HileThoughts

On a recent Leadership St. Louis weekend we learned about some of the problems of health care. Touring health facilities (the photo is part of our class on the St. Louis University heliport), hearing from the head of one of the region’s crown jewels the Missouri Foundation for Health,  and talking with others who are actively tackling health care issues in the region.

As a country the US uses 17% of its GDP for health care. Canada in contrast spends on 9.5%. Yet for all of this expense over 16% of our citizens are uninsured (based on a 2005 report, this percentage has increased significantly during the current recession). Yet we have poorer health outcomes than countries that spend much less.

With the consumer model (which I have previously derided), health care is something that one can never get enough of. Why shouldn’t I get the newest treatment, the most expensive drugs, the more elaborate tests, receive the most aggressive (experimental and/or expensive) care which will not improve my eventual outcome. The US health system based on this "it’s all about me" approach. If you have money you can have care. If not tough. If you are over 65 you can have socialized medicine. If you are younger tough. (The fact that government health insurance is great for folks over 65 and bad for people younger than that is one of the great stupidities of our country.)

It is time that we abandon the consumer model of health care and adopt a citizen’s model. Instead of how can I get the most (not necessarily the best) care for me. The question is how can we as a group best support and improve our health. Instead of how can this insurance/health care corporation makes the most money for it’s share holders. The question is how can we provide the best health care for all.

I have never been entirely comfortable with the term consumer when referred to individuals receiving mental health services - or really any health related services. The term is new, with the earliest OED citation being 1968. Initially it had the implication of a demand for high quality goods and services. Today, however,  it has morphed into implying an insatiable demand for goods and services - generally at lower and lower prices.

This newer meaning always seemed inappropriate to me when it comes to health services  but I could never quite put my finger on exactly why it was troubling. Yesterday, as I was riding my bike along the Gulf of Mexico, I heard a 2004 TED lecture by James Howard Kunstler, The Tragedy of Suburbia. He nailed it for me. The term, he opined, was problematic because it means that consumers "do not have obligations responsibilities and duties to their fellow human beings" (you can find this quote at the very end of the lecture).

For health services including those for physical health, mental health, and substance abuse we should never consider ourselves passive recipients. Rather we should be responsible for our own behaviors, should participate actively in our care, should consider it our duty to help others in similar circumstances, and should widely promote the benefits we have received. In other words, we should not be consumers but active participants and change agents.

In the middle of our year, my Leadership St. Louis spend a weekend learning about race and exploring the racial divisions in our fair city. What I learned shocked me. What I felt humbled me. What I experienced changed me.

Contextually, this weekend comes at a time when the nation is about to get a president elected by the content of his character rather than the color of his skin. When race is a more frequent topic of discussion. When the local paper has launched a new blog to encourage a dialogue about racial issues. And, paradoxically, when there is an increase in the number of hate crimes.

Where I come from.

I was not raised in a household that told racist jokes or denigrated those whose race did not match our own. My only memory of this sort of speech was a single comment my material grandmother made. I do not remember the comment, but I do clearly remember my mother telling her that it was inappropriate.

On the other hand, mine was not a family that talked about racial issues at all. We lived in uniformly white neighborhoods, went to mostly all white schools, and attend a church with no black members.

In graduate school I was in a class of eight - four men, four women, one Chinese, one Japanese, one black, Protestants, Catholics, Jews, and atheists, folks from the East and West coasts and the Midwest, people who had gone strait through school, some with extensive work experience, some young and some old.  In all, a group very carefully selected for its apparent diversity.

Yet for all of this diversity, what I remember is how similar we were to one another. While I remember a split on whether Chinese or Japanese food was better - I do not recall any other discussions of how our different experiences impacted our work or our interactions. We took classes together, partied together, studied together, and all worked hard to succeed.

So,  before this weekend I would have said that prejudice still exists. That some still feel and practice it but that, for the most part, people would be embarrassed to do so. That logically prejudice makes no sense.

What I experienced.

Our weekend had a number of components - survey results, history lessons, local studies, experiences and discussions. Two, however stood out for me.

The first was called the Level Playing Field. We stood shoulder to shoulder holding hands. The facilitators read positive and negative life experiences (e.g., my family vacationed out of the country, my family could afford to pay for my college education, I did not have enough to eat as a child). If the positive item was true you took one step forward. If a negative items was true you took one step backward. At the end we turned to look about us.We were spread widely by our experiences.  However, all of our black classmates were in the back - behind all of our white classmates.

The second was a group discussion. As we talked each of the black classmates spoke of their fears when their sons went out. Fear that they would be arrested, abused, hurt - simply because of the color of their skin. I to have a son. I to worry about his safety when he goes out. So I understand how that feels. However, I never have to worry that the color of his skin will be the cause of that hurt or make being stopped more likely.

The weekend made me understand - in a way I had never had to consider before - that in our city, and by extension our country and world, prejudice is alive and well. The people I know and care about experience it daily. And that I needed to behave in a way that actively seeks to combat its practice and impact.

What can I do?

I do know I can start by talking with my black colleagues to see if there are things we need to address at work. I need to go to local traditionally black universities to actively recruit people to fill my positions. I can pay more attention. I can continue to speak up when I see things that are not as they should be. I can talk about the issue when no one else does. I can continue to learn about racial issues. I can continue to feel, in some small way, the pain and difficulties created by these attitudes and behaviors. Hopefully these steps will start me down a path so that I can make some impact on this foolish and disgraceful practice.

I just read Kate Lovelady’s (the Leader of the St. Louis Ethical Society) blog post discussing one of her new year’s resolutions to make sure her wishes to be an organ donor were recognized.

I checked the back of my license and saw that would not have helped - I would have to sign as well as two witnesses - that seems more dificult than it should be. While my family knows my wishes I decided to take Kate’s advise and visited this national site which has links to information from each of the various states.

Going to the Missouri link, I worked for a while and finally figured out how to register on the state’s web site. The usability of the site clearly has never been tested by watching real people try to walk through the process. They have managed to create a site that is well deigned to frustrate rather than help users. The ability to get to the pages is hidden, the text confusing, and trying to fill out the forms when you are able to get to them is counterintuitive. But, if you are persistent, you can in fact use it to register to make your wishes known.

So I did it - so can you. Find out how to register in your state and make your wishes known so that when you loose your life you can pass parts of it along to others in need.

I recently discussed the availability and presentation of St. Louis’ regional crime data. For the city of St. Louis, the Post Dispatch’s site STLtoday.com has the best graphic presentation of homicide data. An interactive bar chart that presents 4 years’ data. While it is colorful and does provide individual monthly data when the mouse hovers over bar - it is not at all clear what you can learn by looking at this graph. It is not easy to compare changes month by month, to look at trends across a year, or to see underlying patterns in monthly rates.

Rather than simply complain I thought I would try my hand at making the graph understandable.

First I tried a simple line graph. But the overlapping lines made it difficult to see individual patterns. There was no reference to what one might expect on average. So it did not improve the utility of the graph at all.

Next I tried each year paired with the average of all years. This allowed a variety of comparisons. 1) By comparing each year with the average it is easy to see when months have more or less than would be expected. So we can see that 2008 has been pretty much consistently higher each month. 2) It also allows us to see the pattern across the months - you are less likely to get murdered in January and February than any of the other months. 3) Additionally, it also allows us to predict that there will be a spike in rates in November of 2008 when that data becomes available.

Now following the suggestions of graphics visionary Edward Tufte I decided to see if we could further simplify the presentation - conveying the same information with less ink. I believe that the final graph does this by removing the extraneous lines and the vertical axis information. This has the advantage of focusing the viewers attention on the main points - examining the pattern of homicides across the year and differences between the years. It looses the interactive features of the original but it does deal with the fact that the original graph really did not provide any more information to the viewer than a simple table of numbers.

Are there other ways to graphically ring information out of this data? Let me know what you come up with.

NOTE: This entry is cross posted on both my personal and professional blogs.

Saturday my Leadership St. Louis class looked at crime in St. Louis. In my case this examination had already  begun with my 3rd District ride along. We toured the City Justice Center (read that as jail) and heard presentations  by a university professor, women who had experienced incarceration, prosecutors from St. Louis and the Eastern district of Missouri, a judge and the police chiefs of St. Louis city and county. An impressive lineup.

What I learned:

• The police have a difficult job - I am certainly pleased that there are people willing and able to do this dangerous and important job - as they try and get the bad guys off of the streets.
• Prosecutors take a look at the cases brought to them  by the police and decide which of those individuals to try. They are proud of their work in keeping bad guys of the streets.
• The judge’s presentation helped us think about balancing individual needs and community retribution.

But the emphasis seemed to be on getting bad guys off of the street. We did not hear from any public defenders or defense attorneys. We did not hear from any criminal justice watchdog groups. What story would they have told? What would we have seen by looking at the system from the other side? I suspect something quite different.

As a nation we have the highest incarceration rate in the world - 1 out of every 100 American adults is behind  bars. For blacks the rate is 1 out of every 15. Clearly this "law and order" focus - let’s lock ‘em up to keep ‘em off of the street - is not working. We need a different way.

In their presentations to my Leadership St. Louis class both city and county police chiefs complained about the inadequate coverage they get from the local media. Based on this I was posed a challenge - that they make their information available to the citizenry who is paying for these services. They suggested that this information was available so I went looking.

St. Louis City - yes their data is available and easily found with a link on their home page. However, the data is in difficult to aggregate/analyze PDF files. Moreover, the data is summarized into neighborhoods. In my ride along I saw that the police collects a great deal of information. Reports, stops, calls, arrests, accidents - lots more information than is available to the public.

St. Louis County - their data missing in action. No links on their home page. No information using a search from their site. County interactive map - no crime data. No official information found doing a Google search. It seems that the county is not making any information readily available to those who are paying for its services. To be fair, the Missouri Highway Patrol has a web site with crime statistics that includes St. Louis County. But the data accessible only through their query system and is aggregated by county.

The Post Dispatch has recently had a a few articles about the nature of crime statistics (for example here and here) because of the recent CQ Press release of its 15th annual ranking of U.S. cities by crime. The Post has published some graphs and maps of the St. Louis homicide rate (though the graph should have been done using a more informative format the interactive map is quite nice - see my examples of how this might look).

By not making their detailed data available to the public, the police departments are trying to control our access to and understanding of what they are doing. They seek to spin the story to their benefit. By being closed they are easily buffeted by press coverage - it is the press’s interpretation versus theirs. There is no way to look at the facts as shown in the data. So, by not being accessible, by not making their data easily available to the public for independent analysis their complaint about poor press coverage seem rather hollow.

Why would we want this information? Well what about looking at the response time to calls into the police? Or the resolution of individual complaints by block? Or the impact of sobriety checks on accidents? All things that would help the citizens understand the effectiveness of our police force. Take a look at how this sort of information is used in Chicago. Here we have information rather than data. A platform for understanding the distribution of crime and in helping the citizenry deal with it. A system of criminal network knowledge discovery. This sort of resource does not have to be, and probably should not be, created by the police. Rather the data should be made available to the community so that it may make unique uses of that information. As described in the Federal government’s guidelines for its departments’ web sites:

Visitors to federal public websites, and many web-based services, may want to manipulate data that is made public for their own purposes. New uses of your agency’s data may become a valuable public resource that would be out of the scope of your own website, such as helping to keep the public informed about the work of your agency and supporting civic education and participation. You should facilitate the public’s ability to make new uses of your data by providing it in open, machine–processable formats.

Government has gotten a bad name. There is a constant drone to reduce its size - to eliminate programs - to be lean and mean (though the code word is efficient rather than mean). Yet government is the word we use when we want to do something together. What we need is a transparent government. A government that provides all with access to the information about what we are doing together and how effectively (or not as the case may be) we are at doing it. Let’s start this in the St. Louis region by making our detailed crime data widely available.

On Friday our Leadership St. Louis class focused its attention on poverty. Splitting into groups we met in various agencies around the region. I went to the Lessie Bates Davis Neighborhood House in East St. Louis. This 100 year old institution began its life serving the immigrant Bohemian-Slavonic population, working in the local stock yards, and continues today serving the predominantly African-American residents of the area. 

We had been to East St. Louis before but our tour today focused more clearly on the community.

The work being done by the Neighborhood house was very impressive and their facilities were organized and attractive. Their day-care and preschool program would not have been out of place in a much more affluent section of St. Louis. Yet, in the end, I was left with a feeling of sadness.

My overall impression of the area is of its emptiness. Whole blocks have only a smattering of building left sanding with the majority of lots being grass and weed covered. Driving through the center of town we saw few people, many boarded up store fronts, and beautiful empty buildings with trees growing out of the upper stories. There were new buildings and housing - but they were few and far between.

A Jobs program is an importing offering of the Neighborhood House. But our guide indicated that when the program was successful and its graduates could find better than minimum wage employment, the individuals and their families left the area. So even a successful program serves to further concentrate the needs of this community.

In the afternoon our class participated in a poverty simulation. We gathered in one, two, three, and four person groups. Each group has a packet of instructions - describing their family members, detailing their income and expenses, and providing a few transportation tokens and other "valuables" (e.g., a TV, refrigerator, stove). We then had four 15 minute weeks in which we were to get money, pay our bills, send our children to school, and feed our families.

I played a female high school graduate with a 4 and 5 year old. As we calculated our budget it was clear that we had more expenses than money and some things would go unpaid. At the start of the week we rushed to the bank to cash our TANF check then on to the quick mart to get some more transportation tokens so we could go to other sites (we each needed a bus token to get to any location). We stood in long lines and - more often then not - the business or agency would close before we could get to the front of the line.

At the end of our four - 15 minute - weeks we had managed to get cash, pay the rent, and purchase two weeks worth of food. We were out of bus tokens so we could not go anywhere. We had no cash (and the pawn shop would not buy any of our "valuables").

This simulation did a number of things for me. First, it made my intellectual understanding of the morning’s East St. Louis experience much more emotionally real. Second, I understood at that same emotional level, that as the head of a poor family there was no way for us to win - indeed just surviving required a tremendous amount of energy and ingenuity. Third, that I did not make use of my neighbors to join in collective community action to deal with my difficulties (for example we might have set up a shared day care arrangement). Yet trying joint help did not even occur to me because I was trying to help my family survive.

The experience was eye opening and emotionally impactful. Indeed, I would like all Americans, but especially some of my relatives, to experience a poverty simulation before they talk about the "welfare cheats" or vote against programs to support these individuals. My family is fortunate to not be in the shoes of these individuals. This sort of experience - as well as the current economic meltdown - should make us all more understanding of and generous to those in need.

As part of learning about law enforcement in the region the Leadership St. Louis class had the opportunity to ride along with either the city or county police. I signed on with both interest and a bit of trepidation. After all, I grew up in the 60’s when the police did not seem particularly friendly.

I chose to ride in the city. The station was right across the street from where I work and even though it had been there for many years I had never before entered. (Which seems like a good thing.)  My guide, an officer in his first year out of the academy was involved with a case and it took a while for him to arrive. He had not had any warning that he would have a passenger nor did he know of our group. Nonetheless he took me under his wing.

We talked about his experiences and job and how he had gotten into force. We drove around in the third district (the Soulard area) and he explained what he could and could not do. He apologized that there was nothing really exciting happening and that I had missed a shooting earlier in the evening. (I was just as happy to have missed that experience.)

What struck me was the amount of time officers spend just driving around looking for problems - it seemed like a much more boring job that I would have ever imagined. We did, however, have enough action for my taste. We pulled someone over for making an illegal left hand turn (the also got a ticket for driving on a suspended license), went to investigate a reported burglary (it seemed that the reporter was not quite "with it" and had over reacted), dealt with a serious  but non life threatening accident caused by someone running a red light, and finally pulled another car over (they got off with a warning). Yet most of the time we drove about the city quietly.

I met a variety of other officers during the course of the evening. Each introduced themselves and treated me with respect and interest. Each wore a black band around their badge in respect and morning for their fallen brother from University City.

What impressed me most? Well the lights on the roof sound like grating sand, the computer that gave the officer information was old and the different state’s databases it accessed presented information in idiosyncratic formats making it difficult for the officer to find what he was looking for. He had to spend a lot of time hand writing tickets when it should have been quite simple to have a computer generate the forms automatically. It seems that we need to be spending more money, which I am sure is money that we do not have, to make our officers more efficient and improve their equipment.

But the most important thing I learned I did not understand until a few days later. I read in the paper about an young officer being shot on the east side. I wondered if that was my young officer. It was then that I realized that from now on I would put a much more personal face on those that are protecting us and enforcing our laws. Seems like a good outcome for an evening ride.

In the St. Louis region, and probably other places as well, we like living in places where our opinions matter and have sway. We like the feel and identity of a small community. That is why we have more municipalities in the St. Louis region than you can shake a stick at.

Yet we also know that there is great redundancy across these communities. We have a multiple police and fire departments, school systems, library systems, road maintenance crews, … These small units can not easily benefit from the economies of scale. They need to duplicate what others do. They need to spend a more time coordinating with their sister agencies in neighboring communities.

Our small communities are more effective at attending to their citizens. Yet larger organizations are more efficient. What governmental or organizational structures exist that could do both?