Delving into the Paradoxes of Public Service


 
 

Howard Rodenberg, MD | | Monday, November 26, 2007


The world is full of paradoxes. These conundrums encompass such diverse concepts as military intelligence, compassionate conservatism and living in Cleveland. (Although two physicians in a room do not constitute a paradox, they will provide three different opinions. Which reminds me of my favorite doctor joke of all time: A man goes to his doctor, who says, I m sorry, sir. The test results are in, and it looks like you have three months to live. The man says, Gee, doc, I d like a second opinion. Whereupon the doctor looks the man up and down and proclaims, Well, I think you re kind of ugly, too. )

In fairness to the Buckeye State (named after a nut, which gives one pause ), I ve never been to Cleveland. All I know about that city is a joke that my dad used to tell about a contest where the winner got one week in Cleveland, and the loser got a fortnight. Oh, and that Dennis Kucinich used to be its mayor and that the Cuyahoga River once caught on fire probably messages in themselves.

If you think about it, the entire practice of public service is a paradox. Public service done right is designed to put itself out of business. Granted, this thought is more theory than practice. If politicians and public servants really wanted to solve problems, they probably could. It s just that someone has an interest in not resolving these issues that retards progress. But the ideal of public service is, nonetheless, a paradox, one that extends into our realm of fire and EMS. It took my transition into the public health arena for me to recognize this fact.

How it all works

How does this paradox work? Let s take an example from law enforcement. Although the police certainly provide what we might consider acute care interventions, the core mission of an LEA is really crime prevention. Whether it s a planned program of prevention activities, a record of strong enforcement or simply the presence of officers on the streets, the idea is to prevent crime before it happens. The same is true of fire services. While fire suppression is certainly part of the mission, the core of suppression lies in prevention. The same is true of EMS agencies that provide acute on-scene care, but dedicate resources to prevent drunk driving and encourage seatbelt use. The catch is that when prevention works, the need for the service itself falls hence, the idea that doing public service the right way puts yourself out of work.

Let me put this on a more concrete basis. Many programs in public health are funded on a needs basis. This means that if you have a demonstrated need in an area (the incidence or prevalence of a specific illness or injury is high), you receive proportionately more funds to deal with it than those less impacted by the problem. In theory, this makes perfect sense. You devote your resources to those areas where you need to make the most impact.

On the front end, it s hard to argue with the idea. You initially allocate the funds according to your original information. But the problem comes when the funds have been spent and it s time to re-evaluate the need. There are two possibilities.

One is that the impact of the problem is less, and your funds have been well spent. Your numbers look better to the outside world, and it looks like you re making an impact upon community health. But because your numbers look better, you have less need for future funding than others. As your funds disappear, so does your ability to retain those employees who were effective in their roles and made the key difference in the population at risk. The assumption is that any change is permanent and the temporal dimension of prevention that there is always another generation at risk in the pipeline is ignored. So the first paradox is that the better you do, the more you re penalized by your success.

The other scenario is that you re not effective in your programming and the problem persists or even grows. Even if your numbers stay the same, they may be magnified in proportion to diminishing cases in other areas. As a result, it looks as if you need a larger share of the money allotted to deal with the problem. This leads to the second paradox, which is that failure is self-rewarding.

This illogical logic (the trademark of Gracie Allen) leads to some weird permutations. For example, one can be forced to choose between retaining employees and funding by discovering cases, but by not performing any type of effective intervention. This is the best of both worlds, at least in a financial sense. We keep our people, and we keep our funds.

The funding issue

There s one other population paradox involving funding in public health, and it concerns the ideas of populations at risk. It s unquestionably true that for a host of reasons, some segments of the population are at much higher risk of injury, illness and death from certain causes. It s also true that many of these at-risk groups represent minority populations. But efforts to specifically address these health disparities set up their own conundrum.

Let s say that there are 1 million people in a city. Ninety percent have blue eyes, and 10% have green. There are 5,000 cases of Dread Disease X each year in the blue-eyed folks, and 1,000 cases in those with olive-hued eyes. The incidence rate (the number of new cases per unit of time within a population) for the green-eyed group is 1,000 per 100,000 (1 per 100), while it s 5,000 in 900,000 for the azure orbits (0.55 per 100). Clearly, the green-eyed citizens are a population at higher risk, but there are more total cases within the blue-eyed community. Where do you divert the funding to the population at higher risk or to where more of the total cases might be? Regardless of what choice you make, you invariably leave out a segment of the population, and your mission becomes self-defeating.

Don t get me wrong. I m not arguing for a minute with the idea of identifying specific populations at risk for disease and intervening aggressively to address these disparities. In many cases, it s my sense that minority communities might represent more focused targets for effective social marketing campaigns designed to inculcate preventive health behaviors and that efforts to reach these groups may be more effective than drawing wide swaths across the population at large. But I find it interesting that, at least in theory, targeting at-risk populations may lead us to spend our dollars where we don t get the most bang for the buck. Again, we find a paradox between where the funding goes and where it might best be used. (If you really want to have fun with this idea, consider estimates that by the middle of this century, most of the U.S. population will be multiracial. Now, figure out who is the minority population at risk. It s a fascinating mental exercise.)

In real life, of course, it s a lot less cut-and-dried. Most of us are willing to bite the bullet of funding in order to enhance the health of the community, and the funding we do get is spread as widely as possible to address as much of the population as possible. But you can easily see the inherent paradox we face in public health, and I contend that the same is true within the fire and EMS community. Better fire code enforcement is good, but it limits the need for suppression services. Better injury control and community efforts to control chronic disease result in less need for EMS. Less need results in less funding, and without funding, we re out of business. And while I may be decrying the paradox, I think it s important to note that there is something inherently noble about being in a profession that strives to improve society to the point where that profession is no longer needed. That s something to sleep well with at night.

How did we get here?

The more fundamental question is why we accept these paradoxes in the first place. Why don t we aggressively pursue our preventative mission, and look forward to the day we re all obsolete?

I have a friend who is a doctor in Venezuela. He used to come to air medical transport meetings in the United States and become visibly distressed when his American colleagues discussed the need for collaboration with nurses and other health-care professionals. Power, he would proclaim, his rolling r s echoing across the meeting room. You need to have the power!

I would explain his comments to others by noting that for much of the past century, Caracas was the home of a military dictatorship, and that had to rub off on you somehow. In knowing him well, I also recognized that there was quite a bit of Latin hyperbole in his comments. But over time, I ve come to realize that he was merely articulating a fundamental truth. I might have put it differently, less Machiavellian, in terms of spheres of influence. Some might term it self-interest, or the idea might be summarized by the phrase all politics is local. It might also be why we view altruists, such as Mother Teresa, on a higher moral plane than ourselves.

EMS in the scheme of things

Our EMS agencies, homes, and even our ambulances and patients represent our spheres of influence. Everyone wants, and perhaps needs, to be a big fish in some small pond. (And believe me, I m not immune to this effect. There s no grandstanding here.) Taking measures to reduce or eliminate the size of your lake causes our egos, carefully constructed over years to support a single scenario, to suffer. This is why culture change, or a paradigm shift, is so difficult within complex organizations. Our level of control fades, and we are no longer the masters of our domains because our domains have disappeared.

This problem is not unique to EMS, but is shared by most public service agencies. The contraction of acute need services through preventative efforts can only be beneficial to society because we can use our excess time and resources to address new problems. If we re willing to expand our minds, we can create new domains to preserve our place, power and position. Often, however, moving forward in prevention only results in battles for new turf that are mired in old fights for power. By default and inertia, older modes of thought are preserved, and fear of the new becomes a dominant theme. To me, that s the true paradox of public service.


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