I

“Healthcare” is considered to be one of the nation’s critical infrastructures sectors, according to the Department of Homeland Security.

Infrastructures, however, vary considerably in their mandates to provide their services safely and continuously. The energy infrastructure differs depending on whether it is for electricity or natural gas or hazardous liquids, while the latter three differ from large-scale water supplies (I’ve studied all four).

Yet the infrastructures for water and energy, with their central control rooms, are more similar when compared to, say, education or healthcare without such centralized operation centers.

Which provokes a useful question: What would healthcare look like if it were managed more like other infrastructures that have centralized control rooms and systems? Might the high reliability of infrastructural elements within the healthcare sector be a major way to better ensure patient safety?

II

Three points are offered by way of answer:

(1) High reliability theory and practice suggest that the manufacture of standard vaccines and compounds can be made reliable and safe, at least up to the point of the interface with patients. Failure in those back-end processes is exceptional—as in the 2012 fungal meningitis contamination at the New England Compounding Center—precisely because failure is so preventable.

Yet, under routine healthcare, it is the sharp-end of patient interface with those treatments that receives priority attention. The risk here is this focus dilutes attention, encourages complacency and divert management from the strong-end of healthcare, namely, the prevention of key production and distribution errors in healthcare without which patient safety doesn’t stand a chance.

(2) If healthcare were an infrastructure more like those with centralized control centers, the importance of societal dread in driving reliable service provision would be far more visible and dramatic.

Aside from that special and important case of public health emergencies (think the COVID-19 pandemic), civic attitudes toward health and medical safety lack the widespread public dread we find undergirding the reliability demanded of other infrastructures, such as nuclear power and commercial aviation.

Clearly, commission of medical errors hasn’t generated the level of public dread associated with nuclear meltdowns or jumbo-jetliners dropping from the air. Medical errors are often “should-never-happen events,” not “must-never-happen events.” What would generate the widespread societal dread needed to produce “must-never-happen” behavior?

One answer: Hospitals, if not managed reliably kill you. “Going to the hospital always means risking your life” is another way to put the dread. Once societal dread over medical error is high, expect to see medical errors of all sorts to be prevented more effectively.

(3) One response to preceding is to resist their implications and insist on treating healthcare from the doctor’s or specialist’s perspective as a craft or crafts surrounded by advanced infrastructure elements (think technologies and information systems).

Yes, mistakes are made, even horrible ones, but where would healthcare be without first and foremost the patients’ trust in doctors, staff and their expertise? (I’ll leave aside the fact that control room operators in major infrastructures are themselves craft professionals responsible for far more lives in real time than hospital and clinic staff!)

But in the high reliability management research with which I am familiar, distrust is as core as trust. One reason control room and front-line operators are reliable (that is, safe and continuous providers of services) is that they actively distrust the future will be stable or reliable in the absence of the system’s vigilant real-time management. Their wraparound support units—the experts in system engineering, economics, and modeling—may be telling them one thing and their unique real-time experience quite another.

From an infrastructure perspective, it is not surprising then that a US healthcare system that encourages each patient to be his or her own reliability manager entails a basic shift from the healthcare professionals as the primary wraparound for the patient to the patient’s immediate family, friends, and internet searches as primary support. More, the primary role of the latter is now to combat any complacency in patient treatment by healthcare professionals (complacency being a big risk in routine control room operations). Such tensions, including distrust of what are now seen as complacent medical professionals, are understandable from an infrastructure perspective and not ones to be smoothed over or otherwise “solved”.

III

So what?

Limitations of our analogy are obvious. The patient does not share the same situational awareness that his or her team/network of healthcare professionals may have about the him or her, and even then, the healthcare professionals may not have team situational awareness like that we have observed in water or electricity control rooms.

More, the electricity or water user is his or her own reliability manager typically only during severe water or energy shortages, when their participation and collective mindfulness in rationing is critical. Is a reliable patient necessary for a reliable healthcare system during high demand times (and again not just in a public health emergency) in the same way as energy-conscious or water-conserving consumers need to be during their high use times? Presumably, the movement to bring real-time monitoring healthcare technology into the patient’s habitation is increasingly part of the reliability calculus.

Yet in all this focus on the patient, it mustn’t be forgotten that there are healthcare control rooms beyond those of manufacturers of medicines mentioned above: Think most immediately of the pharmacy systems inside and outside hospitals and their pharmacists/prescriptionists as reliability professionals.

Note: I thank Paul Schulman for many discussions, suggestions, and points; the provocations that remain are mine alone.

When asked why they are studying [central bank digital currencies], responses from central banks do not focus on a single reason. The safety or robustness of the payment system, financial stability, efficiency of payments, implementation of monetary policy and the goal of greater inclusivity in accessing payment systems by lower income populations—all seem to be considered at least somewhat important. Lacking a single vision of what they want to accomplish, central bankers seem to be afflicted by a generalized sense of unease. Though scenarios can be only vaguely delineated, shifting sands in the payments and monetary landscape suggest to central banks that, if they do not provide a digital currency, they could find themselves isolated and weakened in unfamiliar ways. Having sufficient control over the retail payments system might, they suppose, prove to be essential for ensuring the stability and efficiency of the monetary and payments system.

From a quote in: Cesaratto, S. and E. Febrero (2022). Private and Central Bank Digital Currencies: a storm in a teacup? A Post-Keynesian appraisal. DT 2022/1, Working Papers, Department of Economics and Finance, Universidad de Castilla – La Mancha, Spain (accessed online at https://www.uclm.es/es/departamentos/daef/-/media/Files/A05-Investigacion-departamentos/daef/documentos_trabajo/2022-01-DT-DAEF.ashx?la=es)

Managed retreat is recommended as a response to rising sea levels confronting coastal communities, cities and major ports. We already have climate migrants in coastal Louisiana and like places, and the idea is to manage this out-migration more systematically.

What’s missing are assessments of the track records in the various managed retreat strategies already out there. The management of moving capitols, for example, has not been without its problems. Relocation of large numbers of people is even more difficult in humanitarian work.

What then might this mean in practice? One place I suggest to start thinking about managed retreat on the West Coast where I live and have done my research is the following:

Every time I visit South Sudan, the angels’ response to my criticisms never varies. “What would you have us do?” asked one exasperated aid worker as we sat drinking cold beers one night by the bank of the Nile. “If we leave, people will die.” He was right. A decade of government withdrawal from the provision of services, enabled by the humanitarian presence, and campaigns of government violence, partly paid for from humanitarian resources, had created a situation in which some people in the camps in Maban would probably starve if it were not for the aid agencies. The only solution the humanitarians can envision is to continue with this dystopic system.

Joshua Craze (2023). “The Angel’s Dilemma” (accessed online at https://thebaffler.com/salvos/the-angels-dilemma-craze)

Imagine, that is, not a historic retreat and resettlement of peoples from the coastline but rather masses of people who stay behind having nowhere else to go practically and who need indefinite humanitarian aid in order to survive.

–The root cause of unsustainability is often specified in ways that render us oblivious to history: The rationale for irrigated agriculture was to sustain crop production throughout the year; the rationale for burning coal was it generated a manifold increase over energy needed to dig it out.

–There is no little irony in a purely self-interested market approach to deregulated electricity coordination and a purely technology-based approach to decentralized electricity coordination that promises to automate out selfishness.

–Beau Brummell, when questioned by a companion which of the lakes he preferred, reportedly asked his valet, “Which one of the northern lakes do I prefer?” “I believe it is Windermere, sir,” replied the valet. Whereupon Brummell turned to his questioner, “Apparently it is Windermere.” Quite droll—until you realize his “apparently” is indifferent even to drollness. Indifference—this not caring one way or another—is a killer in public policy and management.

–I can’t be the only one struck by the affinity between those 19th century novels whose plots were driven by coincidence after coincidence all the way to a happy ending and today’s crisis narratives where one mistake after another has led to certain disaster.

–The obstinate truth is that the costs to society of confronting limitless disaster scenarios is set by the present danger of ignoring ones easy enough to identify and assess already.

Beliefs are like moods or Stimmungen in the sense that one can begin to believe X, and continue to believe X for some time, but then emerge from believing X into some other state of mind. And (the important point) one finds it as difficult to answer questions about one’s beliefs as to answer questions about one’s moods. Why do I believe X (why am I in mood X)? Why did I stop believing X (why did I emerge from mood X)? All one can say is: Today I am in mood X, but as to what mood I will be in tomorrow I cannot say. Today I believe X, but I cannot guarantee I will still believe X tomorrow. . . .
   Now I turn to your main question, which is: What are my beliefs?. . .My response to this question depends on my mood, as defined above. In my present sanguine mood my answer is yes. I believe that nature is orderly, and that, being part of nature, human beings have intuitions of order, of what a just order (a just natural order, a just social order) will feel like. I believe that non-human animals have intuitions of justice too. Furthermore, I believe that through education our inborn sense of justice can be brought to consciousness, cultivated, and fortified, helping us to distinguish (most of the time, though not always) between right and wrong.
   There you have it: the sketch of a moral philosophy with an antique metaphysical grounding.
   When I am in the opposite kind of mood, on the other hand, I believe that the whole creaky philosophical edifice I have erected for myself is nonsense, and life is nothing but the struggle of all against all.
   The fictions I have written – to conclude my response to your question – are not blocks of thought that can be articulated one with another to constitute a coherent set of beliefs. They are essays, ventures, expressions of the moods that have possessed me at successive stages of my life.

“The Summoning: An Interview with J.M. Coetzee.” Interviewer: Robert Boyers (accessed online at https://salmagundi.skidmore.edu/articles/481-the-summoning). The entire interview is a must-read.

Importantly, adaptive capacity [for emergency management] can be facilitated in part by planning and design processes that themselves create prior conditions, such as contacts among diversely skilled people in other infrastructures, robust communications systems and contingent resources in different locations, for restoration actions. In effect, there can be emergency planning process reliability even if the output reliability of subsequent emergency management cannot be predicted or guaranteed.

Paul Schulman, personal communication

I interpret the passage to mean that the mentioned design and planning interventions pass the ‘‘reliability matters’’ test. That is, robust contact lists, communication systems and distributed inventories, when implemented, are more likely to reduce the task volatility that emergency managers face, increase their options to respond more effectively, and/or enhance their maneuverability in responding to different, often unpredictable or uncontrollable, performance conditions. (In case it needs saying, not all design and planning pass the test!)

This notion that there can be reliability in processes to transform inputs into outputs, even if the input variability and output variability of emergency management are not predictable and stable, is incredibly important. Why? Because it shines a bright light on major but under-acknowledged temporal differences key for effective emergency planning and design.

It takes years to seismically retrofit a bridge from start to finish of its planning, funding and implementation. In contrast, a household becoming two-week ready (in terms of having supplies and provisions to last two weeks into the earthquake) is a matter of hours or days. This means the retrofitting of bridges and the implementation of the two-week ready program not only affect the success (or lack) of post-earthquake response. Their prior execution also helps date when planning and design processes started to produce those aforementioned conditions that alter the course (for good or bad) of the unfolding emergency widely visible only after the earthquake happens.

My point is that such mitigation development and implementation prior to the earthquake is measurable with respect to time: Is it in decades, years, months, days or hours? How do these different time horizons vary and congrue by type of mitigation? While no one can reliably predict when the earthquake will occur, it is not clear from our interviews that process reliability as just described is undertaken with an eye to identifying and better managing the different time horizons associated with different pre-disaster mitigations.

Not taking advantage of designing and planning inter-temporal mitigation processes that, together or singly, do increase options and reduce volatility in emergency management is not only a missed opportunity, it is also a correctible error.

Here’s a case in point. Calls by our interviewees for more administrative support to manage and coordinate local emergency preparedness may look like a routine complaint or a small-deal when compared to other city and county priorities. But from the perspective presented here, it is a very big deal in attempting to move the planning and mitigation agenda to identifying and managing latent inter-infrastructural interconnections and vulnerabilities before the earthquake happens.

I

This is based on a true story. Say you are involved in modeling the lifecycle of a listed species. You and your colleagues rightly start out by aiming to develop and then integrate sub-models for: species reproduction; period-to-period, region-based species survival; movements between regions; and juvenile/adult mortality due to exogenous factors, such as human-made disaster.

It doesn’t take long to confirm what you and your colleagues suspected anyway that not only do the pertinent data not exist, but modeling errors and uncertainties work against integrating the exisiting sub-models into a comprehensive lifecycle model (LCM).

With more time and more funding, you all develop much reduced versions, called LCM1, LCM2 and now LCM3, each bringing to light further refinements and significant methodological and data constraints. The team embarks on developing LCM4 in the hopes that the research–funding permitting–is moving closer to identifying management interventions for the species.

The technical reports (now approaching 50 in number) produced during the decade of research track the refinements, improvements, insights and difficulties in modeling species reproduction, movement and survival. In so doing, the peer-reviewed literature on lifecycle models has been advanced in the view of outside experts by this research.

II

Unfortunately, none of the reports identify modeling and data uncertainties in a way that they can be contrasted to the uncertainties and errors made in the existing comprehensive model for managing said species.

What “comprehensive model,” you ask? Didn’t I just write there was no comprehensive lifecycle model? You see, during all the years the modeling research, real-time deliberations of interagency staff and scientists continued with really-existing decisions, period-by-period, over the management of said species.

From time to time the consequences of the management actions find their way into a technical report of the researchers, but here too modeling uncertainties take center-stage: “Though it is tempting to interpret declines in estimated [mortality] as evidence of management success, models of population dynamics are required to disentangle. . .”

III

One would think that the burden of proof has been on the researchers to demonstrate that reliance on life-cycle models would lead to better results compared to the next best alternative of current interagency deliberations of scientists and support staff. . .

But, not to worry: The judge who mandated the research asserted way back when: “All experts agree that application of a lifecycle model is the accepted method for evaluating the effects of an action upon a populations growth rate.”

This means all we need do is assume management isn’t improving faster than the modeling. And what could make more sense in reality than doing what is so needed in theory?

We forget how longstanding is the notion of addressing each case in its own right. Here is Aristotle:

But let it be granted to begin with that the whole theory of conduct is bound to be an outline only and not an exact system, in accordance with the rule we laid down at the beginning, that philosophical theories must only be required to correspond to their subject matter; and matters of conduct and expediency have nothing fixed or invariable about them, any more than have matters of health. And if this is true of the general theory of ethics, still less is exact precision possible in dealing with particular cases of conduct; for these come under no science or professional tradition, but the agents themselves have to consider what is suited to the circumstances on each occasion, just as is the case with the art of medicine or of navigation.

my underline and without endnotes and annotation; from Aristotle’s Nicomachean Ethics http://www.perseus.tufts.edu/hopper/text?doc=Perseus%3Atext%3A1999.01.0054%3Abekker%20page%3D1104a

The underlined, “suited to the circumstances…” (pros ton kairon), has also been translated “as the occasion merits”.

What really strikes me in this passage is the hint of improvisational or makeshift, as in: working with what’s at hand.

Source: Thanks to Otto Linderborg for directing me to this (also see his https://antigonejournal.com/2023/01/history-socratic-problem/)

I

I graduated with a master’s in public policy studies from the University of Michigan in the early 1970’s and with a PhD in public policy from the UC Berkeley a little more than halfway through the 1980’s. I still identify as a policy analyst when asked my occupation/profession.

One misconception has been that in its early days policy analysis assumed problems were simpler and could be solved by the best and the brightest. That’s not how I remember my graduate training.

I had the good fortune to have been a student of Pat Crecine, the founding director of the Institute for Public Policy Studies (now the University of Michigan’s Ford School) and Aaron Wildavsky, a founder of the now Goldman School of Public Policy at UC Berkeley. Two different people you can’t imagine, but one insisting to his first-generation students that policymaking and budgeting were complex, while the other was the last person on earth who would say policy implementation was anything close to simple.

Another misconception: I remember a well-known policy academic upbraiding me that the “policy cycle” from policy formulation through policy evaluation/termination was a signal advance over early notions of incrementalism and the budgeting process. You only need implement something you had earlier planned to realize that the stage of “implementation” is itself a lethal critique of anything like a policy cycle.

II

But implementation is more than critique. We are, for example, used to thinking of a creeping crisis, like slow violence, as one that builds up until outright disaster triggers. Yet would one say that, given the inevitable gap between policies-as-stated and policies-as-implemented, implementation is the creeping crisis of policymaking and planning?

I don’t think so. We are just as apt to say implementation is de facto policymaking, and better for it when rendering more realism. In my view, we don’t ask, “Who’s going to adopt the recommendations and, if so, with what modifications?” before asking: “Who would implement the finalized recommendations and what are implementers’ scenarios for failing to do so?”

III

Realism doesn’t equate with intractability. At no point in my graduate training or later career do I remember being told that a policy problem not amenable to our toolkit was intractable. That toolkit, we were told, always had space for new methods and approaches. Nevertheless, it’s difficult to recapture that sense of policy analysis recasting difficult problems more tractably in the same way that policy analysis originally recast the field of public administration in the late 1960s and early 1970s.

One way I think about what has happened is to distinguish between (1) the discipline as taught in graduate schools and the profession that policy analysts think they are joining upon graduation and (2) the profession as it is actually practiced at any one time or place and the varied careers that policy analysts have across time and place.

IV

For example, when I started out, it was said that 90% of a policy analysis was answering the question, “What’s the problem?” Having defined the problem meant you presumably knew what a solution would look like. It’s my experience today that 90% of a policy analysis—indeed of major policy practice and work—are its initial conditions.

In the 1970s, a key indicator of what is now called “a failed state” was its inability to publish an annual government budget that actually operated over the year. That happens all over the place today, and in parts of the US. But the point isn’t whether the “state” has in this way failed. It’s first about how the initial conditions have changed and become more differentiated.

What arises are cases in their own right. When findings do not converge across multiple orthogonal metrics or measures (populations, landscapes, times and scales…), the analytical search becomes one of identifying specific, localized or idiographic factors at work. What you are studying may in reality be non-generalizable–that is, it may be a case it its own right–and failing to triangulate is one way to help confirm that.

V

A singular purpose of the toolkit remains that policy and management be presented from not just one discipline’s perspective (say, economics), but many—including political science, psychology, organization theory, and more.

Yet what frequently gets missed are the implied hyphens, i.e., “from a socio-politico-economic-cultural-historical-psychological. . .perspective”. Consider Polonius in Hamlet: “The best actors in the world, either for tragedy, comedy, history, pastoral, pastoral-comical, historical-pastoral, tragical-historical, tragical-comical-historical-pastoral. . .”

The hyphens there function as the performative demonstration of Polonius’s long-windedness. Interdisciplinary accounts of policy analysis and management, however, insist that analysts take their added wordage as anything but long-windedness.

The irony has been palpable. Over my policy analysis career, I’ve witnessed the 20-page policy brief reduced to the five-page memo into a fifteen-minute PowerPoint presentation into the three-minute elevator speech into this or that graphic and now a tweet or two. What next: Telepathy? The knowing look? This arc has been our very own version of long-windedness.

I hope to see in the future a peer-reviewed article whose abstract runs something like the following:

This article traces the evolution of Pastoralist Studies from its nascent stages in the 1950s anthropological literature to its current status as a recognized and integral part of global academic discourse. It highlights the field’s vital role in dissecting the multifaceted structures and functions of settler colonialism (Arab, European, domestic agriculture) and standing firm amidst well-funded and systematic counter-efforts to delegitimize it, principally by global or national techno-managerial and urban elites. The ensuing discussion foregrounds pastoralist scholarly achievements in advancing their narrative and countering marginalization, particularly within the academic institutions of both the Global North and the Global (principally urban) South. By examining the political dynamics shaping research methodologies in Pastoralist Studies, this article elucidates how the field has emerged as a legitimate academic discipline, offering new pathways in graduate education centered around Anthropocene uncertainties and complexities. In asserting that Pastoralist Studies is inherently linked to activism, aiming for transformative change, decolonization, and liberation, this article underlines the contribution of the field to challenging dominant colonial epistemologies and methodologies and reshaping power dynamics. Thus, Pastoralist Studies not only elucidates the realities faced by indigenous herder populations but also vocalizes their struggles and aspirations, positioning itself as a critical lens to understand, and engage with, Pastoralist scholarship and its broader anti-colonial implications.

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Source: The above replaces “Palestinian” with “Pastoralist” (along with slight edits) in the abstract of Ilan Pappé, Tariq Dana & Nadia Naser–Najjab (12 May 2024). “Palestine Studies, Knowledge Production, and the Struggle for Decolonisation,” Middle East Critique, (accessed online at DOI: 10.1080/19436149.2024.2342189)