A System for Health

By Lieutenant General Patricia D. Horoho

Picture: An AED in every room. A cardiac catheterization lab in every mall. And 200,000 more gastric bypass surgeons practicing in the United States.

Absurd? Maybe. But if we continue down our current path in this country, relying primarily on a model based on rescue; focusing on intervention over prevention; relying on more pills, procedures, and machines, there’s a good chance that’s where we’ll end up.

Imagine you’re a lifeguard and you find yourself having to save more and more swimmers. The easy answer is to hire more lifeguards. So you do, but still the job isn’t getting done—people are drowning. It wouldn’t take long before it became clear that you must do something different: teach people to swim, make them more aware of the dangers, and for those really dangerous areas, put up a tall fence.

At some point, we must realize that it’s a lot easier to attack problems far upstream, optimally preventing them from happening in the first place. That’s what’s called systems thinking. It’s what we need to do with health, and we need to do it now. Here are some sobering statistics:

  • For the first time in history, a child born in American today has a life expectancy shorter than that of his or her parents.
  • As many as one in three U.S. adults will have diabetes by 2050. One in 10 have it now.
  • The average American is either sitting or lying down a staggering 21 hours a day.

Revisiting our lifeguard metaphor, those behaviors are akin to a weak swimmer wading into a raging riptide.

To attack those problems upstream—to adopt a systems thinking approach—we first must realize that health care is part of a much larger, more complex system. It has become one of America’s wickedly expensive and wickedly complex problems: high costs, high variability, suboptimal outcomes, misaligned incentives, and focused exclusively on rights, not personal responsibility.

We need to do better. We have to think differently. Individual silos and incremental fixes, treating the symptoms and not the disease, aren’t the answer. We need to step back, look at the broader picture and know our part.

Systems thinking put man in space and eventually Neil Armstrong on the moon. It allowed Henry Ford to mass-produce the automobile, allowed Steve Jobs and Apple to invent products that caught the imagination of the world, and in the medical arena, helped us control epidemics like polio, measles, and most recently HIV.

IA systems approach is broad and brings in diverse people with diverse skill sets. But the defining characteristic of systems thinking isn’t studying the individual elements; it’s studying the interaction of those elements that matters.

If you’re an expert in one component of a complex system, but don’t understand or interact with the larger system, your impact on the larger system and mission will be small. Think about NASA’s mission control room during a launch. It’s a room packed full of individuals, but each one is keenly aware that they are part of a larger system and crystal-clear about what the overall mission is. We need to do the same with health: realize we’re part of a larger system, and know that the ultimate mission is health, not just health care.

Health is more than simply the absence of disease or injury; it’s a state of complete social, mental, and physical wellbeing.  It encompasses those components of society that influence health and wellbeing, the social determinants of health—things like education, clean water, outdoor recreational facilities, and safe streets. These lie outside of our medical facilities in a place I call the LifeSpace.

That’s where health happens.

Our lives are embedded in systems within the LifeSpace: families, communities, industries, economies, ecosystems. Our health is embedded in all of these systems, and they are all connected in various and complex ways.

While continuing to provide health care, we must broaden our perspective and widen our focus to health. Only then will we begin to appreciate the interactions in this complex system that contribute to disease and impact wellness.

Army Medicine’s vision is to develop a System for Health (SFH), where we continue to provide and improve combat casualty care and train world-class deployable medics. That’s what we do. It’s our promise to the nation. But we also recognize the opportunity and need to think differently; to broaden our view of health and participate in a larger system where health is integrated throughout every aspect of Soldiers’, families’, and retirees’ lives.

Collaboration is key. Obstacles to good health exist everywhere and vary from community to community, base to base. We need to work at the systems level. Success will require coordination across all sectors touching social, cultural, economic, and environmental spheres.

We must come together and think like social engineers, to develop pattern-changing ideas that will transform the people around them. No one participant in the System for Health holds all the solutions.

We are ready to transform Army Medicine from isolated individual health services to a System for Health. That means working outside of our brick-and-mortar facilities and engaging all sectors of our community to build health into every aspect of our lives.  We in the military have a unique opportunity to influence the LifeSpace in that our bases, both at home and abroad, on land and at sea, have very tightly integrated social services. In the Army, these diverse sectors have been brought together to form Community Health Promotion Councils to discuss, share, and implement health throughout all areas of the community. We view them as innovation laboratories for health where imagination, inspiration, and persistence are harnessed to provide continuous momentum toward a better community, a better Army, a better world.

Let’s keep electricity off of our chests and tubes out of our hearts. Let’s solve the obesity epidemic at the dinner table and not on the operating table. There’s a better way.

Complex? Yes.

Conquerable? Most definitely.

Horoho-Patricia-newLieutenant General Patricia D. Horoho is Surgeon General and Commanding General of the United States Army Medical Command. She earned a bachelor of science in nursing from the University of North Carolina at Chapel Hill, and a master of science degree as a clinical trauma nurse specialist from the University of Pittsburgh. She is a resident graduate of the Army’s Command and General Staff College and the Industrial College of the Armed Forces, where she earned a second master’s in national resource strategy. Lieutenant General Horoho’s awards and decorations include the Distinguished Service Medal, Legion of Merit (2 OLC), the Bronze Star Medal, Meritorious Service Medal (6 OLC), Army Commendation Medal (3 OLC), Army Achievement Medal (1 OLC), Armed Forces Expeditionary Medal, Afghanistan Campaign Medal and various service and unit awards. She served as the Head Nurse of Womack’s Emergency Department when the hospital was awarded the Superior Unit Citation during the Pope AFB Crash in 1994. She is also authorized to wear the DA Staff Badge and is the recipient of the Order of Military Medical Merit Medallion. Follow her on Twitter @LTGHoroho.