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    An administrator pushes, on a shoestring budget, to move his university and the world toward a more sustainable equilibrium.

Systems and words and meanings
January 23, 2014 - 4:56pm

Two recent conversations are in the process of melding in my mind.  (No Vulcan required.)  One of them was with an MD, and the other with a university sustainability officer.

Chatting with the MD, the subject of "quality" came up.  She's a solo practitioner, working with and in -- but not as an employee of -- a large hospital.  Apparently, the hospital is intent on absorbing most or all of the solo and small group practices associated with it, under the pretext of improving quality.  I say "pretext", because their argument is that quality is a function of the number of ways a hands-on practitioner's activities get recorded and scrutinized.  The number of forms that get filled out.  The number of non-MDs passing judgment on what MDs do.  Without apparent reference to what outcomes are produced or what needs and expectations satisfied.  "Quality", in such a context, sounds perilously close to economic efficiency; the concepts aren't inherently in conflict, but neither are they inherently identical.

The Doc seemed to be blaming this, at least in part, on Obamacare.  I really don't know whether that's an accurate assessment or just a conflation motivated, at least in part, by her political preferences.  She clearly doesn't like Obamacare, and for reasons entirely opposite the ones that cause me to dislike it.  (Full disclosure -- I'm convinced that the USA could simply copy the healthcare system of any other developed country and end up with something better than both Obamacare and whatever the GOP envisions coming into play if they're ever able to repeal it.)  The Doc seems convinced that the government wants to tell her how to do her job, kind of like hospital administrators but more faceless.  That doesn't make her happy.

I said "simply" in that last paragraph, and I want to clarify.  Copying another country's healthcare system is simple in concept, but virtually impossible in practice.  The main problem with US healthcare, at its heart, is its fragmentation, its complexity, and the gross inefficiency and inefficacy that come therefrom.  Complexity, once it takes hold in an industry or society, tends not to go away.  It certainly doesn't go away quietly, and it probably doesn't go away at all.  Too many people are too invested in the assumptions behind, the behaviors incented by, and the putative expertise required to navigate complex systems for simplicity to be politically viable.  Things are the way they are because they got that way, and they're likely to stay that way so long as they're profitable to at least a small slice of society.  See Machiavelli.

The conversation with the sustainability officer included her making the point that "sustainability" and "sustainable" are really two different things.  In a sense, she's right -- most of the practices campus sustainability offices promote and coordinate and celebrate aren't, in any strict sense of the word, sustainable.  "Sustainability" has come to refer to pretty much anything less unsustainable than modal behavior.  A campus where most students ride diesel-powered buses promotes this as "sustainable transit".  One where the grossest imaginable HVAC inefficiencies have been corrected celebrates that accomplishment as "sustainable building operation".  "Sustainability" becomes shorthand for recycling and even the slightest increase in energy efficiency.  None of which, to the extent it's embodied in behaviors which continue to pollute and to consume finite natural resources, in strictly sustainable.

"Sustainability", when the term is used in the context of modern Western or westernized society, is kind of like "quality" as used in bureaucratic or bureaucratizing organizations.  Each term is used to create a favorable impression of meaningful change while actually encompassing only marginal improvement in a well-established system.  Systems become established by a history of producing what's perceived as success, even if that success in only measured in terms defined by the system itself.  Politicians can trumpet the best healthcare system or the greatest economy in the world, so long as nobody ever seriously asks "best at what?".  By what measure?  By whose standards? 

The fact that a majority (I'd love to be proven wrong on this one) of our graduates would never even think of asking such questions seriously seems to indicate that, like financial services firms, both the healthcare system and the encompassing socio-economic system have gotten "too big to fail".  Which, of course, really means too big to allow to fail.  Which, in turn, incorrectly implies that somehow it's up to the folks currently positioned to decide.  But reality (healthcare outcomes and expenditures, finite resource and sink depletion, etc.) is what happens while we make other plans.  And teach as if those other plans mattered in the long run.

Quality (satisfaction of needs and expectations) and economic efficiency (maximum ratio of value produced to value consumed) while operating in an explicitly finite ecosystem can all be achieved, at least in theory.  Whether that outcome (which constitutes what I think of as sustainability-without-quotes) is ever achieved in practice will depend on whether colleges and universities start turning out graduates who ask serious questions. 

 

 

 

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