future, open- ended, dynamic sequences of days of activity with various computer communications. 2) The Traditional 20th Century Economy that died last week: it is obsolete, out of date and out of touch with reality. Amazon has hollowed out half of the retail half of the U.S. economy. Most of the retail jobs are supported by the 20th century high technology conspicuous consumption lifestyle. These folks are used to going to work and having the income to pay their bills and support their lifestyle, staying on top of their personal economy, living their life, having fun outside of their jobs, the movies, the parties, the sports events and social life that make their lives worth living – many of those things ended over the weekend. What they are left with during the pandemic is their own boredom. People are going to lose interest in television after a few days. Even the internet will lose its appeal. (Those who don’t get bored with the internet will become 1s or 3s.) They will get so bored that they experience “cabin fever” and start freaking out because they are bored with themselves. Many of these people will discover that they will find relief from their boredom in what is actually Buddhism: accept new change as what is real, then adjust your expectations given the options in the changed reality. 3) The newly Unemployed who are Resilient and Emergent: Mental health is acknowledging a change in your environment and adapting to it. Perhaps half the jobs in the U.S. are 20th century jobs that should disappear. Too often, especially since World War II, politicians have ignored environmental problems in the name of jobs. We need to build a green economy, with people shifting from polluting jobs to activities that promote sustainability, working in natural restoration rather than commercial activities that generate ecological destruction and pollution. People in the health insurance industry can either be retrained to do epidemiological accounting, or they can retrain to work in another field. 4) The Bottom Quarter of the Society: These folks get the dregs of the economy. There are two other key groups who receive government checks: those on Social Security and other forms of government monthly payments. While Social Security is not adequate for most people, it is a now a God-send of stability: when this happened in 1929, so many people were destitute that many people died each winter. The other is the 45% of the U.S. workforce who are on the public payroll. Federal employees presume they can cash their paychecks no matter what, as long as the U.S. dollar is the dominant world currency. Governments at every other level are required by law to have the cash to write the checks. If state and local government revenue dries up because the local economy is in hibernation, then their employees cannot be paid. Most government employees do not have any job security, and retired government bureaucrats may find that their pensions are dependent on the stock market. Monitoring a Constantly Moving Target: Peering into an Uncertain Future “Heuristics” is the label psychologists have given to the patterns of routine behavior that each of us invents to get through our daily lives. With the pandemic and the anticipated weeks of self- quarantine, many of our heuristics are being disrupted. Each of us are being forced to re-invent new daily routines, especially those in the second group. Most organizations have a management structure that defines their routines, focusing on program efficiency with the operations work supervised by a manager. Overall coordination of the entire organization is the responsibility of senior management. That pyramidal structure is how most people are taught to work together. But. That description leaves out the substance of the management dynamic: the mechanics of ongoing coordination, and anticipating the need to adapt to a changing environment. Labeling the management areas: 1) operations, 2) mechanics, 3) coordination, 4) uncertain environment, and 5) senior management. The problem with most 20th century organizations is that they were designed for a specific historical context that has since changed, and the organization has resisted needed adaptation to real environmental evolution. For an organism to survive, it must be adaptive to its ever-changing natural environment: its senior management (5) must be able to choose from (4) adaptation, when (3) should be changed; that the 3-4-5 changes the 1-2-3. For too many 20 th century organizations, they have ignored all of the potential information in (4), so they are only doing 1-2-3. They cannot survive because they cannot see any way to adapt. (“They have collapsed the 3-4-5, so that all they have is the 1- 2-3: continuing to do what they have always done, because it is what they know.”) 3 and 4 have all of the organization’s magic to change, adapt, evolve: 3: marketing and sales, budgeting, quality and productivity, human resources, engineering and accounting. 4: research and development, planning, innovation, finance, market research, projects and environmental relations. In case you don’t recognize it, that is the basics of the Viable System Model. The things that an organization does that are System 3 things and System 4 things look more at how the future might be different, so that you can begin to expand what options you are willing to consider and even pursue. The more you have realistic options, the more likely you can move beyond what you now consider to be a rut. To cope with the current rising uncertainty, you really need to re-catalogue what your environmental constraints are NOW, not what they were a week or a month ago. If you ever needed to abort your plans, create new plans, abort the new plans and then try to move forward, now is that time. This viable system model identifies seven environments that are always changing, and distinctive to each other: commercial, economic, technical, social, political, educational and ecological. Only by ongoing daily monitoring of key environmental variables can you stay close to what is really happening as it is unfolding. The viable system model is designed to help you identify what those key variables are now. Quarantined Inaction: Buddhist Economics is Better than Capitalism Capitalism has a basic motivator: money. Everything is secondary to money. “Cybernetician Geoffrey Vickers points out that Fritz Schumacher said: Call a thing immoral or ugly, soul- destroying or a degradation of man, a peril to the peace of the world or to the well-being of future generations; so long as you have not shown it to be ‘uneconomic’ you have not really questioned its right to exist, grow and prosper. To which Vickers adds: Never did a concept [“economic”] so limited and so factual attain a meaning so general, so normative and so saturated with unjustified connotation of value.” EF Schumacher identifies the contrast with the present materialistic worshipping of money: “Traditional wisdom teaches that the function of work is at heart threefold: 1) to give a person a chance to utilize and develop his faculties; 2) to enable him to overcome his inborn egocentricity by joining with other people in a common task; and, 3) to bring forth the goods and services needed by all of us for a decent existence.” This means shifting the emphasis of economics from financial technology to human fulfillment which would be a complete theoretical reorientation of the values that drive the economic behavior of the individual workers because management is recognized based on its service rather than its power. EF Schumacher’s Small is Beautiful: Economics as if People Mattered: “It might be said that this is a romantic, a utopian vision. True enough. What we have today, in modern industrial society, is not romantic and it is certainly not utopian. But it is in deep trouble and holds no promise of survival. We jolly well have to have the courage to dream if we want to survive and give our children a chance of survival. The crisis will become worse and end in disaster, until or unless we develop a new life-style which is compatible with the real needs of human nature, with the health of living nature around us, and with the resource endowment of the world.” p 125 The communitarian thesis is that individual aspirations should be protected and cultivated into community efforts. It provides an alternative to liberal individualism and a major counterpoint to authoritarian bureaucracy by stressing citizenship: that strong rights presume strong responsibilities and that one should not be neglected in the name of the other. Buddhism is poorly described to the westerner as “a way of coping with pain.” That is a simplistic hook to try to capture the imagination enough to explain how Buddhism is somehow a religion, although it doesn’t have any dogma or rules like Judaism, Christianity, Islam and Hindu. Western psychologist Ram Dass said it best: “Be Here Now.” Be-Do-Have rather than focusing on possessions, Have-Do-Be, as though by accumulating possessions you can become the person you want to be. The central Buddhist concept is that you only have this moment.To the impatient, easily distracted western mind, that is silly because “I am busy accomplishing ‘things’”. But when you are hurt, depressed or bored, the minutes crawl by, and they take for-ev-er. At that point, the westerner wants to escape, to imagine being someplace else, anyplace else, to escape the pain, the suffering, the boredom. The Buddhist has only this moment, so focus on the obvious, the worst part. Analyze all of it, focus on it, own it, own all of it, make it yours. The more familiar it is the more you understand it, appreciate it, and even value the worst part of it until you love all of it. By changing your perception of the problem, you gain control over your attitude about the problem. Then you can explore options for future actions from a broader perspective. Capitalism values profit and technology over people and the natural environment. Buddhist economics’ basic idea is that a “tool” is something that a human can control, and a “machine” is something that is so big and dominant that it controls the thinking of the people who use it. A tool serves people, and a machine forces people to serve it. That applies to social science technology as well as physical things: the budget, the political process should be human scale, and not dependent on big money like it is now. Capitalism as we have known it ended in 2019. All of the financial timelines about the future no longer work for anybody. The things that people worry about today are the kinds of things that people were concerned about in 1931, only worse. People have so much uncertainty about forces beyond anyone’s control that we are all being forced to live in the moment. We have more uncertainty now than we have had at any point in human history. So here is a message from two people in the Internet economy: “This sense that everyone is trying their best, and that somehow our efforts still might not be enough, is overwhelming. That said, there’s something bittersweet, maybe even beautiful, about how even as we are physically distancing ourselves, we are all realizing and feeling our interconnectedness. “Turns out, only when our entire economy is shut down do we finally realize the value of our place in our communities. That when businesses are all closed, we still need to cook for and feed each other. Amidst this entire pandemic, everything has shifted - the only constant is home. “For the foreseeable future, there will be no ‘business-as-usual’. And yet, our work has never felt more important. “We owe it to ourselves and our communities to seize this moment of clarity - to take care of the people who care for us. The work of championing the people who provide community care and weave our collective resilience feels more urgent than ever. When the outside world is safe again, they’ll be doing the work that will make rebuilding and healing possible. They’ve been doing this forever, without the recognition or compensation, and they will keep doing this work regardless. “We’re trying to be thoughtful about where and how to help, and who to join forces with, as this all continues to unfold. So until then, consider this a community check-in with a reminder that we’re still here. Please say hi and let us know how we can help. Charley & Matt, COOKS Alliance” Beginning VSM: Walker, Jon, The VSM Guide, 2006 (Internet) Advanced VSM: Christopher, William (2007), Holistic Management: Managing What Matters for Company Success, Wiley, New Jersey Beer, Stafford (1974), Designing Freedom, Canadian Broadcasting Corporation, Toronto Beer, Stafford (1975, 1994), Platform for Change, reader’s guide by Jon Li, Wiley, Chichester Beer, Stafford (1985), Diagnosing the System: for Organizations, Wiley, Chichester Beer, Stafford (1989), “Disseminated Regulation in Real Time, or How to Run a Country”, in The Viable System Model: Interpretations and Applications, edited by Raul Espejo and Roger Harnden Schumacher, EF, Small is Beautiful: Economics as if People Mattered, 1973, 1999 Siegler, Mark V., An Economic History of the United States: Connecting the Present with the Past, 2017 Silver, Nate, The Signal and the Noise: Why so many predictions fail – and some don’t, 2012 Watts, Alan, The Book: On the Taboo Against Knowing Who You Are, 1966 Wright, Robert, Why Buddhism is True: The Science and Philosophy of Meditation and Enlightenment, 2017 2. New Federalism: Useful Community-City Governance for the XXIst Century It seems like 1929 is happening again, only it is a lot worse this time. Many people who have lost their jobs will not regain them, and the businesses they worked for will never resume to back to the way it was before March 11th (when the World Health Organization declared a world pandemic). This is a proposal for the national government to be organized by human-oriented “cities” and “communities” rather than by rural, land-oriented “counties.” This issue, and the next one, will look at health care. Then issue #20, we will look at how this shift in focus could lead to a green new deal. What would a sustainable economy look like? This is the beginning of a workbook for you to create a sustainable community where you live. The only way the future can be a success is if community economies are so sustainable that the planet can reinvigorate itself, as it has shown by the pronounced drop in air pollution over Milan, New York City, and Beijing. We conclude this issue with criteria for the XXIst century economy to be economic, equitable and ecologic, largely by decentralization. Too many of the US’s institutions are defined by diseconomies of scale. Attached: TR Reid in The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care (2009) claimed that Judgment in Administration (1966) by Ray Brown is the “best book ever written on hospital administration” and I agree with him. I like it except that it was written in 1966, the year I graduated from high school, and the author cannot imagine a woman in an organizational setting. So I have typed a slightly edited version: Changing from “he” to “she” did not change anything most of the time, but some of the time it is weird or inappropriate, and sticks out. A thought experiment in time travel: A new world in which women are expected, accepted, and respected. Crashing Down an Economic Niagara Falls FDR’s New Deal and LBJ’s War on Poverty were attempts to provide some level of social support to the downtrodden of society. During the Great Depression, unemployment in the US was as high as 25%. The US is currently estimated at 15% unemployment now, with the expectation that many more people will be laid off soon. The Trump/US Senate is disconnecting from the Main Street tragedy, focusing on Wall Street. Going into the New Year, Wall Street was in debt close to three times the annual US GDP. Since then, everybody has been spending money like crazy, trying to hold everything up. Where is the money going? A lot of it is going to people who are selling their stocks. Hedge funds, pension funds, major institutions are doing everything they can to replenish the stock market, in hopes that it will stabilize, which it has appeared to do during the past month. The problem is that those deep pockets of the hedge funds are only trillions of dollars, which seemed like a lot of money back in February, which was sometime in ancient history during that eleven year Obama recovery that Trump claimed (three months ago). None of the major institutions are working. The government is scrambling with a seat-of-the- pants do the best we can, and the Congress has made a lot of wasteful decisions throwing money, breaking years of rules and traditions. As the only Democrat to vote against the CARES Act, Congressmember Alexandria Ocasio-Cortez said it was welfare for the rich, and a tragic waste of money in light of the pressing needs caused by the lockdown and the coronavirus. Ironically, the Tea Party people, Trump’s supporters and the corporations have called for the destruction of the government bureaucracy, and now they need it. They have their hands out, expecting the bailout. The amount of money provided is a drop in the bucket compared to what the airlines industry, the restaurant industry, the entertainment industry and the tourist industry would require just to get back on their feet, let alone back to where the economy was in 2019. Many, many businesses are going bankrupt now, and more will once the 2nd quarter ends, and they have to try to balance their books. The third quarter will be worse. This has been coming since before September 2008, and all the tricks they used then didn’t bottom the downturn, it only delayed free fall until now. In 2019, the US public sector was 45% of the Gross Domestic Product. Two months after the WHO declared a pandemic, the US national government continues to spend at that level. For the rest of the US public sector, the “cruising at normal” ends on June 30th, like driving up the edge of the Grand Canyon. Public revenue trends are bleak and growing stark. The new fiscal year begins July 1st for most states, counties, cities and special districts; they are not going to be able to anticipate revenue to pay their bills. Public salaries that have driven global inflation since World War II will suddenly be impossible to continue to pay. State, County, City and Special District jobs that are not eliminated July 1 st will have their salaries drastically cut. We will address the private sector in issue #20; this one is about re-designing the public sector. “decentralizing” the US Government A beginning observation: in the attempt to make social programs work in the 1930s, most US basic programs were designed with “national-state-county” as the regular administrative structure. Eventually, the national government also established clusters of states as regions of as a complicating added level, and expected counties to set up the administrative implementation, creating more layers of obstructive bureaucracy. Over the years, the cities are trying to deal with the real human issues of everyday life. But cities have been burdened with the “national-state-county” division of labor: counties claim they have legal responsibilities, like sheriff, district attorney and other law enforcement functions, as well as supposedly addressing human needs like health and other social services that the counties were never really designed to administer. As a result, cities waste a great deal of time, money and human resources trying to get counties to let cities deal with the problems of society: homelessness, housing, law enforcement, making the economy a success. With legal authority from the federal and state government, the county is incompetent, inadequate, and, with most of these things the county can only inhibit the city from doing any good. What would work? What would be functional now that we have the internet and instantaneous communication? Take counties out of the picture, replacing them with a standard urban unit of a “Community of up to 10,000 people.” It would allow a standard of comparison, equity and consistency. Then a city would be a memorandum of understanding among all of the communities within the city’s boundary. Other units of government would then be as small as possible, serving the Community’s ability to have all of its needs met. International-Federal-State-Area-Region-District-Community-Neighborhood-Village Basically scalar by ten from the bottom. The problem with county government is it was set up to serve property, not people. This shifts most of the emphasis to where it is a problem. Health care? Community. Roads? Region, District. Housing? Neighborhood, Community. Economy? Village, Neighborhood, Community… Organizing Health and Human Services in the US for the XXIst Century Who regulates US health care now? Traditionally, county government is the provider of last resort. With MediCare and MediCaid (MediCal in California), public tax dollars fund close to 2/3rds of the US health dollar, which is 17.7% of the US’s Gross Domestic Product. Mostly, especially from a city’s standpoint, health care is unregulated and out of control, at the mercy of hospitals, medical groups, pharmaceutical companies, and health insurance companies. The professional groups all complain that the health system works against their interests, costs too much, seems out of control. Under Obamacare, the federal government set up new rules for states to run the health insurance industry, and then claimed the market works. The so-called Affordable Care Act has no cost controls. Annual health insurance premium inflation that is much higher than the rest of the economy has been devastating for most family’s pocketbooks. The Current Federal H&HS Full Time Equivalent budget is for 80,000 people. This is a proposal to re-organize the health and human services functions in the US so that the 2022-23 Federal H&HS Full Time Equivalent is less than 1,000 people. The key is to put all the variety at the community clinic level. All care, research, services and information is at the clinic level. If the patient must be treated at a hospital or is somehow involved in research or an experiment, it is at the clinic level, under the supervision of the primary care health professional, and not limited to M.D.s and Ph.Ds in medical schools. The linkage in the health care delivery information system is: Program Design—Day-to-Day-Administration—Research—Program Evaluation, All built around the patient’s needs. Administration of the US Department of Health & Human Services Secretary Deputy Secretary: Health Deputy Secretary: Human Services Deputy Secretary: Behavioral Services Deputy Secretary: Office of Epidemiological Accountability Proposed US Department of Health and Human Services Organization 912 FTE: Health: 2 federal, 100 state coordinators, 100 special projects, 100 admin support, (302) Behavioral Services: 2 federal, 100 state coordinators, 100 special projects, 100 admin support (302) Social Services: 2 federal, 100 state coordinators, 100 special projects, 100 admin support (302) Team Leader-Servants: 1 federal, 50 state coordinators (51) International H&HS Station has capacity for 20 people. Secretary’s immediate office has capacity for 20 people (to stay under 1,000 total FTE) Office of Epidemiological Accountability: Each level of government has a station with seven members: 2 health care, 2 social services, 2 behavioral services, 1 leader-servant: International-Federal-State-Area-Region-District-Community-Neighborhood-Village For evaluation purposes, the International Station is responsible for the US relationship to all global health issues, specifically, the relationship with the UN and WHO, is a leader on climate change, pandemics and all global health issues. For the Federal, State, Area, Region, District and Community levels, the primary responsibility for information will be in the following areas: clinic management to maximize optimal primary care, clinic’s management of hospitals, tertiary care, integrated ancillary and auxiliary support for the clinic’s needs, medical school responsiveness to the clinic needs for the various health professions research questions that are challenging, interesting and essential for the clinic’s patient population identify unmet health needs within the clinic’s designated community’s population identify clinic problems For the Federal, State, Area, Region, District and Community levels, the data will be the same, all from the community level, but the range of questions for a region of a million people is very different than it is when you are only looking at balancing the resources within one city of under 100,000 people. How it works: the product of the Viable System Model analysis is to set up 133 daily statistical measures that have been previously agreed to: 12 major statistical areas, each with 10 subcategoies; the 12 become a statistic: 1+12+120=133. The statistics are OK, or not. Green or Red. Look at the Red ones. They are the trouble spots that are getting worse. Government in the XXth century was caught up in the details; this XXIst century management information system focuses on and highlights making progress within the big picture. There is a difference between what government measures and reality. The London School of Economics named a law after the professor who discovered it: Goodhart’s law: once policy makers begin to target a particular variable, it may begin to lose its value as an economic indicator: once we begin to measure something, its behavior starts to change because we are paying attention to it. How a clinic maximizes optimal primary care can be measured many ways. This process should improve on them. In issue #17 Brazil, we laid out the basic challenges for a good health management information system: “As in many health systems around the world, the Brazilian health system’s challenges include the control of costs, improvement of efficiency, assurance of quality and safety, provision of access to comprehensive care, and coordination with primary health care. The system needs to be better organized into a regionalized network of services nationwide, with systematic, effective regulatory and referral mechanisms in place that can only be monitored with something like the Office of Epidemiological Accountability.” In issue #19, we will lay out the mechanics for an Office of Epidemiological Accountability. Kind of a cross between a Certified Public Accountant, a Masters in Public Health, a Ph.D. in Epidemiology, a Masters in Marriage and Family Counseling, and an administrator with years of experience. Criteria for the XXIst Century Economy: Ecology/Economy/Equity: Cradle to Cradle: Remaking the Way We Make Things, William We imagined a world of industry that made children the standard for safety. “Instead of “Reduce, reuse, recycle,” urged environmentalists, and doing more with less in order to minimize damage, architect Bill McDonough and chemist Michael Braungart argue this only perpetuates the one-way, “cradle to grave” manufacturing model, dating to the Industrial Revolution. It creates such fantastic amounts of waste and pollution. Why not challenge the belief that human industry must damage the natural order? In fact, why not take nature itself as our model for making things? “Waste equals food. “Guided by this principle, production can be redesigned from the outset so that, after their useful lives, they will provide nourishment for something new. They can be conceived as “biological nutrients” that will easily reenter the water or soil without depositing synthetic materials and toxins. Or they can be “technical nutrients” that will continually circulate as pure and valuable materials within closed-loop industrial cycles, rather than being “recycled” - really downcycled - into low-grade materials and uses. How to put this eco-effectiveness into practice is the question of the day. “Eco--effectiveness sees commerce as the engine of change, and honors its need to function quickly and productively. But it also recognizes that if commerce shuns environmental, social, and cultural concerns, it will produce a large-scale tragedy of the commons, destroying valuable natural and human resources for generations to come. Eco- effectiveness celebrates commerce and the commonweal in which it is rooted. Start with a triangle, with Ecology, Economy and Equity at each of the corners. “The extreme lower right represents what we would call the Economy/Economy sector. Here we are in the realm of an extremely pure expenditure/cost/benefit, and the questions we ask would include: can I make or provide my product or service at a profit? If the answer is no, don't do it. The role of commerce is to stay in business as it transforms. It is a commercial company's responsibility to provide value and increase wealth - but not at the expense of the social structure and the natural world. How much do we have to pay people to get our product on the market and make a profit? “We move to the Economy/Equity sector, where we must consider questions of money and fairness; for instance, are employees earning a living wage? Moving into the Equity/Economy sector, the emphasis shifts more toward fairness, so that we are seeing Economy through the lens of Equity, in a sense. Here we might ask, are men and women being paid the same for the same work? In the extreme Equity/Equity corner, the questions are purely social: are people treating one another with respect? And no consideration of economics or ecology. This is where we can discuss issues of sexism and racism. “Moving up to the Ecology corner of the Equity sector, Equity is still in the foreground, and the question is: is it fair to expose workers or customers to toxins in the workplace or in the products? Is it fair to have workers in offices were undefined materials are off-gassing, exposing them to potential health risks? How is this product going to affect future generations' health? Continuing into Ecology/Equity, we consider questions of ecosystem effects, not just in the workplace or at home, but with respect to the entire ecosystem: is it fair to pollute a river or poison the air? “Now deep into the Ecology sector: are we obeying nature's laws? Does waste equal food? Are we using current solar income? Are we sustaining not only our own species but all species? Then we are around to Ecology/Economy, where money reenters the frame: is our ecological strategy economically fecund too? are we designing a building that harnesses solar flows to make more energy than it needs to operate? “Finally, Economy/Ecology: eco-efficiency: trying to do less bad, more with less. Still, eco- efficiency is a valuable tool in optimizing the broader eco-effectiveness approach. “If humans are truly going to prosper, we will have to learn to imitate nature's highly effective cradle-to-cradle system of nutrient flow and metabolism, in which the very concept of waste does not exist. To eliminate the concept of waste means to design things - products, packaging, and systems - from the very beginning on the understanding that waste does not exist. It means that the valuable nutrients contained in the materials shape and determine the design: form follows evolution, not just function. We think this is a more robust prospect than the current way of making things. “There are two discrete metabolisms on the planet. The first is the biological metabolism, or the biosphere - the cycles of nature. The second is the technical metabolism, or the technosphere - the cycles of industry, including the harvesting of technical materials from natural places. With the right design, all of the products and materials manufactured by industry will safely feed these two metabolisms, providing nourishment for something new. “Products can be composed either of materials that biodegrade and become food for biological cycles, or of technical materials that stay in closed-loop technical cycles, in which they continually circulate as valuable nutrients for industry. In order for these two metabolisms to remain healthy, valuable, and successful, great care must be taken to avoid contaminating one with the other. Things that go into the organic metabolism must not contain mutagens, carcinogens, persistent toxins, or other substances that accumulate in natural systems to damaging effect. By the same token, biological nutrients are not designed to be fed into the technical metabolism, where they would not only be lost to the biosphere but would weaken the quality of technical materials or make their retrieval and reuse more complicated. “The vitality of ecosystems depends on relationships: what goes on between species, their uses and exchanges of materials and energy in a given place. A tapestry is the metaphor often invoked to describe diversity, a richly textured web of individual species woven together with interlocking tasks. In such a setting, diversity means strength, and monoculture means weakness. Remove the threads, one by one, and an ecosystem becomes less stable, less able to withstand natural catastrophe and disease, less able to stay healthy and to evolve over time. The more diversity there is, the more productive functions - for the ecosystem, for the planet - are performed. “Each inhabitant of an ecosystem is therefore interdependent to some extent with the others. Every creature is involved in maintaining the entire system; all of them work in creative and ultimately effective ways for the success of the whole. “Humans evolved on the Earth, and we are meant to be here. Its atmosphere, its nutrients, its natural cycles, and our own biological systems evolved together and support us here, now. Let's use our ingenuity here; to become, once again, native to this planet.” Women Administrators: Womenment: OLD WIVES TALES: Organizational Troubles and How to Improve Your Current Predicament Judgment In administration By Ray E. Brown Professor of Administration & Director of Graduate Program in Hospital Administration Duke University (1966 with masculine pronouns; 2019 with feminine pronouns) The book is the best book I have ever read on Management. Better than Peter Drucker. He doesn’t need examples because what he says is so cool. In the preface, the author states that he worked as a university hospital administrator for 15 years and then as a university administrator for another 10 (both Duke University in the United States); TR Reid claims it is "the best book ever written on hospital administration," but that one reference to 15 years is the only way you have a clue he ever worked in health care or with a single woman, let alone a nurse. The book is incredibly generic about management: it applies just as much in the home or the classroom as the battlefield, as the office in a hospital or government, or some crazy startup. For the good points, I am thinking Pelosi, Angela Merkel, Grant, Washington, Eisenhower, Lincoln, and the bad points Trump or UCD’s former Chancellor Katehi. The theme of the book is there are problems that you should learn to identify, avoid and learn to get out of, so it is mostly about poor decision taking process because of ...? What I marvel about the most is how appropriate it is, every page, to advise a nurse on what to say, and what to do, when they interact with a patient, or a parent with their ever changing child. If you think about yourself as the administrator, and then as the recipient of the administrator’s decisions, it is even better psychotherapy than Drucker. I thought about making copies and giving them to people in the city, but then I started writing in my copy. And I like it so much. Almost more than Platform for Change. Chapter 10 is the best argument I have read for the Viable System Model analysis. I like it except that it was written in 1966, the year I graduated from high school, and the author cannot imagine a woman in an organizational setting. So I have typed a slightly edited version: Changing from “he” to “she” did not change anything most of the time, but some of the time it is weird or inappropriate, and sticks out. A thought experiment in time travel: A new world in which women are expected, accepted, and respected. This book is dedicated to that legion of practicing administrators in industry, education, health, and government who have both knowingly and unknowingly helped me confirm the observations and notions about administrative conduct that I have recorded in this book. Preface Arriving at a title for this book represented quite a difficulty to both the author and the publisher. The title that was finally adopted accurately describes what the book is about, but it may be misleading as regards what the author is attempting to accomplish. The title might give the impression that the book is a scientific treatment of a rather abstract subject. This would be a grossly inaccurate impression. It is intended that the book be a very practical treatment of a very practical subject. It is concerned with the practicing judgment of the administrator. The book is a bit unusual in that it concerns itself more with causes of failure in administration than with causes of success. This is the only way that a useful book on judgment in administration can be written. One can preach salvation only by preaching about sin. Good judgment is achieved by avoiding and overcoming the causes of bad judgment. This does not mean that author has attempted to develop a manual of do’s and don’t’s on judgment for the administrator. The approach is one of attempting to mark out the hazards and pitfalls to good judgment. The book is written to be read by anyone who is interested in developing and improving her understanding of administration and her ability to practice it. It is the conviction of the author that there is an art of administration and that it is learnable. Said another way, this book is predicated on the notion that the administrator is a craftsperson, and that her craft is an acquired thing. Stated another way, the author holds the firm belief that administration is a thinking person’s game, and this book is an attempt to help the administrator practice in a more thoughtful manner. The notions expressed in this book were derived from observing my own conduct as an administrator and that of a host of other individuals active in various types of administration. It has been my good fortune to have been both a participant and a spectator in administration for some twenty-five years. During this period I served first as the director of a large university hospital and then as a vice-president of that university. At the same time I served an active role as a professor in the graduate school of business. This dual role provided me the unique opportunity of experiencing what I was teaching. It also conditioned me to observe closely the administrative conduct of colleagues, acquaintances, and former students. This book reflects these observations and the meanings I derived from them. I suspect, however, that a rather considerable portion represents reflections on my own conduct as an administrator. The Preface is traditionally used as a means of acknowledging the author’s obligations and appreciation to those who provided assistance in the production of the manuscript. The number of individuals who have significantly contributed to the production of the ideas making up this book are legion, and it would be impossible to list them all. This impossibility is partially from the fact that I cannot name them all; an individual’s domain of thought is made up of an amalgam of experiences, observations, discussions, and readings. The time, place and source of much of the amalgam represented in this book is not identifiable. Table of Contents 1. Introduction: the role and nature of judgment in administration…1 2. Stress can distress good judgment…22 3. The fear of losing can take the joy out of winning…39 4. Feelings are a common cause of failings…60 5. Success does not always come from succeeding…92 6. The administrator’s best skills sometimes become her greatest handicaps…116 7. The perfectionist in administration often reaps imperfection…139 8. Administration is a matter of proportion…159 9. The administrator must be adept at adapting…182 10. Administration is not a numbers game…200 Index…221 Management by Objectives: Started reading: 1/6/19 Started typing: 1/11/19 Finished typing: 1/22/19 Finished proof-read: 1/24/19 Evaluation: The challenge of the task of typing/editing this book verbatim was to maintain focus in making the shift from he to she, him to her, and his to her; In the proof-read, I mistyped the original male version instead of making the change to the correct female version 16 times (out of thousands), and only once in the second half. When I started reading this book, I felt like James Marshall in Coloma, discovering Gold. 3. Sustainable City as Regulator and Mediator of Community Health Table of Contents Traditional City Problems Overwhelming New City Challenges The City as Coterminous Communities of up to 10,000 People Model for Individualized Community Information Sustainable City as Regulator and Mediator of Community Health Positive City Public Policy Traditional City Problems For 90% of humanity, the city defines daily reality. Lewis Mumford points out that the real action is in The Culture of Cities (1938): “The city, as one finds it in history, is the point of maximum concentration for the power and culture of a community…The city is a fact of nature, like a cave, a run of mackerel, or an ant heap. But it is also a conscious work of art, and it holds within its communal framework many simpler and more personal forms of art. Mind takes form in the city; and in turn, urban forms condition mind… With language itself, it remains man’s greatest work of art. The nature of the city is not to be found simply in its economic base; the city is primarily a social emergent. The mark of the city is its purposive social complexity.” But the city is a giant, amorphous blob. In John Kenneth Galbraith’s The Age of Uncertainty: A history of economic ideas and their consequences, (1985): “In Western Europe and Japan the failure of capitalism in the fields of housing, health care and transportation is largely, though not completely, accepted. There industries have been intensively socialized. In the U.S. there remains the conviction that, however contrary to experience, private enterprise will eventually serve. To assert that the inherently public character of these industries, even though the practice affirms it, still seems radical. Nothing is now so important as to agree that the nature of these services is public and then to ensure that their performance is not merely a matter of adequacy but of pride. City life will never be good while housing, health care and transportation are poor. “There is a larger need. That is to see far more clearly than at present the essentially social character of the metropolis. In its days of greatest elegance, the city was a household, an extension of the domestic arrangements of the ruler. No line then separated private from public tasks. Construction, artistic embellishments and maintenance of the city – what would now be regarded as public tasks – may well have absorbed the larger share of the aggregate public and private income. With the Industrial City it came to be assumed that the payment for public tasks – education, police protection, courts, sanitation, recreation, public entertainment, care of the old and impoverished – would be only a small subtraction from the total revenue. The private household, no one doubted, had the major claim. “This continues to be the assumption. The consequences all recognize. Among the affluent and even among the poor, services supplied out of private income are far more amply endowed than those provided by the city. Houses are clean, streets are filthy. Personal wealth expands; there are too few police officers to protect it. Television sets are omnipresent; schools are deficient. “Where capitalism is efficient, it adds to the public tasks of the city; it increases the number of automobiles that must be accommodated in and through the city, adds to the detritus that must be picked up from the streets and makes progressively more difficult the problem of keeping breathable the air and sustaining a minimum tranquility of life. “This is another way of saying that the social aspect of modern metropolitan life is extremely expensive, far more expensive than we have yet imagined.” Overwhelming New City Challenges 1. The Wuhan Coronavirus: in the 12 weeks of its life, Covid-19 has established itself in 58 countries, caused 83,000 cases, and 2,800 people have died. A pandemic is more than a disease; it tests a society’s health systems, its government and politicians, and its economy. Weeks of quarantine and isolation of the urban population is creating its own constellation of health risks. Most people in the world have heard about the “novel” coronavirus that did not exist in September and is exploring its way through every human population on the planet; they know it is spreading, it can be fatal but is not as lethal as influenza, they don’t know how it spreads, they don’t know how to stop it, and they have not developed a vaccine. The World Health Organization and the U.S. Centers for Disease Control are doing everything they can to track down this new bug that attacks humans. The emergent social disease is how much the Chinese Communist Party and the Trump administration are politicizing the pandemic. The only good thing you can say about this is that most people are much more aware of their own health needs than they were three months ago, and question how inadequate their local health system resources are. 2. Climate Change: Australia lost a billion animals in the fires, as well as a sense of healthiness. The perpetual drought raises the question of the carrying capacity of the continent. Globally, people in cities put tremendous strain on the natural systems for food, water and materials that make life possible inside an urban area. Economic services that everyone assumed would continue may need to be stopped. 3. U.S. Service & Trade Deficit: The U.S. has been in an international Trade Deficit for Goods ever since OPEC in 1972; U.S. Services, like computer consulting, management, and health care were so great that it offset the Goods Deficit until 1992. Ever since Clinton was elected President in 1992, the U.S. has owed other countries more and more with a growing Services & Trade Deficit. In 2019, U.S. imports were $3.1 trillion and exports were $2.5 trillion, for a deficit of $616.8 billion. The goods trade deficit was $866 billion, exporting $1.65 trillion, with biggest categories of commercial aircraft, automobiles and food, and imported $2.51 billion, with largest categories of automobiles, petroleum and cell phones. The U.S. runs a trade deficit with all its major trading partners: China, Mexico, Japan, Germany and Canada. 4. U.S. Budget Deficit: While Keynesians like Paul Krugman challenged Obama to put a trillion dollar stimulus into the U.S. economy, Trump’s plan to stimulate the economy was his tax cut package, his one legislative victory. While the tax cut did stimulate the economy, it was a wave of maybe 18 months, and it has worn out. Now the U.S. has a trillion dollar annual budget deficit as a result of the tax cut. As long as the U.S. dollar is the international currency of exchange, and unemployment is under 4%, it looks like the U.S. economy is doing OK. The Obama Recovery is the longest in history….. 5. Public Employee Pensions: Most city governments are not prepared to pay their pension funds. Local elected officials have been generous with their employee pay, benefit and retirement pension packages, and now they are all exploding in cost, dependent on the stock market’s continued success. This is a looming disaster where the current set of electeds “kick the can down the road” rather than put a cap or some other budgetary control that can begin to face the problems. 6. Amazoned-U.S. economy: Jeff Bezo’s goal is to create an alternative economy, and replace the bricks and mortar with dependence on Amazon. Over half the households in the U.S. have paid the $100 annual fee for Amazon Prime, the service of receiving a product within 24 hours of order. While Amazon’s costs for delivery are outrageous, they have enough funding to stay ahead of the game, and destroy the competition. 50% of the jobs in the U.S. are in retail, and those people are standing around doing nothing because, on the margin, their former or potential customer is now going on line, ordering from Amazon, and expecting the product. Amazon has already succeeded in destroying the Sears/Penny’s shopping mall that defined the U.S. shopping experience post World War II. 7. Trump dismantling the government: when Ebola struck, prudent Obama installed a pandemic expert in the National Security Council, and beefed up the Center for Disease Control; two years ago, Trump eliminated those improvements in an anti-Obama pique. This is typical of what Trump has imposed: most of the State Department has been left unfilled; many countries do not have U.S. Ambassadors. The Secretary of the Department of Health & Human Services is a drug lobbyist; Wilbur Ross is the Secretary of Commerce; together, they are left with all the responsibility. 8. Trump Tariff wars: Trump claims he is a great deal maker. That remains to be seen: Canada & Mexico, at best small improvements. China? Declare a victory, and go back to the same place as before. Then the chaos of the Wuhan pandemic eliminated that and a lot more is now in question. The threats of tariffs are devastating to commercial planning. The intent of Trump’s threats of tariffs is to force U.S. decision takers to bring their production back to the U.S. 9. China 2025: Since the global economic collapse September 2008, China has invested trillions of dollars (exceeding the U.S. and the E.U. combined) in keeping the U.S./Western global economy afloat. Deng’s charm offensive was to become the new “workshop of the world” so much as to take over the dominant role from the U.S. 2008 gave China the opportunity, and Xi has taken it. Xi’s soft power “Belt and Road Initiative” is intended to do what the Marshall Plan did: cement the global dependence on Chinese advice, Chinese design, Chinese firms, Chinese technology, and ultimately, and always, Chinese Communist Party values – which means subservience to Chairman Xi. The goal is for the world to recognize China, and Xi, as the world’s leader (in all the ways that the U.S. was in 1945) by 2025. 10. Social media: the education programs for children were designed after the U.S. Civil War to train people to be cogs in the new industrial economy. Since then, the world has seen the bicycle, the telephone, the automobile, Thomas Edison and the uses of electricity for machines, the radio, film, (in our lifetimes) television, computers, the laptop, the internet, smart phones, and social media. The U.S. has so many college graduates that it doesn’t mean much any more. The Chinese students are using the U.S. colleges the same way the rest of the world have used British universities since the end of World War I, as the easiest way to figure out how to take over the world. The City as Coterminous Communities of up to 10,000 People Within the city, according Kirkpatrick Sale in Human Scale (1984), it is at the community level that society is perpetually redefining itself: “Gandhi once said it was foolish to dream of systems so perfect that people would no longer need to be good. I would rather contemplate a system so simple that people would no longer need to be bad – that is to say, a system of support and sustenance, of rough equality and comfort, that would so guide and goad, chide and chivvy, prompt and protect, that individuals in it would be inclined out of sheer self- and community-interest toward morality and harmony. The small community has provided such a system – not molded through any special design, nor guided by any millennial genius, nor organized by any party or sect, but simply by working out the rough, hard problems of existence as they have come along for many thousands of years.” All of the human systems in operation have been focused from the standpoint of centralization. This is a shift in perspective to a Human Scale City-Oriented concept of governance. U.S. House Speaker Tip O’Neill said “all politics is local.” This recognizes that as a shift towards more natural reality for most people. Most regional, state and national politics is way too complicated for most people to get a handle on. This re-orientation back towards local politics puts the focus where people can have the most influence and impact. The US Civil War (1861-65) was the end of the battle to defend the rural lifestyle. Unfortunately, all of the vestiges of the rural lifestyle remain as the government form: its legal, funding and organizational structure is defined by the federal system of “nation-state-county model”, with county defined in this traditional historic model as the bottom, as local government. Most government social policy since the New Deal such as courts, health and social services has been to try to set up special districts to compensate for the limits of rural-oriented counties. Cities are not part of the “nation-state-county model.” While that rural model may work in the agricultural land focused economy that evolved historically, it does not work well for humans in large numbers. As a result, cities have had to grow in a totally hostile governmental environment. The state should refocus around cities, which would allow the elimination of most of the state’s special districts and half of the state bureaucracy. This is an evolutionary proposal to re-orient U.S. domestic governance at the state and federal levels to eliminate county government by doing a better job of regulating cities, and eliminate the confusion that counties create. Kirkpatrick Sale argues in Human Scale that the 20th century bureaucracy is for organizations that are so big that they don’t work. Too big to succeed. Amazon has eaten out the 50% of the jobs of retail economy of Main Street. Those people have no prospects for job security. The reality is that every suburban community is going to have to discover how to meet their economic needs. The prospects of the Wuhan pandemic slowing down the global economy only highlight how unsustainable the suburban U.S. economy is, and how much local groups are going to have to find new ways to have a successful local economy. The metropolis is a fact of nature, but it is not a constraint of human society. For most people, 10,000 people is more than they will converse with in their lifetimes. Anything bigger than that requires a bureaucratic organization. This is a proposal to eliminate county/rural government that dominates the legal territory of every part of every state in the U.S., replacing it with “community governance” with as much of the politics as possible at the lowest level, within the community. Then whatever is bigger than a community, or shared by many communities, is organized with a “Memorandum of Understanding,” an “MOU,” that equally involves all of the communities that sign on. This is a re-consideration of the compromise that established the House and the Senate in the U.S. Constitution. This way, every single person has the potential for equal representation in their community. All Public Employees work for a particular community: there are State and Federal Elected Officials, but no need for State and Federal Employees. The 20th century bureaucracy is a complete failure, and needs to fold in on itself. The only thing it is is a jobs program. The U.S. economy is 45% public sector. This is a proposal to drop the public sector to 15% or less. Most of the bureaucrats only fight with other bureaucrats. Model for Individualized Community Information This is a model for a computer grid of a person’s local economy. It should be user friendly and provide linkage of the information structure between an individual and the larger economy, decentralization in a global context. The idea is that the model should be useful to individuals and families, and all business people as well as municipal bureaucrats and citizens investigating the government. WikiEconomy: a computer information idea for creating a global grassroots economy. Basically it is a dynamic information catalogue for all the parts of a woman's life: income, food, housing, health care, transportation, clothing, education, media, entertainment, taxes, managing the economy, public services, infrastructure, utilities. That information matrix has components that scale up physically/geographically: family, 10; neighborhood, 100; village, 1,000; community, 10,000; district, 100,000; and region, 1,000,000. Unlike counties, these can be compared. Most current policy emphasizes district-region-state-nation. This model shifts the focus to the village and the community, so that neighborhoods and families get their needs met. Neighborhood, Village and Community matter a lot to most of us. Your Village is big enough that you take it for granted. You have your normal work routine, and then you have your habits of your daily life. Your work routine becomes an automatic traffic pattern that defines your sense of geography. The rest of your life defines your personal community, probably made up of several villages that support businesses that you have a need for. It would focus most politics on local, face-to-face accountability, then with state and national politics defined in terms of how a policy “will affect my community”. To talk about a scale of over 10,000 people is mostly about POWER OVER other people, and not about healthy human relationships. The annual meeting of the United Nations would include representatives from each of the world’s communities of up to 10,000 people. So Africa and Asia will be much better represented. No need for a national military. These ideas will be expanded on in #9 The Computerized Community (1970, 2011, 2019) Sustainable City as Regulator and Mediator of Community Health The City has responsibility to make sure health and other services are provided, but most of them are community-level services. Coordination of hospitals, specialty physicians and other multi- community resources are coordinated by Memorandums of Understanding (MOUs) of the communities they serve, with the city providing an arena for conflict resolution between communities when necessary. Only 10% of health improvement outcomes are due to medical care. 90% of the health outcomes are produced by education, housing, environment, behavior, genetics and social organizations. Non-medical determinants of premature dying include: behavioral patterns like diet, exercise, alcohol and drugs, account for 40%, genetic predisposition, 30%, social circumstances 15%, and environmental exposure 5%. Many of the factors are social determinants, like smoking, income inequality, and race, which turns out to be a marker for poor health outcomes in the U.S. A key indicator of local healthy outcomes is availability of primary care health professionals. In the U.S., 70% of the physicians are in specialty care, only 30% are in primary care like family practice; in Europe, it seems to be working with a 50%-50% split. In Europe, the primary care physicians are as well compensated as the specialists. Of the almost $4 trillion spent annually on health care in the U.S., $1 trillion is inappropriate hospital care fed by the medical specialists. Universal coverage with one comprehensive benefit package and truly streamlined administration leads to higher access to primary care, greater utilization to primary care resources for more appropriate and limited use of specialty medicine and hospitals, better health outcomes and lower costs. This is a program to shift from hospital- dominated expensive medicine to clinic-based prudent health care, with the money for services distributed among 100% of the population, not 25% like it is now. Positive City Public Policy Rather than the legalistic approach of dictating what is not allowed, this is called “Policy Governance.” This is one city’s social contract, with several items that address health and well- being: This is the General Plan for the City of Bryan, Texas: The City of Bryan exists so that Bryan will be a healthy, safe, attractive, and successful community for a reasonable financial burden. 1. There is a safe environment for residents and visitors. 1.1. People can move in, out and within Bryan safely, quickly, and efficiently. 1.1.1. Pedestrians can move in, out and within Bryan safely, quickly, and efficiently. 1.1.2. Vehicles can move in, out and within Bryan safely, quickly, and efficiently. 1.1.3. Air Traffic can move in, out and within Bryan safely, quickly, and efficiently. 1.2. There is an adequate supply of high-quality drinking water. 1.2.1. The current supply of drinking water meets current demand. 1.2.2. The drinking water is wholesome. 1.2.3. The drinking water tastes good. 1.2.4. There is an adequate reserve of high-quality drinking water for the future. 1.3. There is efficient and effective disposal of waste. 1.3.1. Waste is collected and appropriately disposed of in a timely and cost-effective manner. 1.3.2. Recycling is appropriately utilized. 1.4. There is clean air. 1.4.1. Air is of high quality. 1.4.2. Air quality is ensured into the future. 1.5. Animals are appropriately controlled and cared for. 1.5.1. Dangerous animals are restricted. 1.5.2. Human injury from animals is infrequent and insubstantial. 1.5.3. Animal populations are appropriately controlled. 1.6. Residents and visitors are reasonably protected from emergencies and natural disasters. 1.6.1. There is a low crime rate. 1.6.2. There is low loss due to fire. 1.6.3. There is a readiness for emergencies and natural disasters. 1.6.4. Citizens have protection from flooding. 2. The economic life of the community is stable and growing appropriately. 2.1. There is an adequate employment base. 2.1.1. Citizens are employable. 2.1.2. Workforce is employed. 2.1.3. There are adequate business opportunities to meet the employment needs. 2.2. There is a diverse recession proof economy. 2.2.1. There is an appropriate mix of small, medium and large businesses. 2.2.2. There is a diversity in the types of business/industries. 2.2.3. Products are high quality and innovative. 2.2.4. Businesses can compete globally. 2.3. There is a dynamic, positive business climate. 2.3.1. The economic climate is favorable to businesses. 2.3.2. Businesses flourish. 2.3.3. The economic climate is responsive to the changing needs of businesses. 2.3.4. The economic climate is responsive to the changing needs of citizens. 2.3.5. There is growth in the economy. 2.3.6. Businesses contribute to the community. 2.3.7. Businesses collaborate. 2.3.8. Businesses are innovative, knowledge-based and idea-based. 3. The community is attractive, clean, and aesthetically pleasing. 3.1. Neighborhoods are aesthetically pleasing. 3.1.1. Citizens participate in planning and decision-making. 3.1.2. Neighborhoods are neat, orderly, and clean. 3.2. City entrances are attractive. 3.2.1. Other organizations and industries understand the importance of first impressions. 3.2.2. Entrances are symbolic of the character of the City or neighborhood. 3.2.3. Entrances have a pleasant appearance. 3.2.4. Entrances are easily accessible and identifiable. 3.2.5. Major entrances are orderly and neat. 3.2.6. Transportation corridors are attractive. 3.3. The city is well-maintained. 3.3.1. There is controlled vegetation. 3.3.2. There is a lack of visible junked vehicles. 3.3.3. There is a lack of abandoned buildings. 3.4. There is a balance of green and developed space. 3.4.1. There is green space for both recreation and relaxation. 4. Residents have a good quality of life. 4.1. People have physical, mental and social well-being. 4.1.1. People have the information and knowledge they need to pursue a high quality of life. 4.1.2.There is a vibrant cultural life. 4.1.3. There is adequate housing. 4.1.4. People can recreate. 4.2. There is civic pride. 4.2.1. The community shares the vision of a healthy city. 4.2.2. Bryan has a distinct identity. 4.2.3. Residents are active in their community. 4.2.4. People value diversity. 4.2.5. Residents take responsibility for the appearance of the city. 4. The Computerized Community (1970, 2011, 2019) RENASCENCE (1970) from Platform for Change by Stafford Beer: THE FORM OF REFORM Let us start at the beginning: this is about a citizen who must have a record in modern society. Let’s create one. What used to be their birth certificate is now the beginning of their electronic file, housed in the community computer in the community record office. The data trail begins to be generated. The doctor, the school, the employer each enters information about our citizen into the community computer. When the citizen’s life makes a change, they inform the community computer. Is this electronic prison? Really? All this is already known, just inefficiently, expensively known – whereas this would be simple, easy and cheap. Understand that if the government becomes tyrannous, it would have no difficulty in controlling you anyway, as things are now. It has nothing to do with electronics. There is one local file of each person. What happens to the giant bureaucratic files of the different Ministries? They no longer exist, along with their bureaucracies. Since the community computer office networks are all organized similarly, they can all be accessed by any government department. The future of liberty will be all about the design of electronic systems, and hierarchies of filters intended to safeguard the rights of the individual. I believe in your liberty more than any of the people who, although currently engaged in your electronic incarceration in every department of life, do not warn you of the dangers. I am issuing the warning, and with it a message of hope. We can overcome the dangers, but only by intense study, public debate, and early legislation. You will get no protection by shouting me down. Given a citizen’s one record, to which there is a large number of keys each of which grants access to only a part of the record, there is no census to take: we have a perpetual census. The record is up to date and ready: The Tax Bill is the government’s computer program applied to each and every citizen’s record, and zero complicated tax structure (with the prospect for loopholes). The Tax Bill is the Finance Act. The room for maneuver by legislators has never been so great. They may simplify, complicate, elaborate, and distinguish whatever they like. The end is a single computer program, and it does all the work to reflect the final decisions. It means that lawyers will become diagnosticians of mistakes in mapping a set of complicated rules onto a set of complicated circumstances – which is their role in society now. All of this cuts out waste. Does it over-centralize control? Control is vested in the community, the record office is just around the corner. So now the financial operations of the nation have been consolidated. The local authority calls for tax rates and explains its call to the citizen – as it does now. For every element of the government, the information relating the law to the citizen maps onto the citizen’s circumstances. THIS IS ALREADY THE CASE. The proposal is not to obtain more information, only that the tasks be effectively organized. These are the facts. The system is quite easy to design and to implement. It requires a massive change in outlook, and the total reform of the civil service. It requires more moral effort to protect democratic government than even war for the cause of freedom. Aside from the high expense of moral energy, the cost in cash would many orders of magnitude LESS than the cost of any of the wars we have thought it necessary to wage for our liberty. This plan sets the individual where they belong: in their community. If the integrity of the citizen can be maintained, in the existence of their electronic shadow – the integral record – then their liberty can be protected. The community yields only certain information to the locality, the locality to the region, the region to the government – these forms of access are decided by law that are translated into computer filters that prevent the government from gaining information they have no right to. Contrast this with the present, highly dangerous situation. The citizen has already lost their integrity, chopped into bits, and at least a half dozen departments of central government have uninhibited access to personal information about them that is incomplete, and therefore may lead to the wrong judgments. The total person is destroyed, and power over them resides wherever anyone cares to assembly a dossier. RESURRECTING THE COMMUNITY I have hinged my notion of reform entirely on technology, which is all we have besides our love. Humanity’s institutions have grown like cancer. Our cerebral computers are no larger than those of Aristotle and Plato, More and Hobbes, Marx and Lenin…nor is there any evidence that human nature has changed. The one new variable in our situation is new science and technology, including human and social science and technologies like medicine and architecture which are directed towards the needs of the individual. People with small brains and limited data processing capability have the capacity to operate both effectively and happily in relatively small groups [7 people seems like an upper limit]. But since the beginning of the Industrial Revolution, the cancerous growth of institutions has completely broken down the viability of small groups and communities, by suborning individuals to the ends of larger, ill-comprehended, and gigantesque institutions and societies. The control of our lives is no longer vested in the elected government – local or national. It is vested in the firm: the firm for which we work, but more the multi-national corporations which make up our consumer economy. Governments may be meeting, attempting to protect our liberty, but guess who is writing the software that will be used throughout the advanced countries of the world. I am asking that power should be returned to the people. If the operation of community can be reinstated by technological means, to what end is community reborn? The real problems remain around us, some near and some far. Because of the imbalance of our institutions, their gross size and unwieldiness, and because of the general incompetence of our managerial efforts, problems remain unsolved. Forgive me for saying it again. We now have the science and technology required to redesign our institutions, so that they are both autonomous and integral at the same time. We have developed a machinery of government that cuts out people, who are frustrated. There is no chance that people can get back into this machine. So change the machine. Then rely on the people. Post Globalization: Economy, Systems Science & Academy (2011) Prepared for the 55th annual meeting of the International Society for the Systems Sciences Hull, Yorkshire, United Kingdom Theme: All together now – working across disciplines: People, principles and practice Jefferson’s Pursuit of Happiness? Aristotle’s Eudemony (Well-Being) Thomas Jefferson was not what most would consider a happy fellow. He didn’t care much for other people. He did not hold cabinet meetings. He was not an orator, nor did he relish the spotlight. President Kennedy famously welcomed 6 Nobel Laureates into the White House by saying it was the most brainpower there since Jefferson had breakfast alone – the point being that Jefferson always had all of his meals alone. As President, he would ride his big white horse every afternoon, alone. Jefferson’s most famous line of “life, liberty and the pursuit of happiness” was no guarantee for the country’s lucky future inhabitants. It is this sense of future hope that is still the country’s most powerful image around the world. Stafford Beer learned that Aristotle thought the human spirit responds to a sense of well-being, which he called “eudemony”. Prosperity is a big part of it, but more from the standpoint of liberty and self-determination than possessions and economic power. Eudemony measures some highest good, some subjective sense of quality. Eudemony is the higher standard for evaluating the Viable System Model; does it feel right? In Stafford’s introduction of eudemony in Platform for Change, he says “Money is terribly important, both to those paying and to those paid. But money is nonetheless an epiphenomenon of a system which actually runs on eudemony. It is for this reason that I have come to see money as a constraint on the behavior of eudemonic systems, rather than to see eudemony as a by- product of monetary systems.” Innovative Technology: computa, WikiLife, WikiEconomy Building a decentralized global economy We have a problem of too much data, too much noise. Too much junk. Global Data Pollution. In The Pheonomenon of Man, Teilhard de Chardin wrote about the noosphere, the collective consciousness of the planet, a humming web of communication surrounding the planet along with the biosphere and the atmosphere. The idea of computa is to create a central nervous system for the planet economy and political system that is decentralized. We have a physical Internet infrastructure, slow at times but rarely longer than a second or two. We need a social information structure for the global economy. It needs to be neutral/positive, gender rich, culturally respectful, scalar at many political levels, and be a practical useful tool for everyday economic practices for a broad range of economic and social organizations and networks. WikiLife: what it looks like from the individual perspective WikiEconomy: what it looks like from the big picture computa: the insides of the WikiLife/WikiEconomy information network The main purpose of this model is for the INDIVIDUAL to be able to have a standard grid for her to put all of the important information in her life in an organized way. It needs to be supportive of different scales of data, for unique people, to help her organize her way out of her problems and challenges, social, organizational, and economic – both as a consumer and as a producer. This model was first presented in the 1980 Society for General Systems Research proceedings (San Francisco). SGSR became the International Society for Systems Sciences in 1984. The basic concept of the Interpersonal Model is a boundary between the individual and the world. Inside the boundary (your skin) are certain realities, and outside the personal boundary are all kinds of walls, barriers, social hurdles, challenges and confusions. Some are physical and biological. Most are social. Most of the problems humans have now are organizational. The purposes of the model: - provide a historical data grid for accumulating personal information, in a way that is protective of personal privacy, useful, effective and efficient, and confidence inducing; - be the banking systems’ interface with each individual; - be the documentation manager for all economic transactions; - be a reliable public record; - provide a blind database for social policy implementation by the government, as well as public research, analysis, and program evaluation. Model for Individualized Community Information This is a model for a computer grid of a person’s local economy. It should be user friendly and provide linkage of the information structure between an individual and the larger economy, decentralization in a global context. The idea is that the model should be useful to individuals and families, and all business people as well as municipal bureaucrats and citizens investigating the government. WikiEconomy: a computer information idea for creating a global grassroots economy. Basically it is a dynamic information catalogue for all the parts of a woman's life: income, food, housing, health care, transportation, clothing, education, media, entertainment, taxes, managing the economy, public services, infrastructure, utilities. That information matrix has components that scale up physically/geographically: family, 10; neighborhood, 100; village, 1,000; community, 10,000; district, 100,000; and region, 1,000,000. Unlike counties, these can be compared. Most current policy emphasizes district-region-state-nation. This model shifts the focus to the village and the community, so that neighborhoods and families get their needs met. Inputs for the model include: information, money, food, energy, people with talents and potentials, and outputs that include economic goods and services (public and private), waste, pollution, and a changing culture as people evolve, leave and pass away. This computer model does not exist yet. It still needs to be built. Needed features include: a model for today’s city, real time and up to date, called “CityData,” to be interactive and user friendly, with numbers easily converging for analysis; plus “CityFuture” which focuses on the future, identifying options and even assessing the probability of their outcome. WikiLife/WikiEconomy: decentralized economic information system: built up from the individual Most of the global economy is hidden, and in a lot of trouble. This is a mechanism to turn the global economy inside out, so that most of it is transparent, and manageable. Anatomically, a fig fruit has all of its fruit inside the skin; turn it inside out, and it looks like a strawberry. WikiLife is like the strawberry: you can see everything you want to look for. It is an information structure that allows many people to fill in the beginning of cells of a decentralized economy at the neighborhood, village & community levels locally, while other people will discover what is actually happening in the larger economy at the regional, state, national, continental and global levels. This is a few orders of magnitude more complex than Linux or Wikipedia, but it is organized to evolve in a similar fashion. Each cell of the economy will be governed by people who participate in it. Cells at each level will have similar information challenges, and common approaches will emerge when they succeed. The idea is to build a grass roots global economy. Current Information Chaos “The average citizen typically has multiple identity cards, including a voter ID, a tax ID, a ration card, passport, driving license and others. Yet there is no central database, which has created “phantoms” on voter lists and welfare schemes.” That was once a description of India, but it could be any country. India has solved some of its problems with a mandated easily verifiable Unique Identity 12 digit random number (eye pupil scan and thumbprint), which would be the entry point in this kind of model. What would be the design characteristics of a global information system that would serve as the administrative support for the global economy? The past 30 years has been about converting data from the current complicated disconnected systems which aggressively retained the redundant complexity various paper accounting methods require but may be confusing rather than helpful. If it is as complex as possible now, what would be the simplest? What would be the most effective, the most efficient, least complicated? (And easiest to control the security of, in terms of documenting any potential violation: identity, prosecution, punishment.) As practical as possible. Should emphasize customer service, and historical archives so that short run mistakes are caught over time. It needs to include a Facebook type social network set of features, plus all of the tools and information management to control your own life. The end product of this paper is a web site home page for computa, called WikiLife/WikiEconomy. Rather than aggregate information by country, or business, this information system is based on the individual, and then aggregated upward to whatever level matters. Altogether the aggregate makes up the reality of the existing dynamic that makes up an economy. Concerns about violation of information privacy are legitimate, and decades late: our personal information security is violated all the time. We need to invent/design an information system that minimizes the opportunity to encroach on an individual’s privacy. A Real World Example From what I understand, the Danes have an excellent prototype in use as their national information system now. To the extent this is not true of the Danes, this is what I envision: One computer information network unifies the entire country. Each person in the society has an ongoing account, and it includes all of their personal, business, social and commercial activities. A primary job of people who work in the government is to assist people in accessing their individual computer information; if there is some kind of bureaucratic complication preventing someone from doing what they want, to assist them in clearing up the problem. Since this account includes all of the individual’s banking data, when a person is making a business or commercial proposal, there is no question as to the source of the information, and the quality can be determined. How it would feel physically: You custom design your own web page. It includes a portal to your business accounts, which are firewalled. Complete audit trail of anyone who goes in and what they do. You buy a bicycle; it is documented. Included is the annual public fee, which will continue to be charged as long as you own the bike. When you get rid of the bike, you make a data change as documentation, the fee stops, and changes are reflected in other parts of your web sites, and the relevant community statistics about number of bikes owned. If something is improper, you go to a local official, who you have spoken with before and built some trust, and the official helps you through your difficulty. Public officials who do inappropriate things will be identified and handled, and prevented. Most people will see the information system for what it is, a valuable public service that allows them to get on with their lives, get their needs met, and have control of their personal economy. Public Policy Analysis/Academic/Scientific Research The aggregate data becomes the fuel to drive the public policy debate. Part of the debate always remains about protecting individuals from data diving for manipulative commercial purposes. Within the ground rules for data use, it becomes an ongoing census and the basis for public policy debate, decision taking, and ongoing societal evaluation. Social scientists can focus more on population behavior instead of needing to worry about methodological nightmares. Some Parameters: Unique global universal identifying number: 13 digits: 10 for a person, 3 for their country In the US, it is your Social Security Number + 2 digits for state + 2 for US Identity theft is a serious problem now, and confidentiality can too easily be violated, so the security system must be much better. Protect individuality, family, neighborhood, even community, from data mining Start with the individual; aggregate to the country, not the other way around. Matrilineal? Let’s face it: 3000+ years of patriarchy has failed. Socially, ecologically and evolutionarily. The pursuit of material wealth and power has led us to a downward spiral of decay, social and environmental damage. How can we break out of it? This is a proposal to design and develop a global decentralized public/private information network that has so much personal integrity that a majority of the people on the planet/of a country/of a community are willing to be part of it, knowing that their participation increases its potential power. For that to happen, the integrity standard needs to be so high that older women are willing to recommend participation to younger women. Men by and large are more interested in their individual wants, where women are more likely to see other people’s needs as well as wants – in addition to their own. This is in no small part because women birth the children, nurture them through their youth, resolve family disputes through their lives, and care for them as they die. For women, those awarenesses are normal; a man with those positive experiences is considered un-usual. Women find men difficult to trust; men find women confusing; this proposal works to reverse cultural stereotype. This information system is specifically designed to meet a woman’s information needs, while coincidentally also meeting a man’s far simpler information demands. Governance Proposed decentralized evolution like Linux, as decentralized as possible, like ARPANET, the precursor for the Internet. A tool whose power is that it is completely in service. Depth & Breadth of Information The model needs to include as complete a picture of each community as possible, including: - geography: land contour, flooding and drainage problem areas, soil classifications, land uses, roads and their status, sewers, wells, water sources as well as quality; - climatology: seasonal changes, amount of rain, heat in summer, seasonal energy conservation programs; - demography: population age distribution, aging over time, births and deaths; - energy grids: telephone, energy, utilities, ability to have wireless computer connection (current cutting edge criteria for technology-available community), cable tv, potentials for green energy and community self-reliance; - economy: resources, people with skills and credentials, cash flow, incremental growth, dynamic equilibrium, taxes and public finance, commercial/residential/industrial/agricultural/open space uses, infrastructure, privacy protection of personal health and financial records, schools, libraries, child care, senior services, public programs, input/output for local, region, state, national and international; - city and community government: legal constraints, budgets and accounting systems, jawboning, special relationships with other levels of government. The computer model needs to have a dynamic, interactive, democratic evolution, with feedback and internal controls, privacy controls and protections, and at least be compatible with MacIntosh and IBM PC Windows Intel. The focus is to provide a combination of services as a basic package that can replace the current paperflow/banking economy. Such a dynamic interactive program would need to: identify an individual person, record her business transactions, document her contact with the government, give her personal control of her own health and financial records, allow controlled electronic funds transfers, and have up to date information about all government services, and just about anything else that she might want to know. Now this may all seem pretty sterile. Focusing on a particular community can make it a lot more real, as you fill in the pieces in a particular puzzle. The global economy is crumbling around us. We need to build new sustainable communities. By identifying where help is needed, jobs are created. The WikiEconomy model offers space for creating the democratic management of the global economy. To begin to develop your community wiki information, email contact@localwiki.org. Start a chapter of a club: the Liet Kynes club for a sustainable future. Liet Kynes was the planetary ecologist in Dune by Frank Herbert: think globally, act locally. Young children can build a three dimensional map of the area around their school and their homes, and then the route connecting their home and their school, then the entire school population area, the ways people travel, where their food comes from, special places they go, and where their parents go during the day. That is a practical education that builds a tool that will help the older people as well. It will empower the students to gain greater understanding and control of their immediate reality. 4th - 6th graders can build profiles of their shared community, especially in terms of food, transportation, housing, entertainment and recreation, and jobs. Which means beginning to build a profile of the district and region in that policy area. Here the model shows synergy, and the wiki robustness. A group in Los Angeles starts to look at transportation in the entire county (8 regions). Then 8 groups emerge that start filling in their respective district boxes of their region, like the patches of the google map filling in as they are loaded. 6th graders who have just completed their unit on Ancient Egypt can take the leadership on building the model/information for Modern Egypt and Future Egypt. Another group can build a physical model of Japan, and then start identifying key indicators of concern. The problems of Egypt and Japan are very different from each other, but they are suddenly among the most unstable and uncertain places on the planet, and would benefit from identifying incipient instability before they become even bigger problems. High school and college students can look at different parts of the matrix in their community, and fill in gaps and look for directions for future prosperity. Most adults are worn out fighting in the mainstream economy, trying to get ahead of the greed game. A sustainable economy is based on a completely different mindset. Western civilization is so out of touch with reality that the junior high school students are in the best position to talk about reality, and what people's needs are. Most adults have had their reality defined by advertising. As Stafford Beer said, "Theory (Advertising) is the only reality countenanced by our culture." Western civilization has devolved to the point where we are choking in our accumulating waste. In too many areas, the only solution is to do a much better quality job with a much smaller quantity of resources and effort. A local area should be evaluated in three areas: quality of life, cost of living and standard of living. Together, these three commonly recognizable terms add up towards what Stafford Beer calls eudemony, or well-being. They are a first draft at creating a quantifiable measure of “optimal community.” Quality of life includes air and water quality, long term health indicators, and intangibles of the natural environment. Cost of living focuses on a market basket index of basic goods. Standard of living includes measures of percent self-sufficiency, as well as the upper strata for the more high stepping. Communities can compare their statistics with other areas, and gradually come up with standards, by decentralized agreement. People looking for a new place to live will compare different communities’ statistics. Long time residents will understand their own community’s unique idiosyncrasies. And people will try to improve their numbers. WikiEconomy is a tool for public policy and social science, but most of all, it is a useful tool for the individual, in helping her manage and control all the data in her life. Community Governance: A System that Works (2019) What I propose we do with the 20th century political economy is cut out the bureaucracy to only necessary human functions. Let’s minimize the authority and power of the nation state, and the multi-national corporation. Let’s minimize the potential that anyone can accrue power politically or economically enough to threaten other people. While I am writing from a USA California perspective, my intention is that it be globally applicable. Start with an upper population limit of 10,000 people. This is the first of a series of limits that the current greed economy will find offensive. Since each limit will directly improve the potential for each person in the community to benefit, the system is in service to people, not businesses. If a business cannot properly service people, it should not exist. 10,000 people is the upper limit. The idea is to have manageable units of governance. 5,000 people is at least a thousand times more manageable than 10,000 people, due to exploding variety. But with 5,000 people, you will have several people who know most everybody that matters, for a long time. So, balancing how powerful people should have the opportunity to become, and the relative potential to dominate a population, somewhere between 5,000 and 10,000 people would seem most workable. Workability is the criteria for governance. No more of the devil is in the details. The whole point of VSM and systems analysis is to keep in mind what is the expected outcome and work in that general direction. Make all national and state laws focus on enforcement at the community level, with DAILY reporting from all jurisdictions on all areas of non-compliance with current law. Regulation consists of the “governance-computa code” which each community creates as its own compliance compatibility code so that it can be held accountable to national and state law without the national or state authorities being allowed to enter the community’s information system. Beyond elected officials, there are no national or state employees, no bureaucracy. County government and special districts are eliminated completely. All public employees are hired at the community level, and are subject to face-to-face accountability for the consequences of their decisions and actions. All coordination of government services is by Memorandums of Understanding (MOUs) between affected communities. All bureaucratic work is assigned to community employees for the particular MOU. The more important an issue is to a particular community, the more people will be involved in study groups around aspects of the issue that concerns that particular community, and the more public employees, money, time, energy and rhetoric the community council will agree to allocate to that issue. DISTRICT: In the Beer-Li model, the community is your base and the district is the larger shared reality. This is a model for large population centers, not just small towns. A big part of the idea is to create the community within the metropolis. The District is governed by an MOU that involves all of the communities, and their responsibilities to serve the needs of the District. A District Council is elected, with boundaries respectful of community integrity. Low population density communities on the edge of population centers may organize MOUs in an effort to retain their low densities. How it would work: State Governor (the Executive) decides by 9 am on the issue of the day, homelessness, or hunger, or incarceration, or economic development, or violent crime. The ten communities that have significant prominence on the issue are notified. At 1 pm, the Governor leads an hour long televised (streamed) discussion with representatives from the ten communities, which is intended to lead to legislation proposing changes to the computa algorithm that defines certain specific behaviors. All public policy focuses on activity at the community level. Utilities, transit hubs, airports, roadways, and other inter-community connectors are governed at the community-MOU level, with minimum oversight by the state and national legislatures. II. US Health & Human Services Challenges 5. Planning for the Future: Evolving a U.S. Universal Health System Between now and #21 June 1st, this weekly series is organizing a path to create universal health care in the U.S. This issue #5 is about the mechanics of this planning process. Beginning with this issue, each issue will include some of what will become #21, and manage the process along the way. What are Plans? How can they be useful? Bureaucratic silos use these documents to maintain the status quo, to defend their turf. How can we create an integrative mechanism? Stafford Beer talks about the challenges of anticipating uncertainty in The Heart of Enterprise: This is an alternative view of planning: The purpose of planning is so the future turns out differently from what otherwise would simply have happened to us. Planning is a continuous process. This idea conflicts with the stereotype of a PLAN based on the next month, the next year, the next five years or some year in the future. Nature does not have a calendar, except for the seasons. The seasons do not really affect the affairs of business or government. Especially it is not reflected in arbitrary time epochs as decided by administrative convenience. It is surely evident that some events are more predictable than others. There is a continuum of prediction, set against a continuum of probability. In attempting to plan we engage in continuous process. The continuity arises from the constant readjustment of rational expectations against shifting scenarios – in circumstances where some sorts of expectation are more rational than others, and some sorts of scenario are more credible than others. But plans are supposedly set across the board – on which all expectations are equally rational, and all scenarios are equally credible. Only thus is there any meaning (never mind sense) in chopping up future time into planning epochs. Any such assumption is false. Not only is there no logical validity in entailed premises that everything develops at the same pace, or with the same degree of likelihood, but there is no chronological validity in the notion that epochs are somehow marked out to notify the requisite changes that would denote any need for managerial action. For these reasons, most of the planning systems are nonsensical, because they do not relate to continuous process. The only planners are the managers, the people who are entitled to commit resources. This is done continuously, because rational expectations and probably scenarios are both constantly changing, so that the decision taken yesterday is very probably and perhaps ostentatiously wrong today. More information has arrived, and ‘information is what changes us.’ So, Plans must continually abort. Produce a plan, dated so-and-so, which has today been implemented in every detail, and you will see a stupid action. This is just because more information must have become available since the last date. So planning is not an activity carried out by professionals called planners; it is an act of decision carried out by managers empowered to commit resources to a different future. Planning is not activity resulting in products called plans; it is a continuous process, where by the process itself – namely that of aborting the plans – is the pay-off. The plans do not have to be implemented or not by those in authority: what the authority does constitutes the plan – and its realization. The endless flux of the planning process, undertaken by managers, and constantly aborted by their own decisions, is the reality of management. The rest is illusion. To partake in the continuous managerial process of aborting decisions – that is to direct the organization. That is to plan. And in that planning process the manager dispenses the cohesive ‘glue’ that holds the organization together. The institution hangs together, because, and only because, plans are aborting with new decisions, and in so doing realizing the actuality called profit and loss, success and failure, reward and punishment, happiness and misery, and (in the long run for the viable system) life and death. 6. Reducing Unnecessary Complications: Nature’s Efficient Complexity vs 20th Century Complicated Bureaucratic Institutions from too much Variety Health care is naturally complex. Health care administration, finance and policy need not be so complicated. Each new health insurance package creates greater complications in the administration of health care. To protect the health insurance industry, health professionals under Obamacare must spend half their time with desk work entering data, to a quarter time actually seeing patients. The U.S. administrative complications explains why U.S. health care is almost twice the GDP of every other industrial nation that does provide universal coverage. The free market idea of health insurance requires the health professional to prove every action; often with plan limits to control costs. At every step along the way, the health professional must include the insurance in considering treatment options. In most of Europe, they don’t have to talk about insurance because it is automatically covered, based on professional judgment. It isn’t just health insurance that is so complicated that it is chaos. Ever since the Roman Legion and the Roman Catholic Church, the definition of a successful organization has been the large, centralized bureaucratic, ego-driven power structure, exemplified by the dominance of Xi Jinping in China and Trump’s presidency. While nature sets size limits, social systems have grown out of control. What would be a manageable human scale for different social institutions? We are using these definitions to help shape effective public policy: family, 10; neighborhood, 100; village, 1,000; community, 10,000; district, 100,000; region, 1,000,000. Here’s the thing. Most people only know a few hundred people. Most people focus on maybe a dozen people in their every day lives. Almost everybody lives in a geographic space that they share with a few thousand people. Only bureaucrats and elected officials really think about a whole city or a region, or a state or the nation. A big part of the data overload problem is that we are virtually counting everything and getting lost in the digital blizzard. This analysis is a potential solution of focusing on data collection only at the human social scale were it matters. This is a shift in public policy focus from the macro/city level to the micro levels of neighborhood, village and community. - For example, every neighborhood should have safe areas for children to play, within parent’s calling distance. - The child protective services should focus at the school catchment area or village level, because if you look at the city or any higher level, you are only seeing the damage, and not seeing the factors that trouble children in that particular area. If a child is going to get into trouble, to fail in daily society, the troubles will be repeated within what for an adult is a fairly small area. Most of the children at any particular school will share a similar range of challenges and potential problems. At the city level, about all you can do is identify which schools seem to create more problems. - Health care at the community level: this entire series is an argument that managing personal health is a community question. The current system prioritizes hospitals and specialty care. Issue #8 will be about how the City can manage the information for community clinics so as to best manage and coordinate resources to meet the greater needs of the entire city’s population. This is an example of variety management. It is from engineering, which is much less complex than the U.S. health care delivery system. How the VSM Helped Transform a Manufacturing Company in Crisis by Patrick Hoverstadt This is from Holistic Management: Managing What Matters for Company Success by William Christopher, Chapter 3: How the Viable System Model Improves Performance: An Application, page 107-113 This book is designed to be a synthesis of the thinking of Peter Drucker’s Management by Objectives and Stafford Beer’s Viable System Model. Executive Summary GRS was a medium-sized engineering company with approximately 200 employees producing pressed and welded automotive subcomponents for several car and truck manufacturers. Of approximately 2000 different product lines almost all involved work by more than one department. A process flow analysis of workflow between departments for a typical small job needing three pressing operations and two welding operations showed this required no less than 16 interdepartmental information transfers involving six departments. For a group of five fairly typical jobs with two, three, four, four and six operations respectively, there were no less than 27.5 billion different permutations (the variety) for carrying out these five jobs. The proposed new structure showed how much more of the complexity of operations management the new structure would absorb. From receipt to completion of order, the job involving three pressing and two welding operations would now involve only three interdepartmental information transfers between two department instead of 16 transfers between six departments. This change was a significant shortening of the process, giving much greater robustness in the process with much less chance of interruption or misinformation being passed to customers. For the same five jobs, the number of possible permutation had fallen to just 70 from 27.5 billion. For those unfamiliar with variety calculations, this may seem an extraordinary reduction, but in many instances complexity is exponential, so comparisons between very large and relatively speaking very small figures is not uncommon. This reduction meant that the planning process had gone from one that was almost impossible to carry out successfully, to one that was almost trivial. The GRS project is an example of the VSM showing the systemic links between strategic and operational issues. It also illustrates how the VSM and variety analysis can bring out the connections between different operational problems and provide managers with a rigorous language for both the diagnosis of organizational problems and their resolution. The Company Situation GRS was a medium-sized engineering company with approximately 200 employees producing pressed and welded automotive subcomponents for several car and truck manufacturers. One major customer accounted for over half of the company’s total sales. At the time this project took place, this major customer was initiating a program of transformation for its supply base. One part of this program was to move toward stockless, just-in-time production (JIT). JIT can only work if suppliers have the capability to deliver product in exactly the right quantities, to exactly the specified quality, at exactly the right time. Without this supplier capability, the whole production line of this major manufacturer would be brought to a halt for want of a single component not delivered by a supplier. Inevitably then, as part of its change initiative, and to assure meeting the new requirements, the car company was instituting a program to transform the way its suppliers operate. This program involved suppliers in a “total quality” approach to quality management as part of the development of the capability for tighter delivery performance. The program also involved cutting the number of suppliers of pressed components by two-thirds. This left GRS with a set of interconnected strategic and operational challenges. The Challenges: At the operational level, GRS had the problem of radically improving the standards of its operations. Supplying its major customer on a JIT basis would require it to radically improve its standards for product quality, production scheduling, and accuracy of batch sizes, all of which were woefully inadequate. This set of operational problems, important and significant in their own right, was nested within a set of strategic challenges. With its most important customer reducing its supplier base by two thirds, GRS was clearly at risk of losing the customer. Losing the customer would have a catastrophic effect, since in a shrinking and highly competitive market, the loss of the most profitable half of its market would almost certainly mean bankruptcy for GRS. Conversely, retention of the customer would demand that GRS grow significantly to fill the gap left by the de-selected firms. The strategic dilemma facing the GRS management was whether to focus on retaining their status as a preferred supplier, or to broaden their customer base to try to reduce the risk. The operational challenge of meeting their customer’s demands for higher levels of quality and service played a critical role in the strategic decision-making process. Whichever strategy was pursued with whichever customers, success would depend on being able to meet the higher expectations of a changing market. So improving operational capability was a prerequisite of being able to implement either strategic option successfully. Complexity and the Problem Set This group of problems – with a set of operational challenges nested within a set of strategic challenges – will probably look fairly familiar to many business people. If we look at it in terms of complexity or variety, then we can start to see how the VSM relates to solving these sorts of organizational problems. What we have is a situation of an organization that has been more or less in balance with its stable operating environment for many years. The variety of the organization just about matched that of the environment, so it was able to supply the needs of its markets within the environment, only just, and with much swearing, shouting, and firefighting by managers. Nevertheless, usually the work got done, the goods got delivered somehow, and customers eventually paid their bills. Suddenly, a change elsewhere in the environment disturbed this company’s immediate operating environment so that the variety being demanded of the company increased significantly. This increase in variety isn’t just a metaphorical or notional change in the requisite variety required, much of it can be quantified. So, for example, JIT required more and smaller deliveries, which meant more batches to be put through production, a straight-forward and measureable increase in complexity. Similarly, the new requirements for batch accuracy in terms of numbers of components, quality of components, and timing of delivery were all direct and quantifiable in terms of the complexity and variety of operations that the organization needed to be able to deal with. The Initial Response The first response of the company was to undertake a major change initiative using a Deming- based “total quality” program led by an external consultant who specializes in helping companies achieve total quality operations. The implementation plan was based on current best practices and included a significant training program for the directors and managers team down to the supervisor level. The training was fairly successful in changing practice in the shop. In particular, it became increasingly clear that the operating structure of the company was making it difficult fort production scheduling to handle process-based initiatives. Whenever a process crossed organizational boundaries between departments, change tended to stall. Analysis and Intervention using VSM Analyzing the company’s operational base using VSM gave the “unfolding of complexity.” Operations were organized as three functional departments: light pressing, heavy pressing and welding; and two “cells,” one a specialist assembly called “ADO” which assembled two large car sub-assemblies from pressings, and the other department based on new CNC machines. Unfolding of Complexity Tracking the workflow through this structure showed complex interactions between the operational departments. Of approximately 2000 different product lines almost all involved work by more than one department. A process flow analysis of workflow between departments for a typical small job needing three pressing operations and two welding operations showed this required no less than 16 interdepartmental information transfers involving six departments. Coordinating the huge variety of these interactions between departments required a corresponding capacity in the VSM system 2. There was ample evidence that this capacity did not exist. On the floor between the press shop and the welding department, there was a set of wire crates stacked to the roof. These crates were “lost jobs,” subcomponents that had been pressed ready for welding into assemblies, but had never been welded up. Some were known to have been there for months, but no records existed to show how long some had been there. This in-process inventory was evidence of very poor coordination between the welding and pressing departments. Customers calling up to progress-chase their orders were unable to find out where their order was in the process, and would get conflicting information each time they called. This situation showed poor coordination between operational departments, and also created disruption in operations as there were frequent stoppages as the planned production process was altered part way through a batch to “fast-track” another job in response to customer demands on a “who shouts loudest wins” basis. All these were symptoms of persistent breakdowns of system 2 that should have been coordinating production between departments. Production planning is one of the main components of system 2, intended specifically to smooth operations between departments. But GRS system 2 was unable to cope with the complexity of operations. The instability of the production process was obvious every Friday afternoon. Without fail, one of the senior management team would come into the production control office straight from a heated conversation with a valued customer. The manager would be clutching a piece of paper with the details of the customer’s urgent job and insist on the immediate rescheduling of production plans in order to prioritize this particular job. In vain, the planning team would complain that this would wreck the next week’s plans and set the scene for a repeat performance the following week. An unintended emergent property of this persistent failure of system 2 to cope with interdepartmental processes was a culture of blame, which was directed specifically at the planning team. The blame for the persistent failure of scheduling to deliver accurate quantities on time was put on the schedulers, not on the organizational system they were being asked to cope with. Politically, of course, this had major repercussions, as the planning team’s arguments for change were undermined by the perception that they were themselves the problem. A variety calculation of the complexity that thy were trying to deal with soon showed the scale of their problem. For each job requiring pressing operations, a series of decisions were required. Taken in isolation, these were not too difficult, but of course, these were not being taken in isolation as each decision on one job affected the choices available for planning capacity to do other jobs. So the reality facing the schedulers was a need to examine different permutations of jobs going through the system and to prioritize these to optimize overall production. The worst problems were in the light press shop. In the light press shop, the fist stage was to break a “job” down into its component operations each of which was planned and scheduled separately. Immediately, this increased the complexity and fragility of the system and meant that the integrity of the process was only owned by the schedulers, and not by the actual production team. It also of course meant that the production schedule had more things to deal with. The next stage was to prioritize each of these individual operations, then to allocate each of them to one particular press of the 40 in the shop. Once this was done, the press shop team leader would allocate a press operator to each press. Taken altogether, this was a very complicated process. For a group of five fairly typical jobs with two, three, four, four and six operations respectively, there were no less than 27.5 billion different permutations (the variety) for carrying out these five jobs. Given this scale of complexity, it wasn’t really surprising that the production planners frequently failed. The Alternative Structure The sort of massive loading on system 2 that was evident in the original structure is very often an indicator that the basic alignment of an organizational structure is wrong. In this case the recommendation was to switch to a multi-functional “cell” based structure, which would combine equipment and personnel from both the press shop and welding shop. This represents a move from a structure split into departments operating different technologies, to one where structure is split by groups of products. In each of the new cells there was the equipment and personnel necessary to do all the operations for a set of products within the company’s product range. This involved taking presses and welding plant and putting them together to form a mini-production line that could carry out all the operations needed to complete a set of products. This change is a fairly common solution in the engineering industry, but has been carried out with varying success. In those companies where it was successful it had improved both productivity and response times dramatically. However, in some instances it had had little effect, and had even been blamed for some company failures. Using VSM and variety calculations allowed us to work out the likely impact of this change and assess how well it would address the company’s problems. We repeated the same analysis of workflow and complexity of planning decisions as we had used to evaluate the previous structure. The proposed new structure showed how much more of the complexity of operations management the new structure would absorb. From receipt to completion of order, the job involving three pressing and two welding operations would now involve only three interdepartmental information transfers between two department instead of 16 transfers between six departments. This change was a significant shortening of the process, giving much greater robustness in the process with much less chance of interruption or misinformation being passed to customers. Some of the shortening came about because the whole of the actual production process was now contained within a single production cell. Some came about because a reduction in the complexity of production planning allowed a re-engineering of order processing. The analysis of the complexity of decision-making in production planning showed a dramatic change. For the same five jobs, the number of possible permutation had fallen to just 70 from 27.5 billion. For those unfamiliar with variety calculations, this may seem an extraordinary reduction, but in many instances complexity is exponential, so comparisons between very large and relatively speaking very small figures is not uncommon. This reduction meant that the planning process had gone from one that was almost impossible to carry out successfully, to one that was almost trivial. Outcomes and Conclusions Using VSM provided a high-level view of the dynamics of the company’s problems and of the way that these seemingly disparate problems were related, both causally and in time. The new cell-based structure designed using the VSM proved much more cohesive and a better basis for introducing other technical and commercial changes to address both the operational and strategic challenges. While the structural solutions chosen could have been arrived at by other means, what the VSM provided was a rigorous and partially quantified approach that showed why it was likely to be effective in this particular case. The security of this VSM approach contrasts with the risk inherent in adopting such a change plan based purely on copying someone else’s solution and hoping that the fundamentals of both organizations are sufficiently similar for the “solution” to work. 7. The Human Cost of U.S. Health Insurance: Physician Time: 48% computer, 26% patient care: Primitive US Health Insurance vs Sophisticated European Non-Profit Universal Coverage US Proves Health Insurance Cannot Work "It may be possible to finance fair and cost-efficient health care for all through profit-making health insurance, but no country has ever made it work. For-profit health insurance clearly hasn’t worked in the U.S., which spends more than any other country and still leaves millions without any coverage. And no other developed country wants to try it.” The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, T.R. Reid (2009) Ask any European. In Europe, Health Care is a Right. In the U.S.? In the U.S., your level of health care is complicated by your health insurance. Everybody in Europe gets better health care than your insurance company can offer. Even if you are the President or a member of Congress, you are lost in the anti-patient maze that the U.S. calls health care insurance economics. Nobody in the U.S. gets better care than the care all Europeans get every day. The best a U.S. citizen can hope for is normal, every day care in most European countries. Even if you are rich, you are dependent on how much administrative complexity your care givers must contend with as part of your care complications - that do not exist at all if you are receiving care in Europe. The Republican Party rhetoric that the health industry is market driven maximizes the failure of the potential social process of healing. Every time price enters the equation, it complicates the thinking of both the patient and the health professional, in ways that are always detrimental to the healing potential. The health insurance industry designed Obamacare in an attempt to build a successful market for the health insurance industry. Instead, they have proven once again that seeing health care delivery as a competitive economic market is inherently dysfunctional, more expensive, un- affordable, and getting worse, more un-manageable. In the Obamacare legislation, they put in every accounting trick they could imagine, and health care costs have exploded. The Gold standard of Obamacare is barely the minimum in most European non-profit health insurance regulations. The Silver and Bronze plans, and the Trump plans only pay a small portion of the costs - any other health costs will come from out-of-pocket, or more likely neglect. Avoiding going for health care because of potential added expense is a major disease factor as part of human nature. In the U.S. it is an overwhelming problem; in Europe, it isn’t even a cause for concern. The Administrative Burdens of Obamacare Hospitals are reporting that they must have as much as 1 full time billing clerk for every bed. The insurance industry is dedicated to preventing people from receiving the services recommended by their health professionals. The only way that insurance companies make money is by refusing authorization. Outcomes vs Cost: No Comparison Compare European Countries in terms of morbidity, consumer satisfaction, health professional satisfaction, fiduciary responsibilities, and bottom line, the Dutch complain because they have one of the most expensive health care services in Europe, at 10.8% of GDP: they get everything they want, and pay a lot less than U.S. citizens pay 17.7% GDP for inconsistent quality and poorly managed, uncoordinated services. Costs out of control: Obamacare was always expected to be inflationary, 6% - 10% a year. Currently, Obamacare defined health care is costing $12,000 in premiums, employer payments, copays and out of pocket for a family of four with an income of $60,000. Health care is costing an average U.S. family one-fifth of their income, for disorganized, inconsistent care, ranked 37th in the world in too many categories that matter. For too many, health care now costs more than they spend on housing, with high uncertainty and risk of future financial ruin. With health care inflation, costs are expected to take up to half the family’s income by 2025. There is only rhetoric about cost containment in Obamacare, the so-called Affordable Care Act. The solution is locally managed global budgets offering universal benefits for every person in the U.S., like they have in Europe, Canada and even Mexico. Shifting from expensive medical technology to healing 1. Overwhelming administrative stress on Health Professionals: It turns out that the mental cost to health professionals is even greater than it is for the consumer. The Electronic Health Records systems that hospitals and HMOs have installed require each patient encounter to be documented to the insurance company’s satisfaction. There are over 100 insurance companies, and they each have their own set of limits to care. Even with full time medical records clerks doing the typing during the actual visit so that the physician or nurse practitioner can focus on the patient, health professionals, nurses, therapists and clinicians are being required to follow the computer to their next task. Physician Time: 48% computer, 26% patient care. For people devoted to biological science to become enslaved by computers is not professionally satisfying at the end of the day. What happened to practicing health care? 2. Insurance pays for procedures, not health care: The big picture problem is that health insurance pays for sickness intervention rather than health promotion and disease prevention. Hospitals with technology can charge high prices, so they are receiving most of the health care dollars. Insurance pays for intervening, not so much for watching and talking. Surgeons are well- rewarded, primary care not so well. Scientific health care like watching, observing, listening, explaining, probing, being patient with the patient to learn what is going on are things a primary care health professional knows are the only way to allow healing to happen. Primary care health professionals include: family physicians, primary care pediatricians, primary care internists, obstetricians and gynecologists, nurse practitioners, pharmacists, nurse and lay midwives, home health nurses and aides, physician assistants, psychologists and social workers, nutritionists, physical therapists, EMTs and paramedics, dentists and community health workers. In the U.S., 70% of the physicians are in specialty care, only 30% are in primary care like family practice; in Europe, it seems to be working with a 50%-50% split. In Europe, the primary care physicians are as well compensated as the specialists. Only 10% of health improvement outcomes are due to medical care. 90% of the health outcomes are produced by education, housing, environment, behavior, genetics and social organizations. Non-medical determinants of premature dying include: behavioral patterns like diet, exercise, alcohol and drugs, account for 40%, genetic predisposition, 30%, social circumstances 15%, and environmental exposure 5%. Many of the factors are social determinants, like smoking, income inequality, and race, which turns out to be a marker for poor health outcomes in the U.S. A key indicator of local healthy outcomes is availability of primary care health professionals. 3. Primary care clinics are more effective than hospitals at health promotion and sickness prevention: The potential for improvement in health is not to be found in hospitals, with sickness interventions, but with clinics serving a defined population of up to 10,000 people. For 85% of all patient care, the primary care in a community clinic is superior to the same care given in a hospital setting. Near things like knowledge of the patient, the patient’s lifestyle, the patient’s community, the patient’s work environment that will define their health challenges, and what might be an effective intervention or improvement in the patient’s situation are all areas where the patient will benefit if the health professional is familiar with what the patient is talking about. All are more likely in a clinic than in the adjacent hospital. The reality is that a clinic will see many more people each day than any part of the hospital will, so they will have a much broader sense of what is actually going on in the local community from one day to the next. In addition, professional communication within a clinic is so much shorter than it is in a hospital, that there is an automatic additional hospital internal cost. The complicated billing with perhaps a million different prices adds a whole other layer of confusion that a clinic does not have to fight. Each layer of complication is exponential: it automatically complicates everything else. That is why “Medicare for All who want it” only makes the administrative problems worse, adding additional expense to each transaction. Universal coverage eliminates the need for all of that price discrimination, so health professionals can practice medicine, like they do in Europe, Japan, Taiwan, Canada, Mexico, and the rest of the industrial world. Universal coverage with one comprehensive benefit package and truly streamlined administration leads to higher access, greater utilization, better health outcomes and lower costs: by eliminating the private insurance marketing, administrative and regulatory obstacles. This will require retraining and reorientation for several million people in the health insurance industry. Many can be refocused to quality improvement in the local Office of Epidemiological Accountability. When Canada and other countries shifted to universal coverage, primary care use went up, as people were less hesitant to make an appointment. As a result, there was lower demand for more expensive services, specialization and hospitalization. Countries with universal coverage have better patient awareness of their health choices, and how the health care delivery system works, so the patient is an active partner in their own health care, in ways that are too often a mystery for too many U.S. health consumers. Comparing health claims processing: U.S. versus Canada by Henry Broeska “More than 100 insurance companies in the U.S. process claims using their own different rules and their proprietary software. Tens of millions of claims are transacted daily in the U.S. Each claim can trigger thousands of actions. Confusion at every level makes the U.S. claims payment infrastructure the most complex and expensive in the world.” “Health care administration unrelated to patient care costs each American an average of $2,497 per year, compared to Canada’s $551.” “Similar to the method used in the U.S., Canadian physicians and providers make claims electronically to the provincial payer. There is no use for third-party private insurers because Canadians are all members of the same public plan with the same comprehensive coverage.” “There is only one set of prices for each province based on a fee-for-service payment structure. For patients, there is nothing to do; no paperwork, no bills, no out-of-pocket costs. Because the provincial plan pays, no Canadian has ever been denied care, accumulated personal debt, or been forced into bankruptcy for a medical reason.” This is an argument that the U.S. health care delivery system should evolve to more effective health care by closing most of the hospitals except in rural areas, replacing them with 40,000 community clinics nationally, regulated at the city level with global local budgets, providing 85% of the care, with 70% of the resources; and hospitals providing the more sophisticated 15% that they are best designed to provide, with 30% of the resources. Lower infant mortality, improved care quality, better health outcomes, lower costs. Every single country in Europe has proven that universal health care works for about 10% of the GDP, compared to the health insurance chaos U.S. 17.7% of GDP and climbing. III. US Health & Human Services for the 21st Century8. U.S. Universal Health Care with 40,000 Community Clinics that is better than Private Insurance:The Community Health Clinic: The Central Resource for Community Centered Health & Wellness Clinical Care, Michelle S. Famula, M.D. The Universal Expectation From Now On What are the optimum characteristics of a health system? The Health Clinic (FQHC): You are welcomed; you receive immediate attention, your comforts matter. The health professional already knows you and your history, lifestyle, occupation, preferences, and they assume that you take responsibility for your own body (and theirs is a second opinion). If you need special care, you get it. This would require shifting resources to community clinics and closing hospitals, empowering nurses, and focusing on primary care, prevention and health education. If the U.S. had a clinic in every community of up to 10,000 people in every city, then the clinics would manage 85%of the needed care. Then only the sickest 15% who should go are sent to the hospitals by the clinics, preventing hospital swamping because misinformed people don’t understand their options. This would be a national universal health care program based on locally controlled clinics that meet federal standards for quality of care, access, availability, and equity. This clinic-based system is designed to effectively meet community health and social needs and efficiently manage costs, monitored by ongoing evaluation through an Office of Epidemiological Accountability. The Situation We Are Confronted With “’One of the things we learned from Ebola is that you have to have a functioning health system going into a crisis, you can’t rely on one springing up in the midst of a rapidly moving disease. It is becoming clear to us now what happens when you don’t have a fully functioning CDC.’ Zeke Emanuel, professor of health care management, University of Pennsylvania. “’Testing availability remains extraordinarily limited in the U.S.,’ said Michael Mina, assistant professor of epidemiology at the Harvard School of Public Health, who estimates the U.S. is 5 weeks behind where it should be at this stage of the outbreak, given the time it had to prepare. “CDC Director Robert Redfield admitted that budget cuts had taken their toll. ‘The truth is we’ve under-invested in the public health labs,’ he said during a congressional hearing earlier this week. “Between 2010 and 2019, CDC’s funding was cut by 10% in real terms. From 2003 to 2019, the organization’s funding for state and local preparedness was cut by a third.” Center for Disease Control: Chaotic U.S. response puts health agency’s reputation to test Kiran Stacey, Washington; Hannah Kuchler, New York; Financial Times, March 13, p2 “The war against Ebola, fought in the hardest conditions imaginable – including a real, low-level war – is a victory not only for Congo but for the world. If coronavirus has taught us anything it is the fact of our interconnectedness. “These issues have been brilliantly highlighted by author Laurie Garrett, who has written for decades about our eternal vulnerability to microbes. In Betrayal of Trust: Collapse of Global Public Health, she warned against a global shift from public to private health. “In an age when the perceived threat is greater from non-communicable diseases – such as cancer, hypertension, and diabetes – the temptation is to view health through a personal lens. The individual with the best medical insurance will be the healthiest. That ignores two facts. One is that the most effective interventions, from clean water to antibiotics and vaccines, have all been collective. The second is that infectious diseases have not been defeated. They have been at best, kept at bay. “This has implications for rich and poor regions alike. For countries such as the US or the UK, it means you ignore public health – and the health of the most vulnerable in society – at your peril. In poorer parts of the world, it means that anyone’s battle against disease is everyone’s battle. “What public health experts have been telling us for years is in the fight against infectious disease, your problem is also very much my problem.” Only public health can win the battle of infectious diseases Africa, David Pilling, Financial Times, March 13, p9 The Community Health Clinic: The Central Resource for Community Centered Health & Wellness Clinical Care Michelle S. Famula, M.D. I. What is Community-Centered Health and Wellness Clinical Care? Program Mission Vision II. What are the Essential Elements of a Community Health Clinic? Facility Resources (Furnishings, Equipment, Supplies and Materiel) Staffing III. What Community Populations Need Access to Community Health Clinic care? Primary Care for Medical and Mental Health Members of the Patient Community Types of Care Offered Levels of Service Delivered IV. Bridging to Services Beyond the Scope or Resources of the Community Clinic Clinic-Based Services that ensure access to non-clinical resources essential to successful Clinical Outcomes Clinic-Based Services that ensure transfer to higher-level care/rehabilitation Clinic-Based Services that ensure return to Clinic-based care upon discharge from higher-level care/rehabilitation Community Social Support Services to facilitate clinic access Community Resources to secure essential human wellness V. Administration, Management, Governance and Quality Assurance Finance, Budget and Human Resources Facility Management, Materiel Management, Purchasing & Equipment Control Clinic Management, Medical Records, Appointment Scheduling, Billing Accreditation, Compliance, Clinical Care Quality Measures Community-Centered Health and Wellness Clinical Care Program: The optimum Community-Centered Health and Wellness program is a complex integration of coordinated primary care medical and mental health services, combined with a network of tailored ancillary, auxiliary and clinic support services, designed to ensure that illness is prevented, diagnosed, treated and/or managed with maximum efficiency. The goal of Community-Centered Health and Wellness Clinical Care is to prioritize the healthful participation of all community members in all aspects of our community life and eliminate illness as a barrier to a fulfilling and successful personal life. The success of this program is contingent upon resource management expertise that: 1) optimally utilizes clinic resources and services to ensure and augment desired clinical outcomes, and 2) carefully integrates all program services and appropriates program resources to produce financial stability without compromising essential program components or unduly burdening the financial resources of the community as a whole or the individual patient. Mission: The mission of a Community-Centered Health and Wellness program is to provide the community-based health and wellness resources that enable all community members to successfully achieve their individual and collective community goals including health and wellbeing, achievement and productivity, financial and social stability. These resources deliver: quality, accessible, confidential, and cost sensitive medical and mental health care tailored to the unique and diverse needs of all residents and their community consultative, educational and collaborative treatment services as appropriate for social services, government offices and the business community health promotion, education and disease/injury prevention specific to community needs and appropriately focused to address the health risks and unique concerns of vulnerable populations. advocacy for a healthy community environment Vision: The vision of a Community-Centered Health and Wellness program is to be dynamically responsive to changing needs and resources to deliver a community responsive resource that optimally fulfills its mission. The Essential Elements of a Community Health Clinic Facility: A Community-Centered Health and Wellness program requires a facility space plan design optimally configured to deliver outpatient ambulatory health services. This requires a sanitary, accessible, safe, secure, and private environment that facilitates and supports a functional workflow in which patients can be treated quickly and effectively by medical and mental health practitioners. Support service and sub-space types, such as office spaces, storage areas, materiel management receiving and processing areas, housekeeping and IT equipment spaces are required. It is particularly efficient for healthcare delivery and cost containment, as well as convenient for patients and staff, if areas can be co-located and configured to facilitate shared resources and streamline patient flow. Operational spaces can be designed as functional “pods” that may be identically equipped and supplied and built in repeatable units that enable reduced cost in purchasing, furnishing repair and replacement and restocking. Clinic space includes reception/waiting, initial intake, exam, procedure. For certain procedure or treatment care, a pre/post-care consultation area may be needed in accordance with level of care and care standards. The Community-Centered outpatient ambulatory health service facility is adequately configured either within the routine care areas or in a separate uniquely designed and equipped area to provide acute/urgent care walk-in care. This requires space for rapid evaluation that facilitates stabilization and transport to higher level care when needed. Ancillary services include diagnostic/treatment services that provide timely access (as directed by provider staff) to resources that give added visit value. A pharmacy, laboratory and radiology department enable health professionals to best diagnose and offer initial outpatient care in a one- stop-shop approach. On-site services also enable the clinic to be able to diagnose with “point-of-service” testing and treatment pharmaceuticals (e.g. injectables, contraceptive devices) that enable effective clinic appropriate outpatient procedures to occur. Auxiliary services may include a number of health services provided by clinical professionals who augment medical/mental health treatment and recovery care. Space for adequate Dietary counseling, Physical Therapy, Acupuncture, Substance Use Disorder (SUD) counseling are typically Auxiliary care services conveniently delivered in the outpatient ambulatory setting and should be reasonably co-located with medical/mental health primary care. Specialty and Other Health Professions may be reasonably co-located to encourage care integration across disciplines as well as optimal utilization of Ancillary and Auxiliary resources. These may include appropriately configured and resourced Orthopedic, Gynecology, General Surgery, Internal Medicine subspecialty, Psychiatry and Dermatology. In many cases these clinic areas may be utilized on rotation, as not each service may be required to offer services for routine care daily. Uniquely configured areas for Optometry and Dentistry, regularly staffed with appropriate professionals also enhance service integration and patient utilization to improve health and wellness when co-located in the Community Centered Clinic facility. Administrative services should be represented on-site to support clinical functions and ensure adequate oversight and management of clinic operations. Safety, security, sanitation, accessibility and privacy critical to maintenance of a quality environment require on-site staffing and management. Information technology, materiel management, housekeeping and personnel management resources should be readily available to address just-in-time events that may disrupt or compromise service if not readily addressed. Resources: A Community-Centered Health and Wellness program requires the resources that are required to deliver reliable, efficient, high quality care that optimally ensures desired clinical outcomes and community service delivery. These may be reasonably considered individually as furnishings, equipment, materiel and supplies. Furnishings for patient registration and waiting areas, exam and procedure rooms, clinician offices, administrative work spaces and conference rooms are determined, like the spaces and rooms themselves by ambulatory healthcare workplace standards, based on the size of the served community and the staffing goals required to efficiently address high quality service delivery . Equipment needs for clinical diagnostic and treatment services are determined by the health professionals and equipment specialists most familiar with those services housed in this facility. Selection is based on current services, informed by anticipated emerging developments and advances in care. Health administrative, technology and business equipment resources are required to process visit services, maintain records, conduct business operations, as well as collect and report data. Equipment to purchase and store supplies and materials, manage medical waste and ensure a work environment able to achieve the high standards of safety, efficiency, cleanliness and sanitation are also needed. Materiel and Supplies include the disposable and consumable products that are required to provide care. These include all materials used to perform diagnostic tests, conduct physical examinations, and perform office-based therapies, procedures and treatments. This also includes materials needed to document and record care, provide educational and behavioral interventions, stock reagents, agents and processing supplies needed to conduct laboratory tests, obtain radiologic images and manage pharmacy functions. Office and Information Technology supplies, facility maintenance products and housekeeping supplies must be purchased, maintained, inventoried and restocked. Staffing: Delivery of a Community-Centered Health and Wellness program rests upon strategic and sufficient staffing to ensure efficient, high quality healthcare by qualified, proficient healthcare professionals. In accordance with professional standards of care and well published accreditation compliance measures, well established staffing ratios are designed to match levels of care, patient and client numbers and the needs of the multiple unique and diverse patient populations. Scheduling software packages published workflows that serve unique care needs, evidence based best-practices and protocols help inform staffing optimums. The concept of “best practices” in Staffing remains a moving target. The ability to attract, retain, deploy and financially secure staffing, in a high functioning outpatient ambulatory environment that is charged with overseeing the Community-Centered Health and Wellness program, will rely heavily upon what professional staffing resources are reasonably available to the center as well as what next-level care resources will be available in partnership with the program. Presuming the staffing is well matched to the patient/client population, community need, center function, and next-level interface, there is a second “moving target” regarding the optimal staffing: “deployment” of providers based on appointed schedules as well as hours of operation for ancillary, auxiliary and specialty care departments. Hours of Operation and schedules that help drive efficient use of employee time and facility resources helps to drive workflows that inform optimum staffing numbers. One particularly well regarded and well utilized primary care outpatient scheduling practice utilizes the model of “OPEN ACCESS SCHEDULING” for both routine and Urgent Care appointments https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/6-strategies-for- improving/access/strategy6a-openaccess.html This model improves patient access while optimizing staff time to reduce the overall number of healthcare professional staff required to manage on-site care. Integrated workflows and work volumes as well as patient need drives hours of operation for all clinic services. Cost efficiency, transportation needs, support staff expectations, operational efficiencies may all drive hours of operation. The uniqueness of the health system network resources (e.g. Hospitals, Long-term Care Facilities, Surgery/Dialysis/Infusion Centers, Rehabilitation Facilities) that complement the clinic as well as the uniqueness of the community needs and patient population will drive individual department hours of operation. Reasonable workplace staffing schedules to meet established Human Resources shift length expectations will then help establish the number of professional staff needed at each licensure or certification for total clinic staffing. Treatment teams of multidisciplinary providers and support staff to deliver high quality, safe and complete encounters at both the routine and Urgent Care level must be deployed to work the PC appointment and UC clinic schedules identified. Ancillary and Auxiliary care employees also staff services to work collaboratively and in harmony with the clinical care teams. Licensure and legal oversight requirements determine ratios of mid-level provider to doctoral level provider staffing. Diagnostic, treatment, ordering and prescribing authorities determined by practitioner level and credential allow for a variety of staffing mixes to deliver routine and Urgent Care services. Oversight and Accountability for Quality care delivery: It is the charge of the clinic’s Medical and Mental Health Directors, responsible for Medical and Mental Health Quality of Care, to determine the staffing mix (professional and support), numbers, and training/experience levels required to deliver high quality clinical care. Concurrent co-located services may share some reception and support staffing resources. Co-locations may also be the key to successful integrated care models for medical and behavioral health care. Co-locations (e.g. radiology/ sports medicine, orthopedics, urgent care) may be the key to staff efficiencies and patient accessibility. Different clinical care disciplines may require more or less support staff to deliver safe and effective care. Data collection overseen by a clinic Quality Assurance program manager, reporting to the Clinic Executive Director or CEO, must help inform Medical and Mental Health quality. Such data both drives and is driven by policy and procedures for the organization. Department supervisors are responsible for oversight of professional quality and cost efficiency of their operations. For a complex network of multiple clinics, ancillary services and auxiliary departments, program communication flow through a Management Team representative of all departments and services is an optimal structure to ensure accountability for resource management, human resources management, finance, facility and quality oversight. Community Populations Accessing the Community Health Clinic Primary Care of Medical and Mental Health and Wellness: First and foremost, the Community Health Clinic is the community-based resource for Primary Care. When we speak of “Primary” care we are describing care delivered by the medical and mental health providers with whom a patient has their first and continuing contact(s) for prevention and wellness services. The medical Primary Care Provider (PCP) also assumes the role of first and continuing patient contact for assessment and diagnosis of initial symptoms of common, routine illness. PCP care also includes the management of evolving acute illness to resolution and the diagnosis, treatment and management of chronic disease through long-term stability. The PCP orders and monitors screening diagnostics and preventive treatments for wellness; orders the diagnostic workup needed to establish a primary diagnosis, prescribes treatment, and conducts ongoing disease assessments and treatments as needed for both acute and chronic illness. The medical PCP integrates mental and mental health care in collaboration with mental health professional providers. For complex illness, the PCP makes referrals to and coordinates care delivered by allied health professionals in auxiliary departments, medical and mental health specialists and obtained at unique therapy centers. The Community Clinic medical Primary Care Provider, in collaboration with both Clinic and Community social services and case management professionals, coordinates pre-hospitalization/surgery, post- hospital/ post-op and rehabilitation care. Patient Community: The patient community may be thought of as a collective of subgroups with common primary care needs. Typically, primary care populations are subdivided by age and gender. A comprehensive Community-centered clinic offers services working together to address the pediatric, adolescent, adult and geriatric age groups. Within the Adolescent and adult groups, services specific to reproductive and gender health needs must be included. Medical Care for each of these populations may be managed by a team of credentialed clinicians all providing this breadth of care under the discipline of Family Practice or a team of clinicians with separately focused training in the areas of Pediatrics, Internal Medicine, Obstetrics and Gynecology and Geriatrics working together. Importantly, to meet the care needs of the community with comprehensive attention to emotional wellbeing, the care team is incomplete without adequate integration of mental health professionals at the therapist or psychologist level, some of whom may similarly focus their practice to address the unique care needs of some community subpopulations. Types of Care Offered: Certain wellness and treatment care may be uniquely configured to address needs specific to some sectors of the community, but in general, all members of the community should be able to obtain a basic level of prevention, wellness and treatment care that includes routine screening and immunization services, assessment and treatment of common illnesses, management of common chronic conditions, and referral to higher level care with community based follow up of resolving illness. Routine screenings include standard pre-natal and post-partum care, well-baby monitoring for normal fetal growth and well-child assessment of developmental milestones, routine reproductive and gender health assessments for all genders from adolescents throughout reproductive years, and the evidence based, preventive services screenings and prophylactic treatments recommended for all appropriate community members identified by the Agency for Healthcare Research and Quality (AHRQ) based upon the findings of the U.S. Prevention Task Force (USPTF) as Grade A or B https://epss.ahrq.gov/ePSS/Topics.do Where routine screening requires specialized skills or equipment beyond the walls of the Community center (e.g. Colonoscopy, Aortic Ultrasound) providers must work with Center administrative and social services staff to facilitate referral to these resources and manage follow up to care and care documentation needs. Routine Immunizations should be made available to the entire community of all subgroups needing primary care services. Immunizations should be administered on PCP order (or standing order as appropriate) by a clinical staff member trained and certified to the appropriate scope of practice. Immunization practices comply with CDC’s Advisory Committee for Immunization Practices (ACIP) recommendations https://www.cdc.gov/vaccines/acip/index.html Care for Common Illness and injury should be accessible by advanced and same day appointment scheduling as well as urgent/walk-in service. When a community member becomes ill or injured beyond the level of self-care, contact with an appropriately trained and credentialed health care professional should be available in a timely manner appropriate to the level of urgency inherent in the medical need. In discussion of The Institute of Medicine’s 2001 call for Patient-Centered Primary Care as an essential element in improving the US Health System in the 21st Century https://www.ncbi.nlm.nih.gov/books/NBK222274/pdf/Bookshelf_NBK222274.pdf Drs Davis, Schoenbaum and Audet in their 2005 publication, A 2020 Vision of Patient-Centered Primary Care, proposed that truly Patient-Centered Primary Care would include the following highly valued 7 characteristics https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1490238/: Superb access Patient engagement in care Clinical information systems that support high-quality care, practice-based learning and quality improvement Care Coordination and Continuity Integrated, comprehensive care and smooth information transfer across a fixed or virtual team of providers Ongoing, routine patient feedback to the practice Publicly available information on practices Management of Return to Routine care (following Higher Level care) and Chronic Illness Management functions are fundamental to the delivery of quality Patient-Centered Primary care. It is part of the natural course of health and wellbeing, an episode of more severe illness or the presentation of a new onset chronic medical condition will require follow up care through return to wellness or, in the case of chronic care management, on-going care through a restored equilibrium of stable health. The Community Health Clinic serves as the familiar home base for patients following a referral to higher level care, emergency treatment, hospitalization, surgery, or completion of rehabilitative care. In each of these circumstances, the medical PCP is the team leader in charge of assuring access, coordination, continuity and integration of comprehensive care for the patient as they obtain care beyond the Community Clinic setting and return to routine care. Many of the most common new medical or mental health symptoms that present as the first sign of a new onset chronic illness, may be successfully evaluated and treated utilizing the diagnostic and therapeutic resources of the Ancillary and Auxiliary services within the walls of the Community Clinic. However, when new onset chronic illness requires evaluation and treatment resources beyond those of the Clinic, the clinical, administrative and social services support resources must work together to ensure care delivery through stabilization and return to routine care. Levels of Service Delivered: Consistent with its focused primary care mission, the Community Health Clinic program is not well suited to offer high complexity, highly specialized, emergency, or inpatient care. The equipment and staffing needed to deliver such care with high quality, consistency, safety and efficiency would be underutilized and represent poor Community resource management in the Community Clinic setting. In many communities, a Community Health Clinic may be sited in proximity to a hospital, Emergency Department, Rehabilitation Facility, Outpatient Surgery Center, Birthing Center, Dialysis or Infusion Treatment Center, however service levels of these facilities go beyond the scope of the Community Clinic. A wide range of Ancillary diagnostic and therapeutic service levels are achievable in the Community Clinic Program. High level complexity or acuity services require resources that may or may not be appropriate depending on the community standard of care and the timely accessibility of these resources to the clinic through off-site sources. Testing and imaging most appropriate to the typical needs of the Community Clinic include routine laboratory blood and urine testing, cultures, point of service screening tests for infection and microscopy as well as common radiographic imaging of chest, abdomen and extremity films. As technology makes diagnostic equipment and procedures more affordable and accessible to the primary care setting, tomorrow’s Community Clinic may one day offer today’s “higher level” services at what will be considered standard care to future providers. A wide range of Auxiliary services are appropriate for the Community Clinic program. Possible services include dental, optometric, dietary, physical therapy and/or substance use disorder counseling. For each, the expectation is that service levels adhere to the principle of basic assessment and treatment, appropriate to the Clinic’s primary care program, with staffing and resources determined accordingly. Bridging to Services Beyond the Scope of the Community Clinic Ensuring Patients Access Resources Essential to Successful Clinical Outcomes: Education and communication resources are essential to ensure patients are aware of Wellness and Prevention Care as well as treatment resources. Wellness protocols and schedules are seldom a priority for healthy individuals. Pregnant women are more inclined to obtain regular monitoring and screening to manage well established prevention and wellness pre-natal care; families with young children are regularly advised neonatal check-ups and well-child visits to administer required immunizations, monitor developmental milestones, and screen for early onset chronic illness and disability. Throughout their lifespan, community members need to receive notice of ongoing routine screening and prevention recommendations. A well-resourced Community Clinic operationalizes patient education and communication systems to ensure utilization of wellness resources and adherence to illness treatment plans. Information technology can be used to personalize patient messaging, document compliance and follow up, and collect data for the Quality Assurance program to monitor global community health. Case Managers provide critical support for patients needing assistance with in-home care or equipment (e.g. oxygen, heart monitors), especially those without significant family assistance or social support. Case management may focus on social support or be directed toward specific self- care management skills; clinical health educators may teach patients to correctly monitor blood glucose levels or blood pressure, titrate medications or administer home therapies. Ensuring Transfer to Higher-level Care/Rehabilitation: Coordination of care for diagnostic or treatment procedures beyond the Scope of services or Level of care at the Community Clinic requires referral procedures and systems that achieve the same level of access, coordination, continuity and integration a patient should receive within the Clinic Facility. One cannot overemphasize the importance of provider communication, patient engagement, and clinic record information transfer in achieving successful clinical outcomes for patients requiring higher-level or rehabilitation care. Communications, engagement and health records must be accurate, complete, and timely to ensure smooth care transitions. Case Managers and Referral Coordinators are a valuable resource to patients navigating referral to partnering facilities. Many of the procedures, treatments, and consultations obtained outside the Clinic take patients to buildings with unfamiliar patient flow and room locations. Scheduling may require information or contact resources also unfamiliar to the patient. Preliminary testing or health forms may be required prior to the actual appointment. Guidance through each step may be needed to ensure successful scheduling that is both accurate and timely for the medical need. Transfer Policies and Procedures are critical for successful patient referral. The Community Clinic must maintain a protocol for Urgent transfer of unstable patients as well as a protocol for transfer from Urgent Care to higher level care (following stabilization) should an emergency present. However, while not urgent or life threatening, transfer of ambulatory patients needing non-urgent higher-level Care or Rehabilitation (e.g. specialty consultation, surgery, diagnostic/ therapeutic procedure) requires that established policies and procedures are in place to ensure a consistent, reliable process is utilized in order for patients to obtain the intended care. Referral care must be received in a timely fashion, from the appropriate clinicians; those clinicians must also receive the patient’s relevant clinical care records and referring provider’s communications for a successful transition to result in a successful referral outcome. Ensuring Return to Clinic Care Upon Discharge from Higher-level Care/Rehabilitation: Coordination of care that enables return to Community Clinic services is just as important for a patient’s future health and wellness as the referral process that was used to access care beyond the Clinic. A well planned and coordinated return process ensures PCP’s integration of off-site care records and resumption of continuity care when patients return to Community Clinic care. Moving forward after higher-level or rehabilitative care requires the patient’s care team to incorporate off site care into the patient’s clinical record and treatment plan as well as their future health and wellness plan. Case Managers and Clinic Support staff help facilitate return to Community Clinic care by assisting both the patient and all involved providers to provide/ obtain documentation of off-site records. Case managers are most often positioned between patients and their PCP to ensure that patient’s treatment requirements can be fulfilled, and that provider information needs have been met. Clinic Support staff work with providers to ensure that patients schedule appropriate follow up care and obtain the prescribed therapeutic medications, treatments, and procedures. All off-site care contributes to and informs future continuity care and health and wellness needs. Medical Records Policies and Procedures are the heart of successful patient transitions back to Community Clinic care. A comprehensive transfer of documentation from all off-site providers is essential to ensure appropriate, timely and accurate follow up of off-site services by the Community Clinic provider team. Community Social Support Services to Facilitate Clinic Access: Transportation Access Needs are important to ensure that all members of the community are able to obtain clinic-based care. Services may be scheduled to meet the transportation needs of some patient subgroups, however facilitated accessibility for ill, seeing/hearing impaired and non- ambulatory patients requires social support services that are directly integrated with the Clinic program. Consideration of local mass transit or personal transportation requirements should be considered for all patients in citing of the facility or making an investment in shuttle services. Financial Access Needs/Public Program Eligibility and Enrollment Services must be addressed for each patient to support proper utilization of the Community Clinic health and wellness program. The complex multilayer, multi-payer, healthcare funding of the 2020 U.S. model presents a complicated patchwork of programs and payers that can be unnavigable by even the most astute and experienced consumer, regardless of health or wealth. Even with a greatly streamlined or single payer system, the Community Clinic must provide patients with the tools and information to properly process care costs and manage eligibility procedures needed to finance their healthcare with confidence. Fear of unmanageable medical debt is an obvious barrier to care. Cultural Competencies are as important to delivering successful health and wellness care as clinical competencies. While there are numerous accreditation programs and professional organizations that will set standards for all elements of clinical care delivery, it is critical for the Clinic to invest in a program that embraces patient and community feedback and integrates community cultural norms into treatment and care services. Language, unique healing practices, customs that may represent ethnic, religious, generational or geographical tradition should be considered in health and wellness care delivery. Like fear of unmanageable cost, fear of loss of identity or respect, as well as misunderstanding, stigma, and shame in the presence of clinic staff or care providers present a barrier to access that subvert the Clinic’s core service mission. Patient/Community Feedback can be obtained through surveys, comment cards, focus groups and advisory committees. Patient satisfaction is a critical component of patient care quality and must be a measured element of the Clinic’s Quality Assurance Program. Outreach Programs that educate the patient to ensure the most appropriate Clinic utilization and adherence to prevention and treatment programs requires two complimentary but distinct Health Education programs: Health and Wellness Education which may be thought of as a community health education effort that provides community based outreach (to subgroups or the whole), in an effort to create a community of wellness, healthy lifestyle choices and adherence to prescribed chronic illness management principles, and Health Services Education which may be looked at as Community Health Clinic “marketing” to ensure that all community members are well aware of their healthcare resources and most appropriate ways to achieve access. Community Resources to Secure Essential Human Wellness: Much attention has been given to the concept of “Social Determinants of Health” (SDH). By WHO definition the SDH are “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems”. Without nurturing human living conditions, optimal Health and Wellness is simply not possible. It is said that only 10-20% of health and wellness is attributable to medical care with 80-90% dependent upon environmental and social conditions https://www.ncbi.nlm.nih.gov/pubmed/26526164 .The best effort to ensure that the community is optimally served by its Community Health Clinic is to engage a mutually beneficial collaboration to address these Social Determinants together. Importantly, this requires community generated resource investments that do not compromise the resources of the Clinic but work in synergy with the Clinic’s Social Service resources best positioned to embrace them. Administration, Management, Governance and Quality Assurance Finance, Budget and Human Resources: “No money, no mission” are words no passionate advocate of Community Health and Wellness ever wants to hear, but regardless of the funding source, there can be no sustainable service without a financial element and its administrative management. Competing priorities will always drive budgets. This is what makes the dedication to Mission so crucial. If a program, service or staffing falls outside the Community Clinic Mission, regardless of how tempting, it must be considered of lesser priority or perhaps eliminated. There may be opportunities, however, for reconsideration for programs complimentary to the mission that have the potential for further revenue generation to support critical high-cost, low-revenue services. These decisions are not made lightly and must be informed by medical and mental health leadership as well as community advisory input. Healthcare Administration is a critical function. Finance, Budget and Resource Management must be directed by trained and experienced, skilled professionals. The Human Resources department must work hand in hand with Quality Management credentialing functions to ensure that the clinic remains continually staffed with appropriate numbers of high- quality staff, hired and deployed to meet both professional and legal staffing requirements. Staffing costs for a Community Health Clinic are typically the highest line item in the budget. Facility & Materiel Management, Purchasing & Equipment Quality Control: Health Facility management, medical supply (including diagnostic, therapeutic and pharmaceutical supplies), materiel, and equipment purchasing, maintenance and quality control are all critical administrative functions. Many of these functions oversee highly regulated and routinely monitored activities and supplies. The quality and appropriateness and the oversight professionalism of these programs is another critically important element of Clinic success and sustainability. Clinic Management, Medical Records, Appointment Scheduling, Billing: Clinic Support services impact every aspect of care quality. Without the proper attention to clinic flow, documentation, scheduling and service payment (either as fee-for-service or pre-funded program enrollment) the clinic cannot meet its principles of access, coordination, integration, and continuity in the delivery of comprehensive Community Health and Wellness care. In the 21st century, these functions are greatly enhanced and facilitated by the use of Information Technology. The term “meaningful use” as it applies to Health Information systems and Electronic Medical Records, became fully articulated in conjunction with the passage of “Health Information Technology for Economic and Clinical Health (HITECH) Act” of 2009 which included the concept of using electronic health records (EHR) technology to the full benefit of patient care.https://www.cdc.gov/ehrmeaningfuluse/introduction.html When deployed inappropriately, electronic documentation is at the least burdensome. Correctly implemented, however, EHR technology is a tool that supports and enhances all aspects of Clinic Support Services while significantly assisting the clinicians who interact with it daily in every aspect of clinical care. The five goals of “meaningful use”: Improving quality, safety, efficiency, and reducing health disparities Engage patients and families in their health Improve care coordination Improve population and public health Ensure adequate privacy and security protection for personal health information recognize how the EHR permits the clinic support services team to greatly enhance their ability to improve the quality of clinician ordering, health information documentation and provider information exchange, provider to patient communication, and clinic data exchange to public health agencies. Each of these goals and functional enhancements take Clinic Support Services to higher levels of quality and efficiency, supporting patient outcomes and clinic mission success. Accreditation, Compliance, Clinical Care Quality Measures: Quality is about data: what you choose to measure, how you collect, report and analyze what you measure, and what you do with the information you collect. Numerous private and professional organizations and public agencies set standards for all elements of health service delivery. No clinic has to, determine for itself what are important measures for quality assurance and improvement, nor should it. So, it is true: if you do not document it, you cannot be certain you did it; if you don’t measure it you cannot improve it. Data collection is an essential Clinic function. Every Community Clinic must maintain a Quality Assurance and a Risk Management program to verify provider credentials, meet facility safety and security standards, monitor supplies for inventory and expiration, implement comprehensive Risk management and Infection Control programs, and meet legal and professional compliance standards. Once again, a dedicated Quality Assurance professional or a team composed of a Credentialing specialist, Risk Manager, Quality Assurance coordinator, Infection Control Manager or the employment of personnel with these important duties included in their job description is a significant and important resource to the successful function of a well-managed Community Health Clinic. Multiple sources for describing the organization, staffing and functions associated with this critical element exist in healthcare administration and health policy publications. 9. Human Support Services: How to Make the Welfare System Work “The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.” Hubert Humphrey Table of Contents Society’s Bottom Three-Quarters The Ugly View of Human Nature from the U.S. Welfare System An Information System to Help in Time of Need Serious Protective Services Using the Viable System Model to build community sustainability: The Beer-Li Model How to use the Beer-Li model (individual life) How to use the Beer-Li model (institution/organization/business/government) How to use the Beer-Li model (individual work) Tying it all together: Clinic Administrative Support Team: Office of Epidemiological Accountability Society’s Bottom Three-Quarters If you are like most people, you were completely dependent on other people for your first 20 years or so, and probably you will be more dependent on others the last few years of your life. For human society, the real challenges are an orphan, the elderly, the desperate family, the unemployed, the homeless and the mentally ill. Most of the human problems the health system identifies are social services issues: housing, employment, childcare and interpersonal relations. People that have those four things under control can get on with their lives. What about the other three-quarters of us? People in the middle half of society have our ups and downs. Most people’s goals in life include earning a living, with a further goal to find satisfaction, fulfillment and even meaning in your work. They say that the point of a liberal arts education is to be able to adapt to seven career changes during your work life. The second half of this essay is about how this middle half of society, those that just had the rug pulled out from under us, can adapt to this new reality with an information model of your personal community economy. For the bottom quarter of society, life’s challenges continue to be a problem. The mental health challenges of getting along with yourself, with your family, with co-workers, and with strangers in society are really big problems for society, one the U.S. welfare system has completely failed. For the person in need of help and support, the U.S. welfare system is a complicated miss-mash fragmentation of programs that rarely fit together to meet the person’s immediate short-term needs. (The long term needs of the physically disabled and the chronically mentally ill are addressed in #10 Embracing Long Term Service and Support from a Next Friend’s Perspective.) There should be some kind of a floor, some minimum combination of at least health care, food, and temporary housing. The clinical reality is that only 10% of health improvement outcomes are due to medical care. 90% of improved health outcomes are produced by education, housing, environment, behavioral change, genetic analysis and social organization participation. Non-medical determinants of premature dying include: behavioral patterns like diet, exercise, alcohol and drugs, which account for 40%, genetic predisposition, 30%, social circumstances 15%, and environmental exposure 5%. Many of the factors are social determinants, like smoking, income inequality, and race, which is a marker for poor health outcomes in the U.S. A key indicator of local healthy outcomes is availability of primary care health professionals because they are trained to recognize the 90% as well as the 10% the insurance companies pay for. The Ugly View of Human Nature from the U.S. Welfare System In the dark days of the Great Depression, the U.S. invented Social Security to provide a monthly income floor for those aged 65 and older, based on someone’s lifetime work contribution. Part of the Social Security Act established Aid to Families with Dependent Children (AFDC), which became the basis for the U.S. welfare system. In the 1960s, LBJ’s Great Society created numerous War on Poverty programs with varying degrees of success, the Head Start pre-school program among the most popular. In 1996, Clinton replaced AFDC with Temporary Assistance for Needy Families (TANF). The idea was to force families to go to work rather than expecting to remain on the welfare rolls for their entire lives. The summary of all the problems with the U.S. welfare system is categorical aid. In an effort to minimize public expenditure, most welfare programs have a means test: limiting your eligibility according to you income: if you have income, or assets like you own a house, it may disqualify you. This proves to be bankrupt in many ways. One of the worst is that the health insurance industry limited Medicare to cover only 80% of the costs, so everyone over 65 still needs private insurance in addition to Medicare. Low income people can get most of their not-Medicare-paid- 20% costs covered by MediCal, but not all of them, like the last 5% of the cost of surgery. And if you own a home, you probably have too many assets to be eligible for MediCal, no matter how little income you earn. An Information System to Help in Time of Need While each person faces unique challenges, the biggest problem in human society is the male who cannot get along with anyone, and the biggest problem in nature is the abandoned pregnant female. These are complex problems that are not easily solved. In the XXth Century, U.S. government came up with categorical aid programs that claimed to address social problems, with few successes. Part of the problem is that the aid was designed with the intention to limit each program to as few people as possible to save money. Underlying the cheapness criteria is a basic disrespect for humans by the GOP: if you can’t afford to buy something on your own, you are not worthy of it. The welfare system needs to address the two big problems, uncivil men and desperate families, differently. It needs to be re-designed to actually help people improve their lives, instead of being one of the worst parts of government. For the uncivil man, they are living on the very edge of society, and that is a choice they repeatedly confront many times each day: why is everybody else so wrong all the time? Their pattern has probably been that they only get along with people (mostly men) who are just as outside the system as they are. They breed distrust and criminal activity. Society must interact with these outsiders; the challenge is to provide them with social support in an effort to minimize the damage they do by subjecting strangers to various anti-social acts. A homeless shelter for the night, food, and health care is the most that many of these people want, expect or are willing to accept. Beyond them are the 10% or more of the population who do not want society to even know that they exist. For a homeless person to look for work, and not just expect a handout from society, is the first step towards greater self-determination and even self-sustainability. The only thing the society’s welfare system can do is offer the basic survival support. Life is too challenging for society to take care of everybody. Society is everybody, made up of personal achievement. While some people will take advantage of society, and some people will take advantage of other people by doing criminal things, most people want to be on the right side of the law and build positive relationships into friendships with their family, neighbors, co-workers and strangers who are potential friends. The single mom in trouble is so common that it forced the government to set up the welfare system. A woman giving birth is the most challenging thing a human being can do. Men are so indifferent to that reality that we leave families to struggle when they most need the support. 45 years ago, in 1975, the first year Jerry Brown was California’s Governor, I was an expert on California’s county mental health system. I went to work for the State Assembly as the consultant on health, mental health, social services and public assistance. I took on the federal- state-county welfare system. I decided that it was designed not to work. What would work? When I was 10, I created this neighborhood-village-community-district- region-state-nation model. I delivered the Oakland Tribune on Oakland Army Terminal from September 1958 to March 1961: Tribune publisher William Knowland was California’s U.S. Senator, running for Governor against Pat Brown, through the 2nd Eisenhower Recession, and the election of Jack Kennedy over Richard Nixon. Most of the headlines were about the national recession. The front page stories were about California, the U.S., the world, maybe Oakland or Alameda County. The real stories, the human interest stories about people who lived in Oakland were inside. The more detailed, the more really local it was. To learn new things, and keep track of the information, I developed a model information matrix with components that scale up physically/geographically: family, 10; neighborhood, 100; village, 1,000; community, 10,000; district, 100,000; and region, 1,000,000. Unlike counties, these can be compared. Most current policy emphasizes district-region- state-nation. This model shifts the focus to the village and the community, so that neighborhoods and families get their needs met. In real life, the categories are: income, food, housing, health care, transportation, clothing, education, media, entertainment, taxes, managing the economy, public services, infrastructure, utilities. Basically it is a dynamic information catalogue for all the parts of a woman's life. (A man’s life, any man’s life, is so much simpler than every woman’s life that there isn’t anything to talk about: women want choices and options that men don’t understand, let alone appreciate.) I believe the biggest problem in society is keeping track of your kids’ futures. This model is designed to help a mother plan her own life, and her children’s, no matter what happens to the children’s father. This is only a matrix, a blank sheet of paper that mom can fill in so that it is the way she wants it. It becomes a tool that she can use to manage her current options and negotiate new things for her family’s success. What the U.S. welfare system has to offer is beyond the scope of this report. Starting with Food Stamps and Unemployment Insurance, the U.S. welfare system has a limited program, with some housing and other complementary social services. Bringing welfare programs within the authority of the local health clinic will force administrators and social workers to view the person to be served in a positive light, which forces a revolution in thinking and attitude towards people in need. Serious Protective Services Elder Abuse is something that needs much study, support, analysis and action. Nursing homes, board and care homes and other elder housing services are notoriously poorly regulated; daily reporting under the VSM analysis of each patient will go some ways towards improving care, but the warehousing of elderly needs to be completely re-thought. With child abuse and other family problems, compulsory education forces most parents to enroll their children in the local schools. This gives authorities the opportunity to identify children that are getting into trouble. The Kingdom of the Netherlands has a system that works: the commitment of the national ministry of health and social services, the ministry of education, the ministry of justice and the ministry of employment are all focused on having every child fit into Dutch society. Holland has 18,000,000 people, 5,000,000 children. A prosperous country, it is not without its problems: - the total number of crime suspects aged 12 to 24 years: 50,310; - children living in poverty: 345,800 - school dropouts aged under 23: 26,000 - feelings of insecurity, aged 15-24 years: 40.9% - alcohol binge drinkers, aged 12-16 years: 17.7% Approximately 10% of the Dutch adolescents can experience problems and may need some additional support. A further 5% of Dutch youth is considered structurally at risk in their development and is in need of some form of youth care. In Holland, each school (at the Village level of 1,000 people, 250-300 school aged children) has a “Care and Support Team” of local nurses, social workers and police officers who meet regularly to identify students who are getting into trouble. A team member meets with the child, then the team researches this case, and interviews the family to understand the student’s home environment, and then a plan is developed to support the child and their family. Care and Support Team members must qualify as “Youth Guidance Counselor”: they are expected to have the patience, experience, resourcefulness and wisdom to be a role model for both the parents and the student. Universal basic care services include maternity care, preschool, kindergarten, schools, youth welfare, youth facilities for relaxation, sport, art and culture. Also for example youth (social) work, childcare and schools are part of these services. General youth services provide support for: health behavior of young people, growing up safe, talent development, participation and active citizenship. They aim to facilitate the normal development of children and to prevent small problems of children and families turning into severe problems. Municipalities aim to strengthen these universal services in order to enable professionals to adequately solve small problems in children’s upbringing and to detect more severe problems at an early stage. Municipalities in The Netherlands also aim to stimulate the cooperation between the different universal services. Preventative services (or primary youth care services) are for example child health care, general social work, parenting support. Some fields of youth work are also part of the preventive services as e.g. outreach youth work or street corner work to provide individual guidance and support to young people at risk. These preventive services aim to detect problems at an early stage, to intervene at an early stage, to coordinate support and to refer children and families to the specialized youth care services. Very few communities, let alone cities, in the U.S. provide this richness of social program to support society’s social fabric. Actually addressing the issues facing the bottom quarter of society would force the clinic staff to engage in community social change. Too frequently the complaint is made that health professionals are not trained to solve the problems of poverty, food insecurity and racism. They have no clinical tools to address these issues. Nonetheless, all health professionals need to be proficient in providing mental health and social service counseling, especially when they are providing physical health advice. Dr. Famula says, “what is my recommendation if the patient ignores it?” Today’s complicated society is overwhelming a lot of people; the clinic needs to be able to provide interpersonal support, advice, information and community resources to help an individual get on with their life. Each community needs to reassess and upgrade current mental health and social services; the mental health counselors and social service workers need to be part of the clinic staff system so that it is seamless for the person in need of help and support so that they can build some successes in their perpetually challenged life. Using the Viable System Model to build community sustainability: The Beer-Li Model The Viable System Model is a tool for analyzing a living dynamic being, especially an organization, in terms of the information flows as it adapts to a fast changing environment. The key to the Viable System Model is to look at communication at one level as the “System in Focus.” Each analysis has its own unique combination of interactions among its subsystems, and its dynamic changing environment. There is no school book answer to this. What you find is that because these are real life techniques, they appear all over the place. We are going to use the VSM as a design tool to build a responsive community regulation system based on daily reporting of 120+12+1=133 measures of sustainability. You can use the Viable System Model to cultivate institutional transformation. It would involve mapping a catalogue of all the current organizational activities and responsibilities (ALL of them), which in VSM terminology would be the System 1-2-3 (1-different operations, 2- coordination of different operations for shared resources, 3-management of current operations), and then debate what should be the new version (using VSM refinement tools), called System 4, and then identify ways to move from System 1-2-3 towards System 4, refining System 4 as new information becomes available. Senior management is System 5, which mediates between the NOW 1-2-3, and the FUTURE 3-4-5. Measuring Improvement of Community: Governance statistics should measure quality of life and demographic issues as well as economic growth and decay, redefinition and renewal. The VSM analysis encourages looking at real change in the system's environment: commercial, technological, political, social, economic, educational and ecological. How to apply the Viable System Model will be explored in the next issue, #16 Stafford Beer’s Viable System Model, and How to Run a Country: Disseminated Regulation in Real Time. We are applying this “community” model: This model couches community as a niche within its environment: Family/Neighborhood/Village// //Community// //District/Region/State The idea is to shift the information focus in a decentralized way that gives greater meaning and power to each individual. The Beer-Li Model Introducing a new app “mycommunityeconomy”: a computer information structure for creating a global grassroots economy. Basically it is a dynamic information catalogue for all the parts of a woman's life: income, food, housing, health care, transportation, clothing, education, media, entertainment, taxes, managing the economy, public services, infrastructure, utilities. That information matrix has components that scale up physically/geographically: family, 10; neighborhood, 100; village, 1,000; community, 10,000; district, 100,000; and region, 1,000,000. How to use the Beer-Li model (individual) The Beer-Li model is a consolidation of the information of a person’s shared social and economic reality. Each layer has boundaries that are common to most people who share them: most people where you live self-identify the same block/apartment complex as their “neighborhood,” and the urban/suburban services catchment area around your regular grocery store as your “community.” The Beer-Li model is a set of cells of information, and the more cells you can fill in with useful information will do a lot to improve the chances that you can control the options in that part of your life. This is all about self-sufficiency. Getting your needs met, as you define them. The power of the Beer-Li model is happy people building sustainable community. You do the Beer-Li model twice. The first time is as a social consumer/interactor; the second as a contributor to the economy, as an income generator. The first consumer issue is housing. When that is unresolved, where you call home determines most of your lifestyle options. Refine your housing options until you move into a place. Mostly, housing options for single people are based on: work, education, and/or recreation and other people (relatives, significant other…); for families, the criteria are more complicated, and have to do with the kind of school options the parents want for their children. Next is transit: do you have a personal automobile? Or do you rely on public transit, bicycle, walking and shared community vehicle? The primary reason why the Beer-Li model is necessary at this time in history is the transition from the XXthcentury growth oriented destructive economy to a XXI st century that is a global sustainable communities economy is to help people break their dependence on a personal vehicle to achieve daily economic and social needs and wants. Filling in the rest of the cells is mostly fun: how you personally define adventure: what stores you frequent and care about (this is a woman’s model); recreation (much more for the men; for the women, it is more about the interests of their family and close friends); what health care, education and social services you frequent and occasionally use, things that you and your family are actually dependent on. For most things, filling in the cells for neighborhood, village and community will identify 90 percent or more of your every day reality. For most of us, district (100,000 people), even larger region, state and nation only matter as special, unique individual challenges (like driving across country) that most of us don’t do very often. One time challenges, and new adventures are referred to in VSM terminology as “projects.” The coolest thing about the Beer-Li model is finding other people with similar cells at the neighborhood, village and community levels – these are your “communities of interest” – the Beer-Li model offers a context to identify common concerns and suggests strategies to address them. How to use the Beer-Li model (institution/organization/ business/government) One of the biggest problems with politics has been the incongruence between the political systems and the economic forces: multi-national corporations run rough-shod through countries, violating people and natural resources. With the Beer-Li model, you build a finite-element-model of every layer of the political economy. Within each cell, you build a refined picture: an 1) environmental- 2) social- 3) economic model that reflects reality. The economic options are ONLY evaluated within the prioritized context of established environmental and then social parameters – as opposed to disregarding environmental and social consequences as has been the practice for the past 500 years. Using Jon Walkers Internet VSM Guide; Diagnosing the System: for Organizations, Beer Stafford; Holistic Management: Managing What Matters for Company Success, William Christopher; and Allenna Leonard’s “A Viable System Model: Consideration of Knowledge Management,” and “The VSM Applied to Complex Organizations in Crisis,” each institution builds a Viable System Model of at least 8 layers, from the individual workers to senior management, to identify where to start to build a Beer-Li model of the entire organization and its publics and its environments. The institution needs to determine if it has a viable purpose in the future, and then determine how it can become more sustainable. The way the organization can determine if it is viable is the IPSA VSM FLUSH ©, which takes an organization a full 40 hour work week. If it is determined during Day 4 that the organization does not have a viable future, then Day 5 is devoted to planning how to shut down the organization. It is assumed that 75 percent of the businesses and institutions, and governmental agencies in the world that existed in 2010 will no longer exist by the end of 2020. And the world will be a better place for it, especially in terms of people not wasting resources hurting each other. How to use the Beer-Li model (individual work) In the XXthcentury, economic security was defined as a “job.” The Beer-Li model focuses on contributing meaningful work instead of a semi-permanent job. First, the Beer-Li model becomes a record of the past and a map of the future of your work and educational life, and your apparent goals. It becomes a detailed portrait of who you are, what you care about, what you know, what you can do, and what you love. It creates the way to identify potential new adventures in your life. Tying it all together: Clinic Administrative Support Team: Office of Epidemiological Accountability The administrative structure is designed to serve the community clinic. It is invariant at the National, Federal, State, Health Service Area, City, and Community/Clinic levels, known as “Stations.” Each Station has seven positions: 2 Health Care, 2 Behavioral Health, 2 Social Services, and Team Leader-Servant. 10. Embracing Long Term Service and Support from a Next Friend’s Perspective On January 24, 200 MDs, RNs, PhDs, and MPHs (Masters in Public Health) met at the Berkeley International House to talk as the “Physicians for a National Health Program,” focusing on the economics of implementing universal health care. It was organized as the 7th Global Health Economics Consortium by the Institute for Global Health Studies, University of California San Francisco and co-sponsored by University of California, Berkeley School of Public Health and Stanford University Center for Health Policy and Center for Primary Care and Outcomes Research. The challenges of long term care require their own analysis. Allison Hoffman and Charlene Harrington presented a thorough assessment of where the U.S. is today, and the questions that need to be wrestled with. Allison K. Hoffman JD is a Professor of Law at University of Pennsylvania Carey Law School and a Senior Fellow at Penn’s Leonard Davis Institute of Health Economics. Professor Hoffman’s work examines health insurance regulation, the Affordable Care Act, Medicare and retiree healthcare expenses, and long-term care. In particular, she examines the role of regulation and the welfare state in promoting health, as well as how regulation affects conceptions of risk and responsibility. Hoffman was a visiting professor of law at Yale Law School in 2019, a fellow at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard, and formerly on the faculty at the UCLA School of Law. She practiced health law at Ropes & Gray LLP and was a consultant at The Boston Consulting Group and The Bridgespan Group. Start with the assumption that any comprehensive health plan should include coverage for long term care. What is comprehensive coverage? How can we conceptually think about long term care in a way that is going to make a comprehensive policy solution more likely? Basically, with insurance we all pay into a common pool; those of us who need goods or services are covered by insurance, and things that we need are reimbursed. When we decide to include a benefit, it makes the risks of harm, the risks of spending money on medical care, it makes those things collectively felt rather than individually felt. So far, we have left long term care out of the public insurance like Medicare and Medicaid, and private insurance hasn’t worked. What that means is that the risks that people face for long term care needs, or when they are helping others with long term care needs, those risks are born privately rather than collectively. If we think about what the insurance for long term care could and should accomplish, what I want to suggest is that we shift the way we think about that, it will make a comprehensive solution more likely. I suggest we reimagine the way we think about long term care. As a society, as we have thought about long term care, we have conceived it primarily as having a chronic illness or disability serious enough to require sustained care. I call this “care recipient risk”; what these people need are care supports. If those supports are too expensive, it can cause it can cause somebody financial insecurity or if she gets the wrong or insufficient support, she can face health insecurity. It is a risk faced by 10 million people, half of whom are over age 65, and half are under. Too often we think about it as an aging problem, and it is not just that. What I want to ask is what if we look at the same problem from the perspective of the friends and family who become responsible for helping provide the care for people who need it? Any one of us could, al of us will, become responsible for intensive care for a child with a serious illness or disability, an ill or injured spouse or partner, or an ailing parent at some point in our lives. I call this the “next friend risk”. “Next Friend” is a legal term for someone who stands up in court for someone who cannot do so for themselves. I like this term because of its neutrality. It does not imply that the Next Friend is family, it is often not; it is often friends or people in the community who provide this care. It does not imply that the Next Friend is the one who is actually doing the care giving, where the term Care Giver implies that, the Next Friend might help by arranging care or paying for care, or in all kinds of ways. Medicaid shapes our conception of LTC Risk and Ensures reliance on Friends and Family: Medicaid has become the largest payer of LTC by default. As a consequence, it has tremendous influence in how we structure our LTC in this country. Medicaid has reinforced putting the obligations on family and friends to provide care informally, usually without pay, by providing incomplete coverage for the care giving needs of people. If you think back to the origins of Medicare and Medicaid, the emphasis was not on care giving. They focused on protecting against things that posed a threat to householder family wages. Care giving did not pose a threat at the time because most households had a non-wage earning adult in the household, usually a wife, so things like “personal services” are an optional Medicaid benefit rather than a mandatory benefit. As a result, states may but they don’t have to cover certain aspects of long term care, things like feeding or bathing or transferring. The concept was that it would be medical insurance to cover services by licensed providers in licensed facilities. This excluded many of the aspects of long term care, especially when they were happening at home. Medicaid structurally prioritizes medical care over personal care and then cemented this reliance on friends and family for care giving. Medicaid, by design, leaves gaps o Means-tested so that Americans have no LTC insurance unless the “spend down” o Caregiving generally is not paid for because it did not fit initial vision of good social welfare policy o Medicalization of LTC sidelines personal care A more recent shift from nursing home care to home-based care has increased reliance on informal caregivers Medicaid initially had what is called an institutional bias: it paid for long term care mainly in nursing homes and other long term care facilities. Medicaid policies have evolved over the past few decades, motivated by legal obligations to pay for long term care supports to provide care in the “least restrictive setting possible” which in many cases means at home. The result of that has been that a growing percentage of Medicare dollars are now spent on home and community based services for long term care, 57%. Institutional long term care spending in 2000 was 73%, dropping to 43%. In some ways, this has been a success story. People with chronic illness can live at home as long as independently as possible. But structurally it can be quite difficult to provide 24/7 support at home and Medicaid has not met the demand, resulting in limits services and long waiting lists for home and community based services. As a result, people are increasingly relying on friends an family for care, frequently without pay, informal pay, or they pay for it on their own if they can. What if we could look at this problem from the standpoint of Next Friend, people who are coming and providing these supports for their loved ones? How would it change how we provide long term service and support? What does this obligation look like? Some 40 million people provide care ranging from a few hours a week to around the clock. Although families have long provided care, this notion of care as a private obligation is becoming untenable in a changing world. That family with a single breadwinner I was talking about is gone – there is no one in the home who can be fully dedicated to caregiving, there are increasing number of women in paid jobs, the number of two wage earners or single parent families is growing, and families are dispersing geographically. The ratio of people who need care compared to the number who can provide it is growing. With medical and technological advances we are keeping people alive longer, and also needing more supports. As a result, the costs associated with informal care are quite high. It is hard to define exactly what this cost is. It is hard to even think about these costs descriptively; there have been studies done, and what they show is that the average adult child who leaves the workforce to care for their parent experiences about $300,000 in economic loss, from lost wages, pension, lost social security, lost benefits, lost opportunities for advancement. Studies have studied at their non-economic harms, on their health, on their well being, impacts their relationships, higher rates of depression among informal care givers. Part of what concerns me is the way taking care of someone else absorbs time and money in a way that clearly impedes their life choices and their ability to live their own life in a way that is quite difficult to quantify. What I contend is that we should think about these responsibilities for another person’s long term care as a life cycle risk, and an insurable one. It is near universal. It is irreversible, unpredictable, and in most cases when considered from the perspective of the Next Friend, it is uncontrollable. Even when people take on care giving roles, as many of you have, with great generosity and love, they face significant insecurity in doing so. We haven’t thought about this as an insurable risk in part because it is hidden from the public eye and the balance sheet. It happens in homes and where it is hard to measure. But we could come to think of this risk as insurable, and as serious as the risk of needing care from the care recipient’s perspective. So why should we do that? Considering Next Friend’s Risks helps us understand the problems of long term care in four ways that make an effective solution more likely. First is to redefine the scale and make the problem larger, which makes it more challenging, but it makes it more realistic. The current estimates of long term care costs hide behind the costs born by Next Friends. I call them “The invisible copayment,” what people are paying through their time and their spending towards the lack of insurance; by conservative estimate it is $500 billion twice the amount of current funding for long term care. Seeing these costs clearly can help us more realistically think about what it will take to solve this challenge. Second is reframing this as risk, thinking about this as a Next Friend risk rather than obligation implies insurance is indeed the solution. Since very few people can afford to self-insure privately for long term care, it means that public insurance is the solution. Understanding it as a universal risk, one that we all face could help build broad political coalitions that actually want to solve this problem. Third, considering this Next Friend’s perspective suggests that the policy could be designed so that it is more sensitive to the harms experienced by Next Friends. Understanding these harms as risks rather than personal obligations to care for somebody else makes clear that there are two legitimate ways that someone could in theory respond to a loved one’s need for care: they could provide that care, or they could arrange to pay for that care. At the very minimum, a policy should be designed in a way that is more neutral between these options, rather than as is the case in many programs today, biasing towards the family providing care and then providing some minimal supports for them in the best cases. I call this the Toggle, and I believe we should design policies in existing programs that allow people to Toggle between these two options, so that if they do have insurance coverage, they can just as easily use it to provide the care as they could pay somebody else to provide the care. If the benefits allowed recipients to Toggle freely between these two spaces, the Next Friend could consider the benefits to evaluate their own potential risk insecurity, and to balance those risks with the needs and the wants of their loved ones. The current policies are so focused on care recipient risks that they don’t even see the need for this Toggle. They often impede movement between these two choices. The last point is seeing the Next Friend risk raises the question of whether social insurance policies should make different trade offs than they do today in mitigating between recipient and Next Friend care risk. Consider the example of an elderly widower who has a stroke. The goal of the current long term care policy under Medicaid is to insure him adequate long term care supports in the least restrictive setting possible to protect his autonomy. So if his daughter moves him into her home, his needs could be fully met at the lowest possible public cost but the daughter’s costs may be high: the daughter may have to reduce working hours, leave a secure job with benefits, threatening her family’s long term finances. It may disrupt her other relationships, as well as her personal health and well-being. If Next Friend risks were taken seriously, social policy would be better structured to balance the needs and the autonomy of both of the parties, even if it means that the solution that is second best for the care recipient So far what I have covered is why we could think of the responsibilities for another’s long term care as a risk, here is why we should: o To protect against serious lifecycle risk to families o To reduce harm that is disproportionately experienced o Over 60% of informal caregivers are women o Minority communities o Low-income households o To build critical infrastructure to care for a future generation of care recipients, to enhance innovation and build a new labor supply of people who want to do this work; a funding infusion could make it more popular. o To reshape choices and social narrative of responsibility: if Next Friends are able to work with their loved one through a combination of paying for care and providing for their needs, long term care policies could help reshape our conception of what it means to be a “Good Son” or a “Good Daughter”. They might not be the one who takes Mom into their home, but may be the one who helps her figure out how to best meet everybody’s needs. We face many challenges but they are not insurmountable. They are demonstrable programs in the U.S., there are comprehensive long term care policy solutions in other countries that show lots of different ways that long term care policy can be effective. What I am sure many of you are thinking about. If we include the invisible cost copayment, it becomes a bigger problem. If we monetize the current unpaid pay rates, that people spend now, at the average rates of care giver compensation, which is arguably too low, then we triple the size of the problem. This size at first blush may suggest that solving this problem is impossible, or that if we include it in some MediCare for All proposal, it would sink that proposal by adding dollars to what we are already seeing. That is the wrong way to think about it. A failure to address these costs isn’t making these costs go away. One study of Baby Boomers who are taking care of their parents, and this is only a sliver of the story, is about $3 trillion. Our current approach is reinforcing this system where these costs are born privately; the results are inefficient, they are inequitable, and they are going to be felt for decades to come. Including long term care would not only remedy many of these problems, but it might be helpful in building new coalitions for action. I think it is useful to include an accurate version of what we think about the costs of long term care both to design reforms as we are thinking of fundamental reform and a way that truly does provide people with long term security and also get as many people as possible to understand the scope of what it takes to do so. I think a lot of people do deeply care about this problem and may engage with Medicare for All policy, if this is one of the many issues that is discussed as part of it. Long Term Services and Supports (LTSS) for All: Charlene Harrington, PhD, RN is professor emerita of sociology and nursing at UCSF. She was elected to the American Academy of Nursing and the National Academies of Medicine. Her research has included: designing and managing a model California long term care consumer information system (CalQualityCare.org) website (2002-2016); studying state Medicaid home and community based service programs and policies (1994 to 2016); directing the National Center for Personal Assistance Services at UCSF (2003-2013); assisting with the UCSF Community Living Policy Center funded (2013-2017); and conducting international nursing home research with colleagues in 6 countries (2008-2018). Her recent research has focused on the corporate ownership and financing of long term care and its negative effect on quality, access, and costs. She is a member of the Centers for Medicare and Medicaid Technical Advisory Committee for the Medicare Nursing Home Compare website, serves on editorial boards, has testified before the US Congress, and has written more than 250 articles and books on nursing homes, long term care, health policy and nursing. I am going to use the term “Long Term Services and Support” or “LTSS” since this is the new term that disability advocates like us to use. It takes some of the emphasis away from care and puts it more on the supports activities. - About 70% of the population will eventually need LTSS. - LTSS is expensive – average lifetime cost is $260,000. - 25% of children provide caregiving – costs $3 trillion in lost wages, pensions, social security in 2011 (MetLife) - Average retirement savings for 65+ is $148,000 (GAO) - Private long term care insurance is expensive and few people have it - Medicare only covers short-term nursing home and home health, up to about 100 days of care - Must pay out of pocket until poor and Medicaid eligible I am excited about the new House bill, HR 1384 Medicare for All because it does have long term care provisions in it. - Covers broad LTSS for all disabilities and ages to meet physical, mental and social need - Supports civic, social and economic participation - Prioritizes home and community-based services (HCBS) over institutional services to correct institutional bias - LTSS in the least restrictive, most integrated setting - Allows independence, self-determination, and dignity – disability advocate principles HR 1384 recognizes that there are quality problems with current care, and huge inequities across geographic regions and states, so one of the goals is to insure equality in quality in access and availability of resources. It puts a strong emphasis on self-direction by the recipient of care. It has a broad based advisory group that includes recipients, providers, family care givers, labor, rights organizations, and academic and research institutions. The big problem with long term care is the cost. That is why people are concerned about including long term care in any kind of national health program. In 2020, it is estimated that the U.S. is spending $510 billion, which is about 15% of what is spent on all personal care services. This is for nursing homes and residential care $186 billion, home health care $116 billion, other health and personal care $208 billion Total LTSS: $510 billion Of that $510, 13% or $68 billion is currently paid out of pocket. We would have to cover that 13%. Some people argue that we should save cost so we should just pay for the front end coverage, but I don’t think that makes sense because Medicare pays for the first coverage. Other people say we should only pay for catastrophic coverage after the costs get to be too much. Basically that is what Medicaid does, once you spend down. So it is all the in-between-costs that people are paying out of pocket that I think we should pay for. We all know that the risks of needing long term care goes up as the population ages; about half of the people with disabilities are under 65 years old. It is important to include all groups in the 1384 does. The next argument is how many people need LTSS? Number Who Need LTSS: 10.9 million community residents 1.8 million institutional 12.7 million total HR 1384 covers LTSS for all with: - a functional limitation in performance of one or more activities of daily living (ADL), like bathing, dressing, toileting, transferring and eating. Or - a limitation in instrumental ADLs due to cognitive or other impairments, like walking, meals, finances, shopping, participating in the community. This is a rather generous benefit, so one way to cut costs might be to go to 2 ADLs, or more, then that would bring the number of people who need services down to around three million people. Most of the long term care services are provided by unpaid care givers, and friends and family members. Only 13% of the care given at home is paid care that is paid primarily by Medicaid. This means that we would have to come up with care at home that is the equivalent of say 30 billion hours of informal care worth over $500 billion. What economists worry about is if we offer this benefit, then people are going to want the unpaid care that they deliver now to be covered by a national health program. We need to think about design features that support people at home so that we still can have unpaid care givers to stay and and continue to help, but be able to give them enough support to make the care giving possible. Another policy issue that we have to think about is the poor quality of care from some providers. Everyone is familiar with the nursing home problems of quality; this is also true with some home health and hospice care. Most of the long term care providers, institutions and agencies are for profit, so the care is poor. It is compounded by the fact that we pay very low wages and benefits to individuals who deliver the care, at least 15% below what they would make in the hospital setting. Costs would increase if we are to pay reasonable wages and benefits to stabilize the work force and keep people. Also, increase the staffing levels so that we would adequate staffing levels in nursing homes and in agencies. There would be some cost savings from this because we know that right now about 22% of nursing home residents end up back in the hospital; the cost of rehospitalization is billions of dollars. And emergency room use expense is enormous. There would also be potential cost savings from reducing the administrative costs and profits which tend to range from around 20% to 30% in the long term care sector. In summary, the policy issues are: - Coverage: all ages or only 65+ - LTSS coverage: o all institutional, home and community-based services (HCBS), preventive services and supports or limited to home and community-based services o Limited to front end or back end coverage - Eligibility o 1+ ADLs/IADLs or 2+ ADLs/IADLs o Protect current informal caregiving - Include: improvements in quality, wages and benefits - Ensure equity: access to services across and within states; Medicaid is currently grossly inequitable by states and regions because some states put very little money into it - Financial controls of administrative costs and profits should be established. A final word from Allison: What we have learned from Germany and other countries is that this is doable. You have to make careful policy decisions about what you cover, and exactly how you design the policy. To take the German example, one of the issues is if you take the benefits as in kind as opposed to in cash, are they equivalent? If one of them is more valuable than the other, how does that affect how people are going to meet their care needs? How does that shape people’s decisions around these kinds of things? Different countries have done this in different kinds of ways. So even the most nuanced pieces of policy design can have tremendous sociological inter- familial effects. This should definitely be included in any kind of Medicare for All bill, and we should be very careful about how we design policy. 11. Create an Office of Epidemiological Accountability at Your Level [As with any prescribed activity, the benefits are in actually doing the exercise.] Table of Contents Pandemic Diagnosis, Prognosis and Prescription Part 1: Creating a map of what health care is like now and how it should be 5 Viable System Model (VSM) Maps: Bottom-Up, Top-Down, Working Inside the System, The Whole Mess & Community Universal Care VSM Map #1: Bottom-Up VSM Map #2: Top-Down VSM Map #3: Working Inside the System VSM Map #4: The Whole Mess VSM Map #5: Community Universal Care This is the Prototype Clinic Map as the System-In-Focus Environment System 1s for Clinic as System-In-Focus Creating Your first Maps What actually is your current situation? Once You have Something in VSM Maps Part 2: Where We expect to be on July 1, 2021 with US Universal Health Care Dissolve the US Department of H&HS bureaucracy down to the clinic level: Village-Neighborhood-Community-District-Region-Area-State-Federal-International Clinics serving Communities of up to 10,000 people: US $4 trillion health care expenses shift to 40,000 clinics: 75 clinics in each Congressional District, hospitals limited to only the 15% that is appropriate care in a hospital non-clinic setting. Shift in focus to families and community, and integrate primary medical care with health promotion and public health actions, and hospitals limited to 15% appropriate care. Clinic Focused National Health Care Delivery System: Federal VSM-State VSM-Health Services Area VSM-City VSM-Community/Clinic VSM: California as 14 health service areas; health systems coordinated within each region; city administered, monitored and evaluated; health clinics in every community of up to 10,000 people; hospitals and specialty medical services coordinated by clinics. Clinics have several family health care teams: one doctor, one nurse, one auxiliary nurse, and four to six community health workers, plus oral health teams, assigned to a specific geographical area and defined populations of 600-1,000 families. The teams provide a first point of contact with the local health system, coordinate care, and work towards integration with diagnostic, specialist and hospital care. Health services and health promotion activities take place at health facilities, in patients’ homes, and in the community. Part 3: The Office of Epidemiological Accountability The Station of the Office of Epidemiological Accountability H&HS 7 member Team Office of Epidemiological Accountability Responsibilities How the Epidemiological Accountability culture works What should the model evaluate at the Clinic level? Part 4: Aspects of care that distinguish conventional health care from people-centered primary care Part 5: The Science of Evidence Based Medicine and Epidemiology Evidence-based medicine Epidemiology ETIOLOGY Causal inference: what it means to do science: Bradford Hill criteria (thinking about Covid-19?) Research planning Social Determinants of health US Standards by the Joint Commission 2020 National Patient Safety Goals Part 6: New Federalism Village-Neighborhood-Community-District-Region-Area-State-Federal-International Legislative bodies Role of Hospitals, Medical Schools and Tertiary Medical Specialties Health Policy Legislative Questions Political Decision Making Process Big Picture Assessments and Team Building Example: Northern California Part 7: WORKBOOK Part 8: U.S. Universal Care: Health and Social Services Budget 2021-2 through 2024-5 (in billions, 2019 US $) Health Care Policy Making Decisions Decision Tree for Health Policy Revenue Expenditure: 2020-21 to 2024-25 2021-22 U.S. H&HS Community Clinic Budget 2021-2022 U.S. H&HS Medical School and Hospital Budget New U.S. Department of Health and Human Services Administrative Team Structure Part 9: The Political Strategy and Timeline for Implementation The Political Strategy Implementation Timeline June through December, 2020 January through June, 2021: National: Administration: Congress: State: 14 HSAs and their Counties and Cities: Universal Health Care Software Package 1.0: July-December 2020, January-June, 2021, July- December, 2021 Hospitals: 2021-2022 Financial Distribution Component in the new system, effective July 1, 2021 Wind Down US Fee-for-Service Health Insurance Industry: July-December, 2020, January-June, 2021, July 1: no more US Health Insurance Industry services, July-December, 2021 Phase Up US Universal Health Authority: Local Global Budget, July-December, 2021 Transition to Universal Care: Begin Universal Coverage, July 1 2021 - Conversion at the Patient/Taxpayer level from insurance to new payment structure - Conversion for the individual provider; provision for qualified provider groups up to Kaiser to retain their identity - Conversion for the hospitals: all hospitals come under the jurisdiction and control of the community clinics grouped with federal legal Memoranda of Understanding (MOU) - Conversion for the Health Insurance industry: employees aged 60 and older receive a generous retirement package; retraining for all other insurance employees into epidemiological accountability, or transitioning into another line of work - Establish H&HS 7 member Office of Epidemiological Accountability “Health Information Systems Operations Team” with guidance and control at each station level: community/clinic, city, HSA, state and national - Daily accountability of the entire system. System Mission: optimize primary care systemwide in every state in the U.S. Pandemic Diagnosis, Prognosis and Prescription Pandemic Diagnosis: not only are you at risk to your health that no one expected or is prepared for, least of all the health care delivery system professional staff, but for perhaps a quarter of the US workforce, when they lost their job, they lost their health insurance coverage – triple whammy. Prognosis: this virus is so novel it is challenging the basic assumptions of the “germ theory of disease”. It is an unconfirmed idea that some day there might be a vaccine developed that can teach the human immune system to match wits with this virus – often the virus is most dangerous because it makes the immune system over-react uncontrollably to death. It is an untested idea that someone who has had a reaction to the virus and recovered has left residual anti-bodies and might be immune, and if so, for how long, whether for weeks or years. It is an untested idea that using the blood plasma from successfully recovered Covid-19 patients can have a therapeutic effect with other patients. All of these are assumptions derived from the germ theory of disease. The SARS Covid 2 virus is a new fact of life. It is a science fiction writer’s dream come true, the worst that the military planners can scheme about biological warfare: 1) It loves people, jumping from one to the next, settling in and growing rapidly, 2) it is different in bad ways from everything science has seen up to now, continually surprising respiratory and other health specialists who are confronted with thousands of cases, 3) it is outside of the current scientific rules of nature: it is forcing the most advanced scientific thinking in the biological sciences to go back to the very foundation of their thinking. For Social Scientists, it means throwing out Keynes and Marx, and Freud. Prescription: For Health Care? Universal Coverage. Less than a quarter of the US society still have job-supported health insurance, and it will be much more expensive. The whole health care delivery system model needs to be recalibrated so that people can pay a reasonable amount, and receive first class quality health care with easy access and availability wherever they live. Creating a map of what health care is like now and how it should be Covid-19 is so human-friendly and so unique that it remains a complete mystery to the virologists who know the most, as well as everyone else in medical science. This virus is so compatible with humans that every person is on the front line of the battle to gain control over this potentially life- threatening tragedy. This is a plan to mobilize all the resources to help you maintain your vitality, minimize your personal risk to exposure of the virus, and limit your susceptibility to its causing you personal illness or being an asymptomatic carrier transferring the virus to loved ones and friends, co- workers and people you share public space with. Aloha. Hello. Welcome to your very own personal Office of Epidemiological Accountability. This portal to the future is custom designed by you to make sure you are doing what you can to have a healthy community of up to 10,000 people. This is the community that makes up the epidemiological petri dish that you are the center of. This issue #19 is a tool kit for you to build a handbook for organizing your community into an organization that supports all of your community’s health care delivery system. Hopefully, at some point, you will decide to run for a 4-year term to the elected seven-member Community Health Council that is responsible for coordinating your community’s system. The rest of this document is the background for you to use this issue to build your own community health care delivery system handbook: Stella Lobo, MD’s “12 Layer VSM National Design of Brazil’s Health Care Delivery System,” and Michelle Famula, MD’s “The Community Health Clinic: The Central Resource for Community Centered Health & Wellness Clinical Care” are the basic templates for you to begin to build your part of the picture of the dynamic US health care delivery system as we evolve towards universal care July 1, 2021. Technically, to understand the Viable System Model (VSM): the organization, its environment, and its 5 management systems to adapt to a changing environment are best introduced by googling Jon Walker + VSM Guide. Then Stafford Beer’s Viable System Model workbook is called Diagnosing the System: for Organizations, and the Quantified Flow Chart is in “Disseminated Regulation in Real Time” is in issue #16. 5 Viable System Model (VSM) Maps: Bottom-Up, Top-Down, Working Inside the System, The Whole Mess & Community Universal Care This is the 1st stage of a simultaneous five VSM Map process: 1) bottom-up, for everyone as a consumer of health services, 2) top-down, for everyone to learn about how part of the system is set up, 3) if you work in the health system, 4) a sum of the first three which is an aggregate picture of current reality, and 5) your ideal community health care service delivery system to go into effect July 1, 2021: VSM Map #1: Bottom-Up: what is the current health care delivery system for you now? Clinics, physicians, hospitals, treatment centers, what is there? Ambulance? Emergency services? Surgery and Hospitals? Long term service and support? Home visits? Dentistry? Optometry? Alternatives to mainstream medicine? Physical therapy? Pharmacy? Counseling? Social services like transportation, housing, employment, and food? VSM Map #2: Top-Down: somebody else’s reality: pick a job somewhere in the US health care delivery system, and research and map it all the way from H&HS Secretary to your community. This is for everybody: Put your “Health Professional” hat on. Think like a Nurse with a wholistic perspective about a human’s body needs, social and community needs, economic needs. How “should” the local health care delivery system look/work? Learn how the Federal-State system mismanages the resources. Pick some place in the US health care delivery system that you would like to become an expert at, and do a top-middle-bottom-down analysis of that particular part of the US health bureaucracy, and how it attempts to mesh with the administrative chaos. And, if you are a professional in the US health care delivery system, build VSM Map #3: Working Inside the System of where you are, what your responsibilities are, the challenges, the problems, the failures, the potential. Then VSM map all the way from the Secretary of the Department of Health & Human Services to you, then to the person who is the recipient of the service that you provide. VSM Map #4: The Whole Mess is putting together all the VSM Map #1s, VSM Map #2s, and VSM Map #3s to guide us in making sure that each clinic can handle everything they need to be able to handle. Hopefully, as you work on Map #2, you will discover things that should be in Map #1, and guide how you feel the system should be: VSM Map #5: Community Universal Care is how you want it to work: US Universal Health Care Delivery System July 1, 2021 (VSM System 4: the goal to work towards). Clinic-focused New Federalism Stations: Village-Neighborhood-Community-District-Region-Area-State-Federal-International: how you want your personal community clinic to look, feel, work, make sense, deal with you when you have a health problem. Also, talk about what it is that should be the backup support system for your clinic. These are the systems for ongoing evaluation at each H&HS Station level: -Clinics - Hospitals - Medical Schools, Tertiary Care and Allied and Auxiliary Health Personnel - Evaluating Health Professionals - Evaluating Community Responsiveness o Clinic Services to Current Patients o Ecological Analysis o Community Needs This is the Prototype Clinic Map as the System-In-Focus This is only to get you started. Reality will demand that you make lots of Clinic-focused maps and update your maps frequently as you gain new information. Begin by creating specific VSM profiles of the following views as the System-in-Focus: - a health consumer - a health care provider, RN, MD, Nurse Practitioner, Home Care worker, physical therapist, behavioral therapist - a health care administrative support position - someone in the health insurance billing industry Each analysis starts with these System 1s for their System-In-Focus: 1) co-workers, same level, superior and subordinate, 2) record keeping (maybe 50%, goal 25%), 3) personal health/physical stamina, 4) personal life, 5) career development. The health provider has two additional categories: 6) patients, and 7) patient load. Everyone who is not a front line health professional should reflect on the relative professional commitment that health professionals make every day as part of the definition of what they do. You will see if you do the 4 versions that the health professional has a difficult job, and the support staff should have a better understanding of their roles and how to be mutually supportive, which is the key to working as a team. 7) Patient Load is a measure of professional staff coping with the stress level. The experience in Milan and New York City demands that the health system monitor the stress levels of individual staff and ability of different programs to respond to increasing levels of demand for services. If we had such a measure, then problems could be identified and addressed. As it is now, we are left with who can complain the loudest. As a measure of how effectively a health care delivery system is fulfilling its mission, this statistic seems as important as morbidity and mortality. Clinic as System-In-Focus: Environment: Population Focus: Assigned Population for the Clinic to serve; 100% of the people. Demographics. Identified needs of population Percentage of population currently in contact with the clinic. Strategy for outreach to maintain current clinic population contact. Strategy for outreach to remainder of the population to be served. Environments: social, economic, commercial, cultural, technical, educational, political, and ecological. Each has impacts on the healthiness of the community. System 1s for Clinic as System-In-Focus - Clinic professional medical staff - Facility, medical equipment, resources - Health education campaign - Coordination with Hospitals, Medical Schools, Specialty Health Services Creating Your first Maps Look at Jon Walker + VSM Guide. To be able to visualize these ideas, it would be best to have a basic understanding of the VSM graphic, the System-in-Focus, the system’s environments (social, cultural, business, technical, political, educational, ecological), to begin to see the relationships between the 5 Management Systems that are necessary for organizational viability in response to a changing environment, and the System 1 elements of the organization at this level of focus. What actually is your current situation? Creating the maps will help you figure out where you really are. One of Stafford’s introductory ideas is: the world, this situation, has changed a lot since the last time you checked. Too much activity is based on the assumption that nothing in the background has changed. Stafford has a drawing: you change, your situation changes, as your model is stuck in some previous time, stuck, you change, your situation changes, you respond to your model which is stuck from some time before and is not true any longer. Why are you confused that your situation doesn’t work according to what your stuck model expects? This is two-thirds of the way through your favorite STAR WARS movie: R2D2 has just presented The Challenge, and now you need to figure out what to do, given all of the uncertainty. What really is your current situation? Once You have Something in VSM Maps: - show it to your family, friends and colleagues - show it to your boss - show it to your co-workers, your “cousins”, the people who do almost the same thing as you do - show it to your subordinates, the next layer down - show it to the next layer up, and the next layer up after that… Each time, you will probably communicate better. By their reactions, you will discover a lot that is other people’s version of your reality that you were unaware of before. You are more likely to see where you are having communication conflict because of misunderstanding and disagreement about what the problem is. What you are going to discover is that other people see different problems than you do, and they see your problems differently as well. There is a lot of insight in those disagreements, discovering blind spots, lots of potential for learning, adapting to an improved new reality. Maybe even talking about adjusting some part of the organizational structure that seems to be causing the difficulties. The point of the VSM is to adjust the model to see what might be affected in reality without first having to make an irreversible change to reality. The learning, the personal growth, the institutional innovation happens in the LISTENING in those conversations: all of the places where you discover that your assumptions were inaccurate, or at least not the same as you expected. This informal, uncoordinated, disconnected collection will generate over 20 layers between the clinic and the Secretary of the Department of Health and Human Services. A healthier national communication system would have 10 to 12 layers. Part 2: Where We expect to be on July 1, 2021 with US Universal Health Care Dissolve the US Department of H&HS bureaucracy down to the clinic level: Village-Neighborhood-Community-District-Region-Area-State-Federal-International Clinics serving Communities of up to 10,000 people: US $4 trillion health care expenses shift to 40,000 clinics: 75 clinics in each Congressional District, hospitals limited to only the 15% that is appropriate care in a hospital non-clinic setting. Shift in focus to families and community, and integrate primary medical care with health promotion and public health actions, and hospitals limited to 15% appropriate care. Clinic Focused National Health Care Delivery System: Federal VSM-State VSM-Health Services Area VSM-City VSM-Community/Clinic VSM: California as 14 health service areas; health systems coordinated within each region; city administered, monitored and evaluated; health clinics in every community of up to 10,000 people; hospitals and specialty medical services coordinated by clinics. Clinics have several family health care teams: one doctor, one nurse, one auxiliary nurse, and four to six community health workers, plus oral health teams, assigned to a specific geographical area and defined populations of 600-1,000 families. The teams provide a first point of contact with the local health system, coordinate care, and work towards integration with diagnostic, specialist and hospital care. Health services and health promotion activities take place at health facilities, in patients’ homes, and in the community. Part 3: Office of Epidemiological Accountability The Office of Epidemiological Accountability H&HS Station 7 member Team Formerly the budget office, to become all of the management information system necessary for everybody else to figure out how to improve performance and results. At each level, the entire bureaucracy is a 7 member team, called “a station”, with 2 from health policy, 2 from behavioral health policy, 2 from social services policy, and a team leader-servant. They are generalists, with at least 5 years experience in their policy area. Appropriate backgrounds include Registered Nurse, Medical Doctor, Physicians Assistant, Nurse Practitioner, Certified Public Accountant, Lawyer, Ecologist, Ph.D. in epidemiology, Master of Public Health, Master of Maslow’s hierarchy of needs, respected administrator. The responsibilities require generalists, not specialists. Leave your specialization with your ego at the door. Office of Epidemiological Accountability Responsibilities - Maintain daily real time operations database: program patient activity; staff activity; money activity; equipment, reagents, lab and other resources; - Maintain ongoing Community Assessment: ongoing monitoring of critical socio- economic and environmental indicators of this community’s health by neighborhood and family. - Ongoing Program Evaluation: the information structure for this particular community’s future is based on the VSM picture that the Community Health Council is regularly updating as the organization should become more effective in meeting unique community challenges – by becoming more sophisticated about what would be good epidemiological data to maintain. [If this entire idea had a footnote, and the footnote was so important that it was printed in BOLD on every page of the document, it would be: the London School of Economics Law about statistics, named after Professor Goodhart, former chief economist of the Bank of England: “once policy makers target a particular variable, it loses its value as an indicator.” The VSM model/Quantified Flow Charts are to identify potential statistics that can be made from the daily data generated; as long as the data are unique, the statistics are not manipulated.] - Accountability to the Community: every public contact by a member of the Community Clinic H&HS Office of Epidemiological Accountability 7 member team is a re- evaluation of the idea of the office. Members of the community own the clinic resources the office has the honor to shepherd within the intelligent daily life of the community. The office should have the ability to offer the community whatever it wants to know to have confidence in the clinic. - Human Resource Evaluation: Availability of MDs, RNs, NPs, dentists, allied and auxiliary health professionals. - Evolving Community Standards of Care: clinic financial support for alternatives to mainstream acute care western medicine include: Chiropractor, podiatrist, midwife, doula, traditional Chinese medicine, yoga; Local additional considerations to expand the definition of supported health activities, modalities, and methods of health treatment are part of the community dialogue. - Identify Bottom 10%: System performance: clinics, hospitals, med schools, health professionals. How the Epidemiological Accountability culture works: At the clinic level: the H&HS team has built an information model of the health reality of the community, how well the clinic is responding, and what seem to be emerging problems today. The data is from yesterday (within the previous 24 hours). The team identifies emerging problems, and makes their daily report to management within the clinic and up the chain of command. Of the 133 statistics, any RED (not GREEN) numbers include a comment. The day’s team activities are defined somewhat by how the numbers turned out. The City H&HS has a different set of 133 numbers to evaluate. Their database includes every clinic’s reports, in the aggregate, and statistics for managing the entire city’s health care delivery system in a way that no clinic can appreciate. Similarly, the 133 statistics at the Health Service Area H&HS level are a measure of the ability of the Area health care delivery system to respond on a timely basis. (In the current situation, there would be a lot of the 133 statistics at each level that are in trouble, RED.) It would also provide a way to identify where available resources can be shifted to where they can be best used. Similarly, the State H&HS Station Team has a set of 133 statistics to evaluate how well the HSAs are managing the resources statewide. And the National H&HS Station Team identifies potential problems at the state and national level with their 133 statistics. What should the model evaluate at the Clinic level? Evaluation: Inside the clinic: responsiveness, healthy outcomes, measures of prevention/education, comfort level in the clinic, multi-ethnic/language Outside the Clinic: community social services, networking support services, economic/job creation, identify and improve unsafe environments, community discussion about “health,” community discussion about current and future health services and potential resources development (it takes many years to become an RN or a physician). Community Demographics: The model needs to include as complete a picture of each community as possible, including: - demography: population age distribution, aging over time, births and deaths; - economy: resources, people with skills and credentials, cash flow, incremental growth, dynamic equilibrium, taxes and public finance, commercial/residential/industrial/agricultural/open space uses, infrastructure, privacy protection of personal health and financial records, schools, libraries, child care, senior services, public programs, input/output for local, region, state, national and international; - city and community government: legal constraints, budgets and accounting systems, jawboning, special relationships with other levels of government; Secondary Concerns for the model: - geography: land contour, flooding and drainage problem areas, soil classifications, land uses, roads and their status, sewers, wells, water sources as well as quality; - climatology: seasonal changes, amount of rain, heat in summer, cold in winter, seasonal energy conservation programs; and, - energy grids: telephone, energy, utilities, ability to have wireless computer connection (current cutting edge criteria for technology-available community), cable tv, potentials for green energy and community self-reliance. Part 4: Aspects of care that distinguish conventional health care from people-centered primary care Conventional ambulatory medical care in clinics or outpatient departments Focus on illness and cure Relationship limited to the moment of consultation Episodic curative care Responsibility limited to effective and safe advice to the patient at the moment of consultation Users are consumers of the care they purchase People-centered primary care Focus on health needs Enduring personal relationship Comprehensive, continuous and person centered care Responsibility for the health of all in the community along the life cycle; responsibility for tackling determinants of ill-health People are partners in managing their own health and that of their community Part 5: The Science of Evidence Based Medicine and Epidemiology Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” The aim of evidence-based medicine is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The steps for designing explicit, evidence-based guidelines: Formulate the question (population, intervention, comparison intervention, outcomes, time horizon, setting); search the literature to identify studies that inform the question; interpret each study to determine precisely what it says about the question; if several studies address the question, synthesize their results (meta-analysis); summarize the evidence in "evidence tables"; compare the benefits, harms and costs in a "balance sheet"; draw a conclusion about the preferred practice; write the guideline; write the rationale for the guideline; have others review each of the previous steps; implement the guideline. This five step process can broadly be categorized as: Translation of uncertainty to an answerable question and includes critical questioning, study design and levels of evidence; Systematic retrieval of the best evidence available; Critical appraisal of evidence for internal validity that can be broken down into aspects regarding: Systematic errors as a result of selection bias, information bias and confounding Quantitative aspects of diagnosis and treatment The effect size and aspects regarding its precision Clinical importance of results External validity or generalizability Application of results in practice Evaluation of performance Epidemiology is the study and analysis of the distribution (what, who, when, and where), patterns and determinants of health and disease conditions in defined populations, and the application of this study to control health problems. Epidemiology, literally meaning "the study of what is upon the people", is derived from Greek epi, meaning 'upon, among', demos, meaning 'people, district', and logos, meaning 'study, word, discourse'. The distinction between "epidemic" and "endemic" was first drawn by Hippocrates, to distinguish between diseases that are "visited upon" a population (epidemic) from those that "reside within" a population (endemic). The term "epidemiology" appears to have first been used to describe the study of epidemics in 1802 by the Spanish physician Villalba in Epidemiología Española. Epidemiological practice and analysis is unified with management science to provide health care and health guidance to a population. This task requires the forward-looking ability of modern risk management approaches that transform health risk factors, incidence, prevalence and mortality statistics (derived from epidemiological analysis) into management metrics that not only guide how a health system responds to current population health issues but also how a health system can be managed to better respond to future potential population health issues. Population-based health management encompasses the ability to: - Assess the health states and health needs of a target population; - Implement and evaluate interventions that are designed to improve the health of that population; and - Efficiently and effectively provide care for members of that population in a way that is consistent with the community's cultural, policy and health resource values. Major areas of epidemiological study include disease causation, transmission, outbreak investigation, disease surveillance, environmental epidemiology,forensic epidemiology, occupational epidemiology, screening, biomonitoring, and comparisons of treatment effects. Investigators analyze the relationships between (A) environmental, dietary, lifestyle and genetic factors; (B) alterations in cellular or extracellular molecules; and (C) evolution and progression of disease. ETIOLOGY means the understanding of the causes of diseases, or a given phenomenon, and of the network of relationships that culminate with the observed disease/ phenomenon. The term 'epidemiologic triad' is used to describe the intersection of Host, Agent, and Environment in analyzing an outbreak. Causal inference: what it means to do science: "Correlation does not imply causation" is a common theme for much of the epidemiological literature. For epidemiologists, the key is in the term inference. Correlation, or at least association between two variables, is a necessary but not sufficient criterion for inference that one variable causes the other. Epidemiologists use gathered data and a broad range of biomedical and psychosocial theories in an iterative way to generate or expand theory, to test hypotheses, and to make educated, informed assertions about which relationships are causal, and about exactly how they are causal. Epidemiologists emphasize that the "one cause – one effect" understanding is a simplistic mis- belief. Most outcomes, whether disease or death, are caused by a chain or web consisting of many component causes. Bradford Hill criteria (thinking about Covid-19?) In contrast to the explicit intentions of their author, Hill's considerations are now sometimes taught as a checklist to be implemented for assessing causality. Hill himself said "None of my nine viewpoints can bring indisputable evidence for or against the cause-and-effect hypothesis and none can be required sine qua non” - Strength of Association: A small association does not mean that there is not a causal effect, though the larger the association, the more likely that it is causal. - Consistency of Data: Consistent findings observed by different persons in different places with different samples strengthens the likelihood of an effect. - Specificity: Causation is likely if a very specific population at a specific site and disease with no other likely explanation. The more specific an association between a factor and an effect is, the bigger the probability of a causal relationship. - Temporality: The effect has to occur after the cause (and if there is an expected delay between the cause and expected effect, then the effect must occur after that delay). - Biological gradient: Greater exposure should generally lead to greater incidence of the effect. However, in some cases, the mere presence of the factor can trigger the effect. In other cases, an inverse proportion is observed: greater exposure leads to lower incidence. - Plausibility: A plausible mechanism between cause and effect is helpful (but Hill noted that knowledge of the mechanism is limited by current knowledge). - Coherence: Coherence between epidemiological and laboratory findings increases the likelihood of an effect. However, Hill noted that "... lack of such [laboratory] evidence cannot nullify the epidemiological effect on associations". - Experiment: "Occasionally it is possible to appeal to experimental evidence". - Analogy: The effect of similar factors may be considered. Different fields in epidemiology have different levels of validity. One way to assess the validity of findings is the ratio of false-positives (claimed effects that are not correct) to false-negatives (studies which fail to support a true effect). Research planning The correct definition of the main hypothesis and the research plan will reduce errors while taking a decision in understanding a phenomenon. The research plan might include the research question, the hypothesis to be tested, the experimental design,data collection methods, data analysis perspectives and costs involved. The question needs to be concise, at the same time it should be focused on interesting and novel topics that may improve science and knowledge and that field. To define the way to ask the scientific question, an exhaustive literature review is necessary, so that the research can be useful to add value to the scientific community. Social Determinants of health The social determinants of health are the economic and social conditions that influence individual and group differences in health status. They are the health promoting factors found in one’s living and working conditions (such as the distribution of income, wealth, influence, and power), rather than individual risk factors (such as behavioral risk factors or genetics) that influence the risk for a disease, or vulnerability to disease or injury. In Canada, the social determinants of health that have gained wide usage are: income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion/inclusion, social safety network, health services, aboriginal status, gender, race, and disability. The World Health Organization suggested that the social determinants of health include: the socio-economic gradient, stress, early life, social exclusion, work, unemployment, social support, addiction, food, and transportation. They tend to cluster together: for example, those living in poverty experience a number of negative health determinants. The US Centers for Disease Control defines social determinants of health as “life-enhancing resources, such as food supply, housing, economic and social relationships, transportation, education, and health care, whose distribution across populations effectively determines length of life and quality of life. These include access to care and resources such as food, health insurance coverage, income, housing, and transportation. The Brazilian Constitution institutionalizes community engagement in health services. Specific guidelines include: - community participation and comprehensive care; - priority given to primary care; - decentralization through the three levels of government, from the cities where the health care scenario develops, to the states which coordinate health care actions, and the federal government which regulates the system. US Standards by the Joint Commission The Joint Commission accredits and certifies more than 22,000 health care organizations and programs in the United States, including hospitals and health care organizations that provide ambulatory and office-based surgery, behavioral health, home health care, laboratory and nursing care center services. An independent, not-for-profit organization, the Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The National Patient Safety Goals are to improve patient safety. The goals focus on problems in health care safety and how to solve them. 2020 National Patient Safety Goals Ambulatory Health Care: identify patients correctly, use medicines safely, prevent infection, prevent mistakes in surgery. Behavioral Health Care: identify individuals served correctly, use medicines safely, prevent infection, reduce the risk of suicide. Hospital: identify patients correctly, improve staff communication, use medicines safely, use alarms safely, prevent infection, identify patient safety risks, prevent mistakes in surgery. Home Care: identify patients correctly, use medicines safely, prevent infection, prevent patients falling, reduce the risk of suicide. Laboratory: identify patients correctly, improve staff communication, prevent infection. Nursing Care: identify residents correctly, use medicines safely, prevent infection, prevent residents from falling, prevent bed sores. Part 6: New Federalism International-Federal-State-Area-Region-District-Community-Neighborhood-Village Legislative bodies: At each level of governance, define and debate Citizen’s rights and responsibilities, Community’s rights and responsibilities, Clinic’s rights and responsibilities, City’s rights and responsibilities, HSA’s rights and responsibilities, State’s rights and responsibilities, National rights and responsibilities, and International rights and responsibilities; only serve one term, no re-election; Prime Minister form of Executive; shift all judicial positions to the community level; 5% of decisions are about inter-jurisdictional disputes – primary job of the courts is to clarify confused language from the national or state interpretation of current law. Mostly legislative bodies argue over how the current budget computer algorithm should be edited. Role of Hospitals, Medical Schools and Tertiary Medical Specialty: shifting from fee-for-service to block funding means that surgery and specialty medical practice are not as lucrative. The American Medical Association and the American Hospital Association will always advocate for more resources for specialty care. Health Policy Legislative Questions: long term goals and program evaluation, evaluate performance of Office of Epidemiological Accountability: consumer satisfaction, professional criticism, funding flow, information flow, evaluation methodologies, team building, evaluating VSM, anticipating change on the horizon. Political Decision Making Process Within the Community: human scale Above Community: secondary, subservient to human scale, Memorandum of Understanding (MOU): within a city, within a state (each state), multiple states. Helps with big things: roads, cities, etc Start making VSM maps of your situation, unique as it is: Community/Clinic: individual and aggregate patient needs identification; identify internally met health needs, needs met by other social services, needs met by other resources, and unmet needs; ongoing budget and information management, for planning, day-to-day operations, research, and program evaluation. City (Region/District): multi-clinic needs assessment; multi-clinic resource assessment; multi- clinic resource coordination; multi-clinic resource new project development; funding management; ongoing, daily documentation and evaluation; long range improvement in human resources, information systems and emergent, effective technologies. Health System Areas: Area compliance with national standards; clinic compliance with national and state standards; coordination of resources; identify unmet needs; support city regulation of clinics, and MOUs of clinics for hospitals and medical schools State: State compliance with national standards; clinic compliance with national and state standards; coordinate information and best practices between clinics; manage HSAs National/Federal: State compliance with national standards; individual clinic compliance with national standards International: WHO China Global Ecological Assessment Network Climate Change Population Monitor Pandemic leadership Evaluate resource need, long term planning, visioning Big Picture Assessments and Team Building By having the population of service limited to 10,000 people, there should be a great deal of comparability between the different clinics. That means that each H&HS 7 member clinic Team has a lot of similarities, what Stafford calls “cousins”. This should prove a wonderful advantage in terms of accrued memory as the information system becomes more familiar: Meetings between clinic teams in the same city: you compare your numbers with each other’s numbers, and with the city’s much different, unique set of statistics. The city team has an unfair advantage: their set of numbers puts them in a good position to manage the multiple clinics abilities to work together. Meetings of the cities teams (and the clinic teams) with the HSA team brings out the competitive nature of the city teams as they are in a position to shine about the best, or improved performance by particular clinics, while highlighting areas where the clinics and the cities could do a better job of coordination of resources and services. Meetings of the HSA Teams with the State H&HS Team should give an in-depth look at the health of the State and the ability to respond to pandemic or long term service and support issues. Meetings of the State H&HS Team with the Federal H&HS team for that state meet monthly in the state for two days in a different place each month; and quarterly attend a nationwide federal meeting in Washington, D.C. Example US California Northern California San Francisco-Oakland Bay Area San Francisco County West San Francisco Health System Area University of California, San Francisco Medical Center On Lok SF Chinatown Multi-Service Senior Center Golden Empire Health System Area Sacramento County, Yolo County, Davis, Woodland, Winters, West Sacramento University of California, Davis Medical Center Sutter Systemwide, Sutter Sacramento, Sutter-Davis; Woodland Hospital Dignity Health; Kaiser Sacramento, Kaiser Davis Outpatient Only; CommuniCare Davis, Woodland, West Sacramento; Winters Healthcare; Yolo County Adult Day Health Care WORKBOOK Wherever you are, create a H&HS station. Develop a VSM of the layer you are at, the layer above it and below it; 1) your health resource situation currently 2) somewhere in the bureaucracy that you are not, but would like to figure out. 3) If you are in the health care delivery system bureaucracy, what it is really like, especially your level, the layer(s) above and below you 4) 1 + 2 + 3 5) serving your community 1) Your Community’s Clinic: This is the very heart of this document, and this process: for you to design the criteria for a clinic in your community, discover what resources there are currently available in your community and nearby, identify what the health needs are, and build the political network to create a clinic program to meet your community’s needs. Including but not limited to: clinic care, hospital care, dentistry, optometry, specialty medical care, long term services and support. Your first VSM maps should include (after you visit Jon Walker at google): - a complicated VSM of yourself, with several layers for your specific health needs: one for you, your relationships with various physicians and other health professionals; a VSM analysis of each of the institutions your rely on; and an analysis of your diet, your health regime, your addictions, your economy. - VSM analysis of each of the members of your family, and their specific health needs. - VSM analysis of each of your friends, and their specific health needs. Then, VSM Maps: Bottom-Up, Top-Down, Working Inside the System, The Whole Mess & Community Universal Care. Look at the first part of this issue #19 for what should be in each VSM map. Then you want to play around with the VSM maps. Show them to people who know you well enough that you don’t have to explain very much for them to make some interesting contributions, corrections are what you are looking for. How do other people see reality so different than you do? Good starting point in improving communication. The end goal is for your personal community of several thousand people elect seven people to implement the plan that this is the first step of. For the VSM Top-Down: Somewhere in the health care delivery system bureaucracy that you are curious about. It can be the local clinic, an ambulance company, a nursing home, an emergency room physician, a nurse anesthetist, a county public health nurse, a family nurse practitioner, an administrator in a hospital, a computer program analyst organizing the billing, a medical school planner, a county administrator, a state elected official or the state surgeon general, a federal administrator somewhere trying to make MediCare or MediCaid work. Put your “Health Professional” hat on. Think like a Nurse with a wholistic perspective about a human’s body needs, social and community needs, economic needs. Learn how the Federal-State system mismanages the resources. Pick some place in the US health care delivery system that you would like to become an expert at, and do a top-middle-bottom-down analysis of that particular part of the US health bureaucracy, and how it attempts to mesh with the administrative chaos. System Mission: optimize primary care systemwide in every state in the U.S. IV. Making It Work Administratively 12. U.S. Universal Health Care: Brazilian Design, Dutch Administration, Daily Accountability: Optimize Primary Care systemwide in every State in the U.S.: 75 FQHC Community Clinics with $25 million annual budget in each Congressional District This is the reality check. We are talking about going from medicine to health care. That means being engaged in the community and the society in all kinds of ways that your training, and worse, if you are a physician, your day to day to day culture has ignored. The novel coronavirus has forced you to discover your community. The Brazilians have been talking about that for a century. Are you intelligent enough to find out what you don’t know anything about from a culture that is the world’s leading experts in community health discussion. All the way from the family in the favela, what they call their urban ghetto, to the middle class, and the rich, from the city, to the state to the country. Brazil has a leader who is worse than Trump, and he is ignoring the coronavirus at his country’s peril. We have two reports: life before Bolsonaro, and what it was like under Bolsonaro’s foul rule, last October, before all of this coronavirus chaos. There was a time when Brazil was fashionable, when the bossa nova was brand new. It is now a time for health care delivery system discovery. This unfolds the mystery of how Brazil has an ongoing public policy discussion, how decisions are reached, and programs implemented – none of which is currently possible in the U.S., although the U.S. tried to set it up with PL 93-641 from 1978-1983, and we will try to improve on in issue #19. Conclusion: As in many health systems around the world, the Brazilian health system’s challenges include the control of costs, improvement of efficiency, assurance of quality and safety, provision of access to comprehensive care, and better coordination with primary health care. The system needs to be better organized into a regionalized network of services nationwide, with systematic, effective regulatory and referral mechanisms in place that can only be monitored with something like the Office of Epidemiological Accountability, in the next issue, #18. Learning from Brazil’s National Health Awareness Design For over a century, the people of Brazil have been formally discussing what health means, at the city level, state level as well as nationally and translating their discussions into public policy. Brazil has tremendous socio-economic and environmental problems, but it has a social vision for community health that we want to learn from. We are going to do that through the spectacles of Dutch Burger Meister who wants to know about everything so that they can keep everybody as healthy as possible. This project is about improving health care delivery in Brazil, National Health Service (England), California, and China. A billionaire said that when the tide goes out, you can see who is naked. The novel coronavirus is exposing many problems about the health care delivery system: the people are the heroes, but the system doesn’t work. We want to design an information system that empowers city government to understand what is going on in their various communities, and what the health system is doing about it. That will be the Office of Epidemiological Accountability, but you can get a hint of it in Stella’s model. Brazil is too aware of the socio-economic class, and their insurance system for health care is totally biased towards rich people with good insurance. Not acceptable. In the Netherlands, the focus for service delivery is at the municipal level, emphasizing coordination and accountability. Using Holland as a metaphor for a state in the U.S. makes the transition to universal health care easy to understand: 1) everyone has the Gold Standard level of care, so there is no discriminating against people who are low income; 2) 10.8% of the GDP for health care is considered expensive but worth it (compared to the U.S. 17.8%); 3) Holland slipped to #2 in 2018, after a decade of having the #1 ranked health care delivery system in Europe; 4) Dutch private not-for-profit, government regulated health insurance plans could compete with the U.S. system, but it would be at tremendous waste of administrative resources; 5) from the standpoint of the patient requesting services and care, the national system is seamless, but it is known by the insurance industry as “chaos” so that it can accommodate and benefit the patient, whatever the therapeutic response determines, with cost as a tertiary consideration. Technical Correction of No Consequence: Peter Tuddenham, Immediate Past President of the International Society of System Sciences, a wonderful organizer, and an engineer trained at the United Kingdom’s Royal Military Academy Sandhurst, was kind enough to count only twelve slides in Stella’s presentation, not 14. The State Level Health Care is Sao Paulo VSM5, and the Basic Care Clinic is VSM9: VSM5 is in a particular State of Brazil: Sao Paulo: Guarantee Specialists Consultations: VSM State Level Health Care (Sao Paulo): Guarantee access to complex levels of care VSM9 is the clinic: Healthy and happy population: VSM Basic Care Clinic (Basic Health Unit): Promote physical, mental and social well-being Brazil’s 12 Layer National Model of Health Participation A year ago, Stella Lobo, MD and I worked together to develop this 12 layer analysis of Brazil’s health care delivery system that is the model for this analysis. Part 2 is Michelle S. Famula’s The Community Health Clinic: The Central Resource for Community Centered Health & Wellness Clinical Care. Part 3 will be the design for the Office of Epidemiological Accountability Part 4 will be the VSM of a Clinic Focused National Health Care Delivery System: Federal VSM-State VSM-Health Services Area VSM-City VSM-Community/Clinic VSM: California as 14 health service areas; health systems coordinated within each region; city administered, monitored and evaluated; health clinics in every community of up to 10,000 people; hospitals and specialty medical services coordinated by clinics. Stella’s model is a wealth of information. When the first Lord of the Rings movie came out, director Peter Jackson said that Tolkin was so amazing that he had already thought of everything – he was like Mt. Fuji for science fantasy, either Mt Fuji is far or near, or you can’t see it because you are standing on it, and that is the way Stella’s Brazilian model looks at all the issues of health care delivery. Jackson said that whenever they had a question in making the movie, they went back to the books because Tolkin had thought it through. Stella’s model is like that for a health care delivery system anywhere in the world. From the late 1880s, Brazilian public health officials have been making epidemiological history, especially Dr. Emilio Ribas, Dr. Oswaldo Cruz, and Dr. Carlos Chagas. Recurring epidemics from cholera, yellow fever and malaria challenged the public sanitation of the large urban centers, Sao Paulo and Rio de Janeiro, as well as the rest of the largely tropical country. Between 1880 and 1900, the causes of 20 different diseases were determined. The victory over epidemic diseases led to a broadening of concerns to ongoing local diseases, then to the matter of social assistance, as people realized the negative relationship between health and socio-economic structure. This strong civil society movement that still flourishes today mounted a drive for health reform, defining health beyond its biomedical understanding, including social determinants, education, poverty reduction, and preventive measures in the broader context of health as a human right. The Brazilian health reform movement’s political and ideological viewpoint was of health not as an exclusively biological issue to be resolved by medical services, but as a social and political issue to be addressed in public. The ultimate goal is universal, equitable, and sustainable health care to fulfill the right to health enshrined in its 1988 Constitution. The comprehensive model of social protection includes: universal coverage, recognition of individual social rights, affirmation of the State’s duty, and (instead of a market approach) a public-oriented approach – which subordinates private practice to regulation based on public need, in a decentralized arrangement that is co-managed by government and society. The focus is to deliver social policy to the local authority: the format is a decentralized integrated network with political command and funding at each level of government, with deliberative instances of democracy that guarantee equal participation of organized society within and between each level. At the national, state and city levels, the health institutions are governed and managed by a combination of managerial administrators, public policy experts and community health activists. The two key participatory mechanisms are the councils, and the conferences. The councils are the mechanisms of social control and budget approval that assess executive proposals and performance. The conferences are called periodically to discuss various subjects, to convey different interests to a common platform, and to form policy. Historically, state protection of the private sector in Brazil has fostered the privatization of health care in medical practices and the creation of specialist diagnostic and therapeutic clinics, private hospitals and private health insurance companies at the expense of the 75% of the population that does not have private health insurance. Implementation of the national health care system has been complicated by state support for the private sector, the concentration of health resources in more developed regions in the south and southeast, and chronic underfunding. The national health service is tasked with promoting health, health surveillance, vector control and health education, and with ensuring continuity of care to all Brazilians at the primary, specialist and hospital levels. As in many health systems around the world, the Brazilian health system’s challenges include the control of costs, improvement of efficiency, assurance of quality and safety, provision of access to comprehensive care, and better coordination with primary health care. The system needs to be better organized into a regionalized network of services nationwide, with systematic, effective regulatory and referral mechanisms in place that can only be monitored with something like the Office of Epidemiological Accountability, in the next issue. Brazilian Health VSM Twelve Layer Analysis 1.0 VSM1 of conception of Brazil’s health (including voodoo, African, primitive, native, evangelical Christian, Roman Catholic) VSM2 of Brazil’s health: Organized Happy Society VSM3 of Brazil’s health care system resources: Organizing the system VSM4A of Brazil’s unified health system (Sistema Unico de Saude): healthy populations and individuals VSM4B Brazilian Private Health System: Healthy Individuals and Profit VSM5 is in a particular State of Brazil: Sao Paulo: Guarantee Specialists Consultations: VSM State Level Health Care (Sao Paulo): Guarantee access to complex levels of care VSM6 is the municipality’s total health resources: Guarantee Primary Care Full Coverage VSM7 is the health service delivery area of the particular program: AIDS VSM8 is the particular program: AIDS: Universal Access and Empowerment VSM9 is the clinic: Healthy and happy population: VSM Basic Care Clinic (Basic Health Unit): Promote physical, mental and social well-being VSM10 is the Health Family Team: population full coverage: physical, mental, social VSM11 is the interaction with a particular patient. Attached: Stella’s Brazilian Health VSM Twelve Layer Analysis 1.0 & Bolsonaro 2.0 13. Warm Data Nora Bateson: Cold statistical Data versus Warm realistic Data and useful Information The Internet has created exploding complexity. Google transformed the world when it created a mathematical algorithm that could organize all the information in the world, and they are doing a remarkable job of it. The new thing is Big Data, and the race is on to create capacity in the cloud. Those algorithms look like they are able to dominate the world. But Big Data is cold. Too often in public policy, people get lost in the statistics. “Administration is not a numbers game” from Judgment In Administration by Ray E. Brown: “The deification of numbers can cause the administrator to favor those facts that can be measured and to push aside intangibles that may greatly exceed them in importance. She may forget that facts that cannot be quantified are still facts and must be dealt with. Dealing with unquantifiable intangibles is a particular responsibility of the administrator. The concrete and definable tangibles should be acted upon at the organizational level where they first appear if the organization is functioning properly and if the administrator is spending her time appropriately. Serving as the interpreter is not the only concern the administrator has with the ‘indefinables.’ The messages they bring may be the most crucial ones she receives. This is because her most important problems often are an inextricable scramble of value characteristics which defy distinct definition and discrete analysis. The sort of problems that are amenable to logic and yield to the rule of methods seldom possess great consequence for the administrator. It is the problems of people that are likely to affect the enterprise most significantly. These are problems that most stubbornly resist logical reduction because they are so interwoven with the nonlogical values of individuals. It is the things which defy accurate description that should have first claim on the time and interest of the administrator. The things which can be reduced to machine language rarely represent a problem in organizational linguistics. The ultimate concern of the administrator is with human action, and the particulars which affect human action often depend for their influence more on the way they are joined than on the way they are separated. The precision of the line by which the administrator can measure the meaning of each particular in a problem separately is severely restricted. Most particulars of human action become practically meaningless when viewed separately and outside the situation which they jointly constitute. This means that the administrator cannot look only for the particulars in a situation but must also consider their relationships to each other. She must look for the common thread that binds a set of particulars into a specific situation. The administrator acts on a precarious balance and can never expect to accurately comprehend all the possibilities. This does not mean that she should ever rest her case on less than sufficient evidence. It does mean that she must use reasonableness, rather than exactness, as a guide. The administrator can be misled by the illusion of exactness that numbers give. Numbers are actually very ambiguous symbols and most times provide only a glimpse of the reality they are supposed to represent. They are bits and pieces that have been abstracted out of the total reality to simplify it. To be useful to administration, they must be reduced to totals and totals of totals. This means that most of the figures the administrator uses represent averages rather than specifics and are general rather than exact. Because they are reductions of the total reality, they are likely to be anemic representatives of the story they are trying to tell the administrator. Also, in expressing an array as a sum, there is a risk of concealing the most meaningful and consequential elements. The purpose of numbers is to eliminate the individual characteristics of things by standardizing them, and thus numbers have meaning only when they represent a common property. This means that when we utilize numbers, we assume that the uniqueness of things being numbered is not important. Certainly, numbers contribute an invaluable language. The scientist would be helpless without such a language, and the work of the administrator would be both primitive and clumsy. But numbers are not magic. They only represent a narrow, specialized language that permits the administrator to deal concisely with things where ‘number’ can be used to denote a common property. This conciseness can be purchased only at the cost of ignoring the identity of other properties. In many instances such loss of identity of other characteristics of things is not important, and in other instances such loss is justified because of the clumsiness that would result in using everyday language to deal with those things; but in most things with which the administrator is concerned the quantifiable characteristics are least important. The administrator’s job is to determine values, and quantity is only one of the dimensions with which she is concerned. Numbers can efficiently express quantity, but they can seldom ever effectively express worth.” The numbers only reflect some of reality, but are used to define reality, which creates incongruence and chaos. Gregory Bateson saw the universe as patterns that connect. “We do not live in the sort of universe in which simple lineal control is possible. Life is not like that.” “Interesting phenomena occur when two or more rhythmic patterns are combined, and these phenomena illustrate very aptly the enrichment of information that occurs when one description is combined with another.” Gregory’s daughter, Nora Bateson has established the International Bateson Institute in Sweden to study the interactions of complex living systems, at the intersection of ecology, social change, health, economic issues, art and education, what Nora calls “transcontextual.” The key is to look in other ways so that we might find other species of information and new patterns of connection not visible through current methodologies, what Nora calls “Warm Data.” What “Warm Data” means: “Warm Data” is information about the interrelationships that integrate elements of a complex system. It is found in qualitative dynamics and offers another dimension of understanding to what is learned through quantitative data, (cold data). Warm Data will provide leverage in our analysis of other streams of information. The implications for the uses of Warm Data are staggering, and may offer a whole new dimension to the tools of information science we have to work with at present. Why Warm Data is important In order to interface with any complex system without disrupting the circuitry of the interdependencies that give it its integrity we must look at the spread of relationships that make the system robust. Using only analysis of statistical data will offer conclusions that can point to actions that are out of sync with the complexity of the situation. Information without interrelationality is likely to lead us toward actions that are misinformed, thereby creating further destructive patterns. “The more I was thinking about big data the more suspicious I became of having information derived by taking things out of context, and not putting them back into context. So to begin to understand especially living systems and complexity, there is a need for a kind of information that holds the interrelationships and the inter-dependency of all the different aspects that are in process in that complexity or in that system. “We don’t have a word or even a way of being comfortable in deriving information that has to do with that very important relationality. So “Warm Data” became a kind of term to hold space for that idea, that there could be another kind of information that would augment and work with the existing notions of data that are taken by taking things out of context. So we could have decontextualized specific detailed data information, and have another thing, warm data that would give us the information that was about how the system was working, why is it being the way it is being, how it is functioning in its larger set of relationships. These two types of information could be friends; they could be in tandem to each other: we could get all of the statistics on something, and then we could say to someone, and what is the warm data on this? How is it working in its interdependency of other things? “An example might be that you could look at food. You could get the nutritional, quantitative, measureable, repeatable idea about the food on your plate. But that doesn’t actually tell you the other information, which is what are the relationships in which this food has come to be. Is it cultural? Is it economic? Is it political? Are there family, intergenerational relationships? Biological? How is it in relationship to your micro-biome? There is a lot of other information that actually matters. And that information is a different kind of animal. It doesn’t give you the same cold hard facts; what it gives you is context. And sometimes, it gives you multiple contexts. “Warm Data is important, I think in this era, to explore. I think, by no means, are we done figuring out what warm data is. Or how to use it. Or what it looks like. Or how to make it. But to begin with just to recognize that this is a realm of information that matters, especially when we are dealing with complexity, when we are trying to deal with things that we call “wicked problems.” Having specified silo-ed decontextualized information is not enough. It is good, but it is not enough.” What does it mean to live in inter-dependency? “Complex living systems are by nature inter-dependent. They are required for their vitality to engage in interrelational communicational interaction. However our way of studying the world has been largely to take things out of context. Research has been developed since the 1600s as a way to pull things out of context, studying them in their detail and getting wonderful knowledge about them. The problem is that we didn’t put them back. We don’t have an understanding, really, of even how to develop information that is relational information about how inter- dependency really, how vitality is really created. Without that information about vitality, we are not able to understand the complexity of our world. “Who are we, now? We can look back and justify all the things that were done and all the knowledge that has been produced. But until we ask who we are NOW, our very identities will keep us reflecting backward and not forward. Now, we are in another position. Now, the inter- dependency that exists not only inter-culturally but between species, and inter-generationally. “My father, Gregory Bateson, was focused on this question of relationality. He was able to see life in its detail and in its contextual relationships. I grew up in a household in which the currency of our world was not who was right or who had authority but what was it possible to learn. “In inter-generational mutual learning, adults and children are capable of learning together. My father would go out of his way to say things during the day like, I used to think things were like this but now I see some things that are different; he would verbalize his capacity to recognize his own mistakes, his own oversights and show me what he had learned. “When he did this, I learned three things: - I learned what he was learning, whatever it was. Whether it was from the fish tank or the weather, or scientists that were visiting, or something that I had said, or observed. I learned what he was learning. - I also was learning to learn, second-order learning. I was learning that learning is something that is important. - And I learned something that I think it is important for us for these coming days which is the meta-question: I learned that it is possible to have an environment in which there is inter- generational learning mutually taking place all the time. His authority was not premised on his right-ness – his authority was premised upon his ability to learn with me. My respect for my father was not given because he was right; it was given because there was a capacity for authenticity and the ability to respond in new ways; to recognize that we were in this together. “The future is in the relationship between generations. It is in what the older generations can learn and the space that we can make – for new ways of perceiving, new ways of responding to the ecology that we live within. “We need to create a context for the contexts. Education has got to provide another place in which we can have inquiry and exploration, discovery and insights across generations about this thing that frankly we do not understand which is how contextual process takes place. “This is more than interdisciplinary. This requires multiple ways of knowing, multiple perspectives, multiple contextual processes. No living system exists in just one context. Our capacity to respond to complexity is going to require a familiarity with our own complexity. It takes not only intellectual, but all levels of perception, sensorial, emotional, intuitive, artistic. “The education system has been fairly effective piece of the puzzle of the institutions of the world. It has provided an environment in which children and students developed a perception of a world that was divided into silos and ideas, various pieces. If you ask a university to develop a jungle, what will you get? You will get a plant department, a weather department, a reptile department. But what you won’t get is the interdependency. “Up until now, our world has depended on the success of coming generations to perceive and take part in this silo-ed process of thinking, in this epistemology that allowed for these sorts of separations. Our economy is based upon it, our understanding of medicine is based upon it, our understanding of politics, of all sorts of institutional processes. It is like a cookie cutter stamp of the same pattern of thinking. And the education system fed into it beautifully. Now, if we continue to generate this kind of epistemological approach, this kind of thinking, the human species along with thousands of others will die. This cannot continue. “We have created a kind of ecology only it was an ecology of our institutions. That ecology is fatefully out of synch with the ecology of the biosphere. With the ecology of the changing biosphere. That will require a changing, flexible process of inter-generational, inter-cultural inquiry, to better understand, and to better respond to.” Nora’s sister, Mary Catherine Bateson talked about “How to be a Systems Thinker,” and explored the latest developments in Artificial Intelligence: “Until fairly recently, computers could not be said to learn. To create a machine that learns to think more efficiently was a big challenge. In the same sense, one of the things that I wonder about is how we’ll be able to teach a machine to know what it doesn’t know but that it might need to know in order to address a particular issue productively and insightfully. This is a huge problem for human beings. It takes a while for us to learn to solve problems. And then it takes even longer for us to realize what we don’t know all that we would need to know to solve a particular problem, which obviously involves a lot of complexity. “How do you deal with ignorance? I don’t mean how do you shut ignorance out. Rather, how do you deal with an awareness of what you don’t know, and you don’t know how to know, in dealing with a particular problem. When Gregory Bateson was arguing about human purposes, that was where he got involved in environmentalism. We were doing all sorts of things to the planet we live on without recognizing what the side effects would be and the interactions. Although, at that point we were thinking more about side effects than about interactions between multiple processes. Once you begin to understand the nature of side effects, you ask a different set of questions before you make decisions and projections and analyze what’s going to happen. “One of the most essential elements of human wisdom at its best is humility, knowing that you don’t know everything. There’s a sense in which we haven’t learned how to build humility into our interactions with our devices. The computer doesn’t know what it doesn’t know, and it’s willing to make projections when it hasn’t been provided with everything that would be relevant to those projections. How do we get there? I don’t know. It’s important to be aware of it, to realize that there are limits to what we can do with Artificial Intelligence. It’s great for computation and arithmetic, and it saves huge amounts of labor. It seems to me that it lacks humility, lacks imagination, and lacks humor. It doesn’t mean you can’t bring those things into your interactions with your devices, particularly, in communicating with other human beings. But it does mean that elements of intelligence and wisdom – I like the word wisdom, because it is more multi-dimensional – are going to be lacking. “The tragedy of the cybernetic revolution, which had two phases, the computer science side and the systems theory side, has been the neglect of the systems theory side of it. We chose marketable gadgets in preference to a deeper understanding of the world we live in.” 14. Present-Future: Stafford Beer’s Viable System Model & disseminated regulation in real time: How to Run a Country or a City This issue is the formal introduction to the Viable System Model. Unlike organic chemistry, it will become self-evident and then obvious when you read Stella Lobo, MD’s 14 layer VSM analysis of Brazil in issue #17, and you see how you can apply it all around you. Just because health care is complex doesn’t mean it has to be confusing. The Viable System Model is a portal to a sustainable future; it is for social science what the “cell” is for biology: a structure that allows you to study what is changing: for a system to remain viable, it must be able to adapt to a changing environment. This issue introduces you to the basics of the Viable System Model. The key variables are the organization’s Operations, and its Management, and the Environment that is always changing in unexpected and unpredictable ways. Below is a letter to the Economist three months ago about the power of the VSM, a comparing Stafford with revolutionary scientists, a commentary about Stafford, an analysis of a system using Hierarchy Theory instead of VSM terminology, a decade old article about applying VSM to a medium sized city, some of Stafford Beer’s “How to Run a Country: Disseminated Regulation in Real Time”, and tying it together with the Beer-Li Model: family-neighborhood- village-community-district-region-area-state-nation. Memo to the Davis City Council: the city manager’s annual budget for FY 2020-1 is already mythical, out of date and obsolete. Each meeting you will need a new budget, and then eventually (July 1?) you will have to go to real time. At that point, you will be completely inside the Viable System Model’s version of reality. Table of Contents Google: Jon Walker + Viable System Model Guide Economist January 25, 2020, page 16: Letters: Stafford Beer’s Viable System Model Comparing Stafford Beer: Copernicus, Lavoisier & Darwin: Scientific Revolutionary of Social Organization Stafford Beer, Scientist How to analyze a system Looking at Davis through the Viable System Model From “National Government: disseminated regulation in real time, or ‘How to run a country’” by Stafford Beer Applying these ideas to Economic, Health and Human Services: The Beer-Li Model When you read Stafford, understand that he is generalizing many kinds of social institutions, networks and natural organisms. Part of the problem is these concepts are unfamiliar to you, and require figuring out. Stafford believes you have the freedom to learn to think for yourself. But first, there is no substitute for Jon Walker’s “VSM Guide,” at least the 6-page “quick guide” to familiarize yourself with the relationships of the 5 management systems, so that you can see how communication flows in a dynamic organization. Google: Jon Walker + Viable System Model Guide Economist January 25, 2020, page 16: Letters Stafford Beer’s Viable System Model Your essay on “cybernetic dictatorship” was excellent (“Beware the Borg”, December 21st). However, Chile’s “Project Cybersyn” in the early 1970s was not a design of a command-control economy. It was based on Stafford Beer’s Viable System Model (VSM), which specifies a recursive, hierarchical, distributed and decentralized control system. Each VSM is managed locally and has local autonomy. Factory data were centrally analyzed in Project Cybersyn and the results sent directly back to the factory managers for their consideration. The model explicitly incorporated the market mechanism, which is the environment (directly or indirectly) of each factory. Beer was a passionate advocate for democracy, publishing a book on this titled “Designing Freedom”. He argued that it is possible to have effective and efficient control of economies democratically. The VSM was designed to do just that. Professor Graeme Britton Singapore Comparing Stafford Beer: Copernicus, Lavoisier & Darwin: Scientific Revolutionary of Social Organization A paradigm shift is a transformation in social consciousness based on a body of ideas providing a context to see the world in such a new way that it is a new world. Before Copernicus: God above, Earth below, humans have a special relationship with God. Copernicus: Sun is center of only our little solar system. If God is no longer above, where is human in the grand scheme of things? Before Lavoisier: Science involved reading Aristotle’s definitions of air, earth, fire and water. Lavoisier: named hydrogen and oxygen as distinct gases, presented chemistry based on the oxygen theory of combustion (and respiration and fermentation) into carbon dioxide, introduced the two letter chemistry symbols, introduced balanced chemical equations to explain weight differences, rejected Aristotle’s 4 elements for 33 (of which 31 are still considered elements), published the definitive textbook on Chemistry in 1789 which introduced all of these concepts to the emerging European academic and scientific community. Served as the secretary of the committee which invented the metric system – defining calorie and laying the foundation for the analysis of thermodynamics. Before Darwin: Human is top of the evolutionary chain, created in God’s image. Darwin: Natural Selection leads to species specialization, humans lose preeminence among species, becoming part of nature. Before Stafford Beer: Organizations thought of in terms of static organization charts with hierarchical bureaucracies, many layers of administration, TOP down decision taking, with built- in confusions of communication and control that lead to built-in conflicts. Stafford Beer: All organizations that continue to exist have a part that does something in the world, and a second part that looks at how the environment is changing and what the organization should do in the future. The Viable System Model identifies the necessary and sufficient information flow that an organization needs to adapt to its environment over time; the model can be used to help an existing organization identify areas where communication is breaking down, and design new communication structures to accomplish redefined goals. All workers share access to manager’s daily reports, which are designed in a way that empowers all to participate in debate about what the numbers mean, what the policy options are, and what direction the organization should point new efforts towards. It shifts the focus of organizational power down from “the Boss” to the operations level, with the emphasis of management shifted to being in service to operations. Stafford Beer, Scientist Stafford Beer (1926-2002) was a leading advocate for cybernetics, the theory devised in the 1940s by Norbert Wiener which applied lessons from biology to the management of organizations, and which Beer applied to the management of business. Stafford defined management cybernetics as "the science of effective organization". He was the son of the chief statistician at Lloyd's Register; his younger brother Ian was football coach and then headmaster of Harrow. Stafford went to Whitgift School, but at 17, frustrated with the narrowness of his education, got himself expelled. He went to University College, London, to study Philosophy and Psychology for a year before he was old enough to enlist in the Royal Artillery. He was later commissioned in the Royal Fusiliers, then transferred to the 9th Gurkha Rifles in India, serving as Staff Captain, Intelligence, in the Punjab. My favorite quote in Platform for Change: “It seemed clear to me that cultures could be bridged, and that all worth-while ethics mapped onto each other under some transformation. While retired Indian Army veterans were still lecturing in England about ‘the natives’, and how Muslims, Hindus and Sikhs could not mess together (in case an infidel shadow fell across the cooking pot, and so forth), I was sitting round camp fires with all of them, eating sweetmeats and singing: masjid, mandir aur gurdwara ke khuda ek I hain. Masjid is a mosque, mandir is a Hindu temple, and gurdwara a Sikh temple. This line of the song says that the gods of the three places are one. I always wanted to get the word girja, meaning church, but it did not fit the music.” Back in the UK in 1947, he became an Army psychologist commanding an education center where he undertook operational research into psychopathology and illiteracy. For the third of the British army that was illiterate, he designed a literacy program run by sergeants, beginning with phrases that the soldiers easily recognized, focusing on betting, and everybody wanted to be able to read the words they were already using. Leaving the military, Stafford became the first scientist for the British steel industry. Analyzing a steel mill, Stafford found the design complicated and confused communication. He made a report with hundreds of recommendations; they gave him responsibility to implement the proposed adaptations, and the mill improved 30% the next reporting period. For a system to be viable, it must adapt to a changing natural environment. Every system has its routines. As long as they seem to work, people rely on their regular patterns, what scientists call “heuristics.” The problem with life and human nature is that our heuristics become ruts. We keep doing things the same way even though the world around us has changed. Maybe Stafford’s message is: the future may turn out to be different from past patterns – notice what is actually happening that is different from what you expected. His approach was always challenging, even subversive to conventional decision-making. Radically then, and unfashionably now, he believed in the benefits of a scientific approach, though he railed against reductionism. Unlike other management writers, he saw science as freeing thought and action, not trapping it in narrow procedures and techniques. It was his constant theme that the greatest possible autonomy of action should be maintained at all levels of the organization, not just at the top. As Stafford Beer says in Platform for Change, “When the traffic on the roads finally goes mad, disobeying all the regulations that no longer contain it, I shall be risking my neck in there trying to measure things, trying to make a model of the new situation, devising a cybernetic control system that just might work if the authorities dare to listen.” How to analyze a system From Hierarchy Theory: A Vision, Vocabulary and Epistemology, Valerie Ahl and Tim Allen, 1996: [This is how the Viable System Model by Stafford Beer works without the VSM terminology.] While science and society have not exactly tamed complex systems, there has been undeniable progress. Two main strategies are responsible for these advances: one action-oriented and the other more thoughtful. The first strategy is to reduce complex problems by gaining tight control over behavior. The second solution is to expand the problem domain to include the observer as well as the observed. The approach here is not a frontal assault on the problem directly, using mechanical solutions. Rather it is an analysis of the process of problem-solving so that it can be tailored to the specific situation at hand. Complexity can be made tractable by reducing it to an interaction between empirical levels of observation. Notice that this type of analysis is a very different solution from reducing a multileveled system to a small set of variables, over which tight control is exercised. The goal is not to eliminate multiple levels, but rather to identify their boundaries and infer causal relations between them. Addressing complexity one level at a time breaks the phenomenon into components that are still manageable in terms of memory and information processing. After that analysis, one has a grasp of the levels individually, and can begin to piece them back together into a whole. We should emphasize that putting them back together is not a matter of simple summation, because different levels involve differently scaled subsystems. By being aware of the scale of one's investigation, the student of a complex system can shave off a level from the entirety of a phenomenon. Once each level has been analyzed, then the set of levels may be pieced back together according to their scale and observational criteria. The resulting hierarchy will be a coherent set of explanations that answer a particular question. The levels above give meaning, while the levels below explain by giving the origins of behavior. Looking at Davis through the Viable System Model, Jon Li, Davis Enterprise 2/7/10 [Jon Li is the author of the Reader’s Guide in the 2 nd edition of Stafford Beer’s Platform for Change, 1975, 1994, and states on page 468: “(Jon Li has read Brain of the Firm and The Heart of Enterprise and is still confused by some of VSM.)”] Institutions that run our lives have notoriously poor information flow. We label inefficient and unresponsive organizations "bureaucracy," implying incompetency is the standard. The Viable System Model offers a way to see through some of these organizational complications. VSM was developed in the 1950s in a steel mill in Great Britain by Stafford Beer. The model produces hundreds of recommendations about communications improvements. Three months after it was implemented, the mill had a 30% improvement in productivity. Its applications range from a honey bee hive to 75 percent of the social economy of a nation (which took 12 layers of analysis). For the Davis community, there might be 8 or 9 layers. Basically, the Viable System Model creates a graphic distinction of how an organization communicates and decides. The most obvious conclusion is that most organizations focus on their day to day operations and tend to ignore the need to coordinate the different sections of the organization, neglect communication about how their environment is changing, and disregard how the future might be different than expected. The Viable System Model defines a viable system as an entity that has an ongoing impact in a dynamic environment and maintains its identity as change happens in its environment. (See the Viable System Model diagram.) For the "System in Focus," identify several things it does in the world, each of which is represented in the model by a circle. For each circle, the VSM requires 5 management systems as necessary and sufficient for the circle to maintain its viability: System 1: the day to day operations of the circle; System 2: the ongoing coordination of the circles; System 3: the long range resource bargaining with the larger organization and between the circles ("inside and now"); System 4: exploring the changing environment and anticipating future potentialities ("outside and future"); System 5 is the visionary mediation between 3 (the present) & 4 (the future). The problem is that most organization's management behavior focuses on the 1-2-3 relationship and ignores the 3-4-5 communication. Too often, organizations focus on getting better and better at what they do, and ignore the always-changing environment, often until it is too late. This is called “collapsing the 3-4-5,” and it is the most common reason why businesses fail – they don’t see the need to adapt to a changing environment. The VSM analysis allows one to step outside the box limited to traditional thinking about particular inter-relationships. One of the basic concepts of VSM is recursion: that viable systems are nested in viable systems. What is dynamic at one level of analysis is static at the next level up, and perhaps irrelevant at the next level down. So we can pick and choose within the model what variables should be measured, managed and evaluated at that particular level of organization. Recursion applied: As you look at the diagram, the medium sized boxes are the Systems ONE, THREE, FOUR and FIVE of the "System in Focus". (System TWO is the anti-oscillatory triangle symbol.) Within the circle of the System ONE are two very small circles and small System 1 boxes connected to the larger circle's System ONE box which includes the small circles' 2-3-4-5s, all of which is the next recursion down. And, the medium size boxes THREE-FOUR- FIVE that make up the upper right of the diagram are enclosed in a large box, which is the System 1 for a larger recursion in the environment of which this "System in Focus" is one of the circles. Bottom Line on VSM: -identify 8-12 sensitive indicator limits which are defined -measure the key indicators daily -if they go outside of an acceptable range, they are reported up to the next level -maximize local autonomy To find out more about the Viable System Model, the best introduction is Jon Walker's Guide to the VSM which is available on the web. The goal of using the VSM process is to identify information bottlenecks and repair them in a way that improves decision processes. - Jon Li is a long time Davis resident. From “National Government: disseminated regulation in real time, or ‘How to run a country’” by Stafford Beer Stafford Beer’s Viable System Model. Briefly, every living system has sub-systems which are surviving in a natural environment. The subsystems must be coordinated and their resources balanced, and the system must be able to adapt to a changing environment to be sustainable, over time. Stafford laid out his method in “National Government: disseminated regulation in real time, or ‘How to run a country’”, in The Viable System Model: Interpretations and Applications, edited by Raul Espejo and Roger Harnden, 1989. The real world test of this idea was in 1972-3, in Chile. Stafford was recruited by the economists in Salvador Allende’s administration to apply the Viable System Model to the entire country. Each of the major sectors of the economy was mapped, and their production flows monitored on a daily basis, with the information given to the manager, supervising foremen, and workers, for review and discussion about improvement. During the six week Chilean truck strike, with only 20% of the trucks available, using real time information and just in time scheduling and coordinating, essential resources were successfully distributed to meet basic needs throughout the society. The Viable System Model is designed to identify reality, rather than confirm theory. Introduction: The approach of managerial cybernetics to the regulation of large, complicated, probabilistic systems is based on a number of postulates which apply to the organization of government, to the organization of enterprises that generate the national income, and to the organization of the human communities that constitute the nation itself. All of the systems have a powerful investment in their own identity. Each seeks to define its identity, to maintain it, to flourish out of a commitment to itself and a confidence in its selfhood. Each has an organization whose primary purpose is to preserve identity – in a word, to survive. Survival, moreover, is not a concept of stasis. Identity must change – and be gradually modified – as the world changes (it is called adaptation); otherwise there will be no survival. For example, a democratic government, in order to survive, must renew its political mandate at the polls; a dictatorship must instead restrain the exuberance of the people. Enterprises must make a profit, or they will not survive. Communities must find ways to survive in balancing their books – between local and federal taxes, between remunerated and voluntary effort, between recreation and rip-off. Survival is a function of the total organization of any system that does survive, and includes its capacity to learn, to adapt, to evolve. A system that does all these things is called a viable system. The postulates referred to at the start are the natural ‘laws’ of any viable system. The recursive structure of the Viable System Model: The first demonstration of the VSM is that all viable systems contain viable systems, which are themselves of identical cybernetic organization to the totality and which are largely autonomous. Thus in government, Education for example contains primary, secondary and tertiary components. In Enterprises, the holding company may have largely autonomous operating divisions, and they in turn largely autonomous companies or plants. In the largely autonomous provinces or states of the Nation, there are largely autonomous cities, each having largely autonomous fire and police departments. In VSM parlance, a drawing of a level of an organization shows the relationship between one layer and the next layer down. ‘Down’ itself refers simply to organizational containment: the VSM is not essentially hierarchical, it is essentially an interaction of subsystems. It is for pictorial and not for logical reasons that the VSM draws only one pair of recursions at a time. However, every component and every connection to be found in the total picture stand at 45 degrees to the main axes, as will the connections between each of the subsystems across the two recursions. It is this mathematical property (called isomorphism) that entitles us to talk about ‘laws’ of the viable system. Now if we were to enquire into these three major organizations by asking them for their ‘organization charts’, covering every level of recursion, we should find that we had hundreds of charts, each as idiosyncratic as the ‘family tree’ of some noble lineage. Such presentations are without coherence. Any one chart of any one large organization, if reproduced entire, would cover the whole side of the multi-story edifice housing the enterprise, and no one would be able to review its viability. But if all such charts are mapped on to the standard model – the VSM – this becomes possible, severally, and also in interlocking recursions. The practical approach: The mapping of actual organizations on to the VSM is a matter both of cybernetic technique and of profound knowledge about the particular organization under study. Thus any given investigatory team must meld together cyberneticians with local people. Consider now a practical example of what would happen. The constitutional regulatory system of the Nation is Recursion One. This includes (Recursion Two) ministerial government, communities, and the wealth-producing industries, public and private. Select industries, which includes (Recursion Three) Water Supply, Energy, etc. Recursion Four of Energy includes the viable systems of Oil, Gas, Electricity, etc. A VSM team will need to map each of these industries on to the VSM, and in doing so to visit each of the component companies or plants of each: that will be to map at Recursion Five. The level of complexity may sound alarming. It is not. In the first place, the multiplicity of basic activities encountered across the country have to be managed in any case, and have to be incorporated into the governmental perception of the national weal in any case. The cybernetic approach is already making matters easier in two ways. First, by using the same model, the same regulatory language, and the same information technology across the board, it becomes easier to synthesize a view of what is really happening throughout the nation. Second, because the recursions are richly interconnected, inside each other, models of the higher-order recursion can rapidly be integrated once the basic systems have been mapped. In managerial cybernetics, the VSM is passing to-and-fro among the encapsulating recursions not merely numbers, but Gestalten – whole and integrated patterns – of viability. With conventional organization chart thinking, people ‘higher up’ take plenty of credit, because they are ‘organizing’ things. Plenty of costly effort is put into massaging the basic data so that this ‘organizing’ of things is manifestly justified. All of this glossy activity creates the illusion that each level produces. Of course it does not. What it does, if it is effective, is to generate a measure of added-value, deriving from the informational energy of synoptic vision. Even then, things are fine only so long as the basic operations do well; see what happens when they fail or fall short of expectation. The illusion is proven to be such because only credit and not discredit is equally shared. The integration of a set of recursions of VSMs will not underwrite the illusion. It creates the interlocking model fast, as a corporate whole. Now the output of the teams is twofold. In the first place, we expect a VSM-like version of the organization at each level of recursion. And if that organization has weaknesses (and which organization has not?) we expect that the modeling process will generate a succinct list of them. Because the VSM sets out to give a necessary and sufficient account of the laws of any viable system, it is a tool of intense diagnostic power. (Note: if the VSM language is used loosely and merely descriptively, then of course its power is lost.) So we expect some prescriptive suggestions too. After all, the management is itself implicated in these studies – and so are the workforce representatives whose members will doubtless bear the brunt of any substantive operational change. The second output from the teams’ work is a set of quantified flow charts (QFC). These are iconic representations of the wealth-producing or results-generating parts of each organization. The mapping of the organizations on to the VSM retains all the necessary complexity of viability with all the possible simplicity of topological mathematics. The QFC in turn offers necessary complexity in operational realities, depicted by a uniform, iconic set of conventions. And the key conclusions of the QFC work are the agreements that the whole team reaches as to which major flows and which potential bottlenecks shall be monitored. There are usually about ten to twenty of them at each level of recursion, although some may not be simple measurements but more elaborate ones. We readily perceive relative size, relative slope, relative color, and relative movement, whereas tabulations have to be disentangled from their level of arithmetical abstraction into these forms. The cybernetic approach offers to do that for the brain in advance, by automating the tabulations into iconics – or at least animations. Evaluating Well-Being: [warning: this section introduces two new words to your vocabulary.] To this point we have been considering how to structure (by VSM) and how to measure (by QFC) the wealth-producing or result-producing components of the Nation – which in VSM parlance is called System One. Systems Two and Three are concerned entirely with the regulation of balancing a competing group of System Ones. Let us turn to System Four, which handles the interaction of the whole viable system (that is the Nation in this case) with the outside world. Of course, System One deals piecemeal with its own set of environments, as a matter of local adaptation; but System Four acts for the nation as a whole. For instance, the Minister of Education is part of System One, whereas the Foreign Minister is part of System Four. But System Four is especially concerned with an environment that includes the future of its own people. Each component of System One is involved with the home milieu; but overall responsibility for the people’s future is a regulatory function shared between the people themselves and the government agencies that act for them. The problem is how to measure people-satisfaction. What is the QFC for ‘well-being’, which Aristotle called EUDEMONY. The proposed solution is simple, if not simplistic. If people do not always know why they are feeling happy or sad, they do know that they are so. Fact is, they are doing computations on components and subjective categories with nonlinear metrics inside themselves, and they do not have conscious access either to the internalized model or to the weighting system or to the process. Let the respondent do the heavy scientific work for us. An algedonic measure (from algos=pain, hedos=pleasure) offers no analysis of the eudemonic condition, but only measures it: - Respondents are offered a task so straightforward that it is not threatening. - They are very deliberately told that they will not be asked to explain their setting; the setting itself is the end of the encounter. - The measurement system is analogue, and therefore does not pose difficult distinctions: it calls on a ‘right brain’, intuitive response. - Nonetheless, it generates a 100-point two-digit index on the reverse side. - It uses vernacular language, rather than an artificial or academic one – as direct a reading as can be gotten. Respondents are shown a card with an orange circle in the middle, and they can adjust the circle into a pie shape that is blue; the orange represents happy, and the blue shape represents miserable, and the respondent adjusts the pie shape to reflect how they feel on a happy/miserable continuum. What is the use of this measure, if it is not susceptible to analysis? It is intended to: - To discriminate between sex, age, region, education and social class – which are accepted as objective demographic categories. If all the young people are happy, and only the departing are miserable, we are doing well – unless it is a ‘seasonal effect’ of ageing. We shall eventually find that out: possibly a major discovery. Or if twice as many educated are miserable as compared with the less educated, what then? - To observe trends and to correlate them with managerial options. - To detect incipient instability in the sense of any population’s self-image of well-being: a vital potential input, hitherto created, monitored, and reinforced by the media rather than by the people themselves. The quantified flow chart that the sum of the responses generates is broken down at the next level of recursion by the demographic categories used. Measurement in real time: It is a crucial question as to how frequently these measurements (QFC) should be made. In the inherited system they are made on an epochal basis: each month, quarter, year. It is central to the cybernetic thesis here advanced that they ought to be measured continuously. Then the advocacy turns out to say: measure daily. For although a day is itself an epoch, it is sufficiently small as to generate time series that approximate a continuum. We are effectively in real time. Critics often argue that government does not need such rapid information input, and if it had such a thing it would over-react. The first complaint is basically a statement of stereotype: ‘everyone knows’ that such instant input is not needed because no-one has it, nor can they see how to get it – officially, bureaucratically, that is. On the other hand, everyone knows (without quotation marks) that government is driven, as before a storm, by instant information channeled through the mass media, and often generated by them. This makes nonsense of authenticity. The official bureaucratic information system spends its effort in trying to keep pace, to justify its masters, to excuse the mistakes that may not even have been made. The situation is chaotic. The complaint as to likely over-reaction is merely risible in this context. A properly designed cybernetic system does not over-react, because it has properly calculated feedback functions that smooth irregularities and impose delays that are systematically appropriate. The present instant-response system, which has not been properly designed (nor designed at all), is as over-reactive as could possibly be. What is the true case for real-time management? Consider the monthly epoch. Managers are proud if they have last month’s figures by the second Tuesday of this month. It is far too late to do anything about any of that, except to learn. We learn from our mistakes, and resolve to avoid those particular errors in the future. We learn from our successes, too. But nothing has actually changed. If, however, we operate today on yesterday’s figures (approximating today’s, and close to real time), the situation is quite different. It remains the case that we cannot change what happened yesterday. But what we can learn concerns something: recognition of incipient instability. If what happened yesterday, and is probably happening still now, is not so much a triumph or a disaster but a rocking-of-the-boat, and if we can detect that at once, then we may be able to restore the equilibrium. The disaster may never happen. The success may be assured. We can now turn to a concept of management that has the power to manage, that is to say, it may do something now so that the future will be different from the future that would otherwise have been. This is the definition of planning, which is not a matter of toying with scenarios (a support function) but of taking decisions – so that the future may be different. It is easy to see how this holds for the future that ought one day to be, which is the topic of normative planning. It really holds too for the future that could be (if we work hard) fairly soon, whose topic is strategic planning. But the future that will be almost immediately, which is supposedly the subject of tactical planning, is foisted upon us – because our information is so lagged. This ‘future’ has already happened by the time that its likelihood is signaled, simply because the signal itself is still getting through the works. We may ‘return’ to the power to manage in the short-term: ‘return” is proposed because it was once possible to observe activities under command, dislike the outcomes, and issue new orders instantly. In this way, managers quelled incipient instabilities. The inability to do this today is an artifact of our immensely cluttered, bureaucratic and inept systems – computerized though they may be. Consider the absurdity of a government’s employing an army of econometricians in order to forecast (from lagged data) where we already are. It is what happens. And because the forecasts are often wrong, we decide our plans as proceeding from an initial position that we never occupied in the first place. The point of collecting all the data points daily from the QFCs, and channeling them into a steady data stream, is to be instantly aware of a structured reality. The data stream has to be revitalized within that data structure – provided by the logic of the VSMs and the QFCs. That logic is stored in a computer, together with data reference points for every indicator measured. These data points were established when the trans-disciplinary teams agreed their original findings. For each point identified and measured, the teams established a normative (should be) and a strategic (could be) target. What the tactical result (will be) actually is arrives virtually as it occurs. Comparisons of these actual results with the stored expectations at each level of planning provides a set of three indices for each arriving data point. Each is expressed as a two-digit number. The task now is to detect incipient instability in the data streams, and this is the task of Cyberfilter, a computer software package. As to its criterion of instability, it is not merely picking out exceptions to the norm, and not only measuring variances from means, these being traditional accountancy practices. Cyberfilter has the criterion of discovering instabilities that have importance to the manager, in terms of the possibilities of corrective action before any damage is done. Take one index, newly calculated, and set it into its own time series. The program uses a technique to estimate four probabilities. How likely is it that this point is merely a chance variation? How likely is it to be a transient bit of noise in the system? How likely is it to be contributing to a change of slope? And how likely is it to represent a step function? Chance variations or transients are of no importance to a manager, and s/he is not told about them. But if a slope change or a step change seems likely, then this may signify incipient instability. It goes straight to the manager’s desktop computer screen. Because of the rules of local autonomy built into the VSM, no-one but the responsible manager has access to this message. If the trend is not corrected within the agreed time, an algedonic signal goes to the next recursion upward. After appropriate delay, it is passed on to the next level, until matters are in order. Applying these ideas to Economic, Health and Human Services: The Beer-Li Model The Beer-Li model is designed to help the mother support all of her child’s potential needs. The model identifies all of our human needs, to build a personal map to of the local economy, to help figure out how to meet those needs. Beer-Li Model: a computer information idea for creating a global grassroots economy. Basically it is a dynamic information catalogue for all the parts of a woman's life: income, food, housing, health care, transportation, clothing, education, media, entertainment, taxes, managing the economy, public services, infrastructure, utilities. That information matrix has components that scale up physically/geographically: family, 10; neighborhood, 100; village, 1,000; community, 10,000; district, 100,000; and region, 1,000,000. In each cell within the map, you create a Quantified Flow Chart of all the factors that matter. Within each sector of the model, for example, “Health: Family” would have all the information you have on the health of each person in your family, what matters, who to call, instructions for when the usual things go wrong, stuff that you only need in emergencies; “Health: Neighborhood” might have who in your neighborhood you rely on when things are challenging, neighborhood stores, and any particular health professionals; “Health: Village” would have a similar package of information. The bulk of the analysis is in “Health: Community”: a dynamic picture of the resources, how they fit together, (what is missing), and how to access resources, what to do in an emergency, or in time of need. And how the pieces all fit together for the individual patient. At “Health: District” is the range of medical resources that the community depends on, including hospitals, board and care facilities, and tertiary care. At “Health: Region” is the medical school, and other special support services that require specialty services. Each level has a station for the Office of Epidemiological Accountability, to maintain the information about the health of the community and its environment, and the institutional responses to the need for service. Just because health care is complex doesn’t mean it has to be confusing. The XXth Century was a bloated centralized economy with a great deal of waste in the name of competition. This is designed to be decentralized by encouraging and supporting local autonomy and accountability at every level, conserve energy, improve social interaction (even with social distancing) and enhance community. 15. U.S. Universal Care: Health and Social Services Budget 2021-2 through 2024-5 (in billions, 2019 US $) Health Care Policy Making Decisions In the XXth Century, MONEY defined everything, to the harm of people and the environment. Now, the Health Care Delivery System needs an allocation mechanism that balances economy, ecology and equity, towards a healthier society. Decision Tree for Health Policy Each defined Community of up to 10,000 people receives a Federal annual allocation per capita equivalent of $25 million for 10,000 people. This should be far more than most communities need to financially support a robust clinic-based comprehensive program that meets all of the needs of the population served. Currently, the top most costly 1 percent of people in the US account for 21% of total national health spending, the top 5% account for 51%, while the least costly 50% account for only 3% of the total cost of the health care delivery system. Hospitals and Medical Schools are governed by Clinics working together in a Memorandum of Understanding (MOU), with each involved clinic having one vote and an annual federal allocation. Emphasis on long range planning of the health professions to build and improve the health care delivery system. UCSF and UCD Medical Schools would have Clinics from all over the world in their MOU. Revenue 2021-22: for the 3/4ths of the adult population who file income tax, 10% income tax should cover health care. (It is 17.8% now.) For the lower 90% of the taxpaying public, compared to Obamacare, there will be a significant reduction in annual total cost for much more accessible and available services, and better health outcomes. That is what happened in Europe, Canada and Taiwan when they converted from insurance to universal care. Expenditure Health Care & Long Term Total Net Savings Social Services Services & for Taxpayers Support Current System 2020-21 $4,000 $500 $4,500 $0 Universal Care 2021-22 $2,500 $1,500 $4,000 $500 2022-23 $2,000 $1,700 $3,700 $800 2023-24 $1,800*$1,800 $3,600 $900 2024-25 $1,800 $1,800 $3,600 $0 Beginning in 2021-22, of the funds for Health Care & Social Services, 50% goes to Clinics, and 50% goes to Hospitals and Medical Schools; 5% of the total budget (10% of the hospital budget) is for the 5% of the population who live in rural/low density areas where the expense of care minimizes economies of scale. *2023-24: Medical School funding stays the same; Hospitals take $200 billion in cuts 2021-22 U.S. H&HS Community Clinic Budget $1,250 billion 40,000 Community Clinics at $25 million@ =$1,000 billion for annual operating costs. $150 billion innovative community program $100 billion remodel existing or available or new facilities 2021-2022 U.S. H&HS Medical School and Hospital Budget $1,250 billion Half Medical School, Half Hospital For the past century, these two institutions have been at the top, calling the shots, defining the tune everybody else must dance to. From now on, the med schools and the hospitals are totally dependent on the community clinics in their territory of responsibility. Not just accountable to the community clinics, controlled by the needs defined by the community clinics, and financed accordingly. Each med school and each hospital has an annual Memorandum of Understanding defining its relationship with the communities it is responsible to. Hospitals and Medical Schools are owned by the local community clinics, by new federal law. Many hospitals will be shut down, replaced with community clinic services with extensive outreach into the community’s identified populations at risk, with improved health outcomes because hospitals generate illness. Specialty medicine is paid for out of the Hospital global budget. Major reductions in surgeries that were previously motivated by the fee-for-service reward system, and the reduced attendant days recovering in the hospital. At least a $1trillion reduction in costs to the health system by preventing unnecessary surgeries. Total U.S. annual hospital expense reduced by 50%. Similar reduction in pharmaceutical usage and total cost. Shift from medicine to health care. New U.S. Department of Health and Human Services Administrative Team Structure County welfare and social services departments will be replaced by services provided as part of the clinic, for an administrative savings of 50%. Behavioral health services will be provided as part of the basic package for everyone. The shift to universal care requires a complete dismantling of the federal micromanagement in the health care delivery system. All of the data in universal care will be generated at the clinic/community level. Therefore, the Administrative Team of “Reporters” at each of the stations for Health & Human Services at the clinic/community, city, Health Service Area, state, and federal station levels has seven, and only seven, positions: 2 Health, 2 Behavioral Health, 2 Social Services, 1 Team Leader-Servant. Reporters’ responsibilities include: on site witnessing, data collection, and theoretical analysis of what is really going on in the community, and how the clinic is not adequately responding to the changes happening in the community. The Viable System Model is useful for these particular tasks. Google Jon Walker + VSM Guide. For the current federal and state Health & Human Services bureaucrats (Full Time Equivalent: 80,000 bureaucrats) have the choice to be retrained as “Reporters” in the Office of Epidemiological Accountability station in some clinic/community, city, HSA, or state seven member team, or they can be retrained to work in another field besides Health & Human Services, or if they are 60 or older, they can retire with a generous retirement package. The current H&HS federal/state bureaucracy seems completely out of control; this eliminates the bureaucracy and its irresponsible behavior. All of the action is at the clinic/community/city levels: Current Federal H&HS Full Time Equivalent: 80,000 people 2022-23 Federal H&HS Full Time Equivalent: less than 1,000 people Part 9: The Political Strategy and Timeline for Implementation The Political Strategy “Ultimately, organized health care will only happen in the U.S. when doctors are willing to help by working with consumer groups. The key is to network the families of the U.S. to demand restructuring of the entire health care non-system. ‘Grassroots community organizing would be necessary to win any political campaign to establish such a system. The community organizing would develop a base for the community participation necessary to implement this system. While the medical and corporate establishment are split on their support of reform based on their own conflicting interests, to the users of the health care system it is a life or death issue.’” (Systemic Trauma: The Troubled Prospects for Managed Care in California and the United States, 1996) Implementation Timeline June through December, 2020 1. Organizing for US Universal Health Care at the Congressional District level up to the Democratic Party National Convention, Milwaukee, August 17: Each Congressional, State upper house, State lower house: begin a weekly seed group of “Supporters for US Universal Health Care”; initially, a small group can meet as the Congressional team, then the upper house team, then the lower house team; in a meeting, you can initiate 3 different groups that will become independent and a little bit competitive about having the best information about the same territory. The groups have the common purpose of creating self-supporting communities with good health services. Organize a District Health Network: map the health resources serving the district, identify SWOT (strengths, weaknesses, opportunities, threats), identify unmet needs, identify key people who keep the health services going (nurses, case managers, secretaries); create a preliminary map of “Communities of 10,000 people” in every city in the Congressional District and the rural areas. Goal is to establish “Universal Health Care Action Groups” in each community; they will become the core group of the citizens who eventually are the leadership of this community’s health and social services delivery system. “US Universal Health VSM Map Bottom Up”: build a set of VSM maps of all of the health resources used by people in the communities of each city in the Congressional district. 2. County and City levels: July: Congressional committee establishes contact with members of the County Board of Supervisors, the County Administrators Office, and the County Health Department and Public Health Officer about re-establishing the regional Health System Area Agency to coordinate local health resources and services. See PL 93-641: U.S. had 204 Health System Areas (HSAs), California had 14, which need to be reborn. September: make formal presentations on US Universal Health Care to the County Board of Supervisors and City Councils at every meeting, during public comment. October: each community Health Care Action Group has a preliminary map of all the health resources available to members of that community; Congressional District Universal Health Action Group makes scheduled formal presentation to the County Board of Supervisors, and then each of the City Councils, for this particular county to link all the health resources (which the Congressional, Senate and Assembly US Universal Health Committees have been mapping) as the first stage in building a local unified health care delivery system. Mid-November: Supporters for US Universal Health Care committee presentation to the Board of Supervisors and each City Council on how the Health System Agency works, how the universal health care campaign is unfolding, and how people can get involved at the different levels. 4. Make universal health care the #1 issue of the national election campaign at every level (statewide offices, congress, state senate, assembly, county board of supervisor, city council, school district); pressure Biden to commit to implement single payer “even better than Bernie”; have local unified “Biden/Democrat/Universal Health Care” be the heart unifying the Democratic Party’s campaign. 5. GOP Convention Week, August 24-27 Massive national organizing locally for “Supporters for US Universal Health Care” 6. In each city and the rural areas, designate local “communities” of 10,000 people. This model was designed for western Oakland in the San Francisco bay area, so it is intended to be part of an urban area. Organizers in each city should establish preliminary boundaries for each “community.” In a year, those boundaries need to be legal for the management of the clinic services within the community, and focus on the 133 daily accountability measures identified by the Office of Epidemiological Accountability. 7. Democrats win the White House, the Senate (54-46) and the House (300-135) in November; President-elect Biden thanks the grassroots Universal Health Care campaign for unifying the country. Even President Trump belatedly endorses Universal Health Care. January through June, 2021 National: Administration: Executive Order establishes Office of Epidemiological Accountability, using the Viable System Model by Stafford Beer; U.S. Department of Health and Human Services: Set up Office of Epidemiological Accountability at the H&HS Department Deputy Secretary level; Each office in the entire H&HS designate a “Reporter” to be the seed for the new Office of Epidemiological Accountability; the boss in the budget shop is disqualified by definition. Beginning January 21, weekly H&HS nationwide aggregate reports by the local Office of Epidemiological Accountability “Health Information Systems Operations Team”, consolidating the work of each individual in the office February: “US Universal Health VSM Map Top Down”: VSM map of the policy areas of each individual’s area of policy responsibility (80,000 H&HS FTE employees), and aggregate the information into one set of VSM maps – 25 to 40 maps March: Design VSM consolidation of all of the policy maps in each Federal Region, and in each State: 25 to 40 maps, will become 10 and then maybe 6 or 7 that better represent the country and its social needs. April: Create a new master VSM information structure: “National US H&HS VSM System 4”: national-region-state-HSA-city-community/clinic: uniting all H&HS information and policy areas at the community clinic level, limiting bureaucracy at the national-region-state-HSA-city levels. May: implement new structure, eliminating the need for 90% of the H&HS bureaucracy except at the community/clinic level. ALL of the complications are at the community clinic level: at the national-region-state-HSA-city-community levels, it is only the Office of Epidemiological Accountability. Everything is evaluated in terms of community clinic effectiveness in providing primary care and improving health outcomes. June: Daily Program Evaluation and Improvement for Implementation July 1. Congress: January: Khanna HR 5010: State-based Universal Health Care Act is re-introduced, approved in the House and the Senate, and signed by President Biden by the end of January, allows states to apply for a waiver to establish universal care, enabling states to prepare waivers which are expected to go into effect July 1. HR 5010 includes provisions for states to re-establish Health System Area Agencies (HSAs) and establish state H&HS 7 member Office of Epidemiological Accountability “Health Information Systems Operations Team” management structure. Jayapal in the House, and Sanders and Warren in the Senate: Universal Care: Re-introduce this year’s HR 1384 (Jayapal) and S 1129 (Sanders): By the end of February, come out of House Education and Labor, Energy and Commerce Subcommittee on Health, Oversite and Reform, and Ways and Means. March: Debate US Universal Health Care in the House, 350-75. April: Debate US Universal Health Care in the Senate, 75-25. May 1: President Biden signs the Jayapal-Sanders US Universal Health Care Act of 2021. May 10: Governors of each of 50 states sign legislation implementing the waiver plan in HR 5010; red states have well-organized campaigns in every congressional district May 31: Each State H&HS submits a waiver plan to implement US Universal Health Care July 1 June 1: 50 State waivers approved by U.S. H&HS State: February: each state H&HS Agency moves key personnel into new H&HS 7 member Office of Epidemiological Accountability “Health Information Systems Operations Team” management structure, to be fully functional July 1, with everyone else in the agency transitioning into community and clinic health administration. 14 HSAs and their Counties and Cities: February: under HR 5010 Khanna, each state establishes a process to implement the HSA, city, community/clinic process through current county government. March: Every County appoints some provider and consumer representatives to the regional Health System Area Agency, making sure the 32 member Body has representation from all the geographic areas within the HSA territory. April: Each HSA Body meets, picks a 5 member Board, and establishes how each city in the HSA creates communities of 10,000 people to manage health and social services effective July 1. May: HSAs publish maps of the community boundaries to be used effective July 1. Each community has a meeting, largely organized by the community leaders within the Congressional District who have been working on setting this up since last summer. June: People start talking about how the health system can be improved in this community. Universal Health Care Software Package 1.0 The purpose of the information software package is to support the Office of Epidemiological Accountability. Its functions include: personal growth for the patient, the clinicians and the support staff; effective communication; social support; information about management information; resource optimization; and, program evaluation. July-December 2020 Health Funding Information Management Structure: based on H&HS 7 member Office of Epidemiological Accountability “Health Information Systems Operations Team”: July: Parameters Design Committee: criteria for US Universal Health Care guidance and control at each station level: community/clinic, city, HSA, state and national August: Announce RFP October: Select 3 possible software package options December: Choose 1 January-June, 2021 January: 1st prototype February: Statewide skeleton March: Full implementation May: smoothly running operations whole month statewide June 1: error free in all 50 states: operational in every clinic, provider and hospital nationally July 1: daily reporting, evaluation and reassessments – managing in the real time present future. July-December, 2021 Ongoing operations: The master information system allows complete access for the patient up to the communitywide level. However, city, HSA, State and National can only access aggregate community data. Daily reports of patient activity, levels of care, money, problems and challenges. Hospitals 2021-2022: under new federal law, all hospitals are operating under the control of the community clinics in the territory that makes up the hospital’s catchment area; with clinics meeting real needs that lower the demand for more extreme medical interventions, half the urban hospitals are closed, with a cost report closing their books by the end of June, 2022. Hospitals focus much more on high levels of care, and then moving people back into the community under clinic care. Financial Distribution Component in the new system, effective July 1, 2021 Health Provider: provides a service or fulfills a contractual expectation, submits a report, a bill is paid; 30 day review for adjustments; someone with 5 adjustments is a problem to be investigated. Wind Down US Fee-for-Service Health Insurance Industry July-December, 2020 US Health Insurance Industry spends $1 billion opposing US Universal Health Care, especially in US Senate races, losing every major race: Arizona, Martha McSally; Colorado, Cory Gardner; Georgia, Kelly Loeffler; Iowa, Joni Ernst; Maine, Susan Collins; Montana, Steve Daines; North Carolina, Thom Tillis; and the three that make all the difference in the world: Alabama, Doug Jones wins; South Carolina, Lindsey Graham and the biggest symbol of them all, Kentucky, Mitch McConnell: Senate: 54 D, 46 R House: 300 D, 135 R January-June, 2021 600,000 private health insurance employees looking at Universal Health Care: - 200,000 aged 60-65: offered generous lump sum buyout and generous retirement package; - 200,000: enter 3-month retraining program to become Reporter at the clinic, community or city level, 7 member Office of Epidemiological Accountability “Health Information Systems Operations Team” - 200,000: six month structured process to wind down health insurance industry: January-March: begin phase out of all services effective July 1. April-May: ready for complete shutdown US health insurance industry July 1. June: spend the month practicing shut down, July-December, 2021 July 1: no more US Health Insurance Industry services. All questions referred to the Universal Health Authority. All new costs for health services responsibility of local global budgets July-September: Wind down all pending cases: Court of Health Insurance Settlements: binding arbitration: 4 hours to present case, challenge and ruling; no appeal. October-December: Shut down all US businesses related to health insurance industry before December 31. These final 200,000 then get one year retraining transition program (to December 2022) in fields outside of health care. Effective July 1, the national Medicare and Medicaid Funding System will be replaced by the “Universal Health Authority,” which will have a funding channel as part of the daily information linkage: national-state-HSA-city-community/clinic, so that funding is the simplest part of the entire information system. Phase Up US Universal Health Authority: Local Global Budget There are three categories of interest: 1) communities that currently home a Federally Qualified Health Clinic (FQHC), 2) communities served by a FQHC which need to develop their own resources and 3) everywhere else. There are currently 1362 Community Health Centers in the U.S., which means we need 13,638 or so more community clinics. 1) communities of up to 10,000 people that currently home a Federally Qualified Health Clinic (FQHC): currently, FQHCs serve the low income portion of a population of several hundred thousand people. The more affluent receive care from hospitals and specialty practice physicians paid for through their insurance. As much as half of the population have little or no contact with the health care system in recent memory; most men presume that they do not have any health problems, until it is so bad that they need to be hospitalized. Transition to Universal Care: July 1, 2021, either by registration on line, or at any health service provider within the community, every patient is registered in the state’s Universal Health Services System: name, unique number identifier, the beginning of the new health audit trail. Cost information is important for management, but has no direct influence on patient care decisions. Clinic Outreach Team: makes initial contact with as many people within the clinic territory of responsibility as possible, to include them in the ongoing database (or not, if they refuse), and encourage them to come to the clinic for a health assessment every six months. Current Health Resources within the Community Territory: many health resources are going to shift as people start using the clinic more as the coordination for the primary care; free-standing private health practices will become linked with the community clinic, and effective July 1 will be responsible to the 2) communities that are adjacent to a FQHC clinic and 3) everywhere else: currently people with health insurance expect to receive health care from hospitals and independent medical specialist physicians, even though better care is provided more effectively in a clinic setting (for all kinds of reasons). January-June, 2021 During the next six months, this community is going to figure out how the local health services should evolve to meet this community’s needs. Part of that will be to establish an Interim Clinic, to meet the currently under-met needs for primary care in this community. Frankly, every community has under-met needs for primary care. Under the Universal Health Care law, effective July 1, 2021, each HSA will supervise each city creating preliminary boundaries for communities of up to 10,000 people. During the month of September, cities will hold community elections to pick 7 people to serve 2 years on the “Community Health Board”. The Board will have full authority for the $50 million annual Clinic allocation to that community for the delivery of services. In addition, the Board will have one vote on the multi-community Memorandum of Understanding (MOU) governing the annual allocation for medical schools and hospitals serving their community. By July 1, most specialty physicians will be working through a clinic for a salary. July through December 2021 July 1: Begin Universal Coverage - Conversion at the Patient/Taxpayer level from insurance to new payment structure - Conversion for the individual provider; provision for qualified provider groups up to Kaiser to retain their identity - Conversion for the hospitals: all hospitals come under the jurisdiction and control of the community clinics grouped with federal legal Memoranda of Understanding (MOU) - Conversion for the Health Insurance industry: employees aged 60 and older receive a generous retirement package; retraining for all other insurance employees into epidemiological accountability, or transitioning into another line of work - Establish H&HS 7 member Office of Epidemiological Accountability “Health Information Systems Operations Team” with guidance and control at each station level: community/clinic, city, HSA, state and national - Daily accountability of the entire system. System Mission: optimize primary care system wide in every state in the U.S. V. The Global Economic Problems 16. German Mark Stabilizes the World January 1, 2021: G-Curve: Trump Monthly Hockey Sticks; Biden Election; CCP Dissolves into history 11/15/22; Green New Deal save the World Table of Contents Part I: Novel Coronavirus How the World has Changed There is no going back to the XXth Century The Difference between the XXth Century and the XXIst Century: Life this October United States as the Roman Empire, 400 A.D. Timeline for Trump’s Crash: a Hockey Stick crashing down each Month: May: Trump Hockey Stick Stage 1: Official Unemployment 14.7% (estimated at 20%) June: Trump Hockey Stick Stage 2: Official Unemployment 25% (estimated at 30%) July : Trump Hockey Stick Stage 3: Official Unemployment 30% (estimated at 40%) August: Trump Hockey Stick Stage 4: Official Unemployment 35% (estimated at 50%) Sept: Trump Hockey Stick Stage 5: Official Unemployment 40% (estimated at 55%) October: Trump Hockey Stick Stage 6: Official Unemployment 45% (estimated at 60%) November: Hockey Stick Stage 7: Official Unemployment 50% (estimated at 70%) Part II: The World a Year Ago (mostly written March & April, 2019): Marxist Capitalism with Chinese Characteristics: the collapse of the CCP Xi Jinping’s 8 Obstacles to CCP Global Domination China’s Contemporary History: A Fable Before Corona: China domestic economy dependent on global conspicuous consumption Before Corona: China’s Experiment in Modern Monetary Theory to run the Global Economy Xi Jinping’s Standards compared to Zhou Enlai and Deng Xiaoping Before Corona: The Chinese Economic Miracle Comes to an End A Marxist critique of “Totalitarian Capitalism with Chinese Characteristics” Xi Jinping’s Upcoming Disappointments Systems Science on Institutional Collapse and Transformation Socialist Hopes to Work For Protestant Work Ethic versus Buddhist Conservation Work Ethic Buddhism for the Western Mind Transactional Analysis as Buddhist Politics The Beer-Li Model for Communities of 10,000 People From Individual Profit to Community Sustainability: What is Human Nature? Limits of Current Economic Thinking What Guanxi means: personal sense of community Fritz Schumacher, Protégé to John Maynard Keynes Small is Beautiful: Economics as if People Mattered: 25 Years Later with Commentaries The Role of Economics Peace and Permanence A Question of Size Some of The Facts of Life Technology with a Human Face Social and Economic Problems Calling for the Development of Intermediate Technology A Machine to Foretell the Future? Good Work by Fritz Schumacher Social context defines options and choices German Mark Stabilizes the World January 1, 2021 The Potential Collapse of the U.S. Dollar as the Dominant Foreign Exchange Reserve The Inevitable Collapse of the US Dollar as the Global Currency DMark replaces Euro The Day the Euro Snapped The Mechanics of the Elastic 30-Day/90-Day Transition Timeline to January 1, 2021 Criteria for the XXIst Century Economy: Ecology/Economy/Equity Building Sustainable Community Transformation to Ecotopia Using the successful family farm as a definition of community sustainability The New Economy: The Chinese Iron Rice Bowl as the Global Standard: Hukou for Everyone No More: In Praise of the Automobile: A Eulogy Need More Of Berlin’s Recovery of the Rubble at the end of the War: Teufelsberg: Devil’s Mountain A Caravan that starts at the Oregon border with a million people: ecological recovery of California to San Diego: It has to work in Los Angeles, then it will work worldwide. Energy Conservation as a way of life: housing and transportation policies: AFTER THE AUTOMOBILE: better quality of life, improved standard of living, lower cost of living, lower energy usage, conserve non-renewable petrochemicals, healthier daily living Rediscover Nature: Robinson Crusoe in reverse. Conclusion: Nature Bats Last Bibliography for the 21st Century Jon Li, Davis, California, USA, Social Systems Scientist Part I: Novel Coronavirus How the World has Changed For most people around the world, whatever plans you had at the first of the year, sometime in March your plans disappeared. Suddenly we are all living day to day, with the threat of death lurking with the next chance social encounter. This is a terrifying new world that has everyone focused on the sickness and the failures of the health care systems. Our lives have become a petri dish of how each State’s Governors are reacting to the incompetent negligence of Trump. And the economy. What about the future of the economy? And climate change. What are we going to do to create a healthy future? Lots to worry about. What to do? There is no going back to the XXth Century On March 11th, when the World Health Organization declared a “global pandemic,” the world crashed down the Niagra Falls of epidemiology to a confusing new reality. This essay is based on the distinction between the XXth Century, and a much different emerging XXIst Century. For its first 200 years, the United States could count on its natural resources to fuel its growing economy, which culminated in Pax Americana global domination from 1945 to 1972. In 1973, because of its dependence on the personal automobile, the US became dependent on the Organization of Petroleum Exporting Countries (OPEC). The US has had a trade deficit every year since 1973. Every year since 1993, Clinton’s first year, the US has had a growing net services and trade deficit. In 2019, the US is in trade deficit with all of its major trading partners: China $419 billion deficit (on $660 billion traded), Canada $20 billion deficit, Mexico $81 billion deficit, Germany $68 billion deficit, Japan $68 billion deficit. That was before the novel coronavirus. When Trump talks about “making America great again,” he is referring to the 1950s image of the US as the world’s leader in economics, military, technology and culture through the new invention, the television. From 1945 to 1972 was Pax Americana. Ever since 1993, the US has been “Stupor Power”: stupor: a state in which the mind and sense are dulled; partial or complete loss of sensibility, as from the use of a narcotic or from shock; mental or moral dullness or apathy. The XXth Century started on 1/3/1888 when Thomas Edison made a list of “Things doing and to be done,” including: cotton picker, new standard phonograph, slow speed cheap dynamo, deaf apparatus, electronic piano, long distance standard telephone transmitter, which employs devices of recording phongh, grid battery for telephone, artificial cable, duplicating phono cylinders… Edison unleashed the idea of using electricity to move machines as labor saving devices. Starting with the Robber Barron’s explosion of economic development after the Civil War, the potential of the US continental market was laid with the national railroads, and all their graft. The backbone of the high US conspicuous consumption was the monolithic corporate infrastructure characterized by JP Morgan (banking), Ford (mass production and the family automobile), Bell (communications and technological innovation), Edison (applications of electricity), John D Rockefeller (oil and gasoline, especially for transportation) and the Wright Brothers (airplane). Each evolved an economic technology with a centralized administrative system that has high overhead for coordination, and expensive costs to maintain their image. Their innovations were predicated on the assumption that energy was inexpensive, had insignificant consequences, and would last forever. The XXth Century was an explosion of innovative technology that has led the economy around by the nose. Things that were “economic” in 1900 are now completely out of touch with reality. Since 1900, the economy has grown and changed many times, but the education system is still where it was in 1865 at the end of the Civil War. Compulsory education, Kindergarten through high school, college, Masters degrees, Ph.Ds? That whole drill has run its course. There are now so many people with Ph.Ds, Masters and Bachelors degrees that they don’t mean anything any more. The XXth Century was defined by the pursuit of money. Everything in society was redefined in monetary terms. Dick Cheney said that “conservation may be a sign of personal virtue, but it is not a sufficient basis for a sound comprehensive energy policy”. Cheney was wrong. The planet cannot support even one country’s continuing the US waste lifestyle. Now that China has surpassed the US as the number one producer of greenhouse gases, the US is confronted with the challenge of providing the moral leadership to move to a sustainable economic system, and encourage China and the rest of the world to stop trying to out-pollute the dirty US. Fareed Zakaria wrote in a Newsweek magazine featured series on the potential for an US energy transformation (3/13/09), “An energy revolution would produce a world in which we can all use lots of energy without worrying about its costs or consequences…. If we put them to work and create systems that allow for all the growth we want without running out of energy or harming the earth, we will have achieved true energy independence.” Which is along the lines of Cheney’s unlimited greed for more. No, Zakaria has it backwards: we need an ethic where energy is considered valuable and worth conserving, rather than so available (like its original form, sunlight) that it can be used unconditionally. What Zakaria doesn’t seem to understand is that most of the ways we are generating energy now (even hydropower) require what he calls “harming the earth,” while creating escalating social and environmental problems. Does he really believe US could grow its way out of the pollution, congestion and violence that plague the planet? After March 11th, none of the rules of the money economy work any more. Too many things that were certain in 2019 are no longer real. Maybe half of the US workforce is now unemployed, does not have a job to go back to, and is looking hopelessly for work, in a new field, anything. The problem is that multi-national corporate capitalism has defined the past 500 years, and that ended March 11th. Now we are dealing with the death throes of the transition to a new reality. The Geologists call this “Punctuated Equilibrium”: after a long period of stability, there is a major shift, and then everything has to settle into a new reality: 65 million years ago, the dinosaurs ruled the world but a crashing asteroid changed the world’s climate and weather patterns. From that old world, the new environment forced adaptation. The dinosaurs evolved into birds, and a tiny mouse evolved into all the mammals, including humans. Corporate Capitalism valued money, and machines, at the expense of most human labor and the natural environment, until nature has shut down the global economy. While most news reporters are shocked by the recent global lockdown’s impact on the global economy, the social and environmental problems with corporate capitalism have been pointed out by Marx and many others: - Linear thinking instead of comprehensive thinking; - Abraham in the Bible was the first patriarch: women and children serve men; - women prostituting their lives in sacrifice to men’s pleasures and whims, known as “the world’s oldest profession,” including too many women who face domestic abuse in a bad marriage; - Economics define reality: put a price on everything; which reinforces class because the rich can do whatever they want but cost stops most people from even considering doing it; - The Engineer’s Free Body Diagram: eliminate social and environmental consequences from the analysis, from the design, from the operations, from the evaluation; - Pollution, smog, traffic congestion, and crowding are all examples of negative feedback to the damaging system; - Nuclear waste; - Species disappearance due to habitat destruction by civilization; - Human dominance of every cubic centimeter of the planet. The damage caused by the corporate economy include: - World War I - The Depression - World War II - The Korean War - The DDT damage to insects reported in Rachel Carson’s Silent Spring, 1962 - The Santa Barbara oil slick in 1969 that created the modern environmental movement - Nixon Wage and Price Controls - 1986 Chernobyl nuclear disaster - 1989 Valdez oil spill - 2003 Severe Acute Respiratory Syndrome (SARS) - 2008 Economic Collapse - 2011 Fukushima collapse of the nuclear power plant that is polluting now - 2012 Middle East Respiratory Syndrome (MERS) - Climate Change leading to devastating droughts and flooding - Australian wildfires that killed over a billion animals - California wildfires that destroyed Santa Rosa and a year later Paradise - Plastics in the ocean that are growing into marine life The Difference between the XXth Century and the XXIst Century: XXth century Empire, money, domination, growth, consume, competition, multi-national, bureaucracy, technology-focused, giant-scaled, militaristic, consume non-renewable resources, Invisible Hand of corporate law, greed rewarded with profit XXIst century Community, health, interdependent, sustain, conserve, cooperation, local-regional, face-to-face decisions, human-focused, human-scaled, negotiation, conserve non-renewable resources (fossil fuels in particular), respect for labor, Eudemony: seeking well-being The Internet made all of this transition inevitable, exorable, and very quick. Psychologist Amos Trevrsky: “He who sees the past as surprise-free is bound to have a future full of surprises.” Life this October Just like in 2008, the US Dollar collapsed in September. This time there was nothing but debt and hot air to hold the Dollar up. Same with the Euro, the Pound, the Yen and the Yuan. As October unfolded, the Dow Jones Industrial Average became what was left: Amazon and 29 of its subsidiaries. But the Dollar has lost all of its value, its power in the marketplace. When stores ran out of products, there was no replacement because it had been locked down somewhere in the globalized international supply chain. People were realizing that the grocery stores and food banks were not going to be good enough, with most restaurants gone forever. Cities were forced to organize into villages and communities, so that each neighborhood has organized daily communal meals for breakfast, lunch and dinner, and if you are over 4 years old and can walk, you are expected to contribute at least an hour of labor in exchange for each meal by cooking, serving or cleaning up. Amazon is the only business in the world with net cash flow. Amazon is buying up control of whatever it wants. United States as the Roman Empire, 400 A.D. Pax Romana was a 200 year period identified with increased and sustained domestic peace and stability within the Roman Empire, although not without its wars, expansions and revolts. Pax American lasted from 1945 to 1972. Timeline for Trump’s Crash Hockey Stick Month: beginning of the month’s forecast includes the range of a worst case scenario; that becomes new reality before the end of the current month; midway through the month, the government and the media claim they have solved the problem, people become falsely optimistic, and the apparent economic collapse isn’t as bad for a few days of the month. May: Trump Hockey Stick Stage 1: Official Unemployment 14.7% (actual estimated at 20%) A Some businesses reopen B few customers C many gaps in the supply chain D Some businesses become backbone of XXI economy E many gaps in the XX supply chain are permanent, eliminating many XX products and associated services F Some major national and regional businesses declare bankruptcy G Minor construction activity with office tenant improvements to enhance social distancing H Some internet businesses fill gaps I Trumpville Homeless Camps sprout up in Red States J “Fauci Safe Camps” require social distancing, to create as healthy an environment as possible for homeless people: want to eat? Work for an hour. Stay for the night? Work for an hour. In both Red and Blue states; men required to respect women and children. June: Trump Hockey Stick Stage 2: Official Unemployment 25% (actual estimated at 30%) A New Normal: social distancing and masks B most states allow most business activity C many retail businesses never re-open, remain boarded up. D most offices that can use working home, do E limited public transit use requires minimizing public transit to major routes F most downtown type businesses cannot generate revenue G half of home owners cannot make mortgage payments H renters revolt in Manhattan, goes worldwide I Banks cannot maintain solvency and fold, daily J Blackrock invests a Trillion dollars in one day, bringing the Dow Jones Industrial Average back up to 10,000 K Disney, Coca-Cola, Travelers, Raytheon, Procter & Gamble, McDonald’s, Boeing, Caterpillar, Chevron, ExxonMobil, The Home Depot, American Express collapse in bankruptcy L Dow Jones Industrial Average fishtails with the collapse of a major corporation, is invigorated by its replacement, and then the next ICON collapses M Brazilian President Bolsonaro is impeached July : Trump Hockey Stick Stage 3: Official Unemployment 30% (actual estimated at 40%) A Income taxes due July 15: Second quarter, many more businesses declare bankruptcy. B End of the month quarterly reports are even more shocking than anticipated. C Major Airlines declare bankruptcy. D Boeing announces it is converting from building airplanes to dismantling them and recycling as much of the materials as possible E Initial Enhanced Unemployment Benefits end July 31 F Chaotic deflation G Millions of US public sector city, county, special district and state employees are laid off. H Millions of US police and fire fighters go to volunteer, continuing to wear the uniform and do the job. I Mississippi, Alabama, Kentucky and Florida declare bankruptcy. J University of California announces it is going private sector K Goldman Sachs, 3M, Cisco, Dow, IBM, Johnson & Johnson, Merck, Nike, Visa, Walmart, Walgreens collapse in bankruptcy L Escalating volatility and UNCERTAINTY forces public sector and private sector organizations to go to real time, daily information management, with brand new, re-written budgets expected every day, even in China. M Brazilian President Bolsonaro is removed from office. August: Trump Hockey Stick Stage 4: Official Unemployment 35% (actual estimated at 50%) A Millions go off enhanced unemployment benefits, can no longer pay rent B Second Quarter Corporate Reports: massive bankruptcy C Intel, JPMorgan Chase, United Health Group, Verizon collapse in bankruptcy D Democrats hold virtual convention beginning August 17: Biden is present at each evening’s Zoom meeting with various party stalwarts from around the country; party big thinkers are able to focus on the three hours of prime time, and provide useful half hour segments engaging hundreds of people simultaneously, with millions of Democratic Party house parties around the country; half of the programming is designed to educate the electorate about what to look for from Trump during the GOP convention and beyond. E Third day of the U.S. Democratic Party Virtual Convention, Trump tweets: JOE BIDEN IS HOOVER, Not ME. F University of California declares bankruptcy. G GOP Convention: August 24-27: most wear masks; Trump has people screened before he lets them in the same room; the country’s disastrous economic situation forces Trump to try to put on a good face, but no-body, not even Kellyanne Conway thinks Trump can win in November; Trump does not have one good day in his remaining time in office. H Democrats schedule weekly house meetings, social distancing and Zoom, for community building, as the new post-tv sitcoms is a new way of family life as community building: people become considerate and help each other meet their needs with few money transactions. It is social economy, with the emphasis on social, the way it has been through most of human history up to 100 years ago. I Missouri, Kansas, Iowa, Nebraska, Pennsylvania, Louisiana, Illinois, Montana, Idaho, Nevada, Rhode Island, Connecticut, New Hampshire, Maine, Vermont, West Virginia and Wyoming declare bankruptcy. J People with job supported health insurance drops from over 50% to less than 25%, and that large population of people with high need for ongoing health care are left with begging their state for an extension of Obamacare; people are enrolled in MediCaid but the health care delivery system is unable to provide primary care because the hospitals have over-reacted to the Covid-19, and not been able to provide the primary care that the fee-for-service insurance is supposed to finance. Hospital go bankrupt. K Democratic Party Convention: Strong feelings of support for universal health care as the best strategy to unify the country, win the November election, and recover from the pandemic; what the Green New Deal means in terms of creating a post-industrial economy is a much bigger question, with a lot of uncertainty; most everyone knows people who tested positive for Covid- 19, too many know people who are no longer with us. September: Trump Hockey Stick Stage 5: Official Unemployment 40% (actual estimated at 55%) A Housing market prices drop weekly. B Commercial property has no value at all. C New Mexico, Arizona, Texas, Georgia, North Carolina, South Carolina, Tennessee, Virginia, Indiana, Michigan, Ohio, North Dakota, South Dakota, Delaware, Maryland, Hawaii, Alaska, and Arkansas go bankrupt. D Most of the private universities in the US go bankrupt. E Columbia, Penn, Chicago, Brown, Dartmouth, Brandeis, Cornell, Amherst, Notre Dame go bankrupt. October: Trump Hockey Stick Stage 6: Official Unemployment 45% (actual estimated at 60%) A New Federal Fiscal Year: State and local governments entirely dependent on Federal contributions, which are not based on anything but US government computer zeros. B Colorado, Utah, California, Oregon, Washington, New York, Massachusetts go bankrupt. C Nationally recognized stalwart economic stars are added to the Dow Jones Industrial Average, and they fade and die in the next week, replaced by ICONS, that fade and are replaced by national infrastructure firms that should last forever, that don’t make it through the month. D Most of the companies listed as the Dow Jones Industrial Average go bankrupt, except for Amazon and several of its subsidiaries. E Amazon buys the Wall Street Journal, in spite of US Department of Justice attempts to prevent Bezos from adding it to his owning the Washington Post F New York Times goes bankrupt and Bezos buys it for pennies on the dollar. G Dollar goes sideways, along with the British Pound, the European Union Euro, and the Chinese Renminbi (RMB, yuan) H Apple goes bankrupt. I Yale, Harvard, Cambridge and Oxford go bankrupt. November: Hockey Stick Stage 7: Official Unemployment 50% (actual estimated at 70%) Election: Biden wins Bezos buys NBC, CBS, ABC Disney, and CNN. MSNBC goes renegade and creates an independent television network from all the rest of the Bezos exclusively owned media All US Military terminate service, shutting down all foreign bases. States provide Coast Guard and Boundary protection. December A Amazon is the major business in the US; without any unions, wild cat strikes happen daily all over the country. B USPS, the Postal Service struggles to survive attacks from the lame duck US President and US Senate. C Massive national campaigns to boycott Amazon lead to community volunteer efforts to build a grass roots economy, with the USPS carriers as the unifiers D Christmas happens around the US, because of USPS, not because of Amazon. E Universal Health Care and State Health Care Waiver legislation introduced in Congress US Dollar goes to zero. Every US state establishes rules for local communities to establish their own script. Every set of rules includes people automatically receiving 100 script units a month, the capacity to earn up to 10 script units a day providing services to other people, and a rent cost of 10 to 40 units per month per person. Neighborhoods and Villages are encouraged to organize breakfast, lunch and dinner, with the cost being working an hour to help with the meal. Amazon goes to zero value. January German MARK becomes the new global currency. Amazon employees overthrow the boss, and dismantle Amazon. The entire Amazon web empire disappears, as people develop community based economic information systems that are mutually sustainable. USPS is a big part of the little federal government January 20: Biden sworn in. “Unemployment is no longer an issue: every person can make a contribution as best you can, so that we can have a sustainable future together.” January 21: US Government goes to real time, daily reporting, systemwide, private sector and public sector February Donald Trump, Donald Trump, Jr., Ivanka Trump, Eric Trump and Jared Kushner are served by the Federal Prosecutor of the Southern District Court of New York with over a hundred counts of illegal activity while in the White House; half of the cases are based on the files from the Mueller investigation; conviction of a single count would mean over a year of jail time. Community Ecological Recovery Program initiated: each state finds ways to organize volunteers to bring toxic and former industrial sites back to a pristine natural environment. Eliminate most toxic sites. July 1, 2021: Universal Health Care Dismantle all Nuclear bombs July, 2022: Complete Major Environmental Projects July, 2023: Create a program to safely store all nuclear waste July, 2024: Filter the Plastic out of the Ocean July, 2025: Ecotopia Marxist Capitalism with Chinese Characteristics: the political disappearance of the CCP, November 15, 2022 (Xi Jinping’s 10th anniversary in power) China: - unstable at the grassroots, - dejected at the middle class, - out of control at the top. Xi Jinping’s 8 Obstacles to CCP Global Domination: Taiwan, Hong Kong, Tibet, Uyghur Muslims in western China, Wuhan virus, Global economy, Credibility among Han, Credibility with the rest of the world: 1. Taiwan is an obstacle to the image of a unified China. There is nothing special, unique or deserving of the Formosa island that makes it somehow part of China, any more than Vietnam, or the Korean peninsula, or Malayan peninsula, or the Philippines archipelago makes them part of China. For Beijing, it is the standard for judging other countries: their willingness to ignore Taiwan’s independence since 1949. Historically, the Emperor of China saw himself as the center of the entire civilized world, and diplomatic relations in East Asia were based on the theory that all rulers of the world derive their authority from the Emperor. 2. Hong Kong is not going to settle for “One Country, Two Systems” which really means, Hong Kong has to become under increasing control of Beijing, after 400 years of almost democracy under neo-colonial Britain. What gives the Beijing central government the right to have any say over what happens in Shanghai, or Guangdong (Canton), or Hunan? As much as Taiwan, Hong Kong is a symbol to the people of China that Beijing is not good enough. 3. Tibet was invaded and conquered by the Han Chinese in 1951. China built a supertrain to the capital, and millions of Han Chinese are settling in Tibet, diluting the Tibetan culture and language. Thousands of iconic cultural Tibetan temples were destroyed during the Chinese Cultural Revolution. 4. Uyghur Muslims practice their religion, which is against the Communist ideology against religions. It has been estimated that a million people, a tenth of the population, have been forced into re-education camps to give up their Muslim religion for communism (the opiate of the masses). 5. Australia is leading the questioning of why the pandemic was allowed to happen. 6. China has become the world’s workshop, in no small part to keep its billion people preoccupied so that they don’t have time to demonstrate against the government. 7. The domestic lockdown has forced the Chinese government to be even more totalitarian in its manipulation of the populace. 8. China has gone on a foreign policy offensive that any country who questions China about the virus will pay for it economically: China wants all the respect that the US used to have as the global superpower in soft power and global leadership, but with too many things that matter like human rights, China only wants to be a 2nd rate power ignoring the rest of the world too much of the time. China’s Contemporary History: A Fable Before 1919, Confucius ruled the language, and defined people’s relationships within society. Civil War and the Japanese complicated things. In 1949, the Chinese Communist Party took control, and built bureaucratic complexity on top of Confucius. Peasant Mao Zedung led the country by whim. For 40 years Zhou Enlai would accept his role and do the best he could, always with the threat of death at Mao’s whim. Liu Shaoqi and Deng Xiaoping joined Zhou as the three mandarins who administered Mao’s whims. Liu Shaoqui’s first five year plan was a miracle success, so the second five year plan expanded ALL of the expectations, put more tax of rice on the rural peasants to support the expansion of heavy industry in the cities, and FAMINE. 30 million peasants paid their rice taxes but didn’t have enough to live, and died of starvation. Not a very good plan. The brief liberation of “A Hundred Flowers Blooming” led to the extensive crackdown on liberals who had exposed themselves in the country’s temporary moment of fresh thinking beyond Mao. Which ultimately led to the Cultural Revolution, and the destruction of two generations of interpersonal intelligence. The Red Guard humiliated all teachers as apologists for the past mistakes of history, and eliminated their culture’s great wealth of historical and scientific knowledge in the name of the Chinese Communist Party, and it has pretty much been that way ever since. Liu Shaoqui ran the daily government from the First Five Year Plan until the Cultural Revolution and Deng Xiaoping was his worthy pupil. Deng was both the most respected soldier in the Chinese Communist Party AND the most respected politician in the People’s Liberation Army. Clearly Deng was being trained to become Mao’s successor. In the Cultural Revolution, Mao himself wrote the poster demanding that Liu Shaoqui be brought down from power. When it was posted in Tiananmen Square, the Red Guard brought Liu and Deng to examination. After several days, Liu became so sick that he soon died. Deng was rescued by the People’s Liberation Army. Under pressure from Mao’s wife, Mao disowned Deng as his heir-apparent. With Mao clearly in his final days, the PLA hid Deng. Mao died in 1976. In 1979, Deng brought China out of the Dark Ages of the Cultural Revolution. In taking power, he declared scientists were part of the revolution and not the hated establishment, and legitimized science as a positive role within the Chinese Communist Party ideology. Deng also opened up China to western commerce. But the Cultural Revolution destroyed two generations of Chinese intelligence. Mao saw that the western technological advances created a giant middle class bourgeois society that he considered worse than rural poverty. In an attempt to block that social evolution of Chinese society, Mao imposed the Cultural Revolution as the only way he could save Chinese communist society. Deng Yiaoping’s philosophy was to be polite on the world stage so China could become the globe’s workshop for consumer goods. That philosophy has sustained growth of close to 7% a year for almost three decades. To accomplish this world market domination, the Chinese Communist Party runs the government organized “State Owned Enterprises” (“SOE”) that dominate each market. Control is a big idea in the CCP. The CCP wants China to control between 40% and 80% of their domestic market, and a relative share of the global market by 2025. The driving engine of the modern Chinese economy is the state-run banking system. At this point, the top four banks in the world are all Chinese. Chinese have the most available foreign currency to move and manipulate. The Chinese are the only economy in the world with flexibility, like the US did after World War II. They are focusing on the Belt and Road Initiative, which is kind of a peace time Marshall Plan for developing countries to approve infrastructure projects that will benefit Chinese trade, and force the countries into long term debt to pay the Chinese for it. (Just like the US used the Marshall Plan to foist US firms spending US money to rebuild Europe, holding all the countries deeply in Debt. The UK paid off the lend-lease debt to the US from World War II in 2006.) The Chinese have accomplished Deng’s greatest goal of matching the Western economic processes so well that the Chinese have taken over control of the world economy when the collapse happened in September 2008. The Chinese goal had been to match and then exceed the enormity of the volume of commercial transactions of the West. Deng brought modern technological society to China. Now China has achieved Deng’s ultimate goal of outdoing the west in all things economic, and it is striving under Xi Jinping’s China 2025 campaign to become the global leader in all things that matter. The problem is that the Chinese Communist Party doesn’t have standards that include sustainability and democracy, so it doesn’t have the capacity to improve. Before Corona: China domestic economy dependent on global conspicuous consumption The Chinese Communist Party’s most basic strategy is to keep the people busy with jobs so that they don’t have time to revolt. The masses have many reasons to revolt. It turns out that the main change that Xi Jinping has made is to do everything he can to increase CCP influence in the economy and in daily social life. This is the third era of CCP life. Mao’s personal leadership style was so strong that Deng Xiaoping reacted by establishing collective decision making, and the ten year two term limit. November 15, 2012, Xi Jinping came to power as the General Secretary of the Communist Party of China, which makes him the President of the People’s Republic of China. In addition he had himself named Chair of the Central Military Commission. Xi Jinping has reverted back to Mao’s consolidation of institutional power in one person, and then changing the constitution so that he can remain in power as long as he wants. Xi has forced a deeper penetration into Chinese society by the CCP, creating an aggressive surveillance program of individuals, groups, streets and public places. And the CCP is taking an active involvement in even middle size and small businesses, and expecting to influence and even determine business decisions, like where to make investments. Where Deng was gracious and even humble internationally, Xi sees this as China’s century and his responsibility to use an ambitious foreign policy to push China to the center of the world stage. The Belt & Road Initiative (BRI) is the Chinese Marshall Plan, and it is intended to create dependency relationships, just like the US did after World War II. Not only is the BRI intended to create a global distribution system for Chinese products, but a digital revolution as well, where the Chinese government is determining what is on the Internet. In Economist, 3/9/19, columnist Chaguan, “When China praises democracy”: China praises its country’s political “stability.” Brexit and the US government shutdown do not look good by comparison. After Mao’s death, when economic opening was not matched by political liberalization, party leaders assured foreigners that only a firm grip on their vast country could avoid chaos. One party rule is absent messy things like real elections or a free press. Society is visibly policed, potential protesters instantly arrested. The extensive security apparatus is tasked with tracking, threatening or jailing any who challenge the Communist Party monopoly on power. Jump to present day, and foreigners hear Xi Jinping call China a socialist, consultative democracy, featuring the orderly participation of the people and always under the Party’s control. Chinese people do know that American voters can “kick the bums out.” Chinese leaders still mind when their authoritarian system is judged against Western norms. State media hail China’s political system as far more responsive and effective than the West’s conflict-driven, money- tainted politics. But the domestic economy is the main concern for the CCP. Economist, 3/2/19, Free Exchange column: “A Familiar Cycle”: Once the Chinese had hauled the global economy through the global financial crisis of 2007-8, on the back of massive stimulus, China’s leaders pivoted towards economic reform in 2015. They sought to wean the economy off credit, which had grown at mind-boggling rates in 2009-14. They also took steps to open up China’s financial markets. The measures turned out to be premature: as constraints on capital movement were loosened, money fled the country and stock prices crashed. Financial turmoil radiated outwards, threatening to tip large swathes of the world economy into recession. The downward spiral was quickly halted by the Chinese government’s massive credit injection. China put its plans to lift capital controls on ice; the stimulus taps were turned back on. The government eased monetary policy and began spending with gusto. Officially, China’s fiscal deficit expanded only modestly in 2015 and 2016, to [almost] 4% of GDP [, the same enormous percentage as the US and Japan, the first and third largest economies]. But the government is adept at using special financing vehicles, primarily at the local government level, to borrow and to direct funds to projects; these do not affect the official deficit figures. Researchers estimate that China’s “augmented” budget deficit, which includes such tactics, rose to around 15% of GDP in early 2017. The explosion of borrowing did the trick. By the end of 2017, the world was on the road to a synchronized upsurge. Having survived the close call, China’s leaders focused again on the economy’s dismaying reservoirs of red ink. They restricted lending to over-indebted firms and embarked on a bout of fiscal belt-tightening that would make even the Germans blush. China’s augmented budget deficit has narrowed by about six percentage points of GDP since the beginning of 2017. [to a budget deficit of 9% of GDP?] Domestic demand has consequently weakened. China’s imports of manufactures for domestic use have fallen by more than its “processing imports,” or inputs into the products that China makes and exports. Its purchases of American goods has tumbled; imports from the rest of the world have fallen too. Although the trade war has played a role, the world economy’s recent ups and downs are more closely related to China’s on-and-off struggle to reform its economy and curb unruly borrowing. The problem is not so much that the headwinds from China are powerful, but that the rest of the world is poorly prepared to lean against them. Interest rates remain extraordinarily low. If the global manufacturing malaise worsens, America will have precious little room to cut rates in response; Europe and Japan will have none. Fiscal policy could pick up the slack. Advanced economies could badly use a dose of deficit-financed public investment. But neither the euro area nor America seem keen to build. The rich world has chosen to put itself at the mercy of the fiscal management of the Chinese Communist Party. Sacramento Bee, 3/6/19: China’s Vice President Li set this year’s growth target is 6 to 6.5%, reflecting a determination to shore up a cooling state-dominated economy and prevent politically dangerous job losses. Yet it would be slightly below last year’s 6.6% growth in China and would mark a new three-decade low. Li pledged higher spending on development of technologies including artificial intelligence, electric cars, biotechnology and new materials that China’s leaders see as a path to prosperity and global influence. He also promised more money for education, social programs and public works construction. China’s emergence as a competitor in smartphones, telecom equipment, solar power and other technologies has increased the range of products available to consumers and helped to drive down prices. Higher government spending will push the budget deficit from 2.6% of total economic output to 2.8%, Li said. Before Corona: China’s Experiment in Modern Monetary Theory to run the Global Economy Modern Monetary Theory claims that it doesn’t matter how much money a country creates, if its currency has power – like the US Dollar being held by governments and institutions as over 60% of their foreign exchange reserves. Conservative monetary theory followers of Milton Friedman cringe nervously as the US budget deficit continues to grow like Topsy. Isn’t the US economy eventually going to explode with imbalance? Keynesian fiscal advocates point to World War II as what got the Western economy out of the Depression. Recently, eleven years of continuous job expansion and 4% unemployment is almost an economic miracle, the definition of “full employment.” Inflation of under 2% and the Trump budget claiming over 3% growth soon. What more could you ask for? As reported previously, the global economy has been dependent on the Chinese since 2008. Dependent. The US economy has been subservient to the Chinese economy ever since the tail end of W. Bush’s Presidency. Obama chose health care instead of jobs, but it was still in defense of the status quo and probably wouldn’t have made a bit of difference one way or the other. The US, Japan, the European Union and the rest of the world are all completely dependent on the Chinese continuing to underwrite the global economy. China has plunged over $10 trillion into the global economy, the equivalent of their entire annual GDP. Where the US and Britain are 100% of their annual GDP in debt (France, 1.3 times their annual GDP and Greece, 1.8 times their annual GDP), China is almost 100% annual GDP invested into the future. And since the Chinese are capturing that future obligation in US Dollars, it is going into a bottomless black hole that will disappear forever. If the Chinese ask when US will pay back its ever growing global debt of over $500 billion a year, the only answer is: probably never. Unfortunately for the Chinese, tradition does not have much to say about the higher mathematics of global economics, basically value the home and don’t trust barbarians. China’s economy has controls that it has invented from their training in Ph.D. programs in Western universities so China is really flying into the future blind. China has a strong tradition of people saving. The people cannot count on the government or the economic institutions to take care of them when they are sick or in their old age, so they must save to meet their own long-term future needs. Most Western industrial economy countries have at least 60% GDP in consumption (US is around 70% consumption, 20% government spending, 15% private investment, and net imports of 5% makes up the difference.) China only spends under 40% of its GDP on consumption (most recent year: consumption: 38%, government: 44%, private sector: 14%, 4% net exports). For China, the major decision makers are the executives at the State Owned Enterprises, and they have tremendous unilateral arbitrary economic power controlled by the CCP. The Chinese economy is loose in its legal management of the local economy, and it is dominated not by the rule of law but the rule of the Chinese Communist Party. So land, money, and business property are all subject to the whim of the local CCP officials, who can be bribed, even today under Xi’s Inquisition, to gain a favorable decision. That makes the economic machinery subject to artificial expansion. It also means that the numbers about the economy are subject to manipulation at every step along the way. Xi Jinping’s Standards compared to Zhou Enlai and Deng Xiaoping During Mao, Liu Shaoqi, Zhou Enlai and Deng Xiaoping together ran China. For over 30 years, Mao would say things, they would be reported, and a billion people would follow. Zhou Enlai was the mandarin who was responsible for implementing whatever Mao wanted. Each day, Zhou would lay his head on the ax block, Mao would motion the ax man to ready his ax, and the Mao would say to Zhou, “What am I to do today?” At the end of the day, Mao would dismiss the ax man, Zhou would get up, go home and come back and do the same thing the next day. For over 20 years, Zhou was in Mao’s picture, sometimes with ten others in between, but usually 2nd or 3rd. Liu Shaoqi wrote the first 5-year plan, which was a success. The 2nd 5-year plan was a disaster: 30 million people starved to death, in large measure because the plan was unrealistic. Liu lasted until the Cultural Revolution, and then became its biggest target. Deng Xiaoping joined the Long March and became friends with Mao. Mao made him General Secretary of the Communist Party in 1959, in charge of running the day to day government with President Liu Shaoqi. Deng was the “most respected politician in the army” as well as the “most respected soldier in Chinese Communist Party”. After the failure of the Great Leap Forward, Liu and Deng argued that people were motivated by material incentives: rewards, bonuses and higher wages when they excelled or worked harder than others. Liu and Deng claimed these methods were more effective than the moral encouragement, persuasion, and propaganda advocated by Mao. They deemphasized class struggle, and Mao was scandalized; he was convinced the Chinese revolution was in danger. Mao created the Cultural Revolution with a call to the students to be the vanguard in the class struggle to destroy the four olds: old ideas, habits, customs, and culture. Mao’s targets were Liu and Deng, who were strongly criticized and subjected to often physically painful struggle meetings. In the summer of 1967, they were put under house arrest. In 1968, Liu was tortured and beaten by Mao’s Red Guards; he died of pneumonia without medical care. Deng was humiliated, then sent to exile. After Mao died, the Chinese culture went through a two-year period of confusion and lack of direction. Then Deng Xiaoping provided the new direction with his push towards opening the Chinese labor force towards exporting goods to the world’s consumer economy. Deng replaced worshiping the dictates of Chairman Mao with the pursuit of economic wealth, offering the Chinese people the same empty reward that provoked Marx’s criticism of capitalism in the first place. In December, 1978, Deng turned around Mao’s attack on intellectuals, to see production of science as work by the mind. Deng decreed this to be the ongoing evolution of socialist theory, to reconcile Marx and the advanced market economy: “Since science is becoming an increasingly important part of the productive forces, are people engaged in scientific and technological work to be considered workers or not?” Contrary to what Mao had pushed during the Cultural Revolution, Deng argued that scientists and technical experts are workers – Red workers, not counter-revolutionaries, just as much as factory workers. Deng argued that China was in the primary stage of socialism and that the duty of the party was to perfect so-called “socialism with Chinese characteristics.” This interpretation of Chinese Marxism reduced the role of ideology in economic decision-making and deciding policies of proven effectiveness. Downgrading communitarian values but not necessarily the ideology of Marxism-Leninism itself, Deng emphasized that "socialism does not mean shared poverty." Deng's reforms sparked an industrial revolution in China. By participating in export-fed growth, China was able to attain foreign funds, markets, advanced technologies and management experiences, with policies of low tax rates, the establishment of transportation networks, the construction of industrial plants, and a well-trained cheap labor force accelerating its economic development. Deng aggressively opened the window of China to the outside economic world that could provide the resources, technical expertise and financial capital to drive the modern Chinese economic miracle of sustained growth, a per capita Gross Domestic Product increase of 7% per year for the entire 1978-2005 period – the most sustained period of rapid economic growth in human history. Deng’s goals for China were to dominate the global production system so much that it became the “world’s workshop” which Britain had been from 1750 to 1914. He retired but in 1989, the Tiananmen Square demonstrations brought him back to power, to put a lid on any possible future expressions of freedom. Xi Jinping’s father was with Mao in the Great March. Xi is a Princeling. Xi paid his dues: he worked several years in agrarian labor, famously reported by the CCP as having applied and been rejected almost a dozen times before he was finally allowed to join. Xi Jinping has created the most repressive country in history. He is now far and away the most powerful person in the world. Given Chinese advances in electronic surveillance, Xi probably has much more accuracy and speed than Putin has in Russia (or Stalin or Hitler) to repress the population. Before Corona: The Chinese Economic Miracle Comes to an End Xi Jinping thought is vacuous. It is intentionally incompetent. It only stands as a slogan, not as anything of substance that you can actually apply to a situation. The only point is to occupy your consciousness with spouting trivia so that you don’t have time to think for yourself. The Chinese Communist Party is so incredibly dishonest that China is ripe for revolution. Chinese social policy is dominated by whether or not someone has a “Hukou” city (urban) designation. People with Hukuo have access to jobs, housing, health care, education for their children, and a future in the economy. People without Hukuo have a struggle every day, because the economy was designed for people with Hukuo. Three-quarters of China’s population is without Hukou, so every day starts out with many problems. China will be the longest hold-out on decentralization, the final country to decentralize, to implement the community clinic health service delivery system model. It is because the Chinese Communist Party will resist the inherently democratic nature of the clinic oriented health care delivery system. Air and water pollution from industry are tremendous problems. One quarter of the population only has access to water that the Chinese environmental protection agency has declared is unsafe for industry or agriculture, let alone human drinking. Drinking that water causes cancer, which is increasing among children. The Chinese Communist Party has done what it can to ban organized religion. Still, there is a Chinese Christian network of believers. Pope Francis recently negotiated a settlement where he agreed to accept the Chinese Communist Party’s Bishop for official Chinese Catholicism. Somewhere more subversive than the underground Chinese Catholic Church is a network of pollution cancer victims and survivors who are building the communications network for a post- CCP world. Because of the novel Coronavirus, Xi has run into a small problem with his China 2025 plan to dominate the world. Xi wants people in China to respect him the way they respected Deng, let alone worshiped Mao, and it isn’t going to happen. The novel Coronavirus is eating into the power of the CCP to control the people of China. The CCP is not doing a very good job of supporting the health of the people of China – so much that the CCP is losing touch with the reality it is creating. This 20 part report concludes with this update of our project: improving health care in Brazil, NHS (England), California and China with this message to Secretary General of the Chinese Communist Party Xi Jinping: in spite of the opposition of the Chinese Communist Party, community organizations will establish community clinics in China, after every other country in the world, and on the 10th anniversary of your coming to power, on November 15, 2022, you and everyone else in the Chinese Communist Party will resign as the CCP disappears into history as Marx predicted. A Marxist critique of “Totalitarian Capitalism with Chinese Characteristics” There is an evolutionary genetics professor at UC Davis who has an open challenge to Christians to debate evolution, using only the Bible for evidence. I am going to use Marxism to challenge the legitimacy of Xi Jinping. I am the opposite of a Marxist. I think Marx was mostly not sane. I had to read sections of Das Kapital for a history teacher who taught Western Civilization as Freud, Marx and Darwin. I believe that Darwin obsoletes Marx and Freud, that they have both have historically outgrown any usefulness at all. Stalin called Soviet bureaucratic totalitarianism “Actually Existing Socialism,” as though the then-current version of Soviet Communism (the Depression, allied with Hitler, fighting Hitler, losing 3 generations of men to war) is the only hope to someday achieve the dreams of a society that works for everyone. I think Xi Jinping may be the most powerful person in the world, but his power is based on schlock (something cheap or inferior). He has accrued totalitarian power for his ego. In history, I compare Trump to Nixon and Nero, and Xi Jinping to Hitler and Stalin. The US history of Socialism is built around 5 people: Eugene Debs, Norman Thomas (who ran for US President in 5 elections), Mike Harrington, Bernie Sanders, and Alexandria Ocasio-Cortez (the only reason she isn’t the Democratic Party nominee for President this time is she is not old enough to be eligible to run – she brought legitimacy and life to Bernie’s campaign). I am using the works of three Marxists who are anti-communists, Mike Harrington, Andre Gorz and Murray Bookchin. I didn’t know anything about Mike Harrington when I went to see him speak in the lecture hall where I got the lowest C in Engineering Physics and decided to change my major to economics. (This was the hall I packed for Thomas Kuhn. My buddy on the campus paper turned my flyer into a headline: Thomas Kuhn, the populizer of concept Paradigm Shift will be speaking…The faculty arrived late, left to stand lined along the side and back walls.) Mike Harrington (1928-1989) gave the best speech I have ever heard. He brought ideas to life when he added a statistic. He is the only social scientist I have ever heard who was able to make statistics POWERFUL. His 1962 book, The Other America led directly to the “war on poverty” that he called for in the book. “Michael’s book, The Other America, challenged the then all-but-universal opinion (at least among opinion-forming classes) that the US had helped all but a tiny minority of its citizens to a fair share of the astonishing economic abundance of its affluent society. The Other America went on to inspire the most ambitious “scheme of social reform” of the later twentieth century in the US, the war on poverty launched during the administration of LBJ.” Isserman xii Harrington, Michael (1962), The Other America: Poverty in the United States, Collier, Toronto Harrington, Michael (1972), Socialism, Saturday Review Press, NY Isserman, Maurice (2000), The Other American: The Life of Michael Harrington, Public Affairs, NY Andre Gorz (1923-2007) was a French Marxist, a friend of Sartre and Marcuse. Gorz, Andre (1980), Ecology as Politics, South End Press, Boston, Massachusetts Murray Bookchin (1921-2006) was an advocate of anarchy and libertarian municipalism. He lived in Burlington, Vermont, which means that Bernie Sanders was his mayor for 8 years. Bookchin, Murray (1970, 1985, 2004) Post-Scarcity Anarchism, AK Press, Chico, CA Bookchin, Murray (1982), The Ecology of Freedom: The Emergence and Dissolution of Hierarchy, Cheshire, Palo Alto Capitalism and free enterprise are not only two separate things, they are two contradictory things. The day when people in the US become convinced that “socialism” doesn’t mean less freedom and more bureaucracy, but exactly the opposite, there will be a tidal wave of socialism in this country. Gorz, 203 Marxism created a stupendous intellectual furniture that one must clear away to make contact with reality. Bookchin, Post-Scarcity Anarchism 162 In Socialism, Harrington quotes a Chinese critique of the Russian Soviets that seems appropriate for the CCP today: “The Chinese Communists generalize their indictment of such privileges (I find the Chinese criticisms of the Russians, and the Russian criticism of the Chinese, quite persuasive). ‘The members of this privileged stratum,’ the editorial departments of Red Flag and the People’s Daily wrote in 1964, ‘have converted the function of serving the masses into the privilege of dominating them. They are abusing their powers over the means of livelihood for the private benefit of their small clique. The members of this privileged stratum appropriate the fruits of the Soviet people’s labor and pocket incomes that are dozens or even a hundred times those of the average Soviet worker and peasant. They not only secure high incomes in the form of salaries, high awards, high royalties and a great variety of personal subsidies, but also use their privileged position to appropriate public property by graft and bribery.’” Harrington 181 “The Maoists themselves would reply that they were a proletarian party playing the leading role in a multiclass democratic movement of workers, peasants, the urban petty bourgeoisie and the national bourgeoisie (and sometimes they would even add “the enlightened gentry”). In fact, the Communists were a new ruling class and, for a number of reasons, this can be seen more clearly in China than in any other bureaucratic collectivist country.” Harrington 223 Listen, Marxist! “At this point we must ask what role the “revolutionary” party plays in all these developments. In the beginning, as we have seen, it tends to have an inhibitory function, not a “vanguard” role. When it exercises influence, it tends to slow down the flow of events, not “coordinate” the revolutionary forces. This is not accidental. The party is structured along hierarchical lines that reflect the very society it professes to oppose. Despite its theoretical pretensions, it is a bourgeois organism, a miniature state, with an apparatus and a cadre whose function it is to seize power, not dissolve power. Rooted in the prerevolutionary period, it assimilates all the forms, techniques and mentality of bureaucracy. Its membership is schooled in obedience and in the preconceptions of a rigid dogma and is taught to revere the leadership. The party’s leadership, in turn, is schooled in habits born of command, authority, manipulation, and egomania. “As the party expands, the distance between the leadership and the ranks invariably increases. Its leaders not only become “personages,” they lose contact with the living situation below. The local groups, which know their own immediate situation better than any remote leader, are obliged to subordinate their insights to directives from above. The leadership, lacking any direct knowledge of local problems, responds sluggishly and prudently. Although it stakes out a claim to the “larger view,” to greater “theoretical competence,” the competence of the leadership tends to diminish as one ascends the hierarchy of command. The more one approaches the level where real decisions are made, the more conservative is the nature of the decision- making process, the more bureaucratic and extraneous are the factors which come into play, the more considerations of prestige and retrenchment supplant creativity, imagination, and a disinterested dedication to revolutionary goals. “The party becomes les efficient from a revolutionary point of view the more it seeks efficiency by means of hierarchy, cadres and centralization. Although everyone marches in step, the orders are usually wrong, especially when events begin to move rapidly and take unexpected turns – as they do in all revolutions. The party is efficient in only one respect – in molding society in its own hierarchical image if the revolution is successful. It recreates bureaucracy, centralization and the state. It fosters the bureaucracy, centralization and the state. It fosters the very social conditions which justify this kind of society. Hence, instead of “withering away,” the state controlled by the “glorious party” preserves the very conditions which “necessitate” the existence of a state – and a party to guard it.” Bookchin, Post-Scarcity Anarchism 124 Marx and Engels, however, were not centralists because they believed in the virtues of centralism per se. Quite the contrary: both Marxism and anarchism have always agreed that a liberated, communist society entails sweeping decentralization, the dissolution of bureaucracy, the abolition of the state, and the breakup of large cities. Bookchin, Post-Scarcity Anarchism 134 Xi Jinping’s Upcoming Disappointments The novel Coronavirus, “Covid-19”, is a minor setback in Xi Jinping’s China 2025 campaign to achieve recognized Chinese global supremacy and control by 2025. Specifically, that the world is so dependent on the Chinese economy that every country, especially the U.S. acknowledges its subservience to China. Ren Zhiqiang, a former property executive and party member who has been highly critical of Mr Xi’s crackdowns on civil reforms: “No matter how many shortcomings exist in China’s administrative system, if there was free speech citizens could have taken measures to protect themselves. Simply trusting the people with freedom of speech could have achieved a great victory in preventing and managing this epidemic, and there wouldn’t have been such a huge price to pay in restricting personal freedom.” Mr Ren, has since been jailed. Systems Science on Institutional Collapse and Transformation Either revolution will create an ecological society, with new ecotechnologies and ecocommunities, or humanity and the natural world as we know it today will perish. Bookchin, Post-Scarcity Anarchism Xii Futurism is essentially an extrapolation of the present into the century ahead, of “prophecy” denatured to mere projection. It does not challenge existing social relationships and institutions, but seeks to adapt them to seemingly new technological imperatives and possibilities – thereby redeeming rather than critiquing them. The present does not disappear; it persists and acquires eternality at the expense of the future. Futurism, in effect, does not enlarge the future but annihilates it by absorbing it into the present, thereby reducing our vision – even our prophetic abilities – to mere extrapolation. Bookchin, The Ecology of Freedom: The Emergence and Dissolution of Hierarchy 333 Science as Revolution “Why should a change in paradigm be called a revolution? In the face of the vast and essential differences between political and scientific development, what parallelism can justify the metaphor that finds revolutions in both? “One aspect of the parallelism must already be apparent. Political revolutions are inaugurated by a growing sense that existing institutions have ceased adequately to meet the problems posed by an environment that they have in part created. In much the same way, scientific revolutions are inaugurated by a growing sense that an existing paradigm has ceased to function adequately in the exploration of an aspect of nature to which the paradigm itself had previously led the way. In both political and scientific development the sense of malfunction that can lead to crisis is prerequisite to revolution. “Political revolutions aim to change political institutions in ways that those institutions themselves prohibit. Their success therefore necessitates the partial relinquishment of one set of institutions in favor of another, and in the interim, society is not fully governed by institutions at all. … In increasing numbers, individuals become increasingly estranged from political life and behave more and more eccentrically within it. Then, as the crisis deepens, many of these individuals commit themselves to some concrete proposal for the reconstruction of society in a new institutional framework. At that point the society is divided into competing camps or parties, one seeking to defend the old institutional constellation, the others seeking to institute some new one. And, once that polarization has occurred, political recourse fails. Because they differ about the institutional matrix within which political change is to be achieved and evaluated, because they acknowledge no supra-institutional framework for the adjudication of revolutionary difference, the parties to a revolutionary conflict must finally resort to the techniques of mass persuasion. Though revolutions have had a vital role in the evolution of political institutions, that role depends upon their being partially extra-political or extra-institutional events. “Like the choice between competing political institutions, that between competing paradigms proves to be a choice between incompatible modes of community life. Because it has that character, the choice is not and cannot be determined merely by the evaluative procedures characteristic of normal science, for these depend in part upon a particular paradigm, and that paradigm is at issue. When paradigms enter, as they must, into a debate about paradigm choice, their role is necessarily circular. Each group uses its own paradigm to argue in that paradigm’s defense. “Whatever its force, the status of the circular argument is only that of persuasion. It cannot be made logically or even probabilistically compelling for those who refuse to step into the circle. The premises and values shared by the two parties to a debate over paradigms are not sufficiently extensive for that. As in political revolutions, so in paradigm choice – there is no standard higher than the assent of the relevant community. To discover how scientific revolutions are effected, we shall therefore have to examine not only the impact of nature and of logic, but also the techniques of persuasive argumentation effective within the quite special groups that constitute the community of scientists.” Thomas Kuhn, The Structure of Scientific Revolutions 92-4 “When a system becomes unstable, upper-level constraints cannot maintain the system’s current configuration. There are two possible outcomes: either the system collapses to a diffuse, low level of organization; or, alternatively, a new set of upper-level constraints emerge and the system moves to a higher level of organization. In psychology, the first outcome is pathology, as the human psyche collapses and is more vulnerable to external pressure. The second is growth and learning. In this case, learning can produce a more mature condition that is more robust, existing at a higher level. In both cases the material components of which the system was made persist through the collapse. What disappears are the relationships that held the material in some special configuration. “When a system becomes unstable, often it is the normal functioning of the system that tears it apart. Positive feedbacks are unstable, in that signals introduced into the system are amplified. Any change of state causes a further change in the same direction. Pushed into an unstable configuration, positive feedbacks amplify without restraint from normal system controls. Unstable feedbacks in one part of the system set others in motion elsewhere. At the critical moment of collapse the systems usually exhibit vigorous, high-frequency behavior. This behavior can be directly attributed to the way that the positive feedbacks race unrestrained by the constraints which formerly held sway. “Racing positive feedbacks are a naked expression of dynamics. Constraints impose limits on how system parts respond to external stimuli. Stripped of all its former constraints, the system loses almost all capacity to incorporate outside influences. Any input signal can be retrieved in the output of the collapsing system, and any outside influence, even minor fluctuations, affect the system. The positive feedbacks consume biological, monetary or emotional capital, and, as long as the pathological configuration persists, the system never regains its capacity to withstand external influences. “The same initial period of excitation precedes a system collapsing to a higher level of organization. The containment of past instabilities is the very means whereby the system became complex. Lower-level dynamics that went unstable become held in a state of continuing flux in a new, larger system. The lower-level dynamics are trapped in the moment of collapse by new upper-level constraints. “When collapsing to a higher level of organization, a system stabilizes around a new set of constraints that give it more organization, and a greater capacity to ride out external influences. In the process of collapse, positive feedbacks become excited to such a degree that they encounter a new set of limitations, which act as new constraints or organizing factors. This is a general description of incorporation, where the disturbing positive feedbacks become a working part of the dynamics inside the new configuration. In contrast to positive feedbacks, negative feedbacks are self-correcting. Any signal introduced is countered, so values return to their initial levels. In the system collapsing to higher levels, the new constraints are negative feedbacks that restrain the collapsing old system, using a new set of principles. “When systems collapse to higher levels of organization, the new constraints increase the capacity of the system to wait out the effects of external influences. Whatever was the disturbance that caused the original collapse, it is now impotent in the face of the new constraints. It has done its worst, and the new constraints have met and contained the influence. The system has achieved a higher level of organization because it has the capacity to stand firm, the internal dynamics race as if in a perpetual free fall, never allowed to come to the former equilibrium. Valerie Ahl and Tim Allen, Hierarchy Theory: A Vision, Vocabulary and Epistemology 171 Socialist Hopes to Work For “Socialism: a social, economic, ecological and cultural revolution that abolishes the constraints of capitalism and in so doing, establishes a new relationship between the individual and society and between people and nature.” Gorz 4 “The logic of capitalism itself, tends intrinsically towards maximization: creating the greatest possible number of needs and seeking to satisfy them with the largest possible amount of marketable goods and services in order to derive the greatest possible profit from the greatest possible flow of energy and resources. But the link between “more” and “better” has now been broken. “Better” now may mean “less”: creating as few needs as possible, satisfying them with the smallest possible expenditure of materials, energy, and work, and imposing the least possible burden on the environment. “This can be done without impoverishment or social injustice; without reducing the quality of life, providing we are prepared to attack the source of poverty. This source is not the lack of production as such but the nature of the goods produced, the pattern of consumption which capitalism promotes, and the inequality which drives it.” Gorz 27 “Nothing other than the logic of capitalism prevents us from manufacturing and making available to everyone adequate accommodation, clothing, household equipment, and forms of transportation that are energy-conserving, simple to repair, and longlasting, while simultaneously increasing the amount of free time and amount of truly useful products available to the population. Gorz 28 “We should not disdain these almost utopian glimpses of humanity’s potentialities, with their unsullied qualities for giving and collectivity. Preliterate peoples that still lack an “I” with which to replace a “we” are not deficient in individuality as much as they are rich in community.” Murray Bookchin, The Ecology of Freedom: The Emergence and Dissolution of Hierarchy 51 “The myth that our society is more complex than earlier cultures requires short shrift: our complexity is strictly technical, not cultural; our individuality is more neurotic and psychopathic, no more unique or more intricate. What has largely replace the sinews that held community and personality together is an all-encompassing, coldly depersonalizing bureaucracy. Political categories have replaced psychological categories in much the same sense that an electrocardiograph has replaced the heart.” Murray Bookchin, The Ecology of Freedom: The Emergence and Dissolution of Hierarchy 138 “The point is not to govern people and economic processes better, but to allow everyone to take their lives into their own hands and change them, to free themselves from “external powers” and “external goals” [Marx] while establishing a radically new economy – an economy that will function “through the different standard of personal behavior [putting aside selfishness, ownership, and power] and not simply alternative procedures.” (Attali & Guillaume). Gorz 63 Michael acknowledged in a 1974 article for the Nation that most Americans continued to associate the word “socialism” with “totalitarianism, foreign ideology, and atheism.” Still, he argued, there were politically compelling reasons why liberals and socialists alike should cooperate in dispelling such illusions, for as long as socialism remained a taboo word in American political discourse, the possibilities for far-reaching and effective liberal reform would also be hampered: “American anti-socialism … helps create self-fulfilling prophecies which are extremely useful to the conservative cause. If the public is persuaded that the private sector, with its managed desires, its built-in obsolescence, its enormous unpaid social costs, is the realm of freedom, the politicians will see to it that the public sector is as underfinanced and shoddy as possible. Which of course the proves the public sector is bad, the private sector good.” Isserman 309 “In Organic Societies, the inherently nonauthoritarian relationships between children and adults is quite common. It extends not only he ties between children and adults but also to the prevailing notions of property, exchange and leadership. Here again, the terminology of western society fails us. The word property connotes an individual appropriation of goods, a personal claim to tools, land, and other resources. Conceived in this loose sense, property is fairly common in Organic Societies, even in groups that have a very simple, underdeveloped technology. By the same token, cooperative work and the sharing of resources on a scale that could be called communistic is also fairly common. On both the productive side of economic life and the consumptive, appropriation of tools, weapons, food and even clothing may range widely – often idiosyncratically, in western eyes – from the possessive and seemingly individualistic to the most meticulous, often ritualistic, parceling out of a harvest or a hunt among members of a community. “But primary to both of these seemingly contrasting relationships is the practice of usufruct, the freedom of individuals in a community to appropriate resources merely by virtue of the fact that they are using them. Function in effect replaces our hallowed concept of possession – not merely as a loan or even “mutual aid,” but as an unconscious emphasis on use itself, on need that is free of psychological entanglements with proprietorship, work, and even reciprocity. The western identification of individuality with ownership and personality with craft – the latter laden with a metaphysics of selfhood as expressed in a crafted object wrested by human powers from an intractable nature – has yet to emerge from the notion of use itself and the guileless enjoyment of needed things. Need, in effect, still orchestrates work to the point where property of any kind, communal or otherwise, has yet to acquire independence from the claims on satisfaction. A collective need subtly orchestrates work, not personal need alone, for the collective claim is implicit in the primacy of usufruct over proprietorship. Hence, even the work performed in one’s own dwelling has an underlying collective dimension in the potential availability of its products to the entire community.” Bookchin, The Ecology of Freedom: The Emergence and Dissolution of Hierarchy 50 “The Russian Communists had always been careful to specify that they were still building socialism, for if they said that they were actually entering the higher stage of Communism, then their official writ proclaimed that the state should start withering away and people should be paid according to their needs rather than according to the amount of work they did.” Harrington 229 “George Meany, President of the AFL-CIO, 1959, in Congressional testimony, “I still do not know what socialism is, despite the things that I have read. But if socialism means that under a democratic system, this republican form of government that we have, there are people who desire to secure for the great mass of people, the workers, the wage earners, the farmers, and others, a better share of what ever wealth the economy produces, and that by providing that better share we provide a broad base of purchasing power to keep the economy moving forward – if that is socialism, then I guess I am a Socialist and have been a Socialist all my life. I do not figure that, but if that is what socialism means, that is the sort of thing I am interested in.” Harrington, 268 “There is the possibility of a massive change in attitude with regard to consumption. In a socialist system, much of the waste, reduplication and pseudo-needs that are so important to capitalism would no longer be necessary, simply because the economy would be more socially rational. But there is even deeper change that can be hoped for – and promoted. “The consumption needs of people are not eternal but, once the necessities of life are taken care of, historical and social. Adam Smith, Marx remarked, regarded lawyers, priests, state officials, and soldiers as living parasitically upon production and he therefore proposed to keep their cost to a minimum. But, Marx continued, as capitalism grew more prosperous, the bourgeois lost his puritanical attitudes and became positively feudal in the support he provided for servants and other retainers. At the same time, there was, Marx noted, an increase in unproductive work – advertising, credit, insurance – within the capitalist system itself. Harrington 350 “Let us pause at this point to envision how our free community might be integrated with its natural environment. We suppose the community to have been established after a careful study has been made of its natural ecology – its air and water resources, its climate, its geological formations, its raw materials, its soils, and its natural flora and fauna. Land management by the community is guided entirely by ecological principles, so that an equilibrium is maintained between the environment and its human inhabitants. Industrially rounded, the community forms a distinct unit within a natural matrix; it is socially and aesthetically in balance with the area it occupies. Communities will blend with the world of life around them as organically as the community blends with its region. Bookchin, Post-Scarcity Anarchism 66 “Does the new technology lend itself to a system of small-scale production, based on a regional economy and structured physically on a human scale? This type of industrial organization places all economic decisions in the hands of the local community. To the degree that material production is decentralized and localized, the primacy of the community is asserted over national institutions – assuming that any such national institutions develop to a significant extent. In these circumstances, the popular assembly of the local community, convened in a face-to-face democracy, takes over the full management of social life. The question is whether a future society will be organized around technology or whether technology is now sufficiently malleable so that it can be organized around society.” Bookchin, Post-Scarcity Anarchism 57 “By this I mean creating a qualitatively new society, not merely establishing “work democracy,” an “equitable distribution of goods,” ore even “expropriating the expropriators” – ie, retaining capitalism without its capitalists. Lenin’s assertion that “socialism is state capitalism for the benefit of the people” reveals the bankruptcy of the old socialist project of appropriating the present society while unthinkingly perpetuating its old perverse traits within the “new” one. Nor do economistic libertarian movements offer us a qualitatively new alternative, however anti- authoritarian their goals. Bookchin, The Ecology of Freedom: The Emergence and Dissolution of Hierarchy 128 “There are immediate and positive programs that can make abundance a real possibility: through technological innovation, population limitation and a change in consumer tastes it is still possible to work toward a world so collectively wealthy that it can provide a decent life for every man, woman and child on the planet.” Harrington 351 “It is also possible that we will seize this opportunity and make of the earth a homeland rather than an exile. That is the socialist project. It does not promise, or even seek, to abolish the human condition, for that is impossible. It does propose to end that invidious competition and venality which, because scarcity allowed no other alternatives, we have come to think are inseparable from our humanity. “Under socialism, there will be no end to history – but there may be a new history.” Harrington 373 “In desert societies, water is so precious that it is money. People connive and fight and die over it; governments covet it; marriages are even made and broken because of it. If you were to talk to people who have known only that desert and tell them that in the city there are public water fountains and that children turn on the fire hydrants in the summer and frolic in the water, they would be sure you were crazy. “They would assume that, at night, people must come out of their houses to fill buckets and hoard water. For they know, with an existential certitude, that it is human nature to fight over water. It is in our genes. “Our problem is that humankind has lived now for several millennia in deserts of various kinds. Our minds and emotions are conditioned by that bitter experience. There are some who loathe to leave behind the consolation of familiar brutalities; there are others who in one way or another would like to impose the law of the desert upon the Promised Land. “Yet there are signs that we are, without really having planned it that way, marching out of the desert. We are beginning to know that we can end the invidious competition and venality which we had come to think were inseparable from our humanity. You and I accept the fact of societies in which at least one doesn’t die of thirst. Water is the one thing that has been socialized. Hoarding it, fighting over it, marrying for it are not part of human nature after all - because we have confidence that it will be shared. “So why can’t we go a little bit further and imagine societies in which each person also has food and shelter? In which everybody has an education and a chance to know their value? Why not?” Isserman 361 “What we are dealing with is not simply an economic transition, or a political transition. What we are dealing with are new ways of life for all the people of the Earth. By the end of the 21st century existence will nowhere, in any way, look like it does now. And if you know that and even though you know in your lifetime there will be no answer, but you understand that if there is the least possibility of freedom being the answer, it is worth a lifetime commitment. That’s what holds you together. This movement should enrich you, this movement should allow you to lead a different kind of life. This is not a burden. At its best this is a movement of joy…You will have an opportunity to make these ideas come alive.” Isserman 361 “Today, decentralization is not only desirable as a means of restoring the human scale, it is necessary to recreate a viable ecology, to preserve life on this planet from destructive pollutants and soil erosion, to preserve a breathable atmosphere and the balance of nature.” Bookchin, Post- Scarcity Anarchism 142 Protestant Work Ethic versus Buddhist Conservation Work Ethic The Protestant Work Ethic is an idea of Max Weber identified in his 1905 book, The Protestant Ethic and the Spirit of Capitalism, that hard work, discipline and frugality were values espoused by the Protestant faith. Working long hours, sacrificing family life for more income, and having conspicuous consumption opportunities are all parts of the idea of the Protestant work ethic driving the success of western technologically-driven capitalism. Buddhism makes the distinction between what is inside you and what is outside you. This is the part about the inside of me, but most of this paper is going to be about how spirits connect, how outsides can be better than they are now. I like to say that holistic health and environmental awareness are one layer apart in your consciousness, and they are separated by your skin: your body defines your physical reality, and the world you live in defines your options. This dichotomy of inner being and social/outside being has enormous political potential. Buddha (563? – 483? BCE) and Confucius (551? – 479? BCE) were contemporaries. To describe how complimentary they were, I like to spin my hands around at the wrists, and hold them back to back: with Buddha only this moment matters, and with Confucius, if you get your manners, and your policy and your calligraphy penmanship proper, then everything will turn out as it should. While Buddha and Confucius were the opposite in their view of reality, they converge on how you actually live your life, connecting together moments in time. Alas, the history of China, of India, of Southeast Asia, of Northern Asia, is a tragedy of violence and hierarchical domination. The philosophy of the Chinese/Han people is: this rotten government will eventually collapse and be replaced by a different bad government. Buddhism? Confucism? Both have led to just as much social destruction as Christianity, Judaism, and Islam. I blame patriarchy. Inside? The Buddha message has not changed in 4,000 years. But Social/Outside? What works for social organization is a whole lot different now that we have the global internet. Buddhism for the Western Mind Most of what I have seen written about Buddhism has a definite Oriental slant to it, maybe even a feeling. Whatever it is, it doesn’t work for me. Most of what I have seen has been from the perspective of a global awareness of life that most of us in the West are missing to begin with. Western people are atomized. We are individualized to a fault. Part of the discovery I hope you will find in this paper is realizing that the western model of an individual leaves a lot to be desired, a real craving for guanxi (Chinese for “relations”), a need for a sense of social community support and interpersonal connection, what the church provided a thousand years ago. But in the West, the church has lost its connection with spirituality. Maybe it works for you, but for most people, what just happened in the National Football League, or the World Cup (football or fussball), is a lot more important than going to heaven. In my wanderings, Herman Hesse, Alan Watts and others have helped put the ideas of spiritual discovery in some kind of perspective. One book, Why Buddhism is True, addresses many of my western concerns. I think you would find it useful. The main point is that the Buddhist word “dukka” is usually interpreted in the west as “to suffer” and so Buddhism is advertised as being about when you are in misery, on how to get out of your funk. But “dukkha” also means “unsatisfactoriness,” to be out of synch between what you have and what you want. So, when you are miserable, you can either change your situation, or accept it. Buddhism is about three states of being: good, neutral and bad. When life is good, time just flies by. You get a phone call from a friend, and when you hang up, an hour has disappeared. That is the way most of your life is. When something is wrong, time creeps along, and it seems that it will never improve. When you find misery, seek neutrality. Accept your pain, and live with it until you have dealt with it. That is Buddhism. End of story. There really isn’t anything else that you need. Most of the time, your life is going pretty well, and you are not in pain. When you find yourself in pain, examine why, accept it, and work to move beyond it. Why is Buddhism True was written for a class at Princeton University called “Buddhism and Modern Psychology.” It was written for the western mind. It spent some time on the New York Times best seller list, which means that some people in New York City are trying to learn how to chill. As near as I can tell, what Buddhism is really all about is coming back to the moment. Transactional Analysis as Buddhist Politics Transactional Analysis was invented in the 1960s. It was popularized by a book called “I’m OK, You’re OK”. It provides a context for a post-Freudian political analysis. The basis of Transactional Analysis is to see behavior as Adult, Parent or Child. Most people are considered mature adults, and they act accordingly. But sometimes, people do not act appropriately, and when they act like a “Child” then someone else must act as a “Parent” and take responsibility for the other person’s actions. There was a time when there was consensus about what the rules of social behavior were. We are now at a time when there is no longer an agreement about the social contract, in the U.S., and in relations between different countries. Etzioni Hazel Henderson Schumacher Beer Li: Communitarian Economics The 20th century model of economics focuses on the nation, the multi-national corporation, and large institutions. This 21st century communitarian model focuses on the individual community and the people who make it. The communitarian thesis developed by Amitai Etzioni is that individual aspirations should be protected and cultivated into community efforts. It provides an alternative to liberal individualism and a major counterpoint to authoritarian bureaucracy by stressing that strong rights presume strong responsibilities and that one should not be neglected in the name of the other. Communities can be defined with reasonable precision as having two characteristics: first, a web of affect-laden relationships among a group of individuals, relationships that often crisscross and reinforce one another (as opposed to one-on-one or chain-like individual relationships); and second, a measure of commitment to a set of shared values, norms, and meanings, and a shared history and identity – in short, a particular culture. A good society is based on a carefully crafted balance between liberty and social order, between individual rights and social responsibilities, and between pluralistic and socially established values. I assume reality – social and economic – is best described by Hazel Henderson: the economy can be graphically represented by a “cake chart,” a take-off on the pie charts economists use tirelessly to express percentages of this and that. The top layer of the cake is the “private” sector: production, employment, consumption, investment, savings. The next layer is the “public” sector: infrastructure, schools, municipal government and various services. The third layer down is the underground economy including tax dodges, black market exchange, and the like. Beneath these three “monetized” layers, in which cash is used as a means of valuation and exchange, is the non-monetized layer, based on bartering, home-based production, “sweat equity,” and what she calls the “love economy” of volunteerism: working to support family and friends with vegetables, cleaning, baby sitting, medical advice, and so on. In turn, this base layer of the human economy rests on the bottom layer of the cake, nature’s economy: the natural “resource base,” which not only ultimately provide everything basic to the human need for sustenance, but also serves to clean up our messes if we don’t get too far out of hand. [From: Ecocities: Rebuilding Cities in Balance with Nature by Richard Register] From Individual Profit to Community Sustainability: What is Human Nature? Multinational corporate capitalism justifies its cutthroat dog-eat-dog approach to people and nature by saying that is the way nature taught us. The word “economics” means management of the home. Somehow capitalism lost sight of the need to do right things well, and how to make that an improving reality. The internet, with 24/7 global instantaneous communication, allows us to think in terms of whole new ways of being. Especially in terms of how we transact business, and how we arrange to produce goods and services, there are many new ways of creating economies, ways that the 20th century economy is preventing. The battle for survival of the species into the 22nd century will depend on most of the 20th century economy – the automobile-driven suburbs – needs to disappear as inefficient. People can live in the country ecologically, and in close proximity in urban areas connected with lots of transit options, but the suburbs create all kinds of ecological and economic problems that grow worse with scale. The problem is that capitalism had the power to centralize, so they have centralized as much as they could. The result at the local/community level is a selfish, inconsiderate economy. I want to talk about the dismal science of economics, in a way that I hope is more democratic, using the language of political science to argue that we need to reconsider what we mean by economics. Economics deals with 90 percent of a society’s here and now needs, and the clumsy, exploratory, always traditionalist political structure struggles with how to address the other ten percent, and are stuck with the economy’s problems: the sickness, the conflict, the destitute and the criminal. Like a human skeleton, the political structure must define the status quo. It is the last part of a society to change. At the beginning of the 20th century, economics and political science were separated into different disciplines, with completely different views of human nature, different values and incongruent theories using different tools and methods. Economics no longer reflects reality, it only reflects the numbers that happen to be collected. This paper is about re-integrating economics and political science, focusing on the local level, the range in which an individual citizen can have an influence in creating economic activity as renewal and rejuvenation. We need a system that respects the human condition while providing broad leeway for individual exploration and cultural expression. We need a system that works in Johannesburg, Moscow, Mecca or Shanghai, as well as Northern California. Limits of Current Economic Thinking Kenneth Boulding decried what he saw as the narrow focus on commodities as the primary abstraction in contemporary economics, completely neglecting the role of human values and preferences (not to mention other species) in its models of economic exchange: Economists are understood To study goods, if not the Good, Although their goods, we often find Are pale abstractions of the mind. Boulding argues for a reexamination of the goals of economics and a reordering of the relative priorities of progress, stability, justice and freedom. In John Kenneth Galbraith’s The Age of Uncertainty: A history of economic ideas and their consequences, (1985) he concludes his chapter on John Maynard Keynes: “There are other problems. Keynesian support to the economy has come to involve heavy spending for arms. This, we’ve seen, is blessed as sound while spending for welfare and the poor is always thought dangerous. With time, too, it has become evident that Keynesian progress can be an uneven thing: many automobiles, too few houses; many cigarettes, too little health care. The great cities are in trouble. As these problems have obtruded, the confident years have come to an end. The Age of Keynes was for a time but not for all time.” This from the self-proclaimed Crown Prince of Keynesianism. In his chapter on Metropolis, Galbraith gets to the heart of our multi-pronged problem: “On two other matters the prospect is more grim. First there is the fact that capitalism performs excellently in providing things – automobiles, disposable packaging, drugs, alcohol – that cause problems for the city. But it is inherently incompetent in providing the things that city dwellers most urgently need. Capitalism has never anywhere provided good houses at moderate cost. Housing, it seems unnecessary to stress, is an important adjunct of a successful urban life. Nor does capitalism provide good health services, and when people live close together with attendant health risks, these too are important. They are made more urgent because, on coming to the city, people no longer accept as inevitable untended sickness and then a quiet death as they would in some lonesome sharecropper’s cabin. Nor does capitalism provide efficient transportation for people – another essential of the life of the metropolis. “In Western Europe and Japan the failure of capitalism in the fields of housing, health care and transportation is largely, though not completely, accepted. There industries have been intensively socialized. In the U.S. there remains the conviction that, however contrary to experience, private enterprise will eventually serve. To assert that the inherently public character of these industries, even though the practice affirms it, still seems radical. Nothing is now so important as to agree that the nature of these services is public and then to ensure that their performance is not merely a matter of adequacy but of pride. City life will never be good while housing, health care and transportation are poor. “There is a larger need. That is to see far more clearly than at present the essentially social character of the metropolis. In its days of greatest elegance, the city was a household, and extension of the domestic arrangements of the ruler. No line then separated private from public tasks. Construction, artistic embellishments and maintenance of the city – what would now be regarded as public tasks – may well have absorbed the larger share of the aggregate public and private income. With the Industrial City it came to be assumed that the payment for public tasks – education, police protection, courts, sanitation, recreation, public entertainment, care of the old and impoverished – would be only a small subtraction from the total revenue. The private household, no one doubted, had the major claim. “This continues to be the assumption. The consequences all recognize. Among the affluent and even among the poor, services supplied out of private income are far more amply endowed than those provided by the city. Houses are clean, streets are filthy. Personal wealth expands; there are too few police officers to protect it. Television sets are omnipresent; schools are deficient. “Where capitalism is efficient, it adds to the public tasks of the city; it increases the number of automobiles that must be accommodated in and through the city, adds to the detritus that must be picked up from the streets and makes progressively more difficult the problem of keeping breathable the air and sustaining a minimum tranquility of life. “This is another way of saying that the social aspect of modern metropolitan life is extremely expensive, far more expensive than we have yet imagined.” The result at the local/personal level is an economy that is complete chaos. Most people have a difficult time navigating the economy with their career. Eric Fromm looks at the problems with current institutional reality, his conclusion from The Art of Loving, 1956. "Here however, an important question arises. If our whole social and economic organization is based on each one seeking his own advantage, if it is governed by principle of egotism tempered only by the ethical principle of fairness, how can one do business, how can one act within the framework of existing society and at the same time practice love? Does the later not imply giving up all one's secular concerns and sharing the life of the poorest? This question has been raised and answered in a radical way by the Christian monks, and by persons like Tolstoi, Albert Schweitzer, and Simone Weil. There are others who share the opinion of the basic incompatibility between love and normal secular life within our society. They arrive at the result that to speak of love today means only to participate in the general fraud; they claim that only a martyr or a mad person can love in the world of today, hence that all discussion of love is nothing but preaching. This very respectable viewpoint lends itself readily to a rationalization of cynicism. Actually it is shared implicitly by the average person who feels "I would like to be a good Christian - but I would have to starve if I meant it seriously." This "radicalism" results in moral nihilism. Both the "radical thinkers" and the average person are unloving automatons and the only difference between them is that the latter is not aware of it, while the former knows it and recognizes the "historical necessity" of this fact. "I am of the conviction that the answer of the absolute incompatibility of love and "normal" life is correct only in an abstract sense. The principle underlying capitalistic society and the principle of love are incompatible. But modern society seen concretely is a complex phenomenon. A salesman of a useless commodity, for instance, cannot function economically without lying; a skilled worker, a chemist, or a physician can. Similarly, a farmer, a worker, a teacher, and many a type of businessman can try to practice love without ceasing to function economically. Even if one recognizes the principle of capitalism as being incompatible with the principle of love, one must admit that "capitalism" is in itself a complex and constantly changing structure which still permits of a good deal of non-conformity and of personal latitude. "In saying this, however, I do not wish to imply that we can expect the present social system to continue indefinitely, and at the same time to hope for the realization of the ideal of love for one's brother. People capable of love, under the present system, are necessarily the exceptions; love is by necessity a marginal phenomenon in present-day Western society. Not so much because many occupations would not permit of a loving attitude, but because the spirit of a production-centered, commodity-greedy society is such that only a non-conformist can defend himself successfully against it. "Those who are seriously concerned with love as the only rational answer to the problems of human existence must, then, arrive at the conclusion that important and radical changes in our social structure are necessary, if love is to become a social and not a highly individualistic, marginal phenomenon. The direction of such changes can, within the scope of this book, only be hinted at. Our society is run by a managerial bureaucracy, by professional politicians; people are motivated by mass suggestion, their aim is producing more and consuming more, as purposes in themselves. All activities are subordinated to economic goals, means have become ends; human is an automaton - well fed, well clad, but without any ultimate concern for that which is his peculiarly human quality and function. "If human is to be able to love, he must be put in his supreme place. The economic machine must serve him, rather than he serve it. He must be enabled to share experience, to share work, rather than, at best, share in profits. "Society must be organized in such a way that human's social, loving nature is not separated from his social existence, but becomes one with it. If it is true, as I have tried to show, that love is the only sane and satisfactory answer to the problem of human existence, then any society which excludes, relatively, the development of love, must in the long run perish of its own contradiction with the basic necessities of human nature. Indeed, to speak of love is not "preaching," for the simple reason that it means to speak of the ultimate and real need in every human being. That this need has been obscured does not mean that it does not exist. To analyze the nature of love is to discover its general absence today and to criticize the social conditions which are responsible for this absence. To have faith in the possibility of love as a social and not only exceptional-individual phenomenon, is a rational faith based on the insight into the very nature of humanity." What most people think of as 20th century economic reality does not have to be that way. The internet gives us the power to decide to design parts of the economy, parts of the Visible Hand to work to protect everyone, and not just the top 1% the way it is now. Where capitalism seems driven to find a machine process to substitute for human activity, the focus of the economy should instead be to be on meeting human needs on the production side with an emphasis on sustainability and reliance on renewable resource use, not an emphasis on profit. Eric Fromm sounds Buddhist: “Care, responsibility, respect and knowledge are mutually interdependent. They are a syndrome of attitudes which are to be found in the mature person; that is, in the person who develops their own powers productively, who only wants to have that which they have worked for, who have given up narcissistic dreams of omniscience and omnipotence, who have acquired humility based on the inner strength which only genuine productive activity can give.” Lewis Mumford points out that the real action is in The Culture of Cities (1938); “The city, as one finds it in history, is the point of maximum concentration for the power and culture of a community…The city is a fact of nature, like a cave, a run of mackerel, or an ant heap. But it is also a conscious work of art, and it holds within its communal framework many simpler and more personal forms of art. Mind takes form in the city; and in turn, urban forms condition mind… With language itself, it remains man’s greatest work of art. The nature of the city is not to be found simply in its economic base; the city is primarily a social emergent. The mark of the city is its purposive social complexity.” So the challenge is ecologically efficient social action. The answer proposed in this paper is “decentralization” to the community level. The underlying theme is that 5,000 years of centralization of power has created sequences of problems that can only be solved by finding the appropriate political and economic scale with communities of around 10,000 people, and then scaling up as needed. “Gandhi once said it was foolish to dream of systems so perfect that people would no longer need to be good. I would rather contemplate a system so simple that people would no longer need to be bad – that is to say, a system of support and sustenance, of rough equality and comfort, that would so guide and goad, chide and chivvy, prompt and protect, that individuals in it would be inclined out of sheer self- and community- interest toward morality and harmony. The small community has provided such a system – not molded through any special design, nor guided by any millennial genius, nor organized by any party or sect, but simply by working out the rough, hard problems of existence as they have come along for many thousands of years.” Kirkpatrick Sale, Human Scale 490 What Guanxi means: personal sense of community My favorite word in Chinese is “guanxi” which literally translates into “relations” and I believe means the social community that makes up a person’s life. This essay is an expansion of what I believe the word guanxi means. The world of academic psychology in the 21st century is confused, chaotic and splintered in a million different directions. The only thing you can be sure of about a psychology professor is that they are different from everybody else. I blame that confusion on the mythological chaos of the thinking of Freud, which has dominated the political thinking of the 20th century. I am using the term the 20th century to refer to the current obsession with technology, especially around the economic technology of money as though it has value. Fritz Schumacher, Protégé to John Maynard Keynes History goes in cycles, and this one started with East and West divergence about the time of the invention of gunpowder. From 1700 on, the invention of new technology has driven the emergence of a global political economy. The premier idea has been “capitalism,” which emphasizes profit for the top of the organization, then new equipment that improves productivity, at the expense of the other people in the organization who are expected to produce the finished product. These new ideas are called “labor-saving” and that is the primary mechanism by which the values drive the growth machine called the economy. For 21st century psychology, we need a new mainstream view of human nature to replace Freud, which I believe the cognitive scientists have done. To me, the most contemporary science on human behavior confirms the findings of the convergence of the Buddha and Confucius. The leader of guanxi economics is Fritz Schumacher, who discovered that the people in Burma were not that materially modern, but they were happier than most people in modern society. Ernst Friedrich Schumacher was a German graduate student in economics who escaped to England from Nazi Germany in 1933. He became the protégé of John Maynard Keynes. After Germany was defeated, Fritz was part of the group that redesigned Germany. My first video camera work was at Fritz’s 1977 press conference at the UCD Memorial Union; the memorable part was his description of how the US-UK-French Allies redesigned the German economy so that they could take it back in 24 hours. So the German economy doesn’t have the vestiges of the past that haunt France and Italy: archaic family traditions dominated by the church and the mafia, which is why the German economy is the most responsive economy in the world. Then for 20 years, Fritz was the chief economist for the British national coal board, when it controlled the production of coal for the country. At the request of India’s leader Nehru, Fritz developed the idea of appropriate technology, and intermediate technology, rather than the obsession with large technology. Fritz’s most basic idea is that a “tool” is something that a human can control, and a “machine” is something that is so big and dominant that it controls the thinking of the people who use it. A tool serves people, and a machine forces people to serve it. Based on Fritz’s ideas about work, I want to develop a 21st century economics where the religious focus shifts from money to community satisfaction as the highest value. Communitarian economics. To structure this analysis, I am making the distinction about 1) how traditional economists view human nature as male/rational, “machine,” 2) how the changes in big organizations have tried to cope with all the challenges forced by the 20th century Freudian model of human nature, as behavioral, “human,” and 3) how 21st century Buddhist consciousness view of human nature, female/comprehensive, “people.” This 1-machine, 2-human, 3-people distinction is the basic foundation of this essay. The 20th century economic theories are all based on the 1-machine model of human nature. That is so far from reality that it is hard to imagine who an economist is thinking about when they do their work. Certainly not themselves or any of their colleagues, let alone anyone else in their families. The 1-machine model of human nature is such a big problem with the design of the economy because it is fundamentally incongruent with human nature, so every day most people bump into the economy, and spend most of their workday fighting it. Having a production oriented economic system actually doesn’t work for the rich any better than it does the working poor. They just think they can afford to buy their way out of whatever mess they find themselves in. The 1-machine economy has grown enormously expensive, complex, and destructive to the environment and society. The 2-human economy isn’t much better. Its philosophy is how to cope with the problems. The 3-people economy focuses on meeting real personal needs, family needs and community needs. Sustainability within the context of the current cultural environment. That is very different than capitalism. Basically Fritz believed that modest scale works much better than vast massive industrial concentration which entail imbalance, waste, ineptitude and diseconomies of scale – un-necessary long past the point of un-economical, called “too big to fail.” The word “economics” means managing the home. This essay is an exploration of what a 3- people oriented economic model would look like, compared to the 1-machine oriented model that justifies the 20th century economy we have today. Small is Beautiful: Economics as if People Mattered: 25 Years Later with Commentaries by Fritz Schumacher Buddhist Economics Spiritual health and material well-being are not enemies: they are natural allies. There is an optimal human scale, size, or relationship inherent in economic activity, a geometry of life that is independent of economic theory. There are inherent thresholds in the scale of human activity that, when surpassed, produce second- and third-order effects that subtract if not destroy the quality of life. The emerging global economy and the growing domination of science and technology are not only severing our connection to nature and to one another but also breaking down natural and cultural diversity. In so doing, we are threatening our very existence. It is in robust, local-scale economies that we find genuinely “free” markets; free of corporate manipulation, hidden subsidies, waste, and immense promotional costs that characterize today’s global market. Decentralization is a prerequisite for rekindling of community in Western society. Mobility erodes community, but as we put down roots and feel attachment to a place, our human relationships deepen, become more secure, and as they continue over time, more reliable. Great damage to human dignity has resulted from the misguided attempt of the social sciences to adopt and imitate the methods of the physical sciences. Economics, and even more so applied economics, is not an exact science; it is in fact, or ought to be, something much greater: a branch of wisdom. George McRobie: A Buddhist approach to economics would distinguish between misery, sufficiency, and surfeit or surplus. Economic growth would be good only to the point of sufficiency. Limitless growth and consumption would be disastrous. Secondly, a Buddhist economics would be based squarely on renewable resources: an economics of permanence. In contrast, Western economics is based on the ruthless exploitation of nonrenewable resources, and recognizes no limits to production and consumption – a nonsustainable system. Traditional wisdom teaches that the function of work is at heart threefold: 1) to give a person a chance to utilize and develop his faculties; 2) to enable him to overcome his inborn egocentricity by joining with other people in a common task; and, 3) to bring forth the goods and services needed by all of us for a decent existence. To organize work in such a manner that it becomes meaningless, boring, stultifying, or nerve-racking for the worker would be little short of criminal; it would indicate a greater concern with goods than with people, an evil lack of compassion and a soul-destroying degree of attachment to the most primitive side of this worldly existence. Equally, to strive for leisure as an alternative to work would be considered a complete misunderstanding of one of the basic truths of human existence, namely that work and leisure are complementary parts of the same living process and cannot be separated without destroying the joy of work and the bliss of leisure. From the Buddhist point of view, there are therefore two types of mechanization which must be clearly distinguished: one that enhances a man’s skill and power and one that turns the work of man over to a mechanical slave, leaving man in a position of having to serve the slave. It is clear, therefore, that Buddhist economics must be very different from the economics of modern materialism, since the Buddhist sees the essence of civilization not in the multiplication of wants but in the purification of human character. Character, at the same time, is formed primarily by a man’s work. And work, properly conducted in conditions of human dignity and freedom, blesses those who do it and equally their product. It is standing the truth on its head to consider goods to be more important than people and consumption more important than creative activity. While the materialist is mainly interested in goods, the Buddhist is mainly interested in liberation. But Buddhism is “The Middle Way” and therefore in no way antagonistic to physical well-being. It is not wealth that stands in the way of liberation but the attachment to wealth; not the enjoyment of pleasurable things but the craving for them. The keynote of Buddhist economics, therefore, is simplicity and non-violence. From an economist’s point of view, the marvel of the Buddhist way of life is the utter rationality of its pattern – amazingly small means leading to extraordinarily satisfactory results. Buddhist economics is the systematic study of how to attain given ends with the minimum means. Optimum rather than maximum. The Role of Economics Quality is much more difficult to “handle” than quantity, just as the exercise of judgment is a higher function than the ability to count and to calculate. Quantitative differences can be more easily grasped and certainty more easily defined than qualitative differences; their concreteness is beguiling and gives them the appearance of scientific precision, even when this precision has been purchased by the suppression of vital differences of quality. Numbers can only measure what is similar, at the expense of all the other ways that particular category are different. Peace and Permanence Economic growth, which viewed from the point of view of economics, physics, chemistry and technology, has no discernible limit, must necessarily run into decisive bottlenecks when viewed from the point of view of the environmental sciences. An attitude of life which seeks fulfillment in the single-minded pursuit of wealth – in short, materialism – does not fit into this world, because it contains within itself no limiting principle, when the environment in which it is placed is strictly limited. Already, the environment is trying to tell us that certain stresses are becoming excessive. As one problem is being “solved, “ ten new problems arise as a result of the first “solution.” As Professor Barry Commoner emphasizes, the new problems are not the consequences of incidental failure but of technological success. The developments of science and technology over the last hundred years have been such that the dangers have grown even faster than the opportunities. The idea of unlimited economic growth, more and more until everybody is saturated with wealth, needs to be seriously questioned on at least two counts: the availability of basic resources and, alternatively or additionally, the capacity of the environment to cope with the degree of interference implied. There is need for a proper philosophy of WORK which understands work not as that which it has indeed become, an inhuman chore as soon as possible to be abolished by automation, but as something “decreed by Providence for the good of man’s body and soul.” Next to the family, it is work and the relationships established by work that are the true foundation of society. If the foundations are unsound, how can the society be sound? And if society is sick, how could it fail to be a danger to peace? Economically, our wrong living consists primarily in systematically cultivating greed and envy and thus building up a vast array of totally unwarrantable wants. It is the sin of greed that has delivered us over into the power of the machine. If greed were not the master of modern man – ably assisted by envy – how could it be that the frenzy of economism does not abate as higher “standards of living” are attained, and that it is precisely the richest societies which pursue their economic advantage with the greatest ruthlessness? How could we explain the almost universal refusal on the part of the rulers of rich societies – whether organized along private enterprise or collectivist enterprise lines – to work towards the humanization of work? It is only necessary to assert that something would reduce the “standard of living,” and every debate is instantly closed. That soul-destroying, meaningless, mechanical, monotonous, moronic work is an insult to human nature which must necessarily and inevitably produce either escapism or aggression, and that no amount of “bread and circuses” can compensate for the damage done – these are facts which are neither denied nor acknowledged but are met with an unbreakable conspiracy of silence – because to deny them would be too obviously absurd and to acknowledge them would condemn the central preoccupation of modern society as a crime against humanity. A Question of Size William Rees: Urbanization blinds the modern eye to ecological reality by separating people both spatially and psychologically from the ecosystems that (still) support them. The fact remains that cities require ever greater quantities of food, resource commodities, and energy – all often shipped great distances – to sustain the increasingly consumer lifestyles of their inhabitants. The simplest things, which only 50 years ago one could do without difficulty, cannot get done any more. The richer a society, the more impossible it becomes to do worthwhile things without immediate pay-off. The economics of giantism and automation is a left-over of nineteenth century conditions and nineteenth century thinking, and it is totally incapable of solving any of the real problems of today. An entirely new system of thought is needed, a system based on attention to people, and not primarily to goods – (the goods will look after themselves!). It could be summed up in Gandhi’s phrase, “production by the masses, rather than mass production.” What is the meaning of democracy, freedom, human dignity, standard of living, self- realization, fulfillment? Is it a matter of goods, or of people? Of course it is a matter of people. But people can be themselves only in small comprehensible groups. If economic thinking cannot grasp this it is useless. If it cannot go beyond its vast abstractions, and make contact with the human realities, then let us scrap economics and start afresh. Some of The Facts of Life At present, there can be little doubt that the whole of humankind is in mortal danger, not because we are short of scientific and technological know-how, but because we tend to use it destructively without wisdom. More education can help us only if it produces more wisdom. David Orr: The heart of the modern predicament is not simply the problem of overcoming the gulf between scientists and everybody else, as C.P. Snow put it in “Two Cultures.” It is rather a far deeper problem in which know-how has preceded know-why because our central convictions have been thrown into disorder. Man, whether civilized or savage, is a child of nature – he is not the master of the universe. He must conform his actions to certain normal laws if he is to maintain his dominance over his environment. When he tries to circumvent the laws of nature, he usually destroys the natural environment that sustains him. And when his environment deteriorates rapidly, his civilization declines. What is “rational” and what is “sacred”? Is man the master of nature or its child? If it becomes “economical” to synthesize food from inorganic materials – “which is likely to happen sooner or later” – if we become independent of plants, the connection between topsoil and civilization will be broken. Or will it? The most striking thing about modern industry is that it requires so much and accomplishes so little. Modern industry seems to be inefficient to a degree that surpasses one’s ordinary powers of imagination. Its inefficiency therefore remains unnoticed. Technology with a Human Face A technology with a human face, which, instead of making human hands and brains redundant, helps them to become far more productive than they have ever been before. As Gandhi said, the poor of the world cannot be helped by mass production, only by production by the masses. The system of mass production, based on sophisticated, highly capital- intensive, high energy-input dependent, and human labor-saving technology, presupposes that you are already rich, for a great deal of capital investment is needed to establish one single workplace. The system of production by the masses mobilizes the priceless resources which are possessed by all human beings, their clever brains and skillful hands, and supports them with first-class tools. The technology of mass production is inherently violent, ecologically damaging, self-defeating in terms of non-renewable resources, and stultifying for the human person. The technology of production by the masses, making use of the best of modern knowledge and experience, is conducive to decentralization, compatible with the laws of ecology, gentle in its use of scarce resources, and designed to serve the human person instead of making him the servant of machines. I have named it intermediate technology, to signify that it is vastly superior to the primitive technology of bygone ages but at the same time much simpler, cheaper, and freer than the super-technology of the rich. One can also call it self-help technology, or democratic or people’s technology – a technology to which everybody can gain admittance and which is not reserved to those already rich and powerful. Although we are in possession of all requisite knowledge, it still requires a systematic, creative effort to bring this technology into active existence and make it generally visible and available. It is rather more difficult to recapture directness and simplicity than to advance in the direction of ever more sophistication and complexity. Social and Economic Problems Calling for the Development of Intermediate Technology Maximize labor options rather than maximize output/person. A new state of mind: a country where labor has become precious and must be put to the best possible use. Maximize the work opportunities for the unemployed and the underemployed. More labor using forms of organization. Economic Development: First, that workplaces have to be created in the areas where the people are living now, and not primarily in metropolitan areas into which they tend to migrate. Second, that these workplaces must be, on average, cheap enough so that they can be created in large numbers without this calling for an unattainable level of capital formation and imports. Third, that the production methods employed must be relatively simple, so that the demands for high skills are minimized, not only in the production process itself but also in matters of organization, raw material supply, financing, marketing, and so forth. Fourth, that production should be mainly from local materials and mainly for local use. Mark Roseland: The main goal of the Appropriate Technology movement is to enhance the self- reliance of people on the local level. Characteristics of self-reliant communities that Appropriate Technology can help facilitate include: low resource usage coupled with extensive recycling; preference for renewable over nonrenewable resources; emphasis on environmental harmony; emphasis on small-scale industries; and a high degree of social cohesion and sense of community. Much depends on geography and local circumstances. Each “district,” ideally speaking, would have some sort of inner cohesion and identity and possess at least one town to serve as a district center. There is need for a “cultural structure” just as there is need for an “economic structure”: thus, while every village would have a primary school, there would be a few small market towns with secondary schools, and the district center would be big enough to carry an institution of higher learning. The bigger the country, the greater the need for internal “structure” and for a decentralized approach to development. If this need is neglected, there is no hope for the poor. George McRobie: Our starting point was that mass unemployment and rural misery could be overcome only by creating new workplaces in the rural areas – low-cost workplaces that could be created in large numbers, where production methods and associated services were relatively simple, and used local materials for local use. We used the term “intermediate” to indicate that, in terms of cost per workplace, the technology appropriate to a poor country would be somewhere between the cost of a primitive hand tool, and the $40,000 cost of a combine harvester. Thus if a developing country insisted on technologies that needed $40,000 for each new workplace, obviously, being short of capital, relatively few jobs could be created. But with a technology that cost $500, the country could create 80 times as many jobs. The best engineering talent available should be engaged in the task of creating low-cost technologies: tools and equipment that could be owned and controlled by the rural and urban poor with which they could work themselves out of poverty. The idea of intermediate technology does not imply simply a “going back” in history to methods now outdated, although a systematic study of methods employed in the developed countries, say, a hundred years ago could indeed yield highly suggestive results. It is too often assumed that the achievement of Western science, pure and applied, lies mainly in the apparatus and machinery that have been developed from it, and that a rejection of the apparatus and machinery would be tantamount to a rejection of science. This is an excessively superficial view. The real achievement lies in the accumulation of precise knowledge, and this knowledge can be applied in a great variety of ways, of which the current application in modern industry is one. The development of intermediate technology, therefore, means a genuine forward movement into new territory, where the enormous cost and complication of production methods for the sake of labor saving and job elimination is avoided and technology is made appropriate for labor-surplus societies. Economic development is something much wider and deeper than economics, let alone econometrics. Its roots lie outside the economic sphere, in education, organization, discipline, and beyond that, in political independence and a national consciousness of self-reliance. It cannot be “produced” by skillful grafting operations carried out by foreign technicians or an indigenous elite that has lost contact with the ordinary people. It can succeed only if it is carried forward as a broad, popular “movement of reconstruction” with primary emphasis on the full utilization of the drive, enthusiasm, intelligence, and labor power of everyone. Success cannot be obtained by some form of magic produced by scientists, technicians, or economic planners. It can come only through a process of growth involving education, organization and discipline of the whole population. Anything less than this will end in failure. Economic development is primarily a question of getting more work done. For this, there are four essential conditions. First, there must be motivation; second, there must be some know- how; third, there must be some capital; and fourth, there must be an outlet: additional output requires additional markets. A Machine to Foretell the Future? Tempting as it may be to compare the ancient oracles and the modern computer, only a comparison by contrast is possible. The former deal exclusively with qualities; the later with quantities. Helena Norberg-Hodge: Our mainstream culture encourages a linear view of progress, one in which the goal is to free ourselves from our past and from the laws of nature. The modern- day mantra, “we cannot go back, we cannot go back,” is deeply ingrained in our thinking. Of course we could not go back, even if we wanted to, but our search for a future that works is inevitably bringing us back to certain fundamental patterns that are in greater harmony with nature – including human nature. It is not so much forecasting technique, as a full understanding of the current situation that can help in the formation of a sound judgment of the future. Helena Norberg-Hodge: The fabric of industrial society is to a great extent determined by the interaction of science, technology, and a narrow economic paradigm – an interaction that is leading to ever-greater centralization and specialization. Since the Industrial Revolution, the perspective of the individual has become more limited while political and economic units have grown larger. I have become convinced that we need to decentralize our political and economic structures and broaden our approach to knowledge if we are to find our way to a more balanced and sane society. In Ladakh, I have seen how human-scale structures nurture intimate bonds with the earth and an active and participatory democracy, while supporting strong and vital communities, healthy families, and a greater balance between male and female. These structures in turn provide the security needed for individual well-being and paradoxically, for a sense of freedom. Good Work, by Fritz Schumacher Who, it may be asked, calls the tune? Fundamentally, the technologist. Whatever becomes technologically possible – within certain economic limits – must be done. Society must adapt itself to it. The question whether or not it does any good is ruled out on the specious argument that no one knows anyhow what is good or evil, wholesome or unwholesome, worthy of man or unworthy. Professor A. Hill says in his book The Ethical Dilemma of Science: “To imagine that scientific and technical progress alone can solve all the problems that beset mankind is to believe in magic, and magic of the very unattractive kind that denies a place to the human spirit.” What I wish to emphasize is that the modern industrial system does in fact just this and is effectively denying a place to the human spirit. Too much contact with machinery has convinced the masters of the system that economic development is a mechanical, i.e., unalterable, process which could only be thrown into disorder but never stopped or modified by the intrusion of value judgments. Modern industry, by producing comfort on a scale unheard of in human history yet almost destroying the real educational function of daily work, quite clearly sets the most difficult examination task: how not to lose sight of the spiritual in face of the these overwhelming temptations. Why should industrial society fail? Why should the spiritual evils it produces lead to worldly failure? From a severely practical point of view, I should say this: 1. It has disrupted, and continues to disrupt, certain organic relationships in such a manner that world population is growing, apparently irresistibly, beyond the means of subsistence. 2. It is disrupting certain other organic relationships in such a manner as to threaten those means of subsistence themselves, spreading poison, adulterating food, etc. 3. It is rapidly depleting the earth’s nonrenewable stocks of scarce material resources – mainly fuels and metals. 4. It is degrading the moral and intellectual qualities of man while further developing a highly complicated way of life the smooth continuance of which requires ever-increasing moral and intellectual qualities. 5. It breeds violence – a violence against nature which at any moment can turn into violence against one’s fellow men, when there are weapons around which make nonviolence a condition of survival. If our technology has been created mainly by the capitalist system, is it not probable that it bears the marks of its origin, a technology for the few at the expense of the masses, a technology of exploitation, a technology that is class-oriented, undemocratic, inhuman, and also unecological and unconservationist? I do not wish to overstate the case: there is nothing absolutely clear-cut in this world and, no doubt, many different tunes can be played on the same piano; but whatever is played, it will be piano music. I agree with the general meaning of Marx’s rhetorical question: Does it require deep intuition to comprehend that man’s ideas, views, and conceptions – in a word, man’s consciousness – changes with every change in the conditions of his material existence, in his social relations and in his social life? Social context defines options and choices Consider the effect of modern technology on human freedom. This is undoubtedly a tricky subject. What is freedom? Instead of going into long philosophical discussions, let us ask the more or less rebellious young what they are looking for. Their negations are such as these: I don’t want to join the rat race. Not be enslaved by machines, bureaucracies, boredom, ugliness. I don’t want to become a moron, robot, commuter. I don’t want to become a fragment of a person. I want to do my own thing. I want to live (relatively) simply. I want to deal with people, not masks. People matter. Nature matters. Beauty matters. Wholeness matters. I want to be able to care. All this I call a longing for freedom. Technology has taken the wrong turn in four directions: 1. A trend for everything to become bigger and bigger, a tendency towards giantism. 2. A tendency that things are becoming more complex, and therefore more likely to break down. 3. Things have become so capital costly that you have to be already rich and powerful before you can do anything. 4. A widening conception of violence induced by new technology is ecologically an ever increasing warfare against nature: the violent attitude that science can do everything. If this is the correct diagnosis of the development of the last hundred years – ever-bigger size, ever-bigger complexity, ever-bigger capital intensity, and ever-bigger violence – then it would seem to follow that the cure must be sought in the opposite direction. But the cure is not found necessarily in going back, because in a hundred years, in the only knowledge that can accumulate, namely scientific knowledge, knowledge of dead matter really – there will be a great deal of progress. And things that were not possible to do very easily on a small scale in the 19th century we can do on a small scale now. But not when the engineers have been brainwashed and educated all their lives in the opposite direction, so they don’t believe it. It is possible to make things smaller – I’m not saying in every instance, but as regards all basic human requirements. Second, it is possible to do many things in a much simpler way. Any third-rate engineer can make a complicated apparatus more complicated, but it takes a touch of genius to find one’s way back to the basic principles, which are normally fairly simple. Once we go and get down to work, we find we learn to distinguish what is essential and what are sort of almost cancerous growths. If you think in these terms, and look at modern machine tools, you then learn to distinguish between the tool and the machine tool. That, of course, should be the best that human ingenuity can make, and normally it is a very simple thing. And third, if one realizes that the immense capital requirements are a principle of exclusion, are totally incompatible with any ideas of social justice or equality, then one will systematically search for cheaper ways of doing things. And fourth, let’s look in the direction of non-violence. This refers to modes of production which respect ecological principles and strive to work with nature instead of attempting to force their way through natural systems, in the conviction that unintended damage and unforeseen side effects can always be undone by the further application of violence. All too often one problem is “solved” by creating several new ones. Experience shows that whenever you can achieve smallness, simplicity, capital cheapness and nonviolence, or, indeed, any one of these objectives, new possibilities are created for people, singly or collectively, to help themselves, and that the patterns that result from such technologies are more humane, more ecological, less dependent of fossil fuels, and closer to real human needs than the patterns (or life-styles) created by technologies that go for giantism, complexity, capital intensity and violence. We are not going to go on waiting for the central government. We are going to stand on our own two feet and do within the context of our community what needs doing. This sort of self-remembering is now coming, and people are realizing that in order to make what needs doing efficient and effective one must engage intellectual resources to create an appropriate, suitable technology. Working the other side of the street from what Schumacher called “the people of the onward stampede” are what he called “homecomers,” people who more than anything else share a concern about the scale in their lives. They want to bring the perimeters in. Operate closer to home. They want to take responsibility for their lives and the effects of their activities both direct and indirect, and hence they tend to direct energy and attention – once they have had the experience of the macrosystems – toward things they can affect directly. The renewing economy sees a nearly limitless growth potential based on keeping the self- generating, self-regulating, self-disciplining productive capacities of human beings in full partnership with nature, where both are able to operate in accordance with the deepest laws governing their living and flowering. Part of the problem comparing the conventional economy with the renewable economy is that the two economies use different yardsticks to judge things: one measures money, the other measures value. For the conventional, exhausting economy, the gross national product is the standard indicator. But the meta-economist would ask why the GNP would include a table you buy, but not a table you make. Much of what a meta-economist values does not show up in the conventional indicators. In the question periods after his talks, Schumacher would invariably get asked by someone in the audience, “But what can I do?” His simple answer was “Do three things, one after the other, one leading into the other. Inform yourself: Accept the necessity that you will have to begin consciously building your own new map of reality. Support others who are already at work. Initiate where you can and how you can.” And then he said something else, “Start where you are. But start. Don’t wait for the perfect situation.” Work is good when it engages what Huston Smith and others have called “the vertical dimension” of life, the deepest and highest values and motivations that underlie the universe and all human life and activity. To see work as a day-to-day expression of value makes it of far more than economic significance. Then it is no less than the place where our temporal and spiritual dimensions converge to create acts in the world German Mark Stabilizes the World January 1, 2021 The Potential Collapse of the U.S. Dollar as the Dominant Foreign Exchange Reserve Reserve currencies come and go. International currencies in the past have included the Greek drachma, coined in the fifth century B.C., the Roman denari, the Byzantine solidus and Arab dinar of the middle-ages, the Venetian ducato and the Florentine florin of the Renaissance, the seventeenth century Dutch guilder, and the French franc. To understand the temporary power of the lifecycle of a global currency, the British Pound suggests the best pattern. With the defeat of the Spanish Armada in 1588, the Great Britain ruled the seven seas. The British colonialization package included liberal democratic institutions and Christian missionaries in the name of free trade. Beginning in 1700, the industrial revolution meant Britain expanded global markets for manufactured goods, and invented taxes to finance the permanent global Navy, as well as to finance wars. Recall that the problems with the American colonies started over a stamp tax to finance the French & Indian War in North America. It was within this naval-industrial-commercial-military global domination that the British Pound became the global currency. In 1860, over 60% of world trade was in Pound Sterling, which gave the United Kingdom great political power. World War I had many costs for the UK, and the Pound suffered. When the Depression hit, the Pound never really recovered. World War II changed the map: US world military domination, undamaged industrial capacity, a million GIs returning to go to work – and the swagger to walk in the room expecting to get everything you want. The US Dollar ruled the world; it still does today. But everything behind the Dollar has fallen apart. The final year of US global economic dominance was 1973. When OPEC came into being, the US became a trade net importer, and it has been every year since. From 1974 to 1992, the US had a net surplus of services to compensate, but ever since Clinton became President, the US had been a net importer. Every other country, including China, has presumed that the US Dollar would maintain its power so it is the reserve currency held in significant quantities by governments and institutions as over 60% of their total foreign exchange reserves today. Over 70% of all trade transactions are in Dollars. The pattern has been for the US to import $500 billion from China, and export $150 billion for a net import with China of about $350 billion a year. Trump’s plan is to force China to buy more US agriculture to make up some of the difference, but the problem is that the US consumes more than it makes, and it has for decades. There is now an enormous imbalance because the US public presumes that its post-World War II conspicuous consumption lifestyle is its birthright. The Inevitable Collapse of the US Dollar as the Global Currency It is only a matter of time before the Tower of Babel that is the use of US Dollars by a majority of the foreign countries will end. At the beginning of World War I, the power of the British Pound was shaky at best, based on the Gold Standard. In 1944, at Bretton Woods where the International Monetary Fund and the World Bank were invented, the US Dollar pretty much replaced the Gold Standard. One of many ways the world has changed since then is the instantaneous global communication has made decision making 24/7 rather than monthly and yearly, the way our government is organized. So, as I forecast in 2008, “The time lag for the U.S. government to make a decision of consequence is months, and events are going to be emerging in time frames of days and even minutes around the world, and the Cheney/Bush administration is going to be mostly standing by helplessly.” It is the potential of the US to maintain its power that is the source of the US Dollar’s power, but if you lose faith in its potential, then you want to use the US Dollar before it loses its value. That is one of the most fundamental principles of the capitalist economy: buy cheap, sell dear. If the US Dollar is no longer dear, then where do you go? The Chinese are pushing that it be their yuan. Their currency has been included in a market basket that includes the US Dollar and the European Union Euro. But that is lumping the hidden, state-run Chinese economy along with the European Union that is unstable with Brexit. All three currencies are equally unreliable. DMark replaces Euro Most conventional wisdom about global economics went out the window during the September 2008 financial meltdown. No one knows where globalization is heading, but Europe is no longer in charge of the global economy, and neither is the US. The Euro was designed in a bygone era that will never be seen again. The European economy is locked in a status quo defined by the Euro. Every day, France and other Euro countries expect Germany to take on a larger burden because France and the other countries cannot live within the established EU fiscal boundaries. Germany and Denmark are the only countries in the EU that are within the fiscal criteria of being a member of the EU. France, Spain and Italy are a lot more like Greece than they are like Germany. Any talk about the Euro becoming stronger is a joke. At no point in time have a majority of the German people supported the Euro instead of the DMark. Not in the 1990s when the European Union was agreed to; not in 2002 when the Euro was implemented; and not today. In 2012, it was estimated that as many as 13.2 billion DMarks are in circulation (hidden in dresser drawers and mattresses). Trump’s foreign policy is predicated on his personal belief that US deserves to have the rest of the world subservient to the US. His single foreign policy strategy is to use tariffs to force US manufacturers to come home, and make foreign goods so much more expensive that the US somehow benefits. What Trump refuses to understand, even though apparently everyone else in the White House is trying to explain it to Trump, is that the tariffs only mean the American consumer pays more and benefits less. And it hurts the economies of every country. Which is why you do trade agreements. But with Trump going twitter every morning, various countries’ financial ministers start looking for another place to invest their US Dollars. There are two countries in the world that are relatively solvent and self-sufficient: Germany and Israel. Because of its size, Germany becomes the primary beneficiary. So many US Dollars and EU Euros shift in national central banks to German Bunds that the Deutsche Mark emerges. Millions of D Marks come out of boxes under beds and in back closets. Lack of confidence in the US banking system forces every state to overnight create county-local vouchers/script that become currency that people can use as an interim medium of exchange because nobody can trust the Washington, Jefferson, Lincoln, Jackson, Grant, Franklin, McKinley greenbacks any more. The day Germany starts officially using the Deutsche Mark, 1/1/2021 is the day western civilization evolves from an anti-people, anti-ecology technological economy towards an economy that encourages humans beings to live in balance with the rest of nature. Economists Fritz Schumacher and John Kenneth Galbraith were part of the team that came to Germany after World War II; Fritz said at UC Davis that the Allies designed the German economy so that “we” could take it back in 24 hours, so it is the only European economy that is totally post-World War II. This is a plan to make all information in the German economy daily, as “real time.” Then, every other country will have to go to daily statistics to compete as part of the new DMark denominated global economy. ------------------------------------------------------------------------------------------------ The Economy should be able to encourage an individual and a family to have a middle class life style which is affordable and sustainable. The Middle Class is no longer realistic in most European Union countries, especially for those under 30. Even if you have graduated from college. Especially Spain, France and Italy; as well as all the other countries in the Euro, except for Germany. Cost of doing business by the World Bank Group: US 7, UK 8, Germany 14, Japan 29, France 31, Spain 33, Italy 56, Greece 61, Vietnam 78, China 90, Egypt 112, Pakistan 128, India 142. France, Spain and Italy have nothing to brag about. In 2008, after the Lehman Brothers AIG meltdown, the Central Banks of the US, the European Union and China all threw trillions of dollars to bail out the banking industry. From my standpoint, everything in the Bible in Revelation in the New Testament that John predicted about a coming apocalypse is already happening now. What do we do? Does it just keep getting worse and worse? Or do we have the ability to become less toxic to the point where global weirding calms down to stable weather patterns? I believe that Germany's return to the Deutsche Mark is the key to a sustainable global future. ------------------------------------------------------------------------------------------------ From the European Union's very inception in the 1950s, the intention was to speak with one voice, and unite the buying power of all the countries that can compete with the population of the US. The dream of the EU was to have a monetary and a fiscal union, to be an economic superpower equal to the US. The monetary part is the united currency, the Euro. The fiscal part is that the countries of the European Union share domestic tax and spending policies, and that has not happened. The reality of separate country identities has obstructed any real efforts at European political unification. The EU is a giant debating club where each country goes home and continues to do it their own way. The institutional symbol of EU unity is called “the convergence criteria.” The EU policy is that every EU country is expected to convert to the Euro currency, as a step towards EU policy unity. When the EU let the United Kingdom stick with the Pound, it meant that Brexit was ever immanent. The Convergence Criteria stipulate the fiscal requirements for a country to join the EU, and the expectations for ongoing performance by all the countries in order to stay in the EU: 1) inflation upper limit of 1.7%; 2) government budget deficit limit of not more than 3% of the previous years gross domestic product; 3) ratio of government debt to GDP of not more than 60%, 4) exchange rate stability; 5) long-term interest rates no more than 2% higher than the average of the 3 EU countries with the lowest rates of inflation. In the most recent information, Germany and Luxembourg are the only EU countries in full compliance with the Convergence Criteria requirements to be a member of the EU. By the way, the US and Great Britain are as “out of compliance” as other pathetic EU countries. Basically, now and for the near future, every other country wants to join and be a part of the EU and eventually the Euro so that they can benefit from Germany's economic success. How long are Germans willing to carry the rest of Europe? How much guilt for World War II do the German people take before the German people decide to turn their back on the Euro and reclaim the Deutsche Mark? -------------- In Spain, the economy was based on housing growth, which died in 2008, never to return. Now there is 25% unemployment and a second decade of a generation without work experience. Not really much better than Africa. The forces for Spanish decentralization have reached political and media prominence. In Italy, the Catholic Church and the Mafia do what the Army does in Egypt: manipulate the economy at great expense. Suck the life out of it. The Italian economy is the most old fashioned in the antique European economy; it is less competitive with the Asian globalization machine with each passing month. Even if the governmental bureaucracy were efficient, the economy outside the industrial but polluted Po River Valley would have a difficult time competing in the future. But the Italian bureaucracy rivals the Vatican in being obscure and unresponsive. In the weeks after the September 2008 meltdown, US Treasury officials and the Fed did everything they could imagine to bring some kind of normalcy back. Everything they could imagine. Every single arrow in their quiver. They ran out of ideas; using absolutely everything they could think of. US Federal Reserve Chair Ben Bernanke's lesson from his Ph.D. study of the Depression was that the Fed should pour money into the banking system, to flood the clogged up credit markets. The problem is that Bernanke's whole strategy is predicated on the assumption that there is a bottom in the foreseeable future. Before the September 2008 meltdown, banks were comfortable with as little as 5% capital to cover their leveraged outstanding assets; now 15% is probably not enough. Big banks used federal bailout funds to build their capital reserves. No matter how much the national governments flood money into the banking system, they cannot stop the hemorrhaging. Banks keep legions of zombie firms on life support. For lenders, the sheer scale of the debt means the lenders cannot allow bankruptcy without crippling their own survival. [This was written 13 months ago.] When the interest rates did hit zero, the central banks (US, Japan, EU, China) were left with only one tool: artificially expanding the money supply, called quantitative easing. Since European Central Bank's Mario Draghi said he would do everything necessary to protect the Euro, quantitative easing has become the only thing left, besides prayer. All quantitative easing does is cheapen the money supply; it adds the façade of economic growth but no new wealth. It is the same as the Chinese adding poison to food so it passes the scientific test for protein. Since Clinton became President, the financial sector of the US economy has expanded from 5% of the GDP to 15% of the GDP, and consumers are paying bankers for the privilege. The Day the Euro Snapped It wasn't one day in particular that stood out in France. The transit workers called a national demonstration, shutting down the subways, so business in the major cities pretty much froze. Then the university students went on strike, and the culinary workers went on strike in solidarity. At that point, the country that lives for its stomach started to panic. In Italy, the banks froze. The electronics that had been holding the country's banking system together started having glitches, and it set up a chain reaction. It wasn't a physical run on the banks, but automatic transfers became blocked because of a blanket notice of insufficient funds. That quickly spread to the other southern EU countries, and the value of the Euro dropped 10% in 24 hours. The Spanish economy became fractionated, as the Catalonians demanded greater control of their region, fighting Madrid for autonomy. The lack of loan funding in the Iberian peninsula became a constriction that stopped payroll. ---------------------------------------------------------------------------------------------- Any of a variety of unstable things could begin a new unraveling. It took a couple weeks for it to re-stabilize. Week 1: Absolute chaos Week 2: Everyone can see the same trends Week 3: Everyone is on board Week 4: New Sense of Stability and Sustainability Spain falls; Italy falls; France falls; Then Greece falls; Romania, Bulgaria, And Hungary, The next day. Slovakia, Then the Bear, Russia, Then Czech Republic a week later. Denmark, Norway, Sweden kind of hold their own for another week; Great Britain goes crazy, becoming Northern Ireland, Ireland, Scotland, Wales, East Middle England, West Middle England, South England and Greater London. Then China, last not because it is the biggest but because it is the most traditional, and the most internally deceitful. Chinese business people are going to discover businesses that they didn't know they were part of. Too much is deception long built into the Chinese conception of western business practice. ------------------------------------------------------------------------------------------------ German DMark black market: compared to the Euro and compared to the US dollar, unlike most Euro country pre-Euro currencies, the Germans never established the time that the DMark would be out of circulation. There are lots of DMarks out there. In mattresses and safety deposit boxes. The first stage of the black market will start flashing DMarks, because they are cool. Then it will become patriotic, to have some DMarks. Then merchants will start accepting DMarks, first at twice the Euro value. Then comes the real black market, when merchants start listing DMark prices as numbers one third Euro prices. At that point, there is an exchange rate. Then the black market for DMarks goes to 10 Euros to the DMark. At that point, the Euro is the captive of the DMark and the German government is in a financial crisis. Eventually it stabilizes at 12 Euros to the DMark. That kind of transition, in today's instantaneous global economy could take as long as a week, but more likely such a transition would happen a lot faster this time. The string of events that led to World War I took about a month to unfold, when daily newspapers were still the predominant form of communication. Now, unstable communication structures operate in instantaneous over- reaction mode most of the time, and then they are forced to over-correct to accommodate for the mistakes of their initial poor response. Several major over-reactive mistakes can happen in a 24- hour period. At that point, an emerging majority of Germans support responsible action by bringing the DMark currency to life immediately. The Mechanics of the Elastic 30-Day/90-Day Transition Timeline to January 1, 2021 This crisis-response financial routine is built around the day, the week, the month, the three month quarter, and the annual calendar cycles. The crux of this plan is the 30 day implementation cycle; the second phase, to fill the 90 day calendar, is mop-up; it is not part of the necessary decision process - it is absorbing the slack time. It allows everyone the chance to get back to a daily information cycle by the end of the 30 days, and then it just becomes the new daily routine. This plan really only takes two weeks, but it is couched in absorbing communication time lags, so that people have a chance to figure out what they are doing and adjust. Everyone should be on the same page within 15 days, and full implementation at 20 days, cleanup and formal evaluation within 25 days. The plan is easy for someone to implement who cares about their own and their community's future. The whole point of this plan is to give people the power to make effective economic decisions that the 20th Century economy prevents and obstructs. There are two key decisions to be made by the German Bundestag: - what to do in the four weeks following the decision to shift from the Euro to the Deutsche Mark (about 30 calendar days, 20 Monday through Friday work days), immediately following the decision; this will become a laundry list of 1) banking issues - like how to have a bank holiday, and how to distribute the loses, 2) new property laws that guarantee meeting immediate housing needs for renters and the homeless, and 3) economic mop up so that people can minimize conflict over excess material goods; - what has to be done by the end of the current quarter, so that the formal transition goes into effect like clockwork at the beginning of the next quarter? What do You DO? Everybody has to start over. Life in the DMark Global Economy Because German policy makers are frugal, practical, conservative, cautious (ungefahrlich), conservative, nature-loving, and work at being far-sighted, they were ready to implement the digital DMark “at a moment’s notice.” Using a “computa” program format, the German government broadcast a simple computer program (also on its web site) for any individual on the planet to plug in to the DMark global economy. Global economy converts to DMarks. Minimum wage: 1 DMark/hour Maximum wage: 5 DMarks/hour The next day, the daily assessment of the economy (which replaces the Dow Jones and other obsolete stock market indicators) is: German economy: 10 trillion DMarks US economy: 500 billion DMarks Chinese economy: 400 billion DMarks United Kingdom (no Brexit): 200 billion DMarks Brexit: England: 60 billion DMarks, Wales 5 billion DMarks, Scotland 10 billion DMarks, United Ireland 20 billion DMarks A month after the German government established the DMark, the exchange rates had stabilized, reflecting relative buying power: In relation to one DMark, the other currency: 1.5 Singapore Dollar, 2 Australian Dollar, 3 Canadian Dollar, 4 Israeli Shekel, 6 Chinese Yuan, 10 UK Pound, 12 Euro, 14 US Dollar, 14 Mexican Peso, 25 British Brexit Pound, 80 Russian Ruble, 120 Japanese Yen. The whole US Dollar-based global economy, the stock markets, the budgets, the conspicuous consumption, the Visa/MasterCard/American Express credit card world just disappears. China and the US are both tremendously in debt to the rest of the world, financially, as well as morally in terms of natural resources and human resources. Because the British, French and American Allies designed the West Germany economy to take it back over in 24 hours, Germany is now the most modern economy in the world, it will have the easiest time converting to daily reporting. Such disseminated regulation in real time will lead to greater responsiveness to incipient instability, which should improve sustainability at all levels. Criteria for the XXIst Century Economy: Ecology/Economy/Equity: Cradle to Cradle: Remaking We imagined a world of industry that made children the standard for safety. “Instead of “Reduce, reuse, recycle,” urged environmentalists, and doing more with less in order to minimize damage, architect Bill McDonough and chemist Michael Braungart argue this only perpetuates the one-way, “cradle to grave” manufacturing model, dating to the Industrial Revolution. It creates such fantastic amounts of waste and pollution. Why not challenge the belief that human industry must damage the natural order? In fact, why not take nature itself as our model for making things? “Waste equals food. “Guided by this principle, production can be redesigned from the outset so that, after their useful lives, they will provide nourishment for something new. They can be conceived as “biological nutrients” that will easily reenter the water or soil without depositing synthetic materials and toxins. Or they can be “technical nutrients” that will continually circulate as pure and valuable materials within closed-loop industrial cycles, rather than being “recycled” - really downcycled - into low-grade materials and uses. How to put this eco-effectiveness into practice is the question of the day. “Eco-Eff -effectiveness sees commerce as the engine of change, and honors its need to function quickly and productively. But it also recognizes that if commerce shuns environmental, social, and cultural concerns, it will produce a large-scale tragedy of the commons, destroying valuable natural and human resources for generations to come. Eco- effectiveness celebrates commerce and the commonweal in which it is rooted. Start with a triangle, with Ecology, Economy and Equity at each of the corners. “The extreme lower right represents what we would call the Economy/Economy sector. Here we are in the realm of an extremely pure expenditure/cost/benefit, and the questions we ask would include: can I make or provide my product or service at a profit? If the answer is no, don't do it. The role of commerce is to stay in business as it transforms. It is a commercial company's responsibility to provide value and increase wealth - but not at the expense of the social structure and the natural world. How much do we have to pay people to get our product on the market and make a profit? “We move to the Economy/Equity sector, where we must consider questions of money and fairness; for instance, are employees earning a living wage? Moving into the Equity/Economy sector, the emphasis shifts more toward fairness, so that we are seeing Economy through the lens of Equity, in a sense. Here we might ask, are men and women being paid the same for the same work? In the extreme Equity/Equity corner, the questions are purely social: are people treating one another with respect? And no consideration of economics or ecology. This is where we can discuss issues of sexism and racism. “Moving up to the Ecology corner of the Equity sector, Equity is still in the foreground, and the question is: is it fair to expose workers or customers to toxins in the workplace or in the products? Is it fair to have workers in offices were undefined materials are off-gassing, exposing them to potential health risks? How is this product going to affect future generations' health? Continuing into Ecology/Equity, we consider questions of ecosystem effects, not just in the workplace or at home, but with respect to the entire ecosystem: is it fair to pollute a river or poison the air? “Now deep into the Ecology sector: are we obeying nature's laws? Does waste equal food? Are we using current solar income? Are we sustaining not only our own species but all species? Then we are around to Ecology/Economy, where money reenters the frame: is our ecological strategy economically fecund too? are we designing a building that harnesses solar flows to make more energy than it needs to operate? “Finally, Economy/Ecology: eco-efficiency: trying to do less bad, more with less. Still, eco- efficiency is a valuable tool in optimizing the broader eco-effectiveness approach. “If humans are truly going to prosper, we will have to learn to imitate nature's highly effective cradle-to-cradle system of nutrient flow and metabolism, in which the very concept of waste does not exist. To eliminate the concept of waste means to design things - products, packaging, and systems - from the very beginning on the understanding that waste does not exist. It means that the valuable nutrients contained in the materials shape and determine the design: form follows evolution, not just function. We think this is a more robust prospect than the current way of making things. “There are two discrete metabolisms on the planet. The first is the biological metabolism, or the biosphere - the cycles of nature. The second is the technical metabolism, or the technosphere - the cycles of industry, including the harvesting of technical materials from natural places. With the right design, all of the products and materials manufactured by industry will safely feed these two metabolisms, providing nourishment for something new. “Products can be composed either of materials that biodegrade and become food for biological cycles, or of technical materials that stay in closed-loop technical cycles, in which they continually circulate as valuable nutrients for industry. In order for these two metabolisms to remain healthy, valuable, and successful, great care must be taken to avoid contaminating one with the other. Things that go into the organic metabolism must not contain mutagens, carcinogens, persistent toxins, or other substances that accumulate in natural systems to damaging effect. By the same token, biological nutrients are not designed to be fed into the technical metabolism, where they would not only be lost to the biosphere but would weaken the quality of technical materials or make their retrieval and reuse more complicated. “The vitality of ecosystems depends on relationships: what goes on between species, their uses and exchanges of materials and energy in a given place. A tapestry is the metaphor often invoked to describe diversity, a richly textured web of individual species woven together with interlocking tasks. In such a setting, diversity means strength, and monoculture means weakness. Remove the threads, one by one, and an ecosystem becomes less stable, less able to withstand natural catastrophe and disease, less able to stay healthy and to evolve over time. The more diversity there is, the more productive functions - for the ecosystem, for the planet - are performed. “Each inhabitant of an ecosystem is therefore interdependent to some extent with the others. Every creature is involved in maintaining the entire system; all of them work in creative and ultimately effective ways for the success of the whole. “Humans evolved on the Earth, and we are meant to be here. Its atmosphere, its nutrients, its natural cycles, and our own biological systems evolved together and support us here, now. Let's use our ingenuity here; to become, once again, native to this planet.” Building Sustainable Community We are defining “community” within the context of the Beer-Li model introduced in issue #16: Present-Future: Stafford Beer’s Viable System Model & disseminated regulation in real time: How to Run a Country or a City: The Beer-Li model is designed to help the mother support all of her child’s potential needs. The model identifies all of our human needs, to build a personal map of the local economy, to help figure out how to meet those needs. Beer-Li Model: a computer information idea for creating a global grassroots economy. Basically it is a dynamic information catalogue for all the parts of a woman's life: income, food, housing, health care, transportation, clothing, education, media, entertainment, taxes, managing the economy, public services, infrastructure, utilities. That information matrix has components that scale up physically/geographically: family, 10; neighborhood, 100; village, 1,000; community, 10,000; district, 100,000; and region, 1,000,000. Thomas Jefferson actually proposed dividing counties into wards of five or six square miles and to impart to these wards those portions of self-government for which they are best qualified, by confiding to them the care of their poor, their roads, police, elections, the nominations of jurors, administration of justice in small cases, elementary exercises of militia. These wards are pure and elementary republics, the aim of all of which together composes the State, and will make of the whole a true democracy as to the business of the wards, which is that nearest and daily concern. Within this community-sized focus, individuals can mobilize and have a greater impact. Asking how can we improve the quality of life in cities (how can we make them healthier) can become the identified challenge of local groups and governments. First off, the United States needs to recognize that energy consumption and waste generation are out of control, three times Europe’s, even though there is a comparable standard of living. The difference is what Richard Register refers to as “access by proximity.” Because most European cities were laid out before the automobile required an additional 70% space for its roads and parking, cities are much more compact, so they require less energy and resources to maintain. The problem is the automobile. The world has exceeded the peak oil point, the midpoint in our potential use of petroleum on the planet. It is a finite resource, and eventually we will have used up most of it. That is any where from twenty to a hundred years away, but perhaps even in our lifetimes, depending on how rapidly we continue to accelerate our use of it to drive cars. Ivan Illich wrote in Energy & Equity in 1978 that “the exchange value of time is reflected in language: time is spent, saved, invested, wasted and employed. As societies put price tags on time, equity correlates inversely with vehicular speed. The order of magnitude of the top speed which is permitted within a transportation system determines the slice of its time budget that an entire society spends on traffic. The automobile, the accelerating individual capsule enables society to engage in a ritual of progressively paralyzing speed. “The model American annually puts in 1,600 hours including work time to pay for the car and gas, as well as insurance and taxes to get 7,500 miles: less than five miles per hour. In countries deprived of a transportation industry, people manage to do the same, walking wherever they go, and they allocate only three to eight percent of their society’s time budget to traffic instead of the 28 percent Americans sacrifice. What distinguishes the traffic in rich countries from the traffic in poor countries is not more mileage per hour of lifetime for the majority, but more hours of compulsory consumption of high doses of energy, packaged and unequally distributed by the transportation industry. “Self-Powered Mobility: Bicycles are not only thermodynamically efficient, they are also cheap. With his much lower salary, the Chinese acquires his durable bicycle in a fraction of the working hours an American devotes to the purchase of his obsolescent car. The cost of public utilities needed to facilitate bicycle traffic versus the price of an infrastructure tailored to high speeds is proportionately even less than the price differential of the vehicles used in the two systems. In the bicycle system, engineered roads are necessary only at certain points of dense traffic, and people who live far from the surfaced path are not thereby automatically isolated as they would be if they depended on cars or trains. The bicycle has extended man’s radius without shunting him onto roads he cannot walk. Where he cannot ride his bike he can usually push it.” Cities could be designed to work ecologically. According to Richard Register in his book, Ecocities: Building Cities in Balance with Nature (2002), “The quality of life depends largely on how we build our cities. Given that cities are so large, damaging and yet potentially beneficial, you’d think we would have long ago devised the science, study, discipline and art of ecologically- healthy city building. The higher the density and diversity of a city, the less dependent on motorized transport, and the less resources it requires, the less the impact it has on nature”. The idea of Ecocities recognizes all these dilemmas and opportunities and the new realities of the twenty-first century, from rising atmospheric carbon dioxide, shrinking water tables, loss of agricultural land to sprawl – and energy wasting dead end of the automobile/highway/fossil- fueled industrial complex. Yet there are signs of the transition to sustainable communities and cities, which we must make if we humans are to survive; so our goal is: cities that can actually build soil, cultivate biodiversity, restore lands and waters, and make a net gain for the ecological health of the Earth. Hazel Henderson points out that we humans have spent 98% of our collective history together as gatherer-hunters in roving bands. Yet we now comprise a six billion-person human family, living largely in huge mega-cities like Sao Paulo, Mexico City, Shanghai and Tokyo, with very little experience of managing our affairs at such a scale. We are consuming some 40% of the entire planet’s primary biomass production. This is accelerating the rate of extinction of our fellow species on which we are dependent, as we have migrated to the ends of the Earth. According to Henderson, we have overshot the optimum in cars, suburbs, sprawl and its attendant patterns of energy waste, pollution and environmental destruction. We have overshot the mark in losing community and identity among thousands of acres of huge tract homes in former family farms – with even more demand for more roads, concrete, parking lots and strip malls. Henderson thinks the economy can be graphically represented by a “cake chart,” a take-off on the pie charts economists use tirelessly to express percentages of this and that. The top layer of the cake is the “private” sector: production, employment, consumption, investment, savings. The next layer is the “public” sector: infrastructure, schools, municipal government and various services. The third layer down is the underground economy including tax dodges, black market exchange, and the like. Beneath these three “monetized” layers, in which cash is used as a means of valuation and exchange, is the non-monetized layer, based on bartering, home-based production, “sweat equity,” and what she calls the “love economy” of volunteerism: working to support family and friends with vegetables, cleaning, baby sitting, medical advice, and so on. In turn, this base layer of the human economy rests on the bottom layer of the cake, nature’s economy: the natural “resource base,” which not only ultimately provide everything basic to the human need for sustenance, but also serves to clean up our messes if we don’t get too far out of hand. To which Register adds: Given the order, with the human edifice built upon the natural one, it is clear that if our rules differ markedly from nature’s we are likely to run into problems. Back to Register: Cities are by far the largest creations of humanity. Designing, building and operating them have the greatest destructive impact on nature of any human activity. As we construct them today, cities also do little for social justice, not to mention for the grace and subtlety of human intercourse. Yet our built communities, from village and town to city and megalopolis, also shelter and launch many of our most creative collaborations and cultural adventures and artifacts. As we build automobile/sprawl/infrastructures, we create a radically different social and ecological reality than if we build closely-knit communities for pedestrians. Contrast American sprawl with European traditional cities. A study called The Cost of Sprawl was undertaken by three U.S. agencies – The Council on Environmental Quality, Housing and Urban Development, and the Environmental Protection Agency – and released in the spring of 1974. The study compared low-, medium-, and high-density communities, and measured their impact on schools, fire and police services, governmental facilities, roads and utilities. It demonstrated that higher-density communities required 50 percent less land and 45 percent less investment cost in infrastructure (buildings, roads, landscaping and utilities), caused 45 percent less air pollution and a similarly reduced amount of water pollution runoff, and used 14 to 44 percent less energy and 35 percent less water. Costs of fire, police and other governmental services were similarly reduced in the higher-density community. The high-density model was a mix far from the extremes of Manhattan, Hong Kong, or Paris. It included two- to six-story buildings and nothing taller. It left out the cost of the automobile entirely and it did not mention the savings from using transit in higher-density areas. As we build so shall we live. The city, town or village – this arrangement of buildings, streets, vehicles and planned landscapes that serves as home – organizes our resources and technologies, and shapes our forms of expression. It is the key to the future healthy evolution of our species and will determine the fate of countless other species as well. The city, in fact, is the cornerstone of the civilization that currently embraces the entire planet. Insofar as our civilization has gone awry, especially in regard to its impact on the environment, a very large share of the problem can be traced to its physical foundations. Considering the crisis state of life systems on Earth – the collapse of whole habitats and the increasing rates of extinction of species – it follows then that cities need to be radically reshaped. Cities need to be rebuilt from their roots in the soil, from their concrete and steel foundations on up. They need to be reorganized and rebuilt upon ecological principles. Recent trends have not been encouraging: In 1960 one-third of the citizens of the U.S. lived in cities, one-third in suburbs, and one-third in rural locations. By 1990 well over half lived in suburbs. Between 1970 and 1990 the population of California increased approximately 40 percent while the land area of cities and suburbs went up 100 percent. By 1992, after a new wave of suburbanization, the U.S. was getting approximately 60 percent of its oil from the Middle East. The better the gas mileage, the more the suburbs sprawl out over vast landscapes, the more demand there is for cars and freeways, and the more cars are needed to service the expanding suburbia. Ultimately and ironically, the more gasoline is needed. Thus the energy-efficient car helps create the energy-inefficient city. The car is part of a whole system of complex, necessarily interconnecting parts existing in an interdependent relationship with the total environment it helps create. Now that we have spent about half of the planet’s full endowment of petroleum resources, time to rely on petroleum is running out. The bigger picture is far from encouraging. China started closing Beijing’s streets to bicycles to make way for cars in 1998, and it is currently engaged in a massive highway-building program. It plans enormous shifts of population from rural areas and farming to cities and manufacturing and business, and shifts from rail, bicycle and pedestrian cities to cities for motor vehicles on rubber tires – a colossal transformation in the wrong direction. The arrow is in the direction of increasing problems for the Chinese: according to UC Davis China expert Don Gibbs, China uses seven times as much energy as Japan per unit of production, 3.5 times as much as the U.S., and they are designing an exclusively auto based transportation system with highways and little public transit. As Ivan Illich says: “The automobile has created more distances than it has bridged,” and once created, rendered bridging those distances without the automobile virtually impossible. Thus we have become structurally addicted to cars. The structure of the city, even whole national transportation systems, have become thoroughly dependent upon cars”. Register then quotes Jeff Kenworthy and Peter Newman, who studied thirty-two cities around the world and concluded: “Traffic engineers still claim freeways are better for fuel emissions, but the results of our study do not. Economically, they also appear to have failed. Our data show that, instead of people in cities with freeways saving time, and hence being more productive, they just spend more time in their cars. Freeways space cities out and hence overall travel is increased. Those cities which do not go for freeways but instead build up transit and bicycle access have gained economically and environmentally … Some short-term pain will be experienced as businesses and developers adjust their plans to a more transit-oriented city, but experience shows that the transition is worthwhile.” Ecocity takes the idea of urban life in a new direction. The truths from which the ecocity idea emerges are based on the human body – its size, speed and requirements for nourishment, shelter, procreative and creative excitement and fulfillment – and on the relations of living organisms to each other and their environment. The density, diversity, form and function of cities, and the awareness of their citizens in this regard, are now key factors in evolution. On the positive side, the very form of the city, by providing access to culture, resources and nature, has the potential to raise consciousness of evolution to new heights. Though the effects on biology and evolution of today’s enormous sprawled cities are grim, learning about such cities and about the alternatives to them gives us the tools to solve many urban and evolution-sized problems. Register’s favorite idea is “access by proximity,” that the easiest way to cut transportation costs is shorten the distance. He really sees the solution as growing structures up that leave some room for other things besides work. Register is advocating that we build tall compact buildings, and allow open space around them. The size of the center is the horizontal multiplied by the vertical, and so a four-story height limit, though more dense than one or two, still forces horizontal development out several times over relative to a cluster of, say, ten- to twenty-story buildings, and eliminates the kind of civic focus that can produce grand plazas, parks, settings for sculptures and other special features. The vertical dimension can multiply the center’s size several times without affecting whatever horizontal distance is being considered. Tall centers are thus far richer culturally and economically than low rise ones. In fact, given that building materials and construction techniques are easily able to support much taller building and that tens of millions of people are living or working at the fifth story or higher already and appreciating its benefits, it is nothing less than perverse for architects and theorists to refuse to explore the possibilities. Some of the most beautiful buildings on Earth are taller than four stories. Elevated gardens, art and public spaces on rooftops, terracing that could take rooftops up four stories at a step, bridges and rooftop streets that could make a real adventure of the third dimension – almost none of these are seeing serious experimentation. The traditional village structure is one of the most profound inventions in history, and it applies to cities as well as villages. In ecocity transformations there is a direction, scale and form seen here: toward the centers, and smaller and taller. The Beer-Li Model for Communities of 10,000 People The challenge of Ecocities is to find community in harmony with nature. For that, we need up to date information. The biggest change of the last decade is the advancement of the Internet which has made communication and information sharing instantaneous. The technical work requires creating an information grid to manage individual/community/city data, to protect privacy while at the same time allowing public and economic decision making to improve the local community. We are defining “community” as around 10,000 people, usually in a larger population in an urban or suburban setting. The information, data and ideas in a particular module of the matrix (neighborhood, food) is what you use to organize what you want to do. From the individual’s point of view, the computer information model needs to accommodate individuals’ lives to their convenience, and basically include what is called the Consumer’s Economic Space: Housing, Education, Transportation, Food, Health, Media, Clothes, Energy, Recreation/Entertainment/Leisure, Management of the Economy/Banking, Public Assistance/Retirement/Social Security, Taxes/Public Service/Volunteering. Current computer technology would allow the consolidation of the information flows so that any community could maintain its information base if there is local political will. The existing city political structure creates two computer programs, called City Data and City Future. Within them, they build the ground rules for how the local area creates its own future. The next social science challenge is to identify how to improve quality, described on a personal level by Thomas Michael Power in The Economic Pursuit of Quality (1988), “Even in the commercial sector of the economy, what we really purchase is quality, not quantity. Beyond a rather low level of income we do not spend our money mainly for pounds or calories of food, but for taste, nourishment, and variety. Our clothing budget is not spent on homogeneous body covering, but for qualitatively distinctive and stylish clothes. Many important qualities are supplied outside the commercial economy, such as clean air, scenic beauty, safety and a sense of community. It is the sum of commercial and noncommercial qualities that accounts for total economic welfare. These qualities are not independent of physical dimensions, but neither can they be reduced to physical dimensions alone. Economic development is the increase in the sum of marketed and nonmarketed qualities available to individuals in the local community”. Empirically, define local sustainability by means of quantifiable limits and safe minimum standards; establish an optimum scale that takes into account the physical carrying capacity of a defined area, then focus on developing statistics that measure welfare. A local area should be evaluated in three categories: quality of life, cost of living and standard of living. Together, these three commonly recognizable terms add up towards what Stafford Beer calls eudemony, or well-being. They are a first draft at creating a quantifiable measure of “optimal community.” Quality of life includes air and water quality, longterm health indicators, and intangibles of the natural environment. Cost of living focuses on a market basket index of basic goods. Standard of living includes measures of percent self-sufficiency, as well as the upper strata for the more high stepping. Communities can compare their statistics with other areas, and gradually come up with standards, by decentralized agreement. People looking for a new place to live will compare different communities’ statistics. Long time residents will understand their own community’s unique idiosyncrasies. And people will try to improve their numbers. Most people care about their community, and take pride in it. It is the major long term investment of their lives. It would be nice to have an economic language that encourages community action that makes efficient use of scarce resources and is ecological. For a hands on manual for creating good politics around issues in your local community, Economic Renewal Guide: Collaborative Process for Sustainable Community Development, by Michael J. Kinsley, Rocky Mountain Institute, 1997 Illich, Ivan (1973), Tools for Conviviality, Harper & Row, NY Illich, Ivan (1974), Energy and Equity, Harper & Row, NY McDonough, William, Braungart, Michael, (2002), Cradle to Cradle: Remaking the Way We Make Things, North Point Press, NY Register, Richard (2006), Ecocities: Building Cities in Balance with Nature, Berkeley Hills, Berkeley Taylor, Graeme (2008), Evolution's Edge: The Coming Collapse and Transformation of Our World, New Society, BC, Canada TRANSFORMATION TO ECOTOPIA In 1975, Ernest Callenbach published a book called Ecotopia, about an ecologically-responsible society: “a few Ecotopian militants spread the point of view that economic disaster was not identical with survival disaster for persons – and that, in particular, a financial panic could be turned to advantage if the new nation could be organized to devote its real resources of personal energy, knowledge, skills, and materials to the basic necessities of survival. If that were done, even a catastrophic decline in the GDP (which was, in their opinion, largely composed of wasteful activity anyway) might prove politically useful. “What was at stake, informed Ecotopians insist, was nothing less than the revision of the Protestant work ethic upon which America had been built. The consequences were plainly severe. In economic terms, there was a drop in the Gross Domestic Product by more than a third. But the profoundest implications of the decreased work week were philosophical and ecological: mankind, the Ecotopians assumed, was not meant for production, as the 19th and 20th centuries believed. Instead, humans were meant to take their modest place in the seamless, stable-state web of living organisms, disturbing that web as little as possible.This would mean sacrifice of present consumption, but it would ensure future survival – which became an almost religious objective, perhaps akin to earlier doctrines of “salvation.” People were to be happy not to the extent they dominated their fellow creatures on the earth, but to the extent they lived in balance with them. As a basic philosophy, the idea of political power is to put technology and social structure at the service of humankind, rather than the other way around. “The Ecotopian economy must be considered a mixed one, but some elements of the mix are novel, and because of ecological and political considerations the balance of the mix is quite different. During the economic transition, people realized that a new era was indeed upon them and began spontaneously taking over farms, factories and stores. This process was chaotic, but it was not anarchic; it was controlled by the local governments and local courts. Such take-overs set the tone for the ongoing tasks of production and distribution of essentials; and they worked. But more massive and deliberate economic changes soon took place, above all in the diversion of money and manpower toward the construction of stable-state systems in agriculture and sewage practices, and in the scientific and technical deployment of a new plastics industry based upon natural-source, biodegradable plastics. (The public transportation system, which remains an infringement on the stable-state principle, also consumed many resources.) “The new tax system relies entirely on a corporation tax – that is, a tax upon production enterprises (including individuals). It is based partly on net income, but also partly upon “turnover,” or gross income. Like most functions of governing, tax-levying is carried out by the communities (mainly cities), which delegate very limited powers to the regional and national levels. The reasoning behind this system is complex, but it turns upon the view that all taxes are fundamentally a means of the government seizing a share of economic output and putting it to publicly determined purposes – and that this seizure should therefore be at the immediate source, simple, understandable, just, and open to public view. (Ecotopian tax returns are not confidential.) “This tax policy includes laws that redefine the position of the employee. The workers in an Ecotopian enterprise must now all be “partners”: a person cannot just set up a business, offer wages to employees, fire them when they are no longer needed, and pocket the profits. There is no personal income, sales, or property taxes in Ecotopia. Aside from personal articles, no Ecotopian can inherit any property at all. There is a land tax that encourages concentration and probably accounts for the remarkable compactness of Ecotopian cities. There is a widespread aversion to other types of tax on the grounds that they are either regressive or promote divisiveness among people – whereas the enterprise tax, bearing as it does on collective groups, is thought to promote solidarity, and competition between work groups. “There is no super-rich class in Ecotopia. Certain occupational groups, such as artists, scientists and some doctors, have slightly higher incomes, though national training policies deliberately seek to keep such differentials moderate. But there are said to be no individuals in Ecotopia who grow personally rich because they control the means of production and hire other people’s labor power. “Direct absentee investment by one enterprise or person in another enterprise is not permitted. Surpluses can thus only be “invested” by lending them to the national banking system, which in turn lends funds to enterprises. This gives the bank tremendous leverage on the economy; it appears to contradict many Ecotopian protestations of decentralization, even if the national bank does maintain regional branches that have great autonomy. “Ecotopian enterprises generally behave much like capitalist enterprises: they compete with each other, and seek to increase sales and maximize profits, although they are hampered by a variety of ecological regulations. The fact that the members of an enterprise actually own it jointly (each with one vote) puts certain inherent limits on what these enterprises do. For instance, they do not tend to expand endlessly, since the practical maximum size of joint-ownership firms seems to be less than 300 people – beyond that they tend to break down into bureaucratic, inflexible forms and lose both their profitability and their members, who seek more congenial environments. Also, the enterprises seem to be just as concerned with conditions of work as they are with profits, and in many instances members seem willing to accept lower profit and wage levels in exchange for a comfortable place to work or a way of organizing work which offers better relations among people doing it. “The tax revenues are used by the community governments to support their recycling services, housing, power, water, telephone, medical services, police, courts and so on. Education is financed as a free-market private enterprise. A pro rata share of tax funds goes to the regional and national governments, to support operation of larger-scale systems such as the trains, defense, telecommunications, and most of the research establishment. “Despite the importance Ecotopians attach to agriculture and other rural affairs, the Ecotopian constitution is city-based and not rural-based. The Ecotopian main cities dominate their regions through a strict application of one-person-one-vote principles. Furthermore, the county level of government is omitted entirely. “There is a surprisingly small national welfare system, considering that Ecotopians enjoy a lifetime “guarantee” of minimal levels of food, housing, and medical care. While some citizens, especially those working on untried developments in the arts, utilize this guarantee to exist without jobs, most people either feel the guarantee level is too abject to exist on, or find it’s desirable to work in order to provide themselves with a lively social life. The old and disabled, of course, must survive by taking advantage of the guarantee; and, while low, is perhaps slightly higher than the U.S. Social Security system (which does not have the health, housing and food benefits of Ecotopia.) “The Ecotopian government established long-range economic policies of diversification and decentralization of production in each city and region. Laws were introduced that flatly prohibited many types of highly polluting manufacturing and processing operations. Since tens of thousands of employees were put out of work, the new government made two responses to this. One was to absorb the unemployed in construction of a train network and of the sewage and other recycling facilities necessary to establish stable-state life systems. The other move was to adopt 20 hours as the basic work week – which, in effect doubled the number of jobs but virtually halved individual income. (There were, for several years, rigid price controls on all basic foods and other absolute necessities.) “Ecotopians spout statistics on social costs with reckless abandon, calculations that inevitably involve a certain amount of optimistic guesswork. Ecotopians claim their system is considerably cheaper, if all the costs are added – and not ignored, or passed on through subterfuge to posterity or the general public. Acknowledging all the costs is necessary in order to achieve the stable- state life systems that are the fundamental ecological and political goal. If, for instance, the practice of “free” disposal of wastes in watercourses was continued, sooner or later somebody else would have to calculate – and bear – the costs of the resulting dead rivers and lakes. There is a relentless tendency to fix responsibility on producers. “Ecotopian plastics are entirely derived from living biological sources (plants) rather than from fossilized ones (petroleum and coal). Originally there were two major objects for the researchers. One was to produce the plastics, at low cost and in a wide range of types: light, heavy, rigid, flexible, clear, opaque, and so on – and to produce them with a technology that was not itself a pollutant. The other objective was to make them all biodegradable, that is, susceptible to decay. This meant that they could be returned to the fields as fertilizer, which would nourish new crops, which in turn could be made into new plastics – and so on indefinitely, in what the Ecotopians call, with almost religious fervor, another steady-state system”. Using the successful family farm as a definition of community sustainability As we humans emerged at the end of the last Ice Age, 10,000 years ago, we discovered language as we learned how to gather food and to hunt. But the hunter-gatherer society uses up whatever resources are available. While most human societies have rewarded the hunters, everyone else is left to fend for themselves in a pretty rigid power structure: Men in powerful positions, rich men, physically powerful men, business and white collar men, rich women, tradesmen, farmers, boys, women, girls, low income people, destitute, homeless, debtors, criminal. Once the nobles had forced King John to sign the Magna Carta in 1215, it locked in a rigid class structure below it, reflected in the interpersonal relationships in Chaucer’s Canterbury Tales before 1400. Given the need for a division of labor, and the emergence of the trades to serve the growing commercial class, some class structure seemed inevitable. People are going to compare themselves with others, no matter what. If money is the criteria, and material goods follow wealth, then the rich should feel rewarded. While that may have been true some of the time, it seems false. In the new world of Climate Change, whatever you do has an environmental impact; the more you spend the greater your potential negative impact. “Sustainable Agriculture” is the miner’s canary of coming back from pending destruction of the human environment. We are never going to make farming easy. It can be fulfilling, but it is hard work, day after day. The sun comes up and you go to work. The sun goes down, and you figure what you are going to do tomorrow, fix some dinner, try to sleep and stop worrying about all the things you should start doing first thing when the sun comes up again. The Native American Pomo-Miwok word for “farmer” means “person who does a thousand things.” To succeed in farming, you have to know all “thousand things” well, and when to do them. The best is to watch while you are growing up, listening to adults so that next year you can explain that particular growing process as the miracle of nature unfolds. That’s the fascinating and frustrating part: there is so much to take into account in farming. The way the corporate farming economy “works” is with the elusive myth of scale. If you could just get one more piece of machinery, maybe you could do a little better than break even. “Growth” is the mainstream party line, but the machine trade-off is still to eliminate the need for labor. The number of hours in the day are really a farmer’s biggest challenge. Trying to get certain things done that have a sequence can sometimes complicate the rest of your life and what you were planning on getting accomplished before sundown. Regulations are an enormous headache. Too many regulations assume one size fits all, and that size is not the small farm. Most farms do not have the resources to meet the workman’s comp and other paper work requirements that you simply have to stay up with. Setting up a farm means hiring other people to help. Finding labor that is willing to do a hard days work is difficult. Most city people don’t understand much about farming, and don’t realize what a long day it is. You don’t punch in at 8 am, go to lunch at noon, and clock out at 5. You work until the sun goes down, and are thankful for the extra time. Farming is the original definition of work. Going back to sustainable farming as a criteria for evaluating the rest of the economy puts hard work in perspective. We used to compare an engine to horsepower. How about we call a difficult bureaucratic city job to be the equivalent of .5 farmer job. With that kind of calculus, most farmers are underpaid, and most city workers are overpaid. Farming is demanding, long term: physically, emotionally and mentally; farmers often are forced to limit their social activities because the farm work is so demanding; too many farm children won’t continue because it has taken such a heavy toll on their parents. Academics are pretty good on the science and even the business of farming, but what they teach now days does not really prepare for the life on the soil. The key is to develop an attitude that small family farms are a viable way to maintain a sustainable lifestyle. Farming requires people to be committed to what they are doing, in real terms not just words. The county librarian was raised on a farm, went to school in LA, and then library school at UC Berkeley, and then came home to work. She and her brothers continue to farm. She was speaking critically, and with a snarl on the side of her mouth, said, “he’s a handshake farmer.” I figured out that is in the middle of the continuum: what you want is the neighbor who says something, and you can count on it every time; and the other end is the neighbor who offers something, and you say “have your lawyer right it up and send it to my lawyer, and I will see you in court.” We need to move more in the direction of people keeping their word. While the message from the agricultural industry is to grow bigger for advantages in the market, it is best to create a business plan for a specific scale and stay small. Get better at what you like to do and are good at. It is hard to maintain and persevere as you age and change emotionally. Continuing to farm is a blessing but only with perspective. While machines are supposed to make work easier, the capitalist growth model intends machines to be a short-cut to minimize labor. That is the point of the 20th century economy, leading to Artificial Intelligence as a machine substitute for human labor. The first thing I learned in the third grade (when we came to California from Japan) was that Cyrus McCormick’s mechanical reaper in the 1830s cut farm jobs so much that people had to move to towns and cities. President Abraham Lincoln established the USDA because over half the country’s population had moved to towns of 5,000 people or more. In the USA, the rural population struggles to survive in the urban mechanized economy. In China, it is even worse. Some of the urban Chinese have the “Iron Rice Bowl” which is the equivalent of what I am proposing. If you have the urban hukou designation, you have access to employment, housing, health care, education for your children, access to transit and entertainment. In 1949, maybe 20% of the Chinese had hukou standing. Now, with 50% of the Chinese population living in cities, half of the urban residents are former rural peasants looking for a better life in the city, but do not have hukou. It is very difficult for the people without hukou to find work, or housing, health care or education for their children. Every Chinese city has a second-rate economy to service and employ the urban non-hukou, who make up a quarter of the entire Chinese population. As to size, the acre of land as the standard unit of measure, going back to the Greeks and Romans, is the amount of land a person should be expected to be able to plow with a team of oxen in a day. The Polyface Farm described by Michael Pollan in Omnivore’s Dilemma is 550 acres, but 450 acres are woods, and the 100 acres is too rough for row crop farming. So Polyface Farms is based on growing grass to feed the livestock in a way that improves the quality of the soil. Improving the natural environment instead of damaging it is the minimum standard for the 21st century economy: improve the ecology. Indifference to the consequences of toxics, pesticides, and social stress from bureaucratic regulation encourages even further complexification of the global economy. The reason why the family farm struggles in this economy is partly because the Visible Hand of government regulation is dominated by big business so they designed the reward system to benefit themselves. There probably should be an upper limit for the size of a farm. Maybe 640 acres. But it is hard to imagine a family farm being sustainable with more than Polyface’s 100 acres. For the economy to reward the sustainable farm, the economy needs to stop underwriting massive corporate high mechanization industrial farming. If the current economy seems to make it impossible for a small family farm to be successful for many generations, let’s turn that equation on its head: let’s build a global economic information accountability system around how effective each community is in supporting sustainable family farms: organic & ecologic, economic, emotional and educational; and in developing the community science of measuring and monitoring those as the blood pressure of our society. So one working definition of “community” is a sustainable local economy based on viable family farms. The science of community is clear: Walter Goldschimdt compared the towns of Arvin (corporate farm town) with Dinuba (family farm town). As the economy went through its highs and lows, Arvin reflected the dysfunction of the larger economy, but Dinuba did a much better job of absorbing the lows and then recovering. In Arvin, when the economy went sour, people were laid off, couldn’t pay their bills, and things went downhill. In Dinuba, instead of laying off somebody, they moved into the barn until things improve. It is a whole different philosophy of life: some things are more important than money. The sustainable family farm requires a community of passionate people who are willing to support it. That didn’t exist 40 years ago. We have had to develop it, with education, good food and hard work. New people are coming into organic farming, with the hopes of making it sustainable. The key is to start out small, with just a little bit of equipment. The temptation is the need for capital, which is not low income. Working within the market structure means having a farm that is meeting market demand, but it is not self-sustaining. We need to move to where a market can support a self-sustaining farm. Then we can use the rest of the economy to debate what a farmer should be paid, and what other people who work at relatively easier jobs in the city should be paid. West Hall University of California, Davis “Home of Rugged Individualism” The New Economy: The Chinese Iron Rice Bowl as the Global Standard: Hukou for Everyone City Urban Living in China & US: Iron Rice Bowl standards: housing, job, transportation, food, energy (daily), social (daily), relax (weekly), vacation (annual +) Health (daily) activity, injury prevention, recovery, annual checkups The extravagance of the Chinese Communist Party gives 20% of the population HUKOU, at the expense of the 80% who do not have access. HUKOU standards should be universal, globally. No More Compulsory education - definition of being in the minority until legal age of 18 K-12 BA, Masters PhD Entertainment industry Movie theaters Suburban lifestyle Electric cars no better than gas Need total energy conservation Tourists Airlines Hospitality industry In Praise of the Automobile: A Eulogy Here in California we have built our lifestyle and our economic system around the small, high- speed, independently operated vehicles we call automobiles. Cars offer most adults a freedom of movement inconceivable over 100 years ago. We enjoy the luxury of knowing we can come and go as we please – traveling many miles a day to do business, run errands around town, get from city to city for work or recreation, and sometimes get away to what remains of the peaceful countryside. We can move independently with little need to be concerned about the destinations or activities of others who share our elaborate system of roads and freeways. Many of us take pride in our particular type of car as a reflection of our individual personalities and accomplishments. We appreciate the physical comforts of the interiors and sometimes outfit them with sophisticated electronics or otherwise personalize them. We often take the opportunity of the car’s privacy to relax by ourselves, gather our thoughts, or simply get away from it all. Our current state and local economies rely heavily on the use of cars and trucks. Many jobs require a car either for access to the worksite or in the course of the work. Most of our industries require trucks to haul goods to market. And the fueling, maintenance, repair, insurance, selling, re-selling, and finally, the demolition of autos has generated a tremendous number of allied industries and employment skills to support and maintain the complex system of public support for the privately-owned car. It is estimated that over 10% of the state’s workforce is employed in this continuing effort. Unfortunately, the economics of the automobile are crumbling. At this point we are so bought into cars that we don’t recognize their costs: - already autos cost so much to purchase and maintain that they don’t deliver their supposed advantage, speed. The time we spend supporting our car’s costs added to the travel time makes the true velocity 5 miles per hour or less. Bicycles go faster. - The energy expended to build an automobile is generally more than the auto will use during its lifetime. - An electric car’s battery costs at least 5 years worth of petroleum energy to build. - Freeways in urban areas cost more than the public can bare. - 80% of California’s covered space is devoted to supporting the automobile with roads, parking lots and rights of way. HALF (really over 50% of climate weirdness is due to transit vehicles, cars, trucks). The public resources need to shift to the era after the automobile, and it needs to start now. For personal transportation, we need to limit vehicles to maybe 500 pounds and 25 mph max. (Cars now weigh at least 2,000 pounds, and they need a lot of steel for when they have high impact collisions. All of which needs to be reduced or eliminated.) 1. On a personal level, talk with your family, friends and co-workers about how the end of the era of the automobile will change your lifestyle. It may mean you want to change your place of residence or your place of work. 2. In downtown urban areas, the best short run step is to build “Transit Malls”, building jobs and high density housing close to transit stations. 3. Rejuvenate SB 50 to lead a discussion about how cities can change. 4. Most of the state, city and county bureaucrats are never going to need their offices again – they should be turned into housing, especially the state and city office buildings. Compared to convenient public transit, walking, riding a bicycle, using Zoom, and working close to home, how much heartache is your car really worth? Need More Of Redesign MD BA is social services Ecologists Plant scientists Virologists Epidemiologists Decentralized global solar energy grid Berlin’s Recovery of the Rubble at the end of the War: Teufelsberg: Devil’s Mountain In 1948, the Soviet blockade of Berlin forced West Berlin into isolation, daily recovering the badly damaged city. As rubble accumulated, they had no place to ship it, so they piled it on top of never completed Nazi military-technical college designed by Albert Speer. Called Devil’s Mountain (“Teufelsberg”), it is the highest point in Berlin. A Caravan that starts at the Oregon border with a million people: ecological recovery of California to San Diego: It has to work in Los Angeles, then it will work worldwide. Politics is the art of the POSSIBLE, not the insurmountable. What is possible? Energy Conservation as a way of life: housing and transportation policies: AFTER THE AUTOMOBILE: better quality of life, improved standard of living, lower cost of living, lower energy usage, conserve non-renewable petrochemicals, healthier daily living 1. In each community, grassroots Ecotopian committees develop plans for how to make their community more sustainable and self-sufficient. 2. school children start extracurricular Ecotopia clubs that become environmental activist academies. Students are first trained to understand how something is made, and what it will take to de-cycle it, break down its component parts, and move them through their own food chain. Then learn how the economy of that industry works. Then start to identify ways that particular industry pollutes. So far, it is all education. What a 3rd grader can learn and comprehend might amaze you. At the Junior High School and High School level, it is about building an Ecotopian Economy in their community so that they have jobs. The Ecotopian Economy is about breaking down the blighted parts of our cities and suburbs, and creating new ways of compensating people for moving things along the natural economy. 3. Ecotopian Committees meet in every Senate and Assembly district, to pursue grassroots support for a new Constitution. 4. January 2016, Ecotopian committees from all over the state of California converge along the California-Oregon border. Each committee is part of an organic food chain that maintains its own support without having any tax on the local environment, and maintains support from its home base. The committees help implement the local communities plans: most roads are dug up, and the concrete, asphalt and cement is recycled. Many, many buildings constructed between 1940 and 1990 are dismantled, and their inner parts salvaged and recycled. 5. By Yreka, the mass of people has built into over 1 million and it has worked its way down the state of California to Sacramento. It comes to freeways, roads and ugly buildings, and it leaves with pristine natural areas where there had been blight, and the rails for extensive light rail within urban populations, and lots of opportunities to accomplish things within walking distance for most people. 6. By the time the mass is in El Cerrito, and they are met by the Berkeley-Stanford led Bay Area mass, which has over a million people. Since work had been going on in the Bay Area, it only took hours to tear down the MacArthur Freeway from Berkeley to San Jose, and the next day a rail track was laid that went from the North Coast to San Jose. 7. The Los Angeles and the San Diego Ecotopian committees are led by women from UCLA and UC San Diego. When the mass got to Santa Barbara, the rail line was laid from San Diego through Orange County, Los Angeles, Ventura, and up the coast. 8. The winter was memorable because people met new people. They didn’t spend Christmas driving around in their cars, they mostly walked. California Environment: China +USA California Today: CA VSM 1.0 California in transition: CA VSM 2.0 California as Ecotopia: CA VSM 3.0 Rediscover Nature: Robinson Crusoe in reverse. It has to work in Los Angeles, then it will work worldwide. Twenty-five years ago, Willis Harmon wrote, “Modern times are fundamentally different than medieval times because the root metaphor of Western society has shifted. The medieval metaphor was of the universe as a ‘great organism.’ After the scientific revolution, that was replaced by the metaphor of a ‘great machine,’ with all things happening in accordance with discoverable scientific laws. The emerging root metaphor appears to be that of a universe as a ‘great thought.’ If things indeed turn out that way, the impact of this shift on all institutions of society, and on the course of history, will be as great as have been the effects of the scientific revolution. “Regardless of whether the new metaphysic can be clearly identified, there will almost certainly be some fundamental transformation of modern society. The demonstrated inadequacy of the present scientific worldview has produced an imperative. It is impossible to create a well- working society on a knowledge base which is fundamentally inadequate, seriously incomplete, and mistaken in basic assumptions. Yet that is precisely what the modern world has been trying to do. “If these surmises are correct and the metaphysical assumptions underlying modern society are shifting at the same deep level that they did at the time of the scientific revolution, then the ‘trans- modern’ society of the 21st century is likely to be as different from modern society as that is from medieval times.” Willis Harmon, (1989), Redefining the Possible: The Need for Restructuring Science, The Quest magazine Conclusion: Nature Bats Last “No amount of sophistication is going to allay the fact that all your knowledge is about the past and all your decisions are about the future.” - Ian H. Wilson. “We are made wise not by the recollections of our past but by the responsibility for our future.” - George Bernard Shaw. “It is the future that dictates the present.... People act in the present according to their judgment about what the future will hold.” - Gordon O. Pehrson, The collapse of nearly 90% took place between 1929 and 1932. What should the future look like? Appendices: January: U.S. Universal Health Community Clinic System: Discovering how to implement Universal Health Coverage in the United States 21 Monday Morning Weekly Report towards a June 1st Paper #21 This analysis looks at health issues, education, personnel and resources as part of a health system. The United States has the worst health care delivery system in the modern world. The GOP uses free market rhetoric to strangle health services. U.S. health care is overly complicated, expensive, inconsistent, crisis intervention biased, and anti-lifelong health. With Universal Health Coverage, much of the administrative complexity caused by the financing the insurance industry disappears. Because each person is treated as a unique individual with a goal of maximum life long health, the systemic approach maximizes consumer satisfaction, professional fulfillment and resource optimization. We want to design the optimal governmental regulatory information structure at the national, state, regional, city and community level to maximize providing the best and highest level of health care at the community clinic level, and minimize the need for hospitals to the 15% of the situations where clinic care must be backed up. The goal of this process is to bring to life HR 1384 (Jayapal) and S 1129 (Sanders), the Medicare for All Act: Automatic enrollment of all individuals in the United States, cover items or services that are medically necessary or appropriate to maintain health or to diagnose, treat, or rehabilitate a health condition, including hospital services, prescription drugs, mental health and substance abuse treatment, dental and vision services, and long-term care. The bill prohibits cost-sharing (e.g., deductibles, coinsurance and copayments) and other charges for covered services. Private health insurers and employers may only offer coverage that is supplemental to, and not duplicative of, benefits provided under the program. Health insurance exchanges and specified federal health programs terminate upon program implementation, replaced by capped single payer payroll and general taxes with global budgets; local services are managed with community global budgets. Table of Contents #1 of 21: Lessons From the Dutch: Health Care that works for Everyone The Standard We Are Using How This Works Brazilian Health VSM Fourteen Layer Analysis 1.0 #2 of 21: Harvard’s Getting Health Reform Right: A Guide to Improving Performance & Equity #3 of 21: Systems Science Spectacles: London Clinic: Stafford Beer’s Health & Quiet Breathing (1970); Economist January 25, page 16: Letters: Stafford Beer’s Viable System Model #4 of 21: Systemic Trauma: The Troubled Prospects for Managed Care in California & the United States (1996) Appendices #1 of 21: Lessons From the Dutch: Health Care that works for Everyone The Europeans since the end of World War II have developed extensive social services that seem to work much better than the ineffective but much more expensive health and social services in the U.S. What is it really like in Europe? The Netherlands (Holland, the Dutch) has 17 million people, 5 million under 25. 12 provinces, 393 cities. It is the population/size of Los Angeles county, not quite as big as New York City. Health Care in the Kingdom of the Netherlands The Netherlands has 'a chaos system', meaning patients have a great degree of freedom from where to buy their health insurance, to where they get their healthcare service. The difference between the Netherlands and other countries is that the chaos is managed. Healthcare decisions are being made in a dialogue between the patients and healthcare professionals. The Netherlands has a network of 160 acute primary care centers, open 24 hours a day, 7 days a week, making an open clinic within easy reach for most people. Acute primary care is offered by a combination of 121 general practice health centers, that are open outside office hours, and a total of 94 medical emergency units with surgery facilities, of which 90 are at hospital locations, open 24/7. In 71 cases general practice services and emergency rooms are found in one hospital location, bringing the total number of locations where acute care is offered to 160. Analysis by the Netherlands National Institute for Public Health and the Environment showed that 99.8 percent of the people can be transported to an emergency unit / casualty ward, or a hospital offering emergency obstetrics within 45 minutes in 2015. Most hospitals and health insurers in the Netherlands are privately run, non-profit foundations, whereas most healthcare insurers are non-profit companies. There are some 90 hospital organizations in the Netherlands,with some of them running multiple actual physical hospitals, usually as a result of mergers of previously independent hospitals. In general, there are three types of hospitals in the Netherlands: university hospitals, general hospitals, and a category in between that call themselves "top-clinical" teaching hospitals. There are eight academic hospitals, or university medical centers, each of which is directly connected with the medicine faculty of a major Dutch university. In 2016, the Netherlands maintained its number one position at the top of the annual Euro health consumer index (EHCI), which compares healthcare systems in Europe, scoring 916 of a maximum 1,000 points. The Netherlands has been among the top three countries in each report published since 2005. On 48 indicators such as patient rights and information, accessibility, prevention and outcomes, the Netherlands secured its top position among 37 European countries for six years in a row. The Netherlands was ranked first in a study in 2009 comparing the health care systems of the United States, Australia, Canada, Germany and New Zealand. Healthcare in the Netherlands is financed by a dual system that came into effect in January 2006. Long-term treatments, especially those that involve semi-permanent hospitalization, and also disability costs such as wheelchairs, are covered by a state-controlled mandatory insurance. While Dutch residents are automatically insured by the government for long term care, everyone has to take out their own basic healthcare insurance (basisverzekering), except those under 18 who are automatically covered under their parents' premium. If a person decides not to carry out an insurance coverage, the person may be fined. Insurers have to offer a universal package for everyone over the age of 18 years, regardless of age or state of health – it's illegal to refuse an application or impose special conditions. In contrast to many other European systems, the Dutch government is responsible for the accessibility and quality of the healthcare system in the Netherlands, but not in charge of its management. For all regular (short-term) medical treatment, there is a system of obligatory health insurance, with private health insurance companies. These insurance companies are obliged to provide a package with a defined set of insured treatments. This insurance covers 41% of all health care expenses. Other sources of health care payment are taxes (14%), out of pocket payments (9%), additional optional health insurance packages (4%) and a range of other sources (4%). Affordability is guaranteed through a system of income-related allowances and individual and employer-paid income-related premiums. 41+14+9+4+4= 72%, implies that long term care is 28%. The Standard We are Using In The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care T.R. Reid (2009) makes the case: “Universal Coverage Universal coverage has to come first. Universal coverage is an essential tool to control costs and maintain the overall quality of a nation’s health. In a democracy, universal coverage helps create the political will to accept limitations and cost-control measures within the system. Universal coverage also enhances health care results by improving the overall health of the nation. If everyone has access to a doctor, then people can get the diagnostic and preventive treatment that will keep them healthy. “A Unified System A unified system makes it much easier to use digital record-keeping and smart cards like the carte vitale in France and the Gesundheitskarte in Germany. These digital records cut administrative costs, and they make for better medical care as well, because the doctor or pharmacist can instantly see what other treatment, tests, and medications the patent has received. (The French system was designed in the U.S.) “Non-Profit Financing It may be possible to finance fair and cost-efficient health care for all through profit-making health insurance. It may be possible, but no country has ever made it work. For-profit health insurance clearly hasn’t worked in the U.S., which spends more than any other country and still leaves millions without any coverage. And no other developed country wants to try it. “Given our country’s remarkable medical assets – the best-educated doctors and nurses, the most advanced facilities, the most innovative research on earth, a strong infrastructure of preventive medicine – the U.S. could be, and should be, providing its citizens the finest health care in the world. We can heal America’s ailing health care system – and the world’s other industrialized democracies can show us how to do it.” How This Works My name is Jon Li. I am the human in the middle of what we hope to be the organic national network to support and implement universal health care. For 50 years, I have been in the middle of health administration, the consumer/health professional/policy/taxpayer debate about the future of the health care delivery system in the United States. This is called a modified Delphi process, named after the ancient Greek oracle that was consulted about important decisions. The idea is to stimulate an expanding but managed discussion towards a particular finished product, in this case, a paper on June 1st, that is something most people in the U.S. can relate to, about why universal health care supported by community clinics is better for them personally, and better for everyone else in the United States. Each Monday for 20 weeks, we will have a new discussion about how to achieve our goals. Peter Drucker’s Management by Objectives strongly influences this work. The idea is to take the entire Dutch health care delivery system, as an idea, as a practical every day reality, and transfer it to overlay a similar population. This is a systems analysis. Holland has almost 18 million people. Stage 1 analysis: Beijing , New York, Rio de Janeiro, Los Angeles, London, Washington State Stage 2 analysis: Shanghai 23,740,778 Beijing 20,383,994 Sao Paulo 21,066,245 Cairo 18,771,769 New York 18,593,220 Istanbul 15, 029, 231 Buenos Aires 15,180,176 Tokyo 13, 515, 271/38,000,000 Moscow 13, 200,000 Rio de Janeiro 12,902,306 Los Angeles 12,309,530/17,000,000 Paris 10,843,285 London 10,313,307 Johannesburg 9,398,698 Washington State 7,310,300 Stage 3 analysis: Northern California, San Francisco County, Sacramento County, Yolo County, Davis, Woodland, Winters, West Sacramento Stage 4 analysis: University of California, San Francisco Medical Center; On Lok SF Chinatown Multi-Service Senior Center; University of California, Davis Medical Center; Sutter Systemwide, Sutter Sacramento, Sutter-Davis; Woodland Hospital Dignity Health; Kaiser Sacramento, Kaiser Davis Outpatient Only; CommuniCare Davis, Woodland, West Sacramento; Winters Healthcare; Yolo County Adult Day Health Care Stage 5 analysis: The clinical setting: a regular six month check up, a family with three generations, an older person without any family, a homeless person, an orphan, a pregnancy, an abuse victim, an accident, a chronic illness, getting out of the hospital, post-hospital, the clinic health team. Stage 6 cumulative synthesis: That establishes all the layers to be able to lay out an effective, efficient information accountability network, nationally, each state, each region, each city, each community. This is the second time we have done this process. Last spring, we developed a design for a nation to have an ongoing discussion about how to improve the quality of care to enhance the quality of life. Brazil has had a national health discussion for over a century, since Oswaldo Cruz, MD, put down an epidemic in Rio de Janeiro. Since 1985, the Brazilian Constitution has guaranteed that Health Care is a Right, and the Government’s Responsibility. This is our model: Brazil’s Path to a Healthier Global Future: Community Clinic Health Systems; to thoroughly understand it, you need to learn a little about the Viable System Model (google Jon Walker + VSM), but you will probably pick up the environment-organization-management information structure pretty quickly from our 14 layer analysis of how the health system works in Brazil. Unfortunately, we also have an update of how the Bolsonaro Administration is impacting on the health system at each layer, so you can immediately appreciate the power of the VSM as a tool to describe policy challenges. Brazilian Health VSM Fourteen Layer Analysis 1.0 VSM1 of conception of Brazil’s health (including voodoo, African, primitive, native, evangelical Christian) VSM2 of Brazil’s health: Organized Happy Society VSM3 of Brazil’s health care system resources: Organizing the system VSM State Level Health Care (Sao Paulo): Guarantee access to complex levels of care VSM Basic Care Clinic (Basic Health Unit): Promote physical, mental and social well-being VSM4A of Brazil’s unified health system (Sistema Unico de Saude): healthy populations and individuals VSM4B Brazilian Private Health System: Healthy Individuals and Profit VSM5 is in a particular State of Brazil: Sao Paulo: Guarantee Specialists Consultations VSM6 is the municipality’s total health resources: Guarantee Primary Care Full Coverage VSM7 is the health service delivery area of the particular program: AIDS VSM8 is the particular program: AIDS: Universal Access and Empowerment VSM9 is the clinic: Healthy and happy population VSM10 is the Health Family Team: population full coverage: physical, mental, social VSM11 is the interaction with a particular patient. We recommend that every health institution establish an Office of Epidemiological Accountability, begin to do a Viable System Model analysis of the institutions above and below them, and their dynamic, unstable, chaotic environments, and expect more change. Instability and Uncertainty are the watchwords for 2020. During the next 20 weeks, we will be building a dynamic conversation about how the nation can implement universal health care. It is a different situation in every state, requiring adaptation and responsiveness. We want to tie together the healthiness-encouraging consumer experience, a rewarding work life for the a rewarding work life for the various health professionals, an equitable, controlled funding-financing mechanism, regulated with management information for care-planning-administration-evaluation. #2 of 21: Harvard’s Getting Health Reform Right: A Guide to Improving Performance & Equity Marc Roberts, William Hsiao, Peter Berman & Michael Reich, Oxford, 2008. “Not every reference to international experience represents disrespect or “intellectual imperialism.” Health-sector reform is so complex and difficult that self-critical openmindedness is an obligation of all who take the process seriously. We hope that the fact that we come from an industrial country in the world that does a particularly poor job in this regard does not undermine our credibility on this point – for we are hardly defenders of the American system, in part because of its poor equity performance.” “More money for primary care means less for inpatient hospital services.” The Control Knob “Financing”: Resource Allocation and Rationing, page 180 “Embrace Politics: Successful reform thus is not just a matter of the merits of an argument: it is also a matter of symbolism and language, of political skill and personal commitment.” 313 Preface I Health System Analysis 1 Introduction 2 The Health-Reform Cycle 3 Judging Health-Sector Performance: Ethical Theory 4 Political Analysis and Strategies 5 Goals for Evaluating Health Systems 6 Assessing Health-System Performance 7 From Diagnosis to Health-Sector Reform II The Control Knobs 8 Financing 9 Payment 10 Organization 11 Regulation 12 Behavior 13 Conclusions Our approach is based on looking at the health-care system as a means to an end. Our method focuses on the need to identify goals explicitly, diagnose causes of poor performance systematically, and devise reforms that will produce real changes in performance. This analysis is based on a policy reform cycle, presents ethical basis for evaluation, describes ongoing political analysis, sets core health system performance goals and intermediate performance measures, then presents an approach to health system diagnosis, laying out the framework for five “control knobs” that policy makers have to work to improve the health service delivery system. We conceive of a health system “control knob” as something that can be adjusted by government action. Furthermore, adjustments or changes in the control knob must be significant causal determinants of health system performance. The control knobs describe discrete areas of health system structure and function that matter significantly for health system performance and are subject to change as part of health reform. The control knobs are: Financing, Payment, Organization, Regulation, Behavior The Forces Driving Health Reform Force #1: Rising Costs Force #2: Rising Expectations Force #3: Limited Capacity to Pay Force #4: Skepticism of Conventional Ideas 2 The Health-Reform Cycle Step #1: Problem Definition Step #2: Diagnosing the Causes of Health-Sector Problems Step #3: Policy Development: New Ideas, Looking Forward, The Design Process Step #4: Political Decision Step #5: Implementation Step #6: Evaluation 3 Ethical Theory Ethical Theory #1: Utilitarianism Subjective Utilitarianism Objective Utilitarianism Some Utilitarianism Complications: Uncertainty and Time Ethical Theory #2: Liberalism Ethical Theory #3: Communitarianism 4 Agenda Setting for Health Reform Politics of Health-Sector Reform Political Analysis Sources of Power and Influence Position and Commitment Political Strategies for Reform Position Strategies: Bargain to Change the Position of Players Power Strategies: Distribute Power Resources to Strengthen Friends and Weaken Enemies Player Strategies: Change the Number of Players by Creating New Friends and Discouraging Foes Perception Strategies: Change the Perception of the Problem and the Solution 5 Goals for Evaluating Health Systems We propose a set of performance goals: (1) the health status of the population, (2) the satisfaction citizens derive from the system, and (3) the degree to which citizens are protected from the financial risks of ill health. Choosing and Using Performance Goals Health-Sector Performance Goals Health Status Citizen Satisfaction Financial Risk Protection The Role of Cost in Problem Definition Analyzing the Distribution of Costs The Cultural Context and the Political Process 6 Assessing Health-System Performance Efficiency Access Quality Developing a Strategic Performance Problem Focus 7 From Diagnosis to Health-Sector Reform The Genesis of Major Health-Sector Reform Efforts Developing a Health-System Diagnostic Tree Linking Diagnosis to the Control Knobs The Process of Policy Development Screening Tests for Policy Interventions Implementability Political Feasibility Political Controllability II The Control Knobs 8 Financing The 5% or 10% of the people in any insurance pool who are the sickest often account for 60% to 70% of the total cost. 168 Private Insurance Economic effects One argument for private insurance is the claim that competitive insurance markets lower health-care costs. The only health-care market that provides anything close to a test of this claim is the United States – which has primarily relied on private employer-purchased, competitive group insurance for the last 50 years. In the 1990s, as competition among insurance plans increased, there was some impact on health-care costs, as predicted by economic theory. But consumers became very unhappy with the limits on their ability to obtain care from the managed- care plans that came to dominate the market. As a result, insurers have in recent years decreased their efforts to control providers, and costs in the United States have begun to increase at a rate of 10% to 15% per year. Moreover, in part because of the very high transaction costs of a fragmented private insurance system, the United States does have the highest overall health-care costs of any nation in the world – by a substantial margin. 170 Community Financing In this financing method, communities operate and control the provision of their own primary care and secondary services through locally based prepayment schemes. The essential idea is to raise and spend money for primary care locally, at the village level. The theory is that local control will produce transparency and accountability. This will, in turn, help ensure honest, efficient, and culturally competent services. A model community-financing scheme involves a combination of local political accountability, community-operated primary care, and nearly universal prepayment. The concept is of a community-based, mini health-maintenance organization with salaried doctors. Secondary (hospital) care is also contracted by some of these schemes, although it can be expensive and requires a large catchment area to be economically viable. Universal (i.e., compulsory) membership is designed to get around free-riding by the well and adverse selection by the sick. Community resources may also be mobilized in other ways; for example, by labor to construct buildings. 176 9Payment The Impact of Payment on Outcomes On the supply side, payment influences how many providers enter the market and how services will be produced. On the demand side, patients decide what to purchase and how much to consume, based on the amount they have to pay. Payment is a key mechanism to ration scarce economic resources – it determines the production, distribution, and consumption of health services, drug utilization, and the pattern of capital investments. Payments and their incentives play a critical role in determining health-system performance. 193 Global budget This payment method sets an all-inclusive operating budget in advance. Often the organization must meet certain output targets, like a number of bed days or outpatient visits, or face a penalty. A global budget represents the broadest scope of bundling services. Every service performed on every patient during one year is aggregated into a single payment. Under a global budget system managers have an incentive to control their expenses while attaining their production targets, although the potential always exists to distort decisions to reach those targets. 202 Payment Systems and Patients Studies in developing countries consistently show that price elasticity is higher for lower- income households and for children. Thus user fees have a greater adverse impact on the care, utilization, and the well-being of lower income households and children. 205 10 Organization Changing Who-Does-What Restructuring the Public Sector 1: Decentralization Technical education will not necessarily overcome a deficit in “social capital”: the willingness of citizens to cooperate in pursuit of their joint interest in ways that involve trust and reciprocal respect. Double-entry bookkeeping can be taught much more easily than the attitudes required for successful democratic citizenship. It can also be a mistake, however, to delay implementing decentralization until all training is “finished.” That day may never come. Moreover, the pressure of implementing decentralization can produce “teachable moments.” That is, the need to perform can increase the receptivity of local and regional officials to acquiring new skills and concepts. These observations about authority, redistribution, and local capacity-building illustrate our general contention that the outcome of a policy change will depend on the details of its design and implementation. The many choices involved in decentralization need to be made in a consistent and coherent way if the potential benefits are to be realized. For example, to improve efficiency or to produce services more closely tailored to local circumstances, local decision- takers need to have authority over personnel and budgets. Otherwise, how can they hope to produce the desired results? Once a program of decentralization is initiated, the role of the central bureaucracy changes. The center now must advise instead of control, and train instead of command. Regulatory or incentive devices many be needed to push local policy toward national goals. 233 Monitoring performance becomes especially important. Otherwise, the effects of the new arrangements will remain obscure. Needless to say, many central government units find this transformation difficult to accept. One final point involves the differences in local conditions and capacities among different regions, especially in large countries. As a result, decentralization efforts might need to vary by region. 234 11 Regulation Regulation is often more effective when appropriate incentives and efforts to influence individual behavior complement regulatory initiatives. Regulation is not self-implementing, however. The administrative and political tasks that must be accomplished for regulation to work effectively can be daunting. Moreover, poorly designed regulation can make health systems perform worse, rather than better. Policymakers therefore must understand the strengths and limitations of regulation, and what it takes to implement regulatory initiatives, if they are to use this tool successfully. 248 Defining and Justifying Regulation Regulation and Health-System Objectives Most regulation affects intermediate performance measures. 251 The Determinants of Regulatory Success Effective regulation is a complex and demanding process. First, an appropriate regulatory strategy needs to be developed – decision made about what and how to regulate. Then agencies have to be established, including the recruitment of staff and the collection of data. Then the detailed rules have to be written. Next they have to be applied to specific cases. Monitoring processes need to be established so that violators can be identified and either persuaded to change their behavior or penalized if they do not. All of this must be done in a context in which those being regulated will protest and seek to influence the agency to treat them leniently. Effective regulation thus requires a demanding combination of technical expertise, administrative capacity, and political support that is not always easy for nations to provide. 251 Experience with regulatory interventions around the globe suggests that successful regulatory efforts depend on three key aspects of each nation’s situation: cultural attitudes, government competence, and political support. All of these, we believe, need to be taken into account in designing regulatory institutions. 252 Cultural Attitudes Reformers should realize that specific cultural norms and social beliefs influence the effectiveness of regulation. Regulators and regulatees react differently, depending on whether they agree with the goal expressed by the regulation. When legal restrictions are compatible with social beliefs, citizens are more likely to comply; otherwise, the regulated may try to evade the regulations. 252 Capacity of Government The operations of the regulatory agency are often a focus of controversy. Because regulators are trying to change the behavior of specific groups, those being regulated have every reason to deflect or minimize the regulatory agency’s effectiveness. Their efforts are likely to begin with trying to shape the design and wording of rules and administrative decisions, and continue through to all aspects of implementation. The resulting efforts range from persuasion and influence, to political pressure, to outright corruption. Inducement can come in many forms, from bribes, to gifts, to promises of lucrative post-government employment, to favors for the regulator’s relatives and friends. How regulatory officials respond to pressure, persuasion, and bribery depends in part on the political structure and professionalism of the bureaucrats. There are large variations in the nature and extent of corruption in different countries. Political cultures vary. In some societies, the failure of an officeholder to help family or clan members – or even college classmates – would be viewed as dishonorable. Even within a country there can be significant interregional or intersectoral variations. 253 Correct Market Failures and Provide Public and Merit Goods Protect buyers from poor quality: In terms of forms of quality control, we can think of government as regulating the inputs, the processes, or the outcomes of health services. Regulation of inputs is easiest to establish and enforce, so it is the most prevalent. It does not necessarily ensure better outcomes, however. Regulating the processes of care is much more difficult, and the responsibility for doing so is often assigned to the medical profession. Regulation of outcomes may seem ideal, because outcomes are what society should be most concerned with. But because patients may respond to treatment differently, depending on the severity of their disease and their particular physiology, sophisticated sampling and severity adjustment is likely to be required – which is technically very challenging. In addition, the medical profession generally resists regulation based on outcomes as an infringement on its clinical autonomy. This resistance is important, because to succeed, quality regulation must be acceptable to the medical profession. 261 Summary Health-sector reformers who want to make a real difference need to think carefully about the likely enforcement process, the available resources, legal capacity, political support, data and monitoring systems, and the incentives that regulation will generate, before pursuing the regulatory route. 12 Behavior Categories of Individual Behavior Where can the behavior-change control knob be used in health-reform efforts? Here it is important to consider four categories of individual behavior: Treatment-Seeking Behaviors Health Professional Behaviors Patient Compliance Behaviors Lifestyle and Prevention Behaviors Each Category can be related to important objectives for health-sector reform, including core criteria and intermediate criteria. Treatment-Seeking Behaviors Consumer decisions on when, where, and how to seek treatment are an important area for improving health-system performance. These treatment-seeking decisions include the kind of health professional (e.g., specialist versus generalist), the level of health facility (primary care versus teaching hospital), the timing and location of the treatment, and the use of traditional versus Western medicine. These consumer behaviors often involve interaction with a health professional, including physicians, midwives, traditional healers, and private drug sellers. Treatment-seeking behaviors are important for acute health problems (e.g., traumas and fevers) as well as chronic health problems (e.g., diabetes and health disease). 285 Health Professional Behaviors Provider decisions about treatment represent a second important category of individual behavior that can be addressed through this control knob. Important provider decisions include the nature of the treatment, including adherence to practice guidelines; the amount of attention given to preventative care; the location of treatment (a public hospital versus the provider’s private office); and the referral of patients to other providers. Nor is government the only potential actor here, since issues of professional ethics can be addressed by behavior-change campaigns directed at professional societies and targeted at their members. 286 Patient Compliance Behaviors The third category of individual behavior involves patient decisions on whether to follow the treatment instructions of health professionals. These behaviors include the use of pharmaceutical prescriptions, pursuing referrals to other health providers, and other kinds of treatment-following behaviors. One study found the interesting result that behaviors like breastfeeding emerged from a complex social network. Therefore, attempts to change the breastfeeding habits of mothers need to take into account the attitudes and influence of husbands and elders, and especially the mothers of those childbearing mothers. 287 Lifestyle and Prevention Behaviors The fourth category of individual behaviors is consumer decisions on lifestyle habits that have major impacts on their health, especially in preventing disease. Examples of these behaviors include individual decisions about exercise patterns, food consumption, smoking, sexual relations, and contraceptive usage. These behaviors do not necessarily involve interaction with a health professional or a health facility. Indeed, they are often subject to a complex set of influences, from modern commercial marketing to the force of traditional cultural expectations. 288 13 Conclusions Critical Tasks Clarify Your Goals Carry out an Honest Diagnosis Develop a Plan that can Be Expected to Work in Your National Context Embrace Politics Focus on Implementation Successful implementation requires performance measurement. Here again, realism is critical. Lean too hard on a measurement system and you risk dishonesty in reporting or unintended distortions in behavior. Focus on performance, not reports; on outcomes, not inputs; on results, not merely efforts made. Institutions (and people) resist change out of both self-interest and anxiety. Staffs need to be helped through the reform process by leaders who are both credible and committed and who understand the dynamics of organizational change. Implementation does not just happen; it needs to be planned and guided. Critical tasks need to be identified and likely obstacles anticipated – although, of course, not everything can be. Managers need to adapt as experience accumulates. 314 Learn from Your Mistakes Lessons from the Control Knobs Financing Even with an optimally designed financing system, a healthy citizen with an average income will have to pay, directly or indirectly, the costs of their own routine care, plus something for risk-pooling and an amount for redistribution to the poor as well. How much such an individual can and will pay is obviously limited by their economic circumstances. In general we observed that to truly provide risk protection, a universal system based on ability to pay is required. That allows the rich to cross-subsidize the poor and the healthy to pay for the sick. It is no surprise, then, that middle- and upper-income countries mostly rely on social insurance or general revenue to finance their health-care systems. As countries move up the development scale, social insurance is often especially attractive because the social contract implicit in such a system often improves tax compliance. 315 Finally, we view with some trepidation the growth of private insurance in upper-middle- income nations. Such systems have very high transaction costs, require sophisticated regulation, and offer only limited risk-sharing – especially where they allow individuals to withdraw from social insurance pools. We realize that many countries are under pressure from their own elites to allow the creation of such schemes, which give the rich access to better care than the public system can offer. 316 Payment Our general advice to reformers is to try to avoid fee-for-service reimbursement for physician services, in order to minimize the inflationary effects of supplier-induced demand. Similarly, per diem payments for hospital care encourage overly long lengths of stay, even as traditional budget systems create few incentives to improve quality. We do realize the political and technical difficulties of more-sophisticated alternatives –like capitation or per admission payments where the money follows the patients – but we believe they are preferable on incentive grounds in many situations. Then there is the question of payment levels. International experience suggests that providers are never satisfied with their level of payment – no matter what they are paid. The resulting conflicts over payment levels should be anticipated by reformers and considered in the institutional design of the payment-setting process. 316 Organization Many reorganization proposals such as autonomization, decentralization or purchaser- provider separation pose distinct challenges for central administrative agencies. Their functions will not end, but they will be transformed. And the new skills and attitudes that will be required are often not easy for ministries to develop. The same can be said at the institutional level of the changes that are required to improve the functioning of the usual type of public-sector institution. These are both obvious and fly in the face of profound political objections because they undermine the patronage structure characteristic of many public delivery systems. 317 Regulation Regulation is often difficult to implement exactly because it involves using the coercive power of the state to get people to do what they do not want to do. Instead, they resist – and seek to capture, corrupt, or otherwise undermine the process. Thus regulation works best when most of the society, including both regulators and regulatees, sees the goal of the process as generally legitimate. This greatly facilitates voluntary compliance, which in turn significantly increases the deterrence effect of enforcement efforts. For the same reason, ongoing political support is likely to be required to preserve a regulatory agency’s effectiveness. 318 Behavior We stressed throughout the need for a customer-focused approach to behavior change. Reformers need to market their ideas in ways that meet or resonate with customers’ existing needs and values. This means they have to begin with empirical research on those customers and learn how they vary so that appropriate market segments can be identified. Then a plan that unites the four Ps (place, product, price and promotion) can be developed. Such plans require skill and sophistication to develop – whether aimed at individual patients or at providers within the health-care system. 319 Final Thoughts If health-sector reform is so difficult and demands so much from reformers, why take on the challenge? First, health is an important component of both opportunity and well-being for all individuals in a society. So those who work to improve health status are doing genuinely important work from almost any ethical perspective. The same goes for efforts to protect individuals against the financial risks of illness – risks that can cause great anxiety and deprivation for those who lack such protection. Second, providing such gains to those who are most vulnerable in society is, in terms of our own ethics, an especially urgent and praiseworthy task. Improving access to the extraordinary advances of modern medical science could make an enormous difference to the lives of millions, if not billions of our fellow human beings. We hope that the fact that we come from an industrial country in the world that does a particularly poor job in this regard does not undermine our credibility on this point – for we are hardly defenders of the American system, in part because of its poor equity performance. Third, for all of its difficulty and frustration, health-sector reform, we believe, is an arena in which intelligence, energy, passion and critical thinking can make a difference. It is an arena that calls upon many aspects of a person – analytical and intra-personal, creative and purposive. It requires an appreciation of many aspects of human life – from politics and economics to cultural forces, biological processes, and philosophical commitments. It offers opportunities for leadership and craftsmanship, for doing work that is truly worth doing. For those who choose to participate, we hope this book can serve as a handbook and guide, as tool kit and design manual, and that the methods and observations we have offered will improve your chances of getting health reform right in the years ahead. 319 #3 of 21: Systems Science Spectacles: London Clinic: Stafford Beer’s Health & Quiet Breathing (1970) The Sixteenth Centre Lunch Talk, given at the Hospital Centre, London, on the 25th November, 1970. Published in Platform for Change, (1975, 1994), reader’s guide by Jon Li, John Wiley, Chichester To talk within this compass about the management of a business which is now in the top ten largest financial operations in the whole world, a business which employs 3½% of the national labor force, is daunting. Certainly I have no pet or pat solutions to the problems that beset the National Health Service. What I do have is an approach to problems called operational research, and I can perhaps suggest a few clues that point to its effective use. What Operational Research Is and Isn’t O.R. exists to solve management problems by the knowledge and methods of science. Management problems – financial, medical, administrative – are all about people. A problem should be studied in the context of the system generating it. Science is more than labeled topics – it is a codified understanding of how things are and how things work: insight made rigorous; the general educed from particulars. An O.R. team is multidisciplinary, to deal with problems, but one never knows what kind of scientific insight or skill might be needed next. O.R. works by constructing models, expressing a dynamic system to explore the workings of the system under different conditions. The first thing you discover in addressing a problem of top policy in a large enterprise is that no-one dares to experiment with the system as a whole, and rightly so. Then the model stands as surrogate for the system, and you can experiment with the model all you want. Inside a computer model, we can simulate existing conditions, which should result in outputs recognized as normal, which helps validate the model. Then submit the model to all variety of possible perturbations that might in future occur, which will give a sensitive measure of the system’s structure to varying degrees of stress and the vulnerability of the management strategies currently used to a range of possible futures. Third, we can change both the structure and the management strategies (still within the model) about how things might be better, and see what happens. So O.R. is an interdisciplinary and an experimental activity, dealing in the behavior of large and complicated systems. You shall see the kinds of model I should like the Health Service to create later on. They are systemic, and they deal in measures of information. They are not embodiments of mathematical tricks for cutting costs. What a Health Service Is and Isn’t First, there are three monolithic blocks: the hospitals, general practices, and local health authorities. Then we have an organization frozen out of the past; we have institutionalized a set of historical accidents. The result is a structure where the lowest organizational crossover point is the Minister themself. There is an exception, though: a healthy-looking low-level link between general practices and local authorities called a Health Centre, like this one I am speaking in now. You may recognize a study by Curwen and Brookes (Lancet No 7627) that this approach to integration is 50 years old, and yet there are only a hundred centers, and it doesn’t seem to be making much headway. There appear to be no arrangements for the purposeful study of how the whole thing works – in the course of fifty years the vision itself has leaked away at the seams. Second, there seems to be a tremendous spate of commissions, committees, inquiries, white papers, green papers and even Bills, going where? Cross the boundaries of the three monoliths of hospitals, general practices and local authorities with area boards, which the doctors don’t like. Hospitals? Fanatical conservatism. And yet, we should surely all agree that the actual provision of our health service is a matter for some satisfaction. (You should hear me boasting about the British National Health Service in the United States – where I suspect they have hit on a brilliant system of prophylaxis: you frighten folk into good health by the cost of being ill.) The puzzle I put to you is that in a year’s quite intensive reading about organization, statistics, financing, costs, staffing and so forth, your objective observer has not once come across any reference to what the health service is about – namely people who are well or ill. Here is the distinction, then, drawn like this. On the one hand is the ostensible reality: an introverted organization, preoccupied with its own antecedents, its internal power struggles, its levels of status, its costs and its wages, which solves its management problems in equations of political factors and psychological stress. On the other hand is the notion of a health service, to which surely many people in fact dedicate their lives, conceived as a national system for promoting healthiness. An O.R. Approach to Any Large Enterprise If you really want to solve major problems, it is no use tinkering. For one thing, O.R. is a scarce resource. For another, the piecemeal approach takes way too long. Secondly, it is not a question of cost-effectiveness, as much as how to utilize the resources available now. If you were starting from scratch, knowing the current state of the art, having nearly a million staff of various qualifications and the best part of two thousand million pounds to spend, do you think you would come up with a system remotely resembling the one we have today? It is always good O.R. advice to say: work out your objectives, evaluate your resources, take account of real constraints (but not mere prejudices), create and test a system for the purpose, then say what you want to do. Compare the answer with the answer you already have. If it is overwhelmingly better, as well it might be, then stop messing about with making the existing rotten arrangements more efficiently rotten, and get cracking on the plan which can take you from where you are to where you want to be. Concepts of Health Management What do we think about the objectives? Originally founded at a time of great need for curative medicine, our medical services have brought disease under control, and added a structure of preventative medicine and health education. Think of the health service as regulative. We look for a stable society, in which factors affecting healthiness are under control. Our objective is ‘health and quiet breathing’ (from Keats’s Endymion). Society is a very large system, made up of individuals. We can define the health status of every person, beginning by calling each one ‘ill’ or ‘not ill;’ but of course a good recording system would offer a much richer account. The account could exist, but it does not, because of organizational fragmentation and archaic methods of recording and storing medical facts. Suppose one said: let us consolidate all this. What is the state of the art? Do we need costly and inefficient clerical processes spread all over the fragments of the total system? No. If a scientist can have ready access to a computer terminal, then so can a physician. When you want to retrieve something from the record, you can find it and you can read it. I am fully aware of the problems of confidentiality posed by effective and consolidated electronic files. They can and will be solved. You must admit that it would be ludicrous if the only valid means we had to defend our personal freedom in the face of electronic competence were to have a system of personal records so inefficient that no-one could actually use it… So I am beginning to paint the picture of a locality with a proper health center, with proper records about the health status of every resident, and containing all medical facilities for out- patient treatment of every kind. The first recommendation is that an O.R. study be done. Let us work towards the notion that a health locality is defined in terms of packages of information about its individual residents, constantly updated, and that enquires into the nature of the total local system can be made by simulating its integral behavior through a model mounted on a computer. We stand to learn so much about how that system works that we don’t know now, and how environments affect the people in them. We shall know too not only the sorts of disease that patients have, but the sort of patient that has a disease – which Parry of Bath set out to learn two hundred years ago. Next, if a patient does arrive at a hospital (where a majority of our health money is spent) they will obviously arrive enveloped in an infinitely better aura of information that they do today. This package of information has got to undergo a set of transformations: that makes a perfectly good definition of the reason the patient has come. Some of the variables quantifying the parameters of healthiness are out of their limits. They must be brought back to normal. Every stage of the patient’s handling and treatment can be regarded as applying a transformation to their data-set, and the result will be a new data-set – recognizably better or worse than before, or indistinguishable from before, by recognized medical criteria. The model includes uncertainties for both physician and patient, including ‘don’t know’ and ‘something is missing’ as valid data in the information-theoretic model that helps define what needs to be learned. This is the beginning of a reformation of how hospitals are run – a reformation based on the notion that what happens in a hospital is all about information and its transformations. If you could study the hospital wearing spectacles which allowed you to see the movement of information and nothing else, you would understand both the medicine and the administration – and just how the two fail to interact. You would understand the progress of the illness, and of its therapy. You would trace the loops of information that culminated in a very ill patient crawling out of bed to a public telephone – to ring up the hospital and ask how they were. You would trace the loops whereby relatives make enquiries, and you would mark the information filters which substitute ‘as well as can be expected’ for actual information. You would trace the information network by which nurses and sisters know what to do for their patients. The cost of a hospital is clearly correlated with the length of inpatient stay: the length of in- patient stay varies very widely between hospitals for the same types of case, and is directly correlated with the rate of staff turnover as all levels. The explanation is: the linking factor is the availability of nursing information – which affected both the length of stay and nursing morale. When the information flow was bad, no-one knew what was happening. Patients remained in their beds until someone found out. Meanwhile, the nursing staff were made profoundly uneasy by a sense of inadequacy in the care they could offer, and their loss of morale spread throughout the hospital at every level. The converse is also true: improved nursing communication means greater confidence in co-workers. The second recommendation is that these old studies be newly validated, and extended in terms of new ideas and modern facilities. The uses of electronics for patient monitoring, preliminary diagnosis, the computation of diets and therapies, are all known about – but they are not at all integrated within any ‘total systems’ concept of information flow. If the concept is regulative, this is the prerequisite. The hospital is indeed a vast interactive control system for regulating both illness and its own effective performance. That system needs to be modeled, studied, experimented with through the model, and – finally – changed. Models of the System O.R studies of the nature of a possible modern health centre and of a possible modern hospital, both conceived in terms of information flow rather than any other commodity (such as money) would unite readily – because they would both be undertaken with the patient providing the unit data-set. It is the same person who is well, who is exposed to risk, who develops pre-symptoms and then symptoms, who is diagnosed, who is treated at the health centre, then at the hospital, and who finally returns to a pool of the relatively healthy. Transformations of their data-set. Then what happens to society itself is to be understood, planned for, legislated for, by enquiring into the interactions of these transformations. Third, if we wish a service which is regulative of societary health, then we must also build a scientific model of the way in which people flow around this entire system, interacting as they do, and absorbing resources – of skill, equipment, drugs and money –as they go. This big model should be built. Its data base today would have to be rough and ready – because we do not have the channels of information in the locality and in the hospital (which I have proposed) to tap. This paucity of data has always been used as an excuse for not getting on with the job. The excuse is feeble. O.R. studies can show what the optimal organizational structure should be. It is from these studies that civilized people should tease out the best way of organizing things – and in general of managing the world’s tenth largest business –in the best interests of health and quiet breathing. Economist January 25, page 16: Letters Stafford Beer’s Viable System Model Your essay on “cybernetic dictatorship” was excellent (“Beware the Borg”, December 21st). However, Chile’s “Project Cybersyn” in the early 1970s was not a design of a command-control economy. It was based on Stafford Beer’s Viable System Model (VSM), which specifies a recursive, hierarchical, distributed and decentralized control system. Each VSM is managed locally and has local autonomy. Factory data were centrally analyzed in Project Cybersyn and the results sent directly back to the factory managers for their consideration. The model explicitly incorporated the market mechanism, which is the environment (directly or indirectly) of each factory. Beer was a passionate advocate for democracy, publishing a book on this titled “Designing Freedom”. He argued that it is possible to have effective and efficient control of economies democratically. The VSM was designed to do just that. Professor Graeme Britton Singapore #4 of 21: Systemic Trauma: The Troubled Prospects for Managed Care in California & the United States (1996) Jon Li Institute for Public Science & Art 1075 Olive Dr. #4, Davis California 95616 USA; (916) 753-0352; email: jonli@dcn.org prepared for the 1996 Annual Meeting of the International Society for the Systems Sciences (ISSS) Theme: Systems Theory at the end of the Millennium: Revolution in Science & Transformation in Society Abstract Health care costs determine defacto health priorities. The U.S. health financing system is mostly private, profit driven. Insurance has historically evolved to managed care, which has some financial efficiencies but often include questionable quality, health professional dissatisfaction, and a significant percentage of uninsured in the larger population. As an alternative, we start with a goal of optimal care, and look for components of a delivery system which will most effectively encourage healthy individuals and communities. Keywords: U.S. health systems financing; managed care “Our leaders should reject market values as a framework for health care and the market- driven mess into which our health system is evolving. We gave up too easily; we must make another serious attempt to formulate a national policy that will provide health care to all”. --Jerome P. Kassirer, editor, New England Journal of Medicine, 6/6/951 1. Introduction The U.S. spends $1 trillion annually on health care, far more per capita than any other country, and yet has inconsistent quality. At least 14% of the population is not covered at all. The U.S. is the only major industrial nation which does not have universal health care coverage and uses private, for profit insurance to allocate health care funds. Most other developed nations have stabilized their health spending at 9% or less of GNP, while U.S. spending continues to soar -- climbing to above 14% of GNP. Canada spends about 1% of its health care dollar on administration; the U.S. spends over 10% (private insurance is 14%, Medicaid is 4%, Medicare is 2%). During the past five years, Managed Care has replaced fee-for-service billing as the dominant financing structure in U.S. health care. During the 20th century, physician reimbursement has shifted from produce and chickens, to direct payment, to fee-for-service billing, to insurance with consumer co-payments, to Managed Care with fixed monthly premiums without regard to services provided. While Bill and Hillary Clinton were not successful in implementing their dream of universal coverage, they deserve credit for putting health care high on the priority list of U.S. domestic policy. The fee-for-service insurance process has become so complicated that the health care industry is shifting to managed care even though they politically fought the Clintons’ proposal. Americans are signing up for Managed Care coverage at a rate of 5 million more a year. But the U.S. shift to Managed Care has provided less than satisfactory results: duplicated local resource expenditure by competing health plans, poor consumer routing, lots of “lost in the cracks” cases, and exasperated health professionals - primary care providers doubling their burden while specialists lose their caseloads. This paper examines the complexities of Managed Care, and then presents a model for comprehensive, universal coverage with a single payer financing structure. As comprehensive policy, forms of single payer have been proven to work in Canada and in Germany (since 1880). By comparison, Managed Care is still an untested experiment by the insurance industry. Its performance should be evaluated against the standards that define single payer policy: quality of care, cost containment, access, availability, and infrastructure support, as well as health professional satisfaction. Information about money and quality need to be better intertwined. New economic models need to be developed around high standards of resource use and positive consumer outcomes. This paper explores a context for moving toward a more efficient administrative structure, and the use of computers to decentralize power to the individual health consumer and her or his local team of health professionals and special resources. 2. Sources of Systemic Problems Before Managed Care, most doctors didn’t like health administration complexities, and felt that society didn’t respect them enough for all their hard work. They would have felt ok, if their bills weren’t so high, if people didn’t complain so much about what seemed to be excessively high fees and if there weren’t so much paper work. The doctor kind. Ten percent plus of medicine is the paper work, and a nurse can tell a good doctor right away by how frequently they get behind in their chart notes. If a third of health care is what a doctor does, the billing kind of paper work takes you to a half, and the other half of medicine is a quarter nursing and a quarter every thing else. It is the boring paper work that is a challenge for general systems theory. 3. The Drive for Managed Care A. Problems with Fee-For-Service Fee-for-Service is a payment scheme that was designed by M.D.s serving on the boards of young health insurance companies. As the society became more urbanized, the customers no longer had a chicken or a basket of potatoes to give the doctor as payment for care. The insurance companies sold group policies to unions, and tried to spread the costs of care among a large, healthy population, which is the whole point of insurance. Fee-for-Service developed problems that grew in severity. The first is the lack of control of costs. Health care cost increases have exceeded inflation most years since World War II, driving up the risks to insurance companies. Medicare brought doctors the right to bill whatever they want, allowing them to define the “usual, customary and reasonable fees” in their area. Health insurance companies rarely broke even, and were primarily a tax management agreement between the AMA, Congress and the management of corporate America concerned about the cost of health benefits for their labor force. Fee-for-service worked as long as the health insurance companies’ cashflow provided a fund to invest in the stock market for a high profit. During the 1980s, the chances of a health insurance company turning a profit disappeared as the cost of care skyrocketed (even though premiums were climbing in price at annual double digit inflationary rates). A second cost problem is the increase in awards for medical malpractice. Awards have frequently been millions of dollars because juries have to assume that the victim cannot count on the health system to keep costs under control. A third cost problem is complexity. On a case by case basis, billing by item made sense to justify each cost. But with each added bill or item, complications set in. As health services became more technological, and medical specialists charged more to supervise the technicians who ran the machines, the cost of producing the bills grew. The average cost of care in an acute care hospital rose from under a $100 a day to over a $1000. Billing became so complicated that a physician needed to have a billing clerk for each nurse, a computer, and hours of headaches trying to figure out how to get the forms back to the insurance company in the correct fashion so the physician would be reimbursed for services provided. Each insurance company was different, and there seemed to be new ones all the time. There are now around 1,500 health insurance companies, each with their own forms and idiosyncrasies. A fourth cost problem is the worship of the profit motive, meaning that the prioritization of care is secondary to monetary considerations. In evaluating different health care proposals, the money filter is the first and last criteria for comparing proposed changes. A fifth cost problem is the overbuilding of hospitals, which means that the cost of care is higher per unit because each hospital is underutilized. Standards of practice and new micro- technology now allow doctors to perform many procedures in the office or surgi-center where the person stays less than 24 hours. Break even for an acute care hospital is 70% occupancy. Hospitals lost patient days to the point where many for profit hospitals are at 50% occupancy or less, which means costs are higher than revenues, and there is a growing deficit. Finally, the overall complexity of health care administration and the merciless time demands on individual doctors have forced most M.D.s into some type of group practice. What this means for 99% of the M.D.s is the end of the image/reality of the single individual free- enterprise doc working stand alone with his “black bag”; it had become obsolete. For these M.D.s, Managed Care was an appealing alternative: a comprehensive institutional relationship that was just around the corner. 3.B. Managed Care Roots before the Clintons Managed Care is the direction health care is headed in the U.S., even though it has never been shown to work as a public policy, in this country or any other. There is a shift in emphasis in health care from being a service to being a commodity. The fundamental unit of Managed Care is the Health Maintenance Organization or HMO, which is the concept of integrating doctors, hospitals, and other health resources into one organization. Where the fee-for-service system scattered doctors’ responsibilities, the HMO coordinates resources more efficiently. The problem with HMOs is that they must be exclusive to be cost effective. “Clinton’s pro-managed care, pro-competition strategy represents merely an intensification of government and corporate policies that commenced with Richard Nixon’s HMO Act of 1973. Indeed, Paul Ellwood coined the term “HMO” in the early 1970s, and personally sold Nixon on the concept as a counter to Ted Kennedy’s single payer national health insurance proposal”2-187Ellwood wrote in 1971 that he hoped HMOs would create a “change in the health industry that would have some of the classical aspects of the industrial revolution: conversion to larger units of production, technological innovation, division of labor, substitution of capital for labor, vigorous competition, and profitability as the mandatory conditions for survival”.2-236 The HMO is a historical shift in emphasis from a “doctor and his black bag” and a free- standing hospital which legally could not hire the doctor; to an integrated set of doctors, hospitals, and other health resources that is coordinated financially and administratively to provide comprehensive modalities of care. The goals are improving the patient’s health knowledge and increasing the chances of preventing the need to use health resources and therefore saving costs. The original HMO is U.S. military medicine: in the short run, help every body (but put effort into who can be helped the most). The name “Managed Care” is an improvement in U.S. health care policy over fee-for- service (which rewards specialists and leaves the consumer without a primary provider). Managed Care shifts the responsibility to a primary care giver who is supposed to be the consumer’s advocate. Problems with this situation will be discussed later on. Kaiser HMO offered an excellent role model for comparison within the U.S. Since most of Kaiser’s client pool consist of employed workers and their families, Kaiser can emphasize prevention to an already healthy group, and minimize their need for medical intervention. By and large, fee-for-service clients, even with insurance, tend to put off health care until the last moment, increasing the eventual cost of intervention. Recognizing this, Kaiser uses preventive care and education, to minimize the need for higher cost hospital care down the road. Health education is the most efficient use of the health dollar. Kaiser is stingy about using their resources. People wait a long time on the phone to get an appointment. But appointments seem prompt; when you need care, they are ready. HMO fast facts: 10 insurers control 70% of the HMO market nationwide (including Aetna, Prudential, Cigna, Met Life, Traveler’s and Blue Cross) the minimum feasible population to support an HMO is 200,000 enrollees the profit strategy is to “cream off the top” the healthiest customers (who will cost the least) and ignore the rest 3.C. Clintons’ Proposal for Transforming Health Care: Managed Competition Just before the New Hampshire primary in 1992, Bill and Hillary Clinton spent a Sunday in a hotel room in Boston with Ira Magaziner developing a health policy strategy which would dominate the first two years of their term. They decided to make health care the hallmark of their domestic economic policy. Costs had continued to rise, and the industry had grown so complicated that it seemed out of control. Insurance helps pay the bills for many, but over 14% of the population – the underemployed and working poor and their families – are without any coverage. The costs of care have grown so much as to take up 14% of the GNP, eating a chunk out of the profits of many corporations and an evergrowing share of the federal, state and local governmental budgets. Bill and Hillary decided that the U.S. was not ready politically for single payer health financing, so they decided to develop a goal of universal coverage, around the idea of Managed Care, then a foreign idea to most voters and the insurance industry. Bill explained his idea for risk pools, health alliances and other esoteric policy wonk terms. When the Clintons were elected, they took it as a mandate to tackle health care policy using Managed Care. Managed Care is a California-grown idea. Managed Care was initially popularized in the early 1980s by Alain Entoven, a Stanford economist. It was developed as an excellent example of Reaganomics. The idea is to control costs by restricting how and where people seek medical attention by putting the emphasis on market decisions and competition. It is social darwinism which drives into prominence the HMOs with the best package for the lowest price. Less concern is given for the not-so-efficient, and there is no concern at all for the sensitivities of the consumer at large. The Clintons’ wrinkle on Managed Care was to require the insurance companies to work together — to share the risk pool and coordinate the design of information forms. The Administration thought they could put together a package which enough interest groups would support that the insurance industry would buckle under and comply. They didn’t want to kill the health insurance industry, just make it more efficient and responsive. In the name of less complexity, the Clintons introduced an 1100-page proposal which lost sight of its goal. In Congress and the national media (the TV ads with Harry and Louise), the health insurance industry battled back. With each proposal in Congress, they whittled away at the Clintons’ plan. And the seniors, nurses and other special interest groups from whom the Clintons had hoped for support instead were making new demands to specialize the proposal which would make it even longer and more complicated. Not one health care reform bill made it to the President’s desk for signature. Bill Clinton’s September 1993 speech on health care may have been the high point of his first term, but his threat to veto a lousy health bill became an idle threat. 3.D. Transition in the Marketplace While the insurance industry was doing everything it could to kill the Clintons’ plan in Congress and the national media, they were implementing Managed Care in the marketplace. Their desperate need for cost controls was the driving force. The transition had two stages: (1) shift from specialist care to primary care via the gatekeeper, and (2) create an HMO oligopoly, and only pay for services given by preferred providers. 1) Gatekeeper/Costcutter: since World War II, most health innovation involved medical specialists and technology in hospitals, continually driving up the cost of care using the fee-for- service system. Health insurance is risky, even with a healthy pool of insureds who are hardworking premium payers. A few days in the hospital, surgery, and doctors bills can add up to more than all the paid premiums in a hurry. Health insurers have found that they must control their costs, so they keep setting limits. Sometime before Harry and Louise hit the TV airwaves, health insurance companies decided to shift to total cost control rather than itemized fee-for- service billing to control costs. They anointed a primary care doctor with all of a patient’s responsibility — for their care and the cost of their care, including hospitals, specialists, drugs and whatever other services the patient needs. The primary care provider, be it an internist, general practitioner, family practice, or obstetrician/gynecologist, was given the title of “Gatekeeper”. The insurance companies give the Gatekeeper the cost control responsibility, who in return receives a regular payment from the insurance company. If the patient’s cost of care is less than the insurance payment, then the Gatekeeper comes out ahead. If not, the Gatekeeper eats it. This is a better deal for the insurance company because they can manage their financial risk. But for the doctors, it is terrible — the primary care doctors are at the low end of the M.D. income scale, and they have become burdened with inevitable bankruptcy-level risk. If a patient needs a referral to a specialist, the Gatekeeper must arrange, coordinate and pay for it. So it is in the best interest of the Gatekeeper to minimize referrals. It has the docs shaking. The specialists have found their consulting and referral income drying up, with primary providers unwilling to refer patients when the cost comes out of their own pockets, not the insurance company’s. These Gatekeeper responsibilities were forcing free-standing individual doctors into an increasingly difficult administrative work environment with more paperwork and reduced job satisfaction. 2) Shift from Solo and Small Group Practice to PPOs and HMO Oligopoly: In reaction to the scattered chaos of the fee-for-service system, the larger insurance companies like Blue Cross/Blue Shield created “Preferred Provider Organizations” (PPOs) which are pools of physicians who are willing to accept an established lower rate of reimbursement in exchange for being part of the designated pool of available physicians. If the physician is not a part of the pool, the patient has to find a different insurance company, pay out of pocket, or find a new physician from within the accepted pool. At the same time that the Clintons were promoting this new idea of HMOs, large insurance buyers were cutting deals to lower the cost they pay for their members to receive hospital, doctor and pharmaceutical services. Most famous is the California Public Employment Retirement System (CalPERS) which is able to negotiate significant savings because they have such a large pool of fairly healthy members. In California in the greater Sacramento area, the San Francisco bay region and Southern California, Kaiser has been around for years, so many people feel comfortable about signing on. In the Sacramento area, it is estimated that 80% of the population is now covered by one of 12 HMOs or 15 PPOs. As the Clintons were losing in the Congress, their idea was taking hold as the only hope for the insurance industry. Of course, the industry wasn’t worried about Universal Care, or covering people with prior conditions. They were mostly interested in the wealthy well who are willing to pay high monthly premiums and rarely need to use the services. 4. Problems with Emerging Managed Care Industry in California What we are now seeing is a market industry squeezed by the big players in the oligopoly. It is an interesting social problem because oligopolies create the worst of Jungle Capitalism. The antiquated governmental regulatory structure was designed to police individual doctors who have free-standing businesses, and hospitals. HMOs have emerged in the 1990s and are swamping the health industry with a new set of problems the government is not set up to deal with. The regulation of HMOs is a side-action, even though it is eating up a growing portion of the U.S. dollar. Onus on the Gatekeeper: The Gatekeeper forces the fiscalization of health care. While the financial decisions were a competing concern for the clinician, now too often the primary decision is “Can we afford this cost ?” The change in orientation to monetary accounting forces the primary care providers to be the fiscal watchdogs even if they only keep silent about the patient’s options outside their particular HMO. HMOs governed as corporations, not health providers. In California, the fledging HMO industry achieved a major victory in 1974 when the law governing HMOs put the regulation of HMOs in the state department of Corporations rather than Health Services. Called the Knox- Keene law after its two authors, the legislation focuses government regulation on the paperwork requirements of a large public corporate business, and virtually ignores service and quality of care issues. Public Sector Efforts. At the same time (mid-1970s), California tried an experiment with public HMOs to provide services to MediCal recipients, called “Prepaid Health Plans” or PHPs. A major concern was to provide the same consistent quality to low income individuals as is provided to the rich or people with regular insurance. Started during Governor Reagan’s administration, the effort was considered a failure and was killed halfway through Jerry Brown’s 8 years. Questionable business and marketing practices during Reagan’s term tainted the experiment. During the 1980s, California set up a committee with a MediCal Rate Czar, who negotiates secret rates with hospitals for MediCal patients. This has resulted in enormous savings for the state. In the past two years, California has embraced Managed Care as the best way to offer services to low income people. Most counties with large populations are now part of an experiment to offer competing Managed Care plans. The results so far are not pretty. Thousands of people forced to change doctors, and go to giant confusing clinics and wait long hours. It is cost savings by burdening the patient. The State Department of Health Services has jurisdiction and they are developing program and outcome audits. Consumer evaluation: low income health consumers are being asked to evaluate the quality of service they received, and many consider it unsatisfactory. Within the egocentric profession-driven health industry, the opportunity for a consumer to actually criticize medical care is heresy. The adjacent table identifies the results of a recent survey of some of the 150,000 public aid recipients in Sacramento County who were shifted from MediCal to HMOs. These HMOs are being paid $200 million in state and federal funds to provide care. There is lots of room for improvement, even with Kaiser, which is clearly the best in the bunch. Consumer Abuse: This transition to managed care is forcing many patients to change doctors, and to change doctors again, and often in the future. It is inherently unstable and not conducive to good longterm care. Most patients do not get to choose their new doctor, only which plan they are channeled through like cattle. The structure of care is away from small offices towards larger impersonal clinics. Loss of Full Freedom of Choice: Doctors have always prided themselves on their independence. But now we find, in terms of both physician autonomy and consumer independence, single payer is far better than fee-for-service, and Managed Care is the most restrictive of all. M.D.s Squeezed: For most of this century, doctors have commanded economic control of their own work environment more than people in most other areas of the economy. But with Managed Care, the insurance industry bean counters have taken control of the doctors’s daily lives. Doctors are forced to spend less time with patients, use specialists sparingly, and limit the use of health resources. Primary care providers accustomed to serving about 250 patients a year in individual practice are expected to serve 400 to 600 patients a year, and some are expected to serve as many as 1200 patients - in which case there is no way a doctor can remember one patient from another. It is almost impossible now for a new M.D. to start her or his own free-standing private practice. Most solo and small group practices are being swallowed up by HMOs which control the insurance income flows to the doctors. Without regular income from several insurers, a doctor must sign on with one insurer in particular and become a cog in the corporate machine. Suddenly M.D.s are finding themselves in a flooded labor market, which they had never even imagined possible. Perhaps doctors are hurt even more than consumers by the insensitivities of Managed Care. Insurance Companies buy into HMOs: The HMO gets around the whole doctor-hospital legal problem by being an organization the hires both. Basically the HMO internalizes all the fee-for-service costs, and charges one monthly premium per person (often with a copayment). It ties together what the insurance company does and what the hospital and doctors do. Before the Clintons’ national proposal, most HMOs were started by labor groups and were inherently consumer responsive. The Clintons sold the HMO concept to the insurance industry which went out and bought hospitals, hired half the doctors, and created integrated delivery systems exclusively for their population of service. The idea is a consumer could get all their lifelong health care needs met by one organization. Single payer for the few. Actually, the HMO is a descendent of the oldest form of socialized medicine in the U.S., military medicine. Why is Congress so lackadaisical about health care ? Because they are covered just like the military. They go to Walter Reed Army Hospital. Many HMO doctors and administrators come straight out of the military. The idealized objective of the insurance industry is to expand Managed Care: to create 10 Kaisers which provide good care for everyone. Instead, according to longtime professional health policy advocate Emery Soap Dowell, we have seen the quality of Kaiser lowered, and the creation of 9 Walmarts - cheap imitations of Kaiser that claim to have Kaiser level services without the quality control, the range of coverage, the institutional experience, memory or tradition. (See the consumer evaluation table shown.) No proof of HMO cost control: In California, HMO costs “are 19% above the national average and rising more rapidly. Massachusetts and Minnesota, the second and third highest penetration states, have similarly undistinguished cost records”.2-188Non-health costs of Managed Care: As economics columnist Robert Kuttner has pointed out, “Every entrepreneur who profits from a new Managed Care company or network, every case reviewer who second-guesses the doctor, every billing clerk who struggles with insurance forms, every TV commercial trying to divert market share is one more cost to the system that adds nothing to medical care.”4Quality gives way to the Profit Motive: Kaiser and the other early HMOs worked because they emphasized primary care and efficient use of health resources by good communication among an organized team of health professionals. The bottom line of the profit motive for any quarter is much less forgiving, sensitive or responsive than a health professional making an on the spot decision. Who Wins: the investors looking for a short term profit, insurance executives and the HMO marketing people are raking in quick money. As much as 1% of the U.S. Gross Domestic Product is being shifted from health care to the marketing and profits for HMOs (7% of 14% of the GNP). This is money coming in the front end for services expected. If the services are not needed, and the resources are not expended, then a minimal health delivery system is necessary for the people covered by that HMO. Minimum cost, maximum profit. Who Loses: if the services are not provided, or there is great demand for limited services, the consumers lose big time, as do the doctors and nurses. If several HMOs are in the same area, the duplication of service and resource is an added expense, a waste of scarce resources, and a source of greater complexity. Managed Care may be a success in terms of cost containment and being a short term profit engine, but as a policy with a social purpose, Managed Care is a failure because of denial of care, frustration by health professionals, duplication of services and waste of resources, and confusion among consumers. Compared to universal care provided in most modern countries, U.S. care is disorganized and inefficient. - Other Countries by Comparison: Germany and Canada Other countries do not have the U.S. problem of inconsistent service and poor quality. Germany, for example, has had a national health care system written into law since 1880. Each patient is allowed to choose her or his own physician who is given a voucher by the patient which records details of every visit. Every three months, the doctor sends these vouchers to a regional physicians association and is paid a lump sum. Hospitals get a fixed amount for every day a patient stays, no matter the diagnosis, from a regional non-profit insurance group. Costs grow only 3% more than the GNP. The comparable U.S. figure is 33%, Japan 15%.3Canada has socialized insurance: universal comprehensive coverage under a single publicly administered health insurance program in each province. The government pays about 80% of the cost of care for everyone out of taxes, and the government sets all fees charged by doctors and hospitals. People choose their own doctors and hospitals. Canada spends 40 percent less per person on health care than the U.S., yet Canadians visit their doctor more often than people in the U.S. And far fewer Canadians go without care. Furthermore, nearly all expectant mothers in Canada receive prenatal care. In the U.S. recently, only 76% of women who had live births received such care starting in the first trimester.2-91, 255Most Canadian consumers are satisfied, most American consumers are not. Eighty-five percent of the Canadian doctors prefer the Canadian system over the U.S. non-system.2-265Canadians requiring attention within 24 hours receive care at least as quickly as Americans. For elective surgery, Canadians have consolidated many procedures to a limited number of regional hospitals. So, while there are waiting lists for elective surgery, the quality of care is superior because each center performs a large number of procedures and so is better able to maintain competence, while minimizing the costs by avoiding the unnecessary duplication of expensive facilities.2-99 6. Changing the debate to Quality & Establishing Standards for Organized Care While Americans claim to have the best health care in the world, there is open debate. According to U.S. health policy analyst Roger Bolger, “there is embarrassing little the U.S. or any other country can say on this point. Even though this is the information age, we have scant information to determine whether individuals, groups or the nation as a whole are getting a level of care commensurate with the amount we spend on it. “What this nation sorely lacks is a reasonably comprehensive source of information that will enable us to detect unmet health needs, identify cost-effective providers and services, document expenditures on inappropriate procedures, and, ultimately, evaluate and improve our health care. This kind of information is essential if health care reform is to succeed. “Advances in information technology offer a way to meet this need. A network of health data organizations is being established that would collect medical information in states and regions across the country. This information could then be used to keep tabs on the health of the health system. "These organizations would gather secondary health data - not the primary data in physicians’ records - from such sources as insurance claims, hospital discharge records and pharmacy records. The data would be used to understand and improve the performance of the health care system. “Topics of investigation could range from the national to the individual, from the effectiveness of a new heart medication to the performance of individual clinics, hospitals and physicians.”5It used to be that the accreditation of the American Hospital Association for a hospital and the renewed license of an M.D. were accepted evaluations of the quality of care. The inadequacy of fee-for-service and HMOs raises serious questions about establishing higher standards for organized health care. And we must balance our wants and wishes with the reality of finite resources. If the health system in the U.S. is inefficient and extravagant, what would work better ? Especially keeping in mind economist Jane Bryant Quinn’s observation that “as more and more people are swept into cost cutting HMOs, there will be more lawsuits over denied high tech treatments. Any kind of a health care system can give all possible treatments to a limited number of people or limited treatment to a large number of people. But we can’t afford all possible treatment for everyone. No system can afford that. This is the American delusion right now that we can afford that”. A coalition of national church groups developed a group of principles to apply in evaluating any proposals: “access to quality health care for everyone in the U.S.; comprehensive coverage, including long-term care; progressive financing based on ability to pay, through a special tax program involving personal and corporate income; cost containment through simplified administrative procedures; advance budgeting for hospitals and other health institutions, providing them with dependable income based on their past and prospective levels of service; and solutions to reduce the malpractice costs now passed on to consumers.”3 And some choice by physicians and other health professionals about where they work and what they do, and by the consumer about which health professional they get. 7. Best Possible System Management Scientist Stafford Beer (British/Welsh/Canadian) gave a lunch talk called “Health & Quiet Breathing” at the Hospital Centre in London which is recorded in Platform for Change: “If you were starting from scratch, knowing the current state of the art,….do you think you would come up with a system remotely resembling the one we have today ? We have an organization frozen in the past; we have institutionalized a set of historical accidents. “The health service should be redesigned in terms of information about healthiness, and see the health service as an indicator of societal health.”6 What are the optimum characteristics of a health system ? The Neighborhood Health Clinic (NHC): You are welcomed; you receive immediate attention, your comforts matter. The health professional already knows you and your history, lifestyle, occupation, preferences, and they assume that you take responsibility for your own body (and theirs is a second opinion). If you need special care, you get it. This would require shifting resources to small neighborhood clinics and closing hospitals, empowering nurses, and focusing on primary care, prevention and health education. Most places in Cuba have this type of primary care, which is arguably the best in the world. Using Stafford Beer’s Viable System Model, Clare Strawn has built on this idea: “The neighborhood health center (NHC) would be geographically distributed similar to the elementary school system. NHCs would be autonomous but cooperative with the schools to facilitate health education efforts, connection with families and access to the community. The centers would be responsible for primary care in conjunction with local doctors, midwives, dentists, mental health counselors and holistic practitioners. The centers would have a coordinating function between their different services, with other community agencies such as the schools and welfare, with primary care providers and the regional hospital centers. They would be autonomously administered and maintained. They would also function to channel feedback from the community to develop proposals to meet its needs through continuous and future development. The NHCs would be directed by community boards comprised of local professionals and representatives of the community base, ensuring community control of health care. The community control board would set goals and direction for the center. “The next level of service would be the Hospital Service Centers (HSC), which would be distributed according to demographics similar to the high schools. The outpatient burden on the hospitals and expensive inappropriate use of emergency rooms would be alleviated by the decentralized services of the NHCs. In addition to the operational functions of the hospital, the HSC would serve as technical and resource support for the NHCs, for instance providing diagnostic services and health education resources. The HSC would serve as areawide inter-NHC coordination centers and have programs addressing regional concerns such as occupational and environmental health. They would utilize a participatory management system and a minimal administrative staff to maintain operations. HSCs connected with their serviced community directly and through their area NHCs would also have a research and future development function which would make proposals to the national budgeting and coordinating facility. HSCs would be directed by boards comprised of delegates from the community, hospital staff and regional representatives. The board’s primary responsibility would be to ensure that the practice of the system was coherent with its philosophy and goals. “The third subsystem of the Viable Health Care System would be focused on human, scientific and technological development of health care services. This function would be associated with the universities and would also be geographically dispersed. The operations of this function would be on educating doctors and other medical personnel, medical and technical research and development, and specialty high-tech care. These centers would be connected with NHCs and HSCs through coordination of services and exchange of personnel. A scholarship-for- service system would feed ethnically diverse peer-providers and community educators from the NHCs into the medical schools and bring resident doctors from the medical schools back into the communities. “The entire system would be directed by state and national level boards who would administer and appropriate funds. The state and national boards would have cross-level representation. They would be charged with carrying out the philosophical imperative of the system, accountable to and in response to the communities which it serves. They would be responsible for appropriation of funds on the state and federal levels to ensure services. Where ethical considerations arise as a basis for decision making, they would initiate a participatory educational process throughout the system to the neighborhood level in order to delegate the decisions to the appropriate lower level or to come up with a regional or national consensus. “This proposal demands democratic participation; integration of health, education and welfare services; human rather than technological focus. According to the Viable Systems Model of Stafford Beer, each level of the system has an operations, coordination, internal/maintenance, external/development, and identity cohesion function. As a whole system, the NHCs represent the operations function, the HSCs cover the coordination and internal maintenance functions, the medical centers do the future development function, and the state/national boards provide whole system cohesiveness and identity. These recursive functions maintain a homeostasis between the system and its environment, attend to immediate and future needs, and also create autonomy and coordination within the system.”7 8. Pressing Concerns -- Personal Health Information: Currently, information about a person is considered the proprietary property of the doctor and the hospital, not the person. If you want to know what the doctors wrote about you in their medical records, you have to get a good attorney to ask your insurance company to get a copy of the records - because the way the current law is interpreted, that may be the only way to get them. Asking the doctor would be easier, and your doctor actually giving you your own medical records is such a radical idea that I think it should be a consumer’s right. To their own medical record. The consumer would walk in, usually, give the clinician a computer diskette in a uniform format, and the consumer gets an updated copy of their record. What if they try to spare or deceive the consumer ? Those are always critical ethical questions, which the health insurance industry has made necessary, as well as perverse and bizarre for an M.D. who has to try to manipulate the insurance information to match the consumer’s particular situation. If the consumer maintains a master file at home, they can always add to it. If they lose the master, they can go beg their individual health providers to give them another copy but it is the patient’s responsibility to retain their own master. We have designed health information for hospitals and insurance companies with paper approval rather than for electronic information and fund transfers. The patient is essentially assumed to be anonymous. By redesigning the structure for protected universal information sharing, better data can be maintained. -- Aggregate Health Information: putting aside the privacy and confidentiality issues for only a sentence, wouldn’t it be interesting if one could access the health information of most of the people of say, the State of California, or even a small town ? The census tracts are large enough that it is hard to figure out who an individual is, and any aggregate methodology would need to build in some lower limits. Using a statistical cohort for each actual person would allow some types of realistic longitudinal studies, as well as provide a database for cases with similar symptoms. Assume that as much as 60% of the population might be willing to use the full range of connection with the Information Superhighway, and would allow some of their own self- selected demographic information to be retained as part of the larger information base. The potential for research by clinicians and the public is enormous. And so are the ethical questions. These questions must be faced, because the information net is inevitable. It will only be controlled if people politically figure out how to manage the system. -- Consumer Evaluation: Consumers should be able to provide feedback to the system in a way that is taken seriously. Simple questions could include: was your care good or poor ? How could it have been improved ? Were you treated with courtesy ? Promptly ? How would you rank your caregiver ? The receptionist ? The place ? The very best ? Just good enough ? Not Acceptable ? Not Available ? Not Affordable ? Problems ? If we evaluate every single unit of health care provided, and then tabulate the results with a monthly and annual report, much of what is male-domination and misinformation will become identified and stop. The current methods of policing hospitals and M.D.s are not good enough. -- Looking at the bigger picture of the Administrative structure, an alternative to what is being discussed is a radical version of the Single Payer plan. Successful options of national single payer abound. (Unlike Managed Care, which is an unproven experiment.) Nothing is said in the U.S. media about the German or Cuban systems, which are both quite different from Canada’s and yet all work quite well to provide universal coverage for a third less GNP per capita than the U.S. -- A central issue is control and management of the resources and money. I recommend locally elected health boards, which elect regional boards and a state board. Groups of health workers, or individuals, would contract to provide services and coordination. All hospitals and labs would contract with the local boards. -- The Expenditure Side of the Ledger: Funding would need to be an alternative to the fee-for-service system. An equitable alternative is per capita payments to the local board with some kind of group responsibility for populations of people to assure universal coverage and promotion of prevention. -- The Income Side of the Ledger: The most equitable financing would be a progressive payroll tax, to include paying for the quarter of the population who cannot afford to pay for their own health care. I think there should still be tax breaks if the employer pays for a substantial portion of the employee’s health care. -- Single Payer encourages cost containment: “A single payer system facilitates cost containment in three ways. First, it can achieve substantial administrative savings that are not attainable under a multi-payer system. Second, the single payer is easily able to set and enforce overall budgetary limits, which is extremely difficult under our multi-payer system. Finally, a single payer system facilitates health planning to eliminate duplication of facilities and expensive technology that often wastes money and sometimes worsens quality”.2-118-9“As reported in the New Yorker, this is a case where you can get more, better, and cheaper, all at once”.2-248 Conclusion: The politics of getting from here to there When Bill and Hillary Clinton started, they rejected Single Payer as politically unacceptable to Corporate America in general and the insurance industry and the medical profession in particular. But as their Managed Care proposal was being soundly rejected in the Congress as not being good enough, more and more of the Administration’s subtextual message was “This is not quite Single Payer, but…” Many consumers are hearing for the first time that Canadian care is considered quite satisfactory by a majority in Canada, as well as a majority of their health workers, and a majority of the country’s employers. In the U.S. there is less than 10% satisfaction. Then the market place quickly shifted to Managed Care for the affluent and wealthy, and now government is using it for low income people to control costs. Doctors are finding that large HMOs are insensitive to their needs and wishes. Doctors are realizing that we will never go back to the single practitioner with just a black bag. Recent polls suggest that a majority of the members of the AMA are not satisfied with the working conditions provoked by HMOs. Some states may move to single payer, with potential the greatest in California, Minnesota, New York and Massachusetts because they have the highest HMO enrollments. Ultimately, organized health care will only happen in the U.S. when doctors are willing to help by working with consumer groups. The key is to network the families of the U.S. to demand restructuring of the entire health care non-system. “Grassroots community organizing would be necessary to win any political campaign to establish such a system. The community organizing would develop a base for the community participation necessary to implement this system. While the medical and corporate establishment are split on their support of reform based on their own conflicting interests, to the users of the health care system it is a life or death issue.”7 (Emphasis added.) Physicians need an institutional environment in which they can nurture health as well as battle illness. We need a system that works. Jon Li has been writing about health policy and general systems theory for over 40 years. References: 1. “The Dangers of Managed Care”, by Dr. Jerome P. Kassirer, editor of the New England Journal of Medicine, in the SF Chronicle 8/14/95, adapted from the 7/6 edition of the Journal 2. The National Health Program Book: A Source Guide for Advocates; David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H., Common Courage Press, 1994 3. “League study focuses on national health insurance crisis”, Berdyne Musolf, in the Davis Enterprise 4. “The doctors and Medicare”, Robert Kuttner, Sacramento Bee, 10/9/95 5. “How healthy are we? No one knows”, Roger Bulger, Davis Enterprise, 3/20/94 6. “Health & Quiet Breathing”, in Platform for Change, Stafford Beer, 1974, Wiley (reprinted in 1994 by Wiley Chichester with Jon Li’s Reader’s Guide) 7. “A Viable System for Health Care”, Clare Strawn, a response to Jon Garfield “Crisis in Health Care: Prospects for Change”, 1/14/1990 Bibliography for the 21st Century Ahl, Valerie, and Allen, Tim (1996), Hierarchy Theory: A Vision, Vocabulary and Epistemology, Columbia University Press, NY Bahro, Rudolf, (1977), The Alternative in Eastern Europe, New Left Press/Verso, London Beer, Stafford (1972, 1994), Brain of the Firm, Wiley, Chichester Beer, Stafford (1974), Designing Freedom, Canadian Broadcasting Corporation, Toronto Beer, Stafford (1975, 1994), Platform for Change, reader’s guide in the 2nd edition by Jon Li, Wiley, Chichester Beer, Stafford (1979, 1994), The Heart of Enterprise, Wiley, Chichester Beer, Stafford (1985), Diagnosing the System: for Organizations, Wiley, Chichester Beer, Stafford (1989), “Disseminated Regulation in Real Time, or How to Run a Country”, in The Viable System Model: Interpretations and Applications, edited by Raul Espejo and Roger Harnden Beer, Stafford (1994), Stafford Beer Initiates an Audience into the World of Systems and Managerial Cybernetics, Liverpool Business School, John Moores University, Liverpool, UK Beer, Stafford (1994), Beyond Dispute: The Invention of Team Syntegrity, Wiley, Chichester Bookchin, Murray (1970, 1985, 2004) Post-Scarcity Anarchism, AK Press, Chico, CA Bookchin, Murray (1982), The Ecology of Freedom: The Emergence and Dissolution of Hierarchy, Cheshire, Palo Alto Boulding, Kenneth, (1956), “General Systems Theory: the Skeleton of Science,” Management Science 2, p 197-208 Boulding, Kenneth (1964), Meaning of the 20th Century, McGraw-Hill, NY Boulding, Kenneth (1970), Economics as a Science, McGraw-Hill, NY Breed, Warren, (1971), The Self-Guiding Society, Free Press, NY, NY Brooks, David, (2011), The Social Animal: The Hidden Sources of Love, Character & Achievement, Random House, NY Brown, Ray E., (1966), Judgment in Administration, McGraw-Hill, New York Callenbach, Ernest (1975), Ecotopia, Banyan Tree, Berkeley Callenbach, Ernest (1981), Ecotopia Emerging, Banyan Tree, Berkeley Chardin, Teilard de, (1955), Phenomenon of Man Chernow, Ron (2004), Alexander Hamilton, Penguin Press, London Chernow, Ron (2017), Grant, Penguin Press, New York Christopher, William (2007), Holistic Management: Managing What Matters for Company Success, Wiley, New Jersey Clark, Glen (2002), A Human Effort (A fifty part poem of history up to now), self-published Daly, Herman, Cobb, John Jr. (1994). For the Common Good: Redirecting the Economy toward Community, the Environment and a Sustainable Future, Beacon Press, Boston De Grazia, Alfred (1973), Politics for Better or Worse, Scott, Foresman, Glenview, Illinois De Grazia, Alfred (1975), Eight Goods – Eight Bads: The American Contradictions, Anchor Doubleday, Garden City, NY Diamond, Jared (2005), Collapse: How Societies Choose to Fail or Succeed, Viking, NY Downs, Anthony (1967), Inside Bureaucracy, Little Brown, Boston Drucker, Peter (1969), Age of Discontinuity, Harper & Row, NY Drucker, Peter (1973), Management: Tasks, Responsibilities and Practices, Harper & Row, NY Espejo, Raul, and Harnden, Roger (edited by) (1989), The Viable System Model: Interpretations and Applications of Stafford Beer’s VSM, especially Stafford Beer’s “National Government: disseminated regulation in real time, or ‘How to run a country’” Ferguson, Niall (2003), Empire: The Rise and Demise of the British World Order and the Lessons for Global Power. New York: Basic Books Ferguson, Niall (2004), Colossus: The Price of American Empire, Penguin Press, NY Ferguson, Niall (2008), The Ascent of Money, Penguin Press, NY Friedman, Milton, Schwartz, Anna (2008), The Great Contraction, 1929-1933, Princeton University Press, Princeton Friedman, Thomas (2008), Hot, Flat & Crowded, Farrar, Straus & Giroux, NY Fromkin, David (1989), A Peace to End all Peace: The Fall of the Ottoman Empire and the Creation of the Modern Middle East, Avon, NY Galbraith, John Kenneth (1977), The Age of Uncertainty: A History of Economic Ideas & their Consequences, Houghton Mifflin, Boston Goldwater, Barry (1976), The Coming Breakpoint, Macmillian, NY Gorz, Andre (1980), Ecology as Politics, South End Press, Boston, Massachusetts Hammond, Debora (2003), Science of Synthesis: Exploring the Social Implications of General Systems Theory, University of Colorado Press, Colorado Hardin, Garrett (1968), “The Tragedy of the Commons”, Science, vol 162, no 3859, pp 1243- 1248 Harman, Willis (1976), An Incomplete Guide to the Future, San Francisco Books, SF Harman, Willis (1989), “Redefining the Possible: The Need for Restructuring Science,” The Quest magazine Harrington, Michael (1962), The Other America: Poverty in the United States, Collier, Toronto Harrington, Michael (1972), Socialism, Saturday Review Press, NY Henderson, Hazel (1978), Creating Alternative Futures: The End of Economics, Perigee, NY Heller, Alfred, editor (1972), California Tomorrow Plan: The Future is Now, Kaufmann, Los Altos CA Hourani, Albert (1991), A History of the Arab Peoples, Warner, NY Hutchinson, G. Evelyn (1978), An Introduction to Population Ecology, Yale, New Haven Illich, Ivan (1973), Tools for Conviviality, Harper & Row, NY Illich, Ivan (1974), Energy and Equity, Harper & Row, NY Isserman, Maurice (2000), The Other American: The Life of Michael Harrington, Public Affairs, NY Jacobs, Jane (1961), The Death and Life of Great American Cities, Random House, NY Jacobs, Jane (1969), The Economy of Cities, Random House, NY Jacobs, Jane (1984), Cities and the Wealth of Nations, Random House, NY Jacobs, Jane (1992), Systems of Survival, Vintage, NY Jacobs, Jane (2000), The Nature of Economies, Modern Library, NY Kaplan, Abraham (1964), Conduct of Inquiry: Methodology for Behavioral Science, Chandler, SF Kinsley, Michael J. (1997), Economic Renewal Guide: Collaborative Process for Sustainable Community Development, Rocky Mountain Institute, Snowmass Colorado Kuhn, Thomas (1970), The Structure of Scientific Revolutions, University of Chicago Press, Chicago Kumar, Satish, editor (1980), The Schumacher Lectures, Blond & Briggs, London Lakoff, George (2008), The Political Mind: Why You Can't Understand 21st-Century American Politics with an 18th-Century Brain, Viking, NY Leonard, Allenna (1999), A Viable System Model: Consideration of Knowledge Management, Journal of Knowledge Management Practice Leonard, Allenna, The VSM Applied to Complex Organizations in Crisis, Address to the 2nd Cwarel Isaf Institute Conference, Internet Leonard, George (1972), The Transformation: A Guide to the Inevitable Changes in Humankind, Dell, NY Lewis, Bernard (2002), What Went Wrong? Western Impact and Middle Eastern Response, Oxford Press Lewis, Bernard (2003), The Crisis of Islam: Holy War and Unholy Terror, Modern Library, NY, NY Loomis, Mildred (1980), Decentralism: Where it Came From and Where is it Going?, School of Living Press, York, Pennsylvania Magnuson, Joel (2008), Mindful Economics: How the U.S. Economy Works, Why it Matters, and How it Could Be Different, Seven Stories Press, NY, NY Maslow, Abraham, (1966), The Psychology of Science: A Reconnaissance, Henry Regnery, Chicago Maslow, Abraham (1970), Motivation and Personality, Harper & Row, NY McDonough, William, Braungart, Michael, (2002), Cradle to Cradle: Remaking the Way We Make Things, North Point Press, NY Meadows, Donella, Meadows, Dennis, Randers, Jorgen (1992), Beyond the Limits, Chelsea Green, Mills Vermont Medina, Eden (2006), “Designing Freedom, Regulating a Nation: Socialist Cybernetics in Allende’s Chile,” Journal of Latin American Studies 38, 571-606, Cambridge University Press Mowry, George (1951), The California Progressives, Quadrangle, Chicago Muir, John (1973), The Velvet Monkey Wrench, John Muir, Santa Fe Mumford, Lewis (1934), Technics and Civilization, Harcourt, Brace, NY Mumford, Lewis (1961), The City in History, Harcourt, Brace, NY Naughton, Barry (2007), The Chinese Economy: Transitions and Growth, MIT, Cambridge Obama, Barack, (1995), Dreams From My Father, Three Rivers Press, NY Obama, Barack, (2006), Audacity of Hope, Three Rivers Press, NY Odum, Howard, Odum, Elisabeth (2001), A Prosperous Way Down, U. of Colorado Press, Boulder Owens, John, Costantini, Edmond, Weschler, Louis (1970), California Politics and Parties, Macmillian Packard, Vance, (1960), The Waste Makers, John David McKay, NY Piercy, Marge, Woman on the Edge of Time, 1976 Pollan, Michael (2006), The Omnivore’s Dilemma: A Natural History of Four Meals, Penguin, NY Pollan, Michael, Author’s Talk, Campus Community Book Project, Mondavi Center, University of California – Davis, 11/29/06, transcribed by Jon Li Pollan, Michael (2009), Food Rules: eat mostly plants a third grader can recognize and pronounce, Penguin, NY Rapoport, Roger (1982), California Dreaming: The Political Odyssey of Pat & Jerry Brown, Nolo Press, Berkeley Register, Richard (2006), Ecocities: Building Cities in Balance with Nature, Berkeley Hills, Berkeley Reid, T.R., (2009), The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, Penguin, New York Reisner, Marc (1986), Cadillac Desert: The American West and its Disappearing Water, Penguin, NY Roberts, Marc J., Hsiao, William, Berman, Peter, Reich, Michael R., (2008), Getting Health Reform Right: A Guide to Improving Performance and Equity, Oxford, New York Robinson, Kim Stanley (2002), The Years of Rice and Salt, Bantam, NY Rogan, Eugene, (2009), The Arabs: A History, Basic Books, NY Roszak, Theodore (1986), The Cult of Information, UC Press, Berkeley Saviano, Roberto (2007), Gomorrah: A Personal Journey into the Violent International Empire of Naples’ Organized Crime System, Picador – Farrar, Straus & Giroux, NY Sale, Kirkpatrick (1980), Human Scale, Coward, McCann & Geoghegan, NY Sale, Kirkpatrick (1985), Dwellers of the Land: The Bioregional Vision, Sierra Club, San Francisco Snow, C.P. (1959), The Two Cultures and the Scientific Revolution, Cambridge, NY Taylor, Graeme (2008), Evolution's Edge: The Coming Collapse and Transformation of Our World, New Society, BC, Canada Tuchman, Barbara (1966), The Proud Tower: A Portrait of The World Before the War: 1890- 1914, Ballantine, NY Walker, Jon (2006), Viable System Model Guide, on the Internet Weisman, Alan (2007), The World Without Us, St. Martin’s, NY Wills, Garry (1978), Inventing America: Jefferson’s Declaration of Independence, Doubleday, Garden City, NY Wills, Garry (2005), Henry Adams and the Making of America: Jefferson & Madison (1801- 1816), Houghton Miflin, Boston Wilson, Dick (1984), Zhou Enlai: A Biography, Viking, New York Wright, Robert (2017), Why Buddhism is True: The Science and Philosophy of Meditation and Enlightenment, Simon and Schuster, NY Jon Li, Davis, California, USA, Social Systems Scientist Jon Li is a decentralist, a republican socialist, county mental health administrator, urban economist, health planner. Hayward High School, Class of 1966; Bank of America Award in Math & Science University of California, Davis, Class of 1971 in Economics & Political Science, macro economics, urban economics, California state and local government, US voting behavior, survey research and other social science methods, the role of computers in the workplace. Graduate School in Public Administration, California State University, Sacramento, incomplete. Interests: program evaluation, budgets and other public resource allocation processes, the evolution of organizational structures, cybernetics and applied general systems theory. My 1975 master’s thesis proposals are below. I have coached Ph.D.s in the history of systems science, cultural anthropology about how they make music in Jamaica, engineering (the annual study the campus measures vehicle mode use to cut car use), neurological genetics, watershed management, innovation in the state justice system in Argentina, plant physiology, a Masters in Fine Art in oil painting, a Masters in hydrology, and a change in direction from entomology of the evolution and ecology of the mosquito and its habitat to teaching science in the inner city. ASUCD 1st year VP; Management Intern, Chief Administrator California State Department of Mental Hygiene; Research Intern, Governor Reagan’s survey research firm, Decision Making Information; Campaign Manager, ASUCD President, VP, 5 Senate Seats; Administrative Assistant, El Dorado, Amador, Calaveras, Mono & Alpine County Mental Health Services; Sonoma County Coordinator for Committee to Re-elect Nixon; Business Manager, Sutter-Yuba Bi-County Mental Health Services, active in the California Conference of Local Mental Health Directors, Administrative seat on the Committee on Research and Evaluation; during California Governor Jerry Brown’s first year as Governor, Assembly Republican Caucus Consultant on Health, Mental Health, Public Assistance; local political volunteer, county US-USSR bilateral nuclear weapons freeze, Green Party (organizing committee, 3 US annual national gatherings), city commissions on business and economics, public finance, computer network, governance, education technology, oral history, and health council. Carrier, Oakland Tribune, Oakland Army Terminal; Page, Hayward Public Library; Counselor, Mt. Cross Lutheran Camp; Loan & Reserves, UCD library; Bus Conductor, ASUCD Unitrans; Dishwasher, Segundo Dining Commons; Test Tube Cleaner, Department of Environmental Toxicology; Counselor, San Francisco Lutheran Church Day Camp Program in North Beach and Hunters Point; Dishwasher, Cook, Waitperson, Management Team, Blue Mango Co-op Vegetarian Restaurant; Video Operator, UCD College of Engineering; maintain a weekly multiple listing service of all the properties in retail, commercial and office for sale in Sacramento, El Dorado, Placer, Sutter, Yuba and Yolo counties; Laundry Counter Help; Dog Handler. Jon Li’s CSU-Sacramento 1975 Master’s in Public Administration thesis proposals: 1. County Mental Health Program Evaluation methodology: as the administrator of the county mental health program serving Sutter and Yuba counties, I was the only non- clinician (M.D. psychiatrist, Ph.D. clinical psychologist) on the committee on Research and Evaluation of the California Conference of Local Mental Health Directors. We were implementing a Client Episode Outcome Summery to gather data for cost-benefit analysis. CSU-S rejected the topic as something they were unqualified to manage. It would have defined the art. 2. Welfare Transformation: by connecting data from personal computers via phone (this is 1975, the state of the art is the isolated mainframe IBM 360), the state of California could have one unified information system, and cut out the need for a lot of the paper control obstacles. 3. Implement Socialized Medicine in California: published in the 1996 proceedings of the International Society for the System Sciences as “Systemic Trauma: The Troubled Prospects for Managed Care in California and the US. Obamacare is hopelessly bureaucratic. 4. Legislative Management: each member of the legislature should have a laptop (1995 it happened), connected to the State Department of Finance’s computer model of the future of the state of California (which is now Irena Asmundson’s responsibility), which was established in 1970, with the capacity to extrapolate trends for bill analysis. Then, in legislative committee, the consultant doesn’t say, oh, I will get back to you in two weeks when it is totally irrelevant…a member of the legislature can crank out the numbers right then and there, to see what the long term budget implications are of a legislative proposal. 5. Replace Counties with Community: County is a rural unit; it was designed to serve the landowners when they were a small percentage of the population. Government was the elected council, and the sheriff to enforce the laws. The Great Depression changed all that, and Counties became the administrative arm of the federal government, a task they have proved sorely unable to manage. Defining a Community as a population of around 10,000 people allows consistency and uniqueness in public policy. Building clear communication with regional and state units would then be easy, possible, lead to a lot less confusion and need for bureaucratic mazes. This would require a new state constitution; the current constitution includes provisions that add up to preventing any possibility of transcending it with a new social contract. Each election, additional propositions further complicate California governance. 6. The Internet will make Ph.D.s obsolete. We need teachers, but we don’t need people who know almost everything about some tiny subject. We need listeners who are good synthesizers, who can say Do you really think that, because they HEAR the student’s confusion. It questions the entire hierarchy of the academic world. Jon has been writing about California health policy since 1969. In addition, Jon has written about Davis, Chile, the Philippines, Brazil, China, Germany, Greece and Egypt. This is an open invitation to improve our discussion. Jon Li, Institute for Public Science & Art, Davis California, (530) 753-0352 www.decentralizetheplanet.network,jonli@dcn.org, Ecotopia: evolving to a healthier future with US-global universal health care