Thursday, December 31, 2015

New Year’s Resolution: Making Ethical Choices

I’ve had the pleasure of spending a great deal of time reading really interesting stuff over the holiday break. My reading has inspired me to help the Mid-Michigan District Health Department make a New Year’s resolution to take additional steps to avoid ethical lapses in the future. Let me explain.

The Atlantic magazine has a great article by Jerry Useem on how ethical lapses happen in organizations called What was Volkswagen Thinking? (in reference to the automaker’s installing software in their vehicles to defeat emissions tests). Useem explores other well-known examples including the decision by Ford to keep making Pintos even after it was shown they were prone to exploding; Morton-Thiokol’s vote to launch the Challenger even after they knew the O rings were leaking in cold weather; and B. F. Goodrich’s sale of aircraft brakes to the Air Force that they knew would overheat and fail.

Useem shows that often ethical lapses happen even though otherwise good and intelligent people are involved. He says that one thing organizations can do to reduce the chances of ethical failures is to have an explicit code of conduct that empowers people to act to prevent abuses. He uses the example of Johnson & Johnson’s “Credo”—their code of conduct—which guided their decision to immediately recall every bottle of Tylenol capsules at a cost of $100 million when they learned that someone had contaminated a few with a deadly poison. In Useem’s telling, the CEO was on an airplane when the news broke, and by the time he landed the recalls were already in motion.

Of course these are all examples from business. But there are plenty of examples from public health and the CDC has even developed a course on ethics in public health which is here.

I am thinking about how organizations can fight ethical lapses because Michigan is wrestling with a big one of its own right now: The failure of the responsible State government agencies to alert the residents of Flint that it was likely their water was contaminated with lead over the past spring and summer. Unlike many of the cases explored by Useem in which it took years for the facts to come out, you can read in detail about what really happened right now, because Flintwaterstudy.org has posted FOIAed documents on its website. I personally know many, perhaps most, of the people whose emails are there. I know them to be good and intelligent and consider many close friends. But in their emails you can see them struggling to understand what to do when data emerge that seem to show that lead levels are increasing. At the time, they believe there are contradictory sets of results. We now know with hindsight that wasn’t the case—all the data showed that lead levels were increasing. But at the time, they hadn’t figured that out yet. It took weeks, but you finally see more emails asking what it means if there is a chance the high lead results are correct? (It would mean we should sound the alarm.)

But none of this prompts me to throw rocks at the State, it makes me worry about where, in my own organization, we might be at risk of making similar mistakes.  And, it makes me wonder how we can strengthen our code of conduct (we call it our Guiding Principles—page four of this document) to make it clear employees are empowered to warn against ethical lapses.

There are some things happening that could turn into ethical lapses if we don’t watch it. For example, are we doing enough to raise the issue of ground water quality? After all, I am sitting on a mountain of data that says there is potentially disease causing human poop from failed or non-existent septic systems in our rivers and streams, where people canoe, fish and even swim. But there is only a little bit of activity going on to do anything about it. Of course our situation is different from Flint, because while we do have citizens on one side of the issue clamoring for a clean-up, we have just as many on the other side clamoring for nothing to be done because it could raise costs to real estate and agriculture. So we are on the horns of a political dilemma, and that means things will only change very slowly.

Another threat of a lapse could be coming from some of the innovative new clinical projects we have started that are costing us money, without as of yet having generated much new revenue. One example is the project in which we are supporting primary care services being offered to patients of Community Mental Health in one of the counties we serve. I love this project because really sick people are getting good physical health care for the first time. But I have had staff come to me and ask me to shut the project down because of its costs and the strain it places on our billing “department” (one person—go Bonnie!) while it hasn’t generated the expected income. I’ve asked them to keep going because I think we are learning things that will help us innovate in the future, and I think the money will come.  But maybe I’m just NASA not listening to Morton-Thiokol and there will be a financial explosion. Okay, it isn’t completely like that because our partner in this project is committed to it and is covering most of the cost overruns. Or am I just rationalizing a threat away?

And then there is another set of lapses that are created by omission rather than commission. For example, how can we do more to reach out to the growing migrant laborer population in our district? Why can’t the Collaboratives in our counties do more to address stagnating incomes and stubbornly high poverty rates? Why do I always seem to be too busy to spend more time just hanging out with staff and getting to know them better? (That’s the advice Coach Dantonio would give me I’m sure--see the 10th paragraph of this.)

Clearly I can’t foresee all the potential ethical lapses on my own.  Co-workers will know about others that I am unaware of. What I want to do is encourage everyone in the organization to take the threat of ethical lapses seriously.  When I wanted to get staff to stop collecting data on paper (which cost us a lot of staff time which means money) and always automate data collection projects I “branded” the concept with the phrase “Let the robots do the work” which seemed to create a helpful picture of where we wanted to go. I’d like to do something similar with the concept of avoiding ethical lapses.  I’m having trouble coming up with something. I don’t think any of these work:

If it could explode—that’s a bad thing.
It’s been _____ days since anyone was poisoned.
Not losing our jobs because of ethical lapses is job one!

Did you laugh?  I hope so. I think one thing that is wrong with these is that they are negatively phrased; they talk about what is to be avoided rather than what to do.  How ethical lapses happen is an important question, but the solution ought to be phrased positively as making ethical choices.

So help us out here. If you can think of some way to brand the concept of making ethical choices that works in a public health setting please send it along.

Saturday, December 12, 2015

Gripped by Fear

This post was inspired by a question my mother, Barbara Cheatham, of Issaquah, Washington asked me. 

According to the media we are all gripped by fear. The media is focusing on terrorism in particular right now, but we also have guns, mass shootings, police violence against minorities, violence against people thought to be Muslim, and lots of other things to be fearful of, apparently. I am not going to pick apart all the trends in this short article. I just want to quickly make the point that violence overall, including gun violence, is not increasing.

When Barack Obama was elected president gun sales shot up, apparently because people thought gun laws were about to be tightened up.  I thought it would be enlightening (in a dark kind of way) to see if gun violence increased as  a result. More guns = more shootings, right? I waited for a few years to pass and then made the following chart for my state of Michigan.


Gun violence had not increased even though there were more guns out there!  Many years each of the three counties I work in have no homicides at all, even though the air is filled with the sound of gunshots throughout the fall (Thank a hunter for saving you from a car-deer crash).

Curious about what this meant I then graphed the number of assaults. The chart below is for Montcalm County, one of the counties I work in, although you'll get similar results for most, if not all, communities in the country.


Assaults are actually going down! This is a nationwide trend. We just don't beat on each other like we used to.

Remember when looking at these data on homicide and assaults that people mostly shoot or otherwise kill or maim their own family members, friends and acquaintances. Of 532 homicides in Michigan last year, 52 victims were strangers to their killer (in 204 cases the relationship could not be discerned from the report). The rest of the victims were family members, friends or acquaintances. Strangers are not attacking us at an increasing rate in public places. This is not happening. The chart below is the overall homicide rate for Michigan going back to 1980. The homicide rate has been cut in half.  But not our fear.


I've done a little bit of reading on this, and I do not think there is a good explanation for this decline. Obvious candidates like the aging of society don't survive statistical tests. For whatever reason, overall, we are a more peaceful people than we have ever been. This is a wonderful thing and we need to avoid messing it up by over-reacting to the bad things that are happening.

It is true that the United States has a higher homicide rate, especially for gun homicides, than many other places. And it is true that while gun homicides are declining, gun suicides are increasing. And, yes, terrorism is real.  So there are many serious problems related to violence with which we must wrestle. But lets do so while understanding that overall we are safer than ever before.