Healthcare Information Systems and Informatics Research and Practices Advances in Healthcare Information Systems and Informatics 1st Edition Joseph Tan
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PART IV Design, Planning, Control, and Management of Healthcare Systems
June M. Worley and Toni L. Doolen
Peter F. Hooper IV.H
George G. Klee
IV.I
J. Eric Dietz, David R. Black, Julia E. Drifmeyer, and Jennifer A. Smock
Eva K. Lee, Anna Yang Yang, Ferdinand Pietz, and Bernard Benecke
IV.J
H. Stephen Leff, David R. Hughes, Clifton M. Chow, Steven Noyes, and Laysha Ostrow
Abrahamson, Karis Pressler, and Melissa Grabner-Hagen
IV.K
L. Charnette Norton 45 Healthcare-Product Su pply Ch ains: Me dical–Surgical Su pplies, Ph armaceuticals, an d Or thopedic De vices: Fl ows
Leroy B. Schwarz
IV.L
Ben-Tzion Karsh, Tosha B. Wetterneck, Richard J. Holden, A. Joy Rivera-Rodriguez, Hélène Faye, Matthew C. Scanlon, Pascale Carayon, and Samuel J. Alper
Foreword
The Handbook of Healthcare Delivery Systems is being published at a very opportune t ime. According to t he 2010 report of t he Economist I ntelligence Unit, healthcare delivery in t he Middle E ast a nd A frica accounts for 5.7% of t he g ross domestic product. In Eastern Europe a nd Russia it accounts for 5.9%, in L atin A merica for 7.6%, i n Western Europe for 10.2%, a nd i n North A merica for a whopping 15.5%. Currently, t here a re 523 million people over t he a ge of 65 worldwide. As t his number continues to i ncrease because of i mproved healthcare delivery, t he cost of healthcare i n terms of percentage of t he g ross domestic product w ill a lso f urther i ncrease. Th is, i n turn, w ill d rive up costs and raise t he old age dependency ratio, reducing the amount of cash available to fund healthcare systems everywhere.
This handbook presents t he latest a nd best methods a nd tools of systems engineering a imed at i mproving t he design, planning, control, a nd management of healthcare delivery. E xperience i n a variety of other industries suggests t hat when t hese k nown industrial engineering tools were applied to t he design, operation, a nd management of enterprise, costs were t ypically reduced by 25% or more. In addition to t he concern about t he rising cost of healthcare delivery, t here is a lso a major concern about t he quality of healthcare delivery a nd t he reduction of errors, which impact costs a nd t he well-being of t he patient. If i ndustrial engineering tools a nd methods such as total quality management, Six Sigma, a nd other process i mprovement a nd methods a re effectively applied, t hey w ill i mprove quality a nd reduce t he error rate by 40% or higher.
With t his i n m ind, t he utilization of t he information presented in t his handbook w ill have a major i mpact on reducing costs a nd i mproving t he quality of healthcare worldwide. Th is i nformation is presented i n 50 chapters authored by 106 contributors f rom 8 countries. The handbook consists of 41 useful tables a nd 132 figures t hat v isually i llustrate t he utilization of tools and methods; it a lso provides over 2000 references for t hose who would like to pursue a n i n-depth study of t he subject matter. The handbook should be of special value to administrators of healthcare delivery systems, i ncluding t hose working i n hospitals, clinics, i nsurance companies, a nd to t hose involved i n t he consultancy a nd research of healthcare delivery systems.
Gavriel Salvendy Series Editor
Preface
Today we a re facing many challenges i n healthcare, ranging f rom patient access, safety, care quality, a nd cost effectiveness. The rapidly r ising cost of healthcare has a d irect i mpact on t he economy as well as on our standard of l iving. The Committee on t he Quality of Health C are i n America released t wo reports, To Err Is Human (1999) a nd Crossing the Quality Chasm (2001), to address issues of patient safety a nd overall healthcare delivery systems. The si x main a reas of concern include safety, effectiveness, patient-centeredness, t imeliness, efficiency, a nd equity. To develop strategies to address t hese a reas requires a holistic approach by u nderstanding t he processes, patients, families, providers, payers, governments, a nd organizations i n t he healthcare delivery system, a nd t heir dependencies a nd i nteractions. Furthermore, due to specialization i n medicine a nd advances i n science and technology, t he healthcare delivery system intersects w ith t he d isciplines of medicine, engineering, management, science, technology, and sociology.
This handbook a ims to document t he healthcare delivery system f rom a system engineering perspective to provide t heoretical foundations, methodologies, a nd case studies i n each sector of t he system. In particular, it covers t he system engineering methodologies a nd t heir applications i n designing, evaluating, a nd optimizing t he operations of t he healthcare system to i mprove patient outcomes a nd cost effectiveness. The handbook consists of 50 chapters divided i nto four parts. The four broad parts a re as follows: Healthcare Delivery System O verview; Performance Assessment a nd Process I mprovement Management; System Engineering: Technologies a nd Methodologies; a nd Design, Planning, C ontrol, a nd Management of Healthcare Systems.
Part I presents a n overview of t he h istory a nd current challenges of t he healthcare system, a nd t he potential i mpact of system engineering on healthcare a nd healthcare-related networks a nd organizations, such as VA systems, outpatient clinics, nurse-managed clinics, long-term care, a nd t hird-party payers. The last chapter i n t his part (Chapter 8) describes a n i ntegrated f ramework for t he delivery system. Part II describes t he tools a nd methodologies used, such as lean concept, evidence-based practice, a nd r isk assessment, for performance a ssessment a nd process improvement i n healthcare systems. Part III reviews system engineering methodologies a nd technologies a nd t heir applications in healthcare. Each chapter i n t his part i ntroduces a system engineering method w ith a case study i n healthcare application. The methods discussed i nclude si mulation, optimization, queuing t heory, Markov decision processes, statistical a nalysis a nd modeling, machine learning, inventory model, facility planning, value stream mapping, scheduling, data mining, economic analysis, and causal risk analysis.
Part I V is devoted to t he design, planning, control, a nd management of healthcare systems. The chapters i n t his part a re d ivided i nto 12 service sectors: preventive care, telemedicine, t ransplant services, pharmacy operation, ED/ICU operation, OR management, decontamination service, laboratories, emergency response a nd pandemics planning, mental health, food a nd supplies, a nd t racking a nd i nformation systems. Th is part presents t he state-of-the-art operations a nd t he challenges i n each service u nit. It is clear t hat system engineering concepts have been broadly applied in healthcare systems. However, most of t he i mprovements have focused on a specific segment or u nit of t he delivery system.
For example, in a hospital, there are process improvement projects within individual units, such as ED, OR, L ab, a nd R adiology. However, each unit has a strong i nteraction w ith t he other u nits a nd a ny significant i mprovement is more likely to be sustained over t ime by integrating t he process a nd reevaluating t he system design f rom a holistic point of v iew. Redesigning t he delivery system w ith a n integrated approach w ill t ransform t he operations of t he healthcare system, i mproving patient safety, care quality, patient access, system efficiency, a nd overall cost effectiveness. By providing a n overview of i ndividual operational sectors i n t he extremely complex healthcare system a nd introducing a w ide a rray of engineering methods a nd tools, t his handbook establishes t he foundation to facilitate i ntegrated system t hinking to redesign the next-generation healthcare system.
I would l ike to express my si ncere g ratitude a nd appreciation to over 100 authors who took t he t ime a nd effort to share t heir scientific insights a nd invaluable experiences i n healthcare research a nd practices. I a m particularly touched by t he fact t hat a ll t he authors contributed to t his book w ith t heir jampacked schedules a nd some despite personal t ragedies. I would a lso like to t hank t he Advisory Board of t his handbook, Dr. W. Dale C ompton, Dr. Steven M. Witz, a nd Dr. James P. Bagian, who helped define a nd shape t he scope of t his book. My personal t hanks go to Sanmit Ambedkar, Vishal Chandrasekar, Tze Chao Chiam, Vi kram Chitnis, Imran Hasan, Sangbok L ee, Haocheng (Vincent) Liu, Daiki Min, Sally Perng, Varun R amamohan, Benjavan (Den) Upatising, a nd Sue Wongweragiat for t heir assistance, a nd Dr. Gavriel Salvendy for his continuous support a nd encouragement. L astly, I would l ike to t hank my husband, Daniel, for his patience and understanding that made this project possible.
Yuehwern Yih
Regenstrief Center for Healthcare Engineering Faculty Scholar School of Industrial Engineering Purdue University West Lafayette, Indiana
Editor
Dr. Yuehwern Yih is a professor i n t he School of I ndustrial Engineering a nd t he director of t he Smart Systems a nd Operations L aboratory at Purdue University, West L afayette, Indiana. She is t he faculty scholar of t he Regenstrief C enter for Healthcare Engineering. Dr. Yih received her BS f rom t he National Tsing Hua University i n Taiwan a nd her PhD i n industrial engineering f rom t he University of Wisconsin–Madison, Madison, Wisconsin. She specializes i n system a nd process designing, monitoring, a nd controlling to i mprove its quality a nd efficiency. Her research work has been focused on dynamic process control a nd decision making for operations i n complex systems (or systems in systems), such as healthcare delivery systems, manufacturing systems, supply chains, a nd advanced life support systems for missions to Mars.
Dr. Yih has published over 100 journal papers, conference proceedings, a nd book chapters on system a nd operation control, a nd her contributions i n t his a rea have been recognized t hrough national awards a nd fellowships. She is a n IIE Fellow a nd a member of t he Institute for Operations Research a nd Management Science, the Society of Automobile Engineers, and the Omega Rho Honor Society.
Kathleen Abrahamson Department of Public Health
Western Kentucky University
Bowling Green, Kentucky
Farrokh Alemi
Health Systems Administration
Georgetown University Washington, District of Columbia
Raza Ali
Royal Society/Wolfson MIC Laboratory Department of Computing Imperial College London London, United Kingdom
George Oscar Allen Department of Veterans Affairs Nebraska-Western Iowa Health Care System Omaha, Nebraska
Samuel J. Alper Exponent Chicago, Illinois
Priscilla A. Arling College of Business Butler University Indianapolis, Indiana
George H. Avery Department of Health and Kinesiology
Purdue University West Lafayette, Indiana
Contributors
Hari Balasubramanian Department of Mechanical and Industrial Engineering
University of Massachusetts at Amherst Amherst, Massachusetts
Mehmet A. Begen
Richard Ivey School of Business University of Western Ontario London, Ontario, Canada
Jeroen Beliën Center for Modeling and Simulation Hogeschool Universiteit Brussel Brussels, Belgium
Bernard Benecke Strategic National Stockpile Centers for Disease Control and Prevention Atlanta, Georgia
David R. Black College of Health and Human Services Purdue University West Lafayette, Indiana
John T. Blake Department of Industrial Engineering Dalhousie University Halifax, Nova Scotia, Canada
Edmund K. Burke School of Computer Science University of Nottingham Nottingham, United Kingdom
Wenhua Cao
Department of Industrial Engineering
University of Houston Houston, Texas
Pascale Carayon
Center for Quality and Productivity Improvement
Department of Industrial and Systems Engineering
University of Wisconsin–Madison Madison, Wisconsin
Brecht Cardoen
Operations and Technology Management Center Vlerick Leuven Gent Management School Gent, Belgium
Sean Carr
Edward P. Fitts Department of Industrial and Systems Engineering
North Carolina State University Raleigh, North Carolina
Clifton M. Chow
Human Services Research Institute Cambridge, Massachusetts
W. Dale Compton
School of Industrial Engineering
Purdue University West Lafayette, Indiana
Jennifer Cornacchione
College of Communication Arts and Sciences
Michigan State University East Lansing, Michigan
Mark E. Cowen
St. Joseph Mercy Health System Ypsilanti, Michigan
Timothy Curtois
School of Computer Science
University of Nottingham Nottingham, United Kingdom
Erik Demeulemeester
Department of Decision Sciences and Information Management Research Center for Operations Management Katholieke Universiteit Leuven Leuven, Belgium
Brian T. Denton
Edward P. Fitts Department of Industrial and Systems Engineering
North Carolina State University Raleigh, North Carolina
J. Eric Dietz
Purdue Homeland Security Institute and Computer and Information Technology
Purdue University West Lafayette, Indiana
Bradley N. Doebbeling
Veterans Affairs Health Services Research & Development Center on Implementing Evidence-Based Practice and Regenstrief Institute, Inc. and Indiana Transforming Healthcare Research Initiative
Indiana University School of Medicine Indianapolis, Indiana
Jeff Donnell NoMoreClipboard.com Indianapolis, Indiana
Toni L. Doolen
School of Mechanical, Industrial, and Manufacturing Engineering
Oregon State University Corvallis, Oregon
Julia E. Drifmeyer
Purdue Homeland Security Institute
Purdue University West Lafayette, Indiana
Stephanie R. Earnshaw
RTI Health Solutions
RTI International Research Triangle Park, North Carolina
Paul G. Farnham
Division of HIV/AIDS Prevention Centers for Disease Control and Prevention Atlanta, Georgia
Hélène Faye
Institut de Radioprotection et de Sûreté Nucléaire
Fontenay-aux-Roses, France
Rebekah L. Fox
Department of Communication Studies
Texas State University San Marcos, Texas
Randal G. Garner
Medical Practice & Management Partners, Inc. Grayson, Georgia
Melissa Grabner-Hagen
Department of Educational Psychology Indiana University Kokomo, Indiana
Linda V. Green
Decision, Risk and Operations Division
Columbia Business School Columbia University New York, New York
William H. Hass
Anesthesia Cooperative of the Panhandle Pensacola, Florida
Joshua A. Hilton
Department of Emergency Medicine University of Pennsylvania Philadelphia, Pennsylvania
Richard J. Holden
School of Medicine and Public Health University of Wisconsin–Madison Madison, Wisconsin
Peter F. Hooper
Central Sterilising Club Banbury, United Kingdom
David R. Hughes
Human Services Research Institute Cambridge, Massachusetts
Ann Schoofs Hundt
Center for Quality and Productivity Improvement University of Wisconsin–Madison Madison, Wisconsin
Cindy Jimmerson
Lean Healthcare West Missoula, Montana
Philip C. Jones
Department of Management Sciences
Tippie College of Business University of Iowa Iowa City, Iowa
Ben-Tzion Karsh
Department of Industrial and Systems Engineering University of Wisconsin–Madison Madison, Wisconsin
George G. Klee
Department of Laboratory Medicine and Pathology
Mayo Clinic Rochester, Minnesota
Cleo Kontoravdi
Department of Chemical Engineering
Imperial College London London, United Kingdom
Arielle Lasry
Division of HIV/AIDS Prevention Centers for Disease Control and Prevention Atlanta, Georgia
David M. Lawrence
Kaiser Foundation Health Plan and Hospitals Healdsburg, California
Eva K. Lee
School of Industrial and Systems Engineering Georgia Institute of Technology Atlanta, Georgia
H. Stephen Leff
Human Services Research Institute Cambridge, Massachusetts
Mark Lehto
School of Industrial Engineering
Purdue University West Lafayette, Indiana
Kara E. Leonard
Division of Management, Policy, a nd C ommunity Health School of Public Health
University of Texas Medical Branch Houston, Texas
Gino J. Lim
Department of Industrial Engineering University of Houston Houston, Texas
Qi Ming Lin EInk Corporation Cambridge, Massachusetts
Alex Macario Stanford University Medical Center Stanford University School of Medicine Stanford, California
Cheryl McDade
RTI Health Solutions
RTI International Research Triangle Park, North Carolina
Steve P. McKenzie Department of Health and Kinesiology and Department of Foods and Nutrition Purdue University West Lafayette, Indiana
Richard L. Miller
Earl Swensson Associates, Inc. (ESa) Nashville, Tennessee
Kenneth J. Musselman
Regenstrief Center for Healthcare Engineering Purdue University West Lafayette, Indiana
Samantha A. Nazione College of Communication Arts and Sciences Michigan State University East Lansing, Michigan
Joel D. Newman
UNOS Communications Richmond, Virginia
Tomas Eric Nordlander Department of Applied Mathematics SINTEF Information and Communication Technology Trondheim, Norway
L. Charnette Norton
DM & A Chula Vista, California and
The Norton Group, Inc. Missouri City, Texas
Julie Cowan Novak School of Nursing
University of Texas Health Science Center at San A ntonio San Antonio, Texas
Steven Noyes
Human Services Research Institute Cambridge, Massachusetts
Laysha Ostrow
Human Services Research Institute Cambridge, Massachusetts
Jonathan Patrick Telfer School of Management University of Ottawa Ottawa, Ontario, Canada
James A.C. Patterson
Royal Society/Wolfson MIC Laboratory Department of Computing Imperial College London London, United Kingdom
Niels Peek
Department of Medical Informatics
Academic Medical Center University of Amsterdam Amsterdam, the Netherlands
Ferdinand Pietz
Strategic National Stockpile Centers for Disease Control and Prevention Atlanta, Georgia
Jesse M. Pines
Department of Emergency Medicine and Health Policy
George Washington University Washington, District of Columbia
Karen M. Polizzi
Division of Molecular Biosciences
Department of Life Sciences and Department of Chemical Engineering Imperial College London London, United Kingdom
Karis Pressler
Department of Sociology Purdue University West Lafayette, Indiana
Timothy L. Pruett
Division of Transplantation University of Minnesota Minneapolis, Minnesota
Proctor P. Reid
National Academy of Engineering Washington, District of Columbia
Atle Riise
Department of Applied Mathematics
SINTEF Information and Communication Technology Trondheim, Norway
A. Joy Rivera-Rodriguez
Department of Industrial and Systems Engineering University of Wisconsin–Madison Madison, Wisconsin
Stephen D. Roberts
Edward P. Fitts Department of Industrial and Systems Engineering North Carolina State University Raleigh, North Carolina
Vinod K. Sahney
Blue Cross Blue Shield of Massachusetts Boston, Massachusetts
Matthew C. Scanlon
Department of Pediatrics Medical College of Wisconsin Milwaukee, Wisconsin
Leroy B. Schwarz
Krannert Graduate School of Management Purdue University West Lafayette, Indiana
Jennifer A. Smock
National Association of County and City Health Officials (NACCHO) Washington, District of Columbia
Karen Spens
Department of Marketing Hanken School of Economics Helsinki, Finland
Airica Steed
Advocate Health Care Libertyville, Illinois
Thomas N. Taylor
Department of Pharmacy Practice Wayne State University Detroit, Michigan
Barrett W. Thomas
Department of Management Sciences
Tippie College of Business University of Iowa Iowa City, Iowa
Ann Tousignant
Blue Cross Blue Shield of Massachusetts Boston, Massachusetts
Jose Antonio Valdez
Quality Resources Department University of Wisconsin Hospital and Clinics Madison, Wisconsin
Rupa Sheth Valdez
Department of Industrial and Systems Engineering University of Wisconsin–Madison Madison, Wisconsin
Jan de Vries
Faculty of Economics and Business University of Groningen Groningen, the Netherlands
Tosha B. Wetterneck
School of Medicine and Public Health
University of Wisconsin–Madison Madison, Wisconsin
Pamela Whitten
College of Communication Arts and Sciences
Michigan State University East Lansing, Michigan
Deanna R. Willis
Department of Family Medicine Indiana University School of Medicine Indianapolis, Indiana
Steven M. Witz
Regenstrief Center for Healthcare Engineering Purdue University West Lafayette, Indiana
Janusz Wojtusiak
Department of Health Administration and Policy George Mason University Fairfax, Virginia
Peter Arthur Woodbridge College of Public Health
University of Nebraska Medical Center and Department of Veterans Affairs
Mid-West Mountain Veterans Engineering Resource Center and Department of Veterans Affairs Nebraska-Western Iowa Health Care System Omaha, Nebraska
June M. Worley
School of Mechanical, Industrial, and Manufacturing Engineering Oregon State University Corvallis, Oregon
Sze-jung Sandra Wu Risk Department JP Morgan Chase Wilmington, Delaware
Anna Yang Yang
School of Industrial and Systems Engineering
Georgia Institute of Technology Atlanta, Georgia
Guang-Zhong Yang
Royal Society/Wolfson MIC Laboratory Department of Computing Imperial College London London, United Kingdom
Elizabeth M. Yano
Veterans Affairs Greater Los Angeles Health Services Research & Development Center of E xcellence Sepulveda, California and
School of Public Health
University of California, Los Angeles Los Angeles, California
Yuehwern Yih
Regenstrief Center for Healthcare Engineering School of Industrial Engineering
Purdue University West Lafayette, Indiana
Manaf Zargoush ESSEC Business School Paris, France
Min Zhang Department of Statistics
Purdue University West Lafayette, Indiana
I Healthcare Delivery System Overview
Healthcare: How Did We Get Here and Where
How Did We Get Here? • Physician Culture • Growth of Medical Science • Changing Demographics a nd Demand What Does This Mean for the Future?........................................................
Balanced Healthcare • Fou r Battlefronts • Sick C are Delivery System • Consumer-Health E cosystem • New Personalized Medicine
David M. Lawrence Kaiser Foundation Health Plan
a nd
Between the health care we have and the care we could have lies not just a gap, but a chasm.
Institute of Medicine (2001)
Introduction
Healthcare delivery is in transition. A new ad ministration pledges to overhaul the “broken” system as pa rt of a comprehensive economic st imulus package; the recent report of the Medicare Tr ust Fu nd indicates that Medicare wi ll be insolvent in less than a decade; a nat ional comparative effectiveness program wi ll determine wh ich treatments are most useful; and the innovations in ca re delivery continue to come. To understand where these changes could lead requires an understanding of the st arting point.
This chapter provides a short overview of the growth of the healthcare system du ring the twentieth century and the significant forces that wi ll shape it going forward. Based on these observations, I suggest four areas where important bat tles are most li kely in the future: inside the sick ca re system; between the sick ca re system and the emerging consumer-health ecosystem; over-personalized or predictive medicine; and in the so -called accountable healthcare organizations. In each instance the bat tles wi ll revolve around cr itical questions: What is included in ca re? Who is in charge? And what do doctors do? The outcomes of these bat tles wi ll determine, in la rge measure, the future of he ath ca re in the Un ited St ates.
How Did We Get Here?
Prior to World Wa r II, me dical ca re in the Un ited St ates wa s provided by generalist physicians who wielded li mited di agnostic and therapeutic te chnologies in their solo pr actices and community
hospitals s taffed by nonacademically prepared nurses. I n just over half a c entury s ince, c are h as b ecome a maze of nearly u nfathomable complexity: well over 6 00,000 physicians practice i n one or more of nearly 130 s pecialties (U.S. Department of L abor, 2 009), supported by more t han 2 00 d istinct categories of support p ersonnel, i n a w ide v ariety of c linical s ettings where u ncertain accountabilities a nd c ompeting professional a nd e conomic i mperatives a bound. The c are t hat results i s superb for s ome, but its costs a re u nsustainable, its quality a nd s afety u npredictable, a nd t he v alue it delivers ( health/dollar i nvested) markedly lower t han t hat found i n other d eveloped countries (Arnold a nd C arrie, 2 009).*,† Accessing a nd navigating t hrough t his maze is a challenge, e specially for t hose w ith l imited fi nancial means, for m inorities, a nd t hose for w hom E nglish is a s econd language.‡ A s a consequence, t he b enefits of outstanding i ndividual physicians a nd world-leading c linical s cience a nd technology a re often lost i n i mpersonal, c onfusing, a nd f ragmented c are, while t he t hreat of p ersonal bankruptcy g rows a s medical expenses e xceed t he a bility of patients a nd t heir f amilies to pay.§
In its 2001 study, “Crossing t he Quality Chasm: A New System for t he 21st C entury,” t he Institute of Medicine decried t he absence of “real progress towards solving t hese problems” because care delivery continues to rely on “…outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard t hey t ry. If we want safer, higher-quality care, we w ill need to have redesigned systems of care” (Institute of Medicine, 2001).
Little has changed si nce t he report was w ritten nearly a decade ago. W hy? W hy are systems of work outmoded? W hy is care, so r ich in t alent a nd resources, a n expensive “nightmare to navigate” for many patients.¶ W hy has it proven so d ifficult to build i ntegrated care organizations a fter more t han half a century of recommendations to do just t hat?** W hy is t here a chasm between “…the care we have a nd t he care we could have”?
The p erformance of t he c are s ystem, I suggest, i s a predictable outcome of a r apidly g rowing s cientific enterprise a nd f undamental shifts i n consumer demands t hat a re i ncompatible w ith t he organizing a ssumptions a nd practices of a dominant physician c ulture. A deeply challenged U.S. economy adds f urther u rgency to t he need to fi nd b etter w ays t o organize a nd deliver c are i n t he f uture. The fee for s ervice payment s ystem reinforces t he problems, a nd l ittle i mprovement i n c are c an be expected u ntil t his changes. But t he payment s ystem i s not a primary c ause. It is, a fter a ll, t he result of decades of e ffort by doctors a nd hospitals to b e paid for w hat t hey h ave b een prepared to do.†† Nor i s t he m anaged c are movement of t he late 1980s a nd e arly 1990s t he c ulprit, t hough t he a ftereffects of
* The study reports a 23% “value gap” between t he United States a nd t he G-5 (Canada, Japan, Germany, United K ingdom, a nd France), and a 46% value gap with emerging competitors Brazil, India, and China (Arnold and Carrie, 2009).
† Elizabeth McGlynn a nd colleagues at t he R AND Corporation have pioneered studies t hat explore t he consistency w ith which patients receive scientifically “appropriate” medical care. See, for example, McGlynn et al. (2003).
‡ The issue of access, a nd i n particular access for minorities a nd t hose for whom English is a second language, has been of concern to policy makers for at least two decades. The IOM has published several reports on the subject.
§ This is a controversial issue. The organization “Fact C heck” concludes t hat t here is a relationship, but t hat t he e xtent to which medical expenses “cause” bankruptcy remains unclear. http://www.factcheck.org/askfactcheck/what_is_the_ percentage_of_total_personal.html (last accessed on March 20, 2010).
¶ The “nightmare to navigate” description is found i n t he joint publication of t he Picker Institute w ith t he A merican Hospital Association (1996). The Picker Institute assesses t he interactions of patients, families w ith t he care system “through the eyes of the patient.” (http://www.pickerinstitute.org/)
** The modern Mayo Clinic t races its origins to t he m id-1880s. In t he report of t he independent “Committee on C ost C ontainment” 1927–1932, a key recommendation was to form multi-specialty g roups to offset f ragmentation a nd cost pressures. The H MO act i n 1973 was designed to foster organized s ystems of c are. And t he IOM series on quality of care i n t he United States, published over t he period 1999–2002, a rgued for t he formation of organized, integrated systems of care.
†† Health i nsurance, which b egan i n t he 1920s, g rew r apidly in t he 1930s as doctors a nd hospitals sought ways to ensure steady i ncomes du ring t he Depression. The boards of t he Blues plans were dominated by physicians a nd hospital administrators u ntil t he r ise of t he for-profit health i nsurers, including t he conversion of a number of Blues plans f rom not-for-profit to for-profit companies.
that e xperiment remain (Ludmerer, 1999). The movement opened t he black box of clinical decisionmaking a nd c are organization t hat u ntil t hen h ad b een l argely u nder t he control of physicians, i n e ffect weakening t heir s overeignty over t he medical c are enterprise a nd i ntroducing s carcity a nd t he need for choices i nto t he public debate. These a re i mportant s hifts. But t he failure of t he movement to control costs a nd i mprove c are over t he longer term s ays a s much about t he power t hat physicians a re still able to w ield when t heir s overeignty is t hreatened a s it does about t he m any flaws i n t he movement itself.
Physician Culture
Autonomy
Not u ntil t he 1930s, a fter decades of struggle to emerge f rom a hodgepodge of charlatans, quacks, a nd self-trained healers, did physicians assume leadership of A merican medicine a nd establish t he u nique physician culture as t he bedrock for today’s c are system.* C entral to t hat c ulture is t he concept of professional autonomy. The doctor is h is own judge, responsible to himself a nd his profession to make decisions i n t he i nterest of his patients based on t he best combination of science, experience, a nd judgment t hat he can bring together.† A t rained skeptic of t he work of others, gathering h is own i nformation by c arrying out a n i ndependent a ssessment of each patient, he prefers to work a lone surrounded by his support staff, interacting w ith h is patients on his terms. Only when he reaches t he l imits of his largely self-defined competence (or h is tolerance for legal r isk), does he refer t he patient to a nother doctor, who repeats t he same process. He is responsible for staying c urrent w ith t he latest t reatments a nd procedures t hroughout h is professional c areer, a nd is accountable to h imself a nd his physician peers for h is decisions and judgments.‡
This is not surprising. A profession is “ …a calling requiring specialized k nowledge a nd often long a nd i ntensive academic preparation” (Webster, 2009). For t he physician, t he educational process is particularly extended; t he k nowledge to master a nd t he judgments a nd skills to develop require i ntensive study a nd supervised practice. W hat most d istinguishes t he physician culture from other professionals, t hough, is t he extent to which autonomy is its defining feature. The reinforcement for autonomy fi nds its way into every nook a nd cranny of t he physician’s early development, encouraged by senior physicians a nd medical school curricula t hat provide few opportunities to learn t he skills of shared decision-making or to work in teams of physicians or other health professionals (Lawrence, 2002).§ The doctor is socialized, t hen, over long years of medical school a nd residency t raining to f unction h ighly i ndependently within the tightly protected world of his profession.
Doctors practice t his way when t heir formal training ends. A lthough t here has been a slow but g rowing t rend a mong younger physicians to practice i n small g roups, t he majority of physicians still practice i n single-specialty g roups of 10 physicians or less, a nd a t hird of a ll physicians work a lone (Liebhaber a nd Grossman, 2007). Beyond practice choice, autonomy expresses itself i n t he profession’s battles
* Starr a rgues t hat t he physicians became sovereign i n medical c are, e stablishing t heir leadership of t he hierarchy w ithin t he care system, t he laws a nd regulations surrounding t he practice of medicine, t he control of t he hospitals where t hey practice, a nd t he development of reimbursement a nd federal a nd state support models. The sovereign physician model is t he prototype for medical delivery s ystems t hroughout t he world. Only where t here i s i nsufficient physician manpower a re nonphysician a lternatives encouraged f rom a policy point of v iew. Of course, many cultures have extensive networks of nonphysician local healers, but even t hese exist side by side w ith t he physician-centric solutions of “modern” medicine (Starr, 1982).
† For ease of reading, I refer to physicians in t he masculine form, recognizing t hat w ithin t he past 20 years, t he proportion of women entering the profession is roughly equal to men.
‡ Of course, he is accountable to t he legal system, a lthough t ypically most court cases i nclude dueling physician expert w itnesses.
§ In its fi rst roundtable, t he Lucian Leape Institute of t he National Patient Safety Foundation focused on t he preparation of physicians, and the lack of emphasis on collaborative learning and care.
with administrators a nd managed care companies over t he control of t he clinical workplace, a nd i n t he 50-year fight to l imit t he roles t hat nurse practitioners, physician’s a ssistants, a nd, more recently, pharmacists, play i n providing care to patients. It contributes to t he w ide variation i n physician practice patterns observed f rom one community to t he next,* a nd is one i mportant reason why doctors have resisted t he t ransparency t hat shared information technology i ntroduces into t he care-delivery process. It produces a f ragmented “ job shop” organization of care i n which each independent doctor-cum-smallbusinessman customizes his practice to his preference a nd his i nterpretation of what his patients need a nd expect.
As one m ight a nticipate, autonomy i s t he m ajor s tumbling block to t he formation of e ffective c are organizations.† Group decision-making, t ransparency, a nd a ccountability t hat organizations require to b e e ffective a re i n c onflict w ith t he e xpectation for c linical autonomy t hat g uides physicians. Th is c an lead to profound d iscomfort a nd s uspicion. D octors h ave l imited e xposure to t he tools required to address t he c omplex problems t hat organizations must r esolve, w here t he w isdom of t he c ollective a nd t he d eliberative process itself i s c ritical to successful problem resolution a nd d ecision i mplementation. Even t he process of c linical decision-making i s d ifferent f rom organizational d ecision-making;‡ a s a result physicians a re i ll-prepared to d eal w ith t he a mbiguities, t rade-offs, a nd workforce e ngagement c hallenges t hat d rive organizational s trategy a nd operational e ffectiveness.
Physician Exceptionalism
As central a s autonomy i s to t he physician c ulture, it i s not t he only element t hat shapes t he c are system. The physician is t rained to employ h is long t raining, deep k nowledge, well-honed judgment, a nd advanced skills—his professional i nsights—to d istinguish t he common problem f rom t he serious i llness i n d isguise, t hen c ustomize t he c are he provides to meet t he u nique needs of each patient. He seeks t he u ncommon b ehind t he apparently simple clinical presentation (Groopman, 2 007). A nd he is t rained to believe t hat only a doctor is c apable of t hese i nsights. The sine qua non of care excellence i s t he doctor–patient relationship, to be protected at a ll costs f rom a nything t hat t hreatens it; a nd above a ll, t he doctor must be i n t he lead i n t he c are process. As a result, physicians have been slow to accept practices a nd clinical approaches t hat d iffer f rom t heir own experiences; have resisted efforts to codify clinical decision-making u sing “ best practices” or e vidence-based medicine; a nd have fought t he i ntroduction of nonphysician clinicians i nto d aily practice u nless t hey a re u nder t heir d irect supervision a nd control.
Intuition versus Prediction
The resistance to organizations, especially t hose not controlled by physicians; t he d ismissing of clinical pathways a nd g uidelines a s “cookbook medicine”; t he u nwillingness to accept t ransparency a nd accountability; a nd t he belief i n physician exceptionalism—these a re t he d irect outgrowth of t he physician c ulture t hat has shaped t he care system into what we see today. In t heir recent b ook, The Innovator’s Prescription, Christensen, Grossman, a nd Hwang provide a u seful f ramework to help u nderstand how t his culture a ffects t he organization of c are (Christensen e t a l., 2009). The authors describe c are a s a continuum of problem-solving challenges f rom i ntuition to predictive precision, w ith empiricism
* Wennberg, E lliot, a nd t heir colleagues at Dartmouth have documented t hese “small area variations” i n medical practice since the early 1970s.
† In t he i nterest of simplicity, I u se t he term “effective” to cover t he six goals for care systems of t he f uture a rticulated i n t he Crossing the Quality Chasm report: effectiveness, safety, timeliness, responsiveness, affordability, and equity.
‡ In clinical practice one utilizes t wo frameworks. Fi rst is a pattern-recognition skill i n which a problem is “slotted” into a d iagnosis a nd t reatment based on its similarity to previously encountered “patterns” of i llness presentation a nd t reatment. Second is a heuristic i n which t he physician makes judgments based on t he likelihood t hat a g iven collection of objective and subjective information is disease x, y, or z.
somewhere i n t he middle, t he result of t he developments i n t he science of medicine. The expectations of t he physician, however, a re t hat most medicine is i ntuitive. The arduous t raining to develop t he physician’s clinical acumen g uides t his v iew, colors his assessment of efforts to introduce empiricism into care (“best practices; evidence-based medicine”), a nd l ies at t he heart of his resistance to t he precision of predictive care. As a consequence, t he doctor’s professional identity a nd t he s ystems of work t hat result conflict w ith t he c are t hat medical science now makes possible, as well as t he care t hat health consumers i ncreasingly demand and need.
Growth of Medical Science
Biological Science
In parallel w ith t he development of t he modern care system, i n fact f ueling many of t he advances t hat have been i ntroduced over t he past half century, is t he creation of a powerful medical scientific enterprise. The National Institutes of Health (NIH) is t he primary engine of d iscovery for t he biological sciences i n t he nation. Created by Congress in 1946 to expand t he scientific, primarily biological base of medicine, its budget g rew f rom $8 m illion i n 1947 to more t han $1 billion in 1966, $13.7 billion by 1997, a nd $29 billion i n 2008. It now supports over 200,000 scientists i n 3100 research centers a round t he country, i n addition to its intramural scientists a nd programs located at t he N IH home, a nd i ncludes 27 centers and institutes covering a broad range of clinical conditions.*
Other sources have played significant roles i n biomedical research a nd development. Pharmaceutical company i nvestments i n research a nd development (“R&D”) overtook federal support for t he N IH in 1980 a nd have continued at a higher level si nce t hen. I n 1970 t he industry i nvested approximately $8B in R&D; by 2008 t hat number had g rown to $50.3B. In addition, t he publicly listed biotech d rug i ndustry i nvested $14.6B i n 2008, bringing t he total private sector i nvestment i n basic science a nd bio-pharma to $65B ($64.9B) (Burrill & C ompany, 2009).† Added to t his a re t he estimated 6000 medical device companies t hat build on advances in engineering, microcircuitry, i maging, computing, a nd w ireless communications to produce a w ide assortment of d iagnostic a nd t herapeutic devices. According to t he g roup “Research!America,” i nvestments in medical science a nd technology f rom a ll t hese sources reached $111B by 2005.‡
Today, advanced bio-computational capabilities join w ith deepening understanding of how individual human molecules operate to enable investigators to explore complex biological pathways a nd clinical correlations for relationships t hat escape notice w ith less sophisticated tools. As t he c apacity to identify a nd read information related to genes a nd proteins g rows, so too does t he ability to a nalyze millions of bits of i nformation using complex computer a lgorithms to identify patterns (so-called signatures) correlated to t he presence of disease or pre-disease. A lready t his has led to advances in cancer a nd heart disease diagnosis and treatment.§
* See History of the National Institutes of Health; Wikipedia.
† Available f rom Burrill a nd Company, S an Francisco, C alifornia. The numbers a re inconsistent because some reports a re on ly for publicly l isted companies; others i nclude venture f unding for early-stage companies. A figure of a round $65B in 2008 is as accurate an estimate as can be found.
‡ Some controversy exists over t his total related to t he estimates of pr ivate sector i nvestments i n R&D. Research!America errs on t he h igh side of t he e stimates. R alph Snyderman, MD, Chancellor Emeritus of Duke University Health Sciences C enter, once estimated t hat between 1950 a nd 2000, t he United States i nvested $1 t rillion in public a nd pr ivately fi nanced medical R&D. Based on current e stimates, t he same a mount w ill be i nvested between 2000 a nd 2010. (personal communications) (Research!America, 2005).
§ Perhaps t he best example of t his c an be fou nd i n a g raph developed by David A ltshuler for t he IOM meeting of October 8, 2007. A ltshuler i llustrates t he rapid growth in t he identification of gene variants associated w ith common d iseases. The g raph is found in Learning Healthcare System Concepts v. 2008 (Institute of Medicine, 2009). A recent series of articles i n t he New England Journal of Medicine sound a cautionary note about how quickly t hese advances a re occurring (see e.g., Kraft and Hunter, 2009).
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being obliged to join this host of merciless and sanguinary slavehunters, who, regardless of the beauty of the country and the cheerful happiness of the natives, were only intent upon enriching themselves with the spoil of the inhabitants. After a march of a little less than five miles, we emerged from the thick forest, and entered upon stubble-fields with numerous groups of huts and widespreading trees, whose branches were all used for storing up the ranks of nutritious grass of these swampy grounds, for a supply in the dry season. The country was pleasant in the extreme. Several artificial ponds enlivened the hamlet, and called to mind similar scenes in my native country, except that ducks and geese were wanting. The only scenes of active life which were at present to be seen were those of pillage and destruction.
The architecture of the huts, and the whole arrangement of the yards, was very similar to that of the village we had first seen on entering the country. But the tops of the granaries in general were here provided with a sort of “fennel,” covered in by a roof of straw. Broad well-trodden paths, lined by thick fences of a peculiar bush called “mágara” in Kanúri, which I have mentioned in another locality, were winding along through the fields in every direction. But there was one object which attracted my attention in particular, as it testified to a certain degree of civilization, which might have shamed the proud Mohammedan inhabitants of these countries. For while the latter are extremely negligent in burying their dead, leaving them without any sufficient protection against the wild beasts, so that most of them are devoured in a few days by the hyænas, here we had regular sepulchres, covered in with large well-rounded vaults, the tops of which were adorned by a couple of beams crosslaid, or by an earthen urn. The same sort of worship as paid by these pagans to their ancestors prevails in a great part of Africa, and however greatly the peculiar customs attached to the mode of worship may vary, the principle is the same; but I nowhere more regretted having no one at hand to explain to me the customs of these people, than I did on this occasion. The urn most probably
contains the head of the deceased; but what is indicated by the cross-laid beams I cannot say.
I was so absorbed in contemplating this interesting scene, that I entirely forgot my own personal safety; for the vizier, without my becoming aware of it, had pursued the track on his powerful charger at an uncommonly quick rate, and was far in advance. Looking around me, I found only a small number of Shúwa horsemen near me, and keeping close to them pursued the path; but when we emerged from the thick forest, and entered another well-cultivated and thickly-peopled district, every trace of a trodden footpath ceased, and I became aware that I was entirely cut off from the main body of the army. A scene of wild disorder here presented itself. Single horsemen were roving about to and fro between the fences of the villages; here a poor native, pursued by sanguinary foes, running for his life in wild despair; there another dragged from his place of refuge; while a third was observed in the thick covert of a ficus, and soon became a mark for numerous arrows and balls. A small troop of Shúwa horsemen were collected under the shade of a tree, trying to keep together a drove of cattle, which they had taken. In vain did I address Shúwa and Kanúri, anxiously inquiring what direction the commander-in-chief had taken; nobody was able to give me any information with regard to his whereabouts. I therefore scoured the village in all directions, to see if I could find by myself the track of the army; but the traces ran in every direction.
Here I fell in with several troops of horsemen, in the same state of uncertainty as myself, and joined one of them, where there were some heavy cavalry; neither the attendants of the vizier, nor the man who carried his carpet, could tell which direction he had taken. While anxiously looking about, I suddenly heard behind us the beating of a drum or “gánga,” and following the sound found a considerable number of horsemen, of every description, collected on an open area; and here I received the exciting news that the pagans had broken through the line of march at the weakest point, and that while the vizier had pursued his track, the rear had been dispersed. If these poor pagans, who certainly are not wanting in courage,
were led on by experienced chieftains, and waited for the proper opportunity, they would be able, in these dense forests, where cavalry is scarcely of any use, to do an immense deal of damage to this cowardly host, and might easily disperse them altogether. But the principal reason of the weakness of these Músgu tribes is, that they have only spears and the “góliyó,” and no arrows; else they would certainly be able to keep these troublesome neighbours at a respectful distance. Of what little use even the firelock is to the latter, I had ample opportunity of judging, several musketeers having come to me anxiously entreating me to provide them with flints, as their own had been lost or had proved useless.
At length the motley host moved on without order or array; but their irresolution and fear, owing to a few pagans who were concealed in a thicket, were so great, that after a while we retraced our steps. Having then taken a more easterly direction, we reached, through a thick forest, a large swampy piece of water in low meadow-grounds, not less than a mile in breadth, covered with rank grass, the dry ground in some places intervening. Here I found a considerable part of the cavalry, drawn up in a line and watering their horses, and I learned that the encampment was near. It would have been very unsatisfactory to be exposed to a serious attack in the company of the disorderly host in which I had lately found myself.
ENCAMPMENT IN THE FOREST.
Having watered my horse, I followed the deep sound of the big drum of the vizier, and found the body of the army a few hundred yards from the eastern border of this ngáljam, in rich stubble-fields shaded by beautiful trees; but as yet no tent was pitched, and a great deal of anxiety prevailed, the first camels having arrived without their loads, which they had thrown off, their drivers having taken to flight; but this circumstance ensured the safety of the greater part of the train, as the commander immediately despatched two officers with their squadrons to bring up the rear. To this circumstance we were indebted for the safety of our own camels, which had been in imminent danger, the pagans having collected again in the rear of the principal body of the army. The Bórnu camels are half mehára, and, while they surpass in strength the camels of the desert, possess a great deal of their swiftness. Not only does the camel which carries the war-drum always follow close behind the commander, at whatever rate he may pursue his march,
but even his other camels generally keep at a very short distance, and the best camels of the courtiers follow close behind.
The village we had just reached was named Kákalá, and is one of the most considerable places in the Músgu country. A large number of slaves had been caught this day; and in the course of the evening, after some skirmishing, in which three Bórnu horsemen were killed, a great many more were brought in: altogether they were said to have taken one thousand, and there were certainly not less than five hundred. To our utmost horror, not less than one hundred and seventy full-grown men were mercilessly slaughtered in cold blood, the greater part of them being allowed to bleed to death, a leg having been severed from the body. Most of them were tall men, with not very pleasing features. Their forehead, instead of shelving backwards, was generally very high, and the line of the face straight; but their thick eyelashes, wide, open nostrils, thick lips, high cheek-bones, and coarse bushy hair, gave them a very wild appearance. The proportions of the legs, with the knee-bone bent inward, were particularly ugly; and on the whole they were more bony than the Marghí. They were all of a dirty black colour, very far from that glossy lustre which is observed in other tribes. Most of them wore a short beard. The ears of several were adorned with small copper rings, while almost all of them wore round their necks a thick rope made of the dúm-bush or ngílle, coarsely twisted, as a sort of ornament.
Monday, Dec. 29. Soon after setting out from the place of encampment, we had to cross the ngáljam, which here also was thickly overgrown with rank grass, and the passage of which was very difficult, owing to the countless holes caused by the footprints of the elephant. We then entered a dense forest, where I saw again, for the first time, my old Háusa acquaintance, the kókia, a middlesized tree with large leaves and with a fruit of the size of an apple, which at present was green, but even when ripe is not edible. This tree, in the course of the expedition, I found to be very common in the wilds of this country.
The unwarlike spirit of our large army became more apparent than ever by to-day’s proceedings: for a vigorous commander would certainly have accelerated his march through this forest, in order to take the enemy unawares; but long before noon a halt was ordered in the midst of the forest—certainly against the inclination of the majority. There was a great deal of indecision; and in truth there seemed to be many who wished rather that the enemy should have time to escape, than to incite him to make a desperate struggle for his safety. The neighbouring pond (where, on our arrival, a herdsman who had come to water his cattle had been slain), we were told, did not contain a sufficient supply of water for the wants of the whole army; and when at length we had fairly dismounted, the rank grass being burnt down in order to clear the ground, and the fire being fed by a strong wind, a terrible conflagration ensued, which threw us into the greatest confusion, and obliged us to seek our safety in a hasty retreat. Nevertheless, after a great deal of hesitation, it was at length determined to encamp here. There was no scarcity of water—for the pond proved to be very spacious and of great depth; but the grass having been burned, the whole ground was covered with a layer of hot ashes, which blackened everything.
By-and-by the camels arrived, the encampment was formed, and every one had given himself up to repose of mind and body, when suddenly the alarm-drums were beaten, and everybody hastened to arms, and mounted his horse. It seemed incredible that an enemy whose movements were uncombined, and not directed by any good leaders, should attack such an army, of more than ten thousand cavalry, and a still greater number of foot, although I am persuaded that a resolute attack of a few hundred brave men would have defeated the whole of this vain and cowardly host. The alarm, as was to be expected, proved unfounded; but it showed the small degree of confidence which the people had in their own strength. Three pagan women had been seen endeavouring to reach the water by stealth; and this gave rise to the conclusion that the enemy was near, for the dense forest all around hemmed in the view entirely.
When at length the encampment had resumed its former state of tranquillity, the prince Ádishén, with a numerous suite of naked followers, came to my tent, and I requested him to enter; there was, however, nothing attractive or interesting about him, and I was glad to get rid of him with a few presents. The difference between the Marghí and Músgu, notwithstanding the affinity indicated by their language and some of their manners, is indeed great, and is, as I have already intimated above, rather to the disadvantage of the latter, whose forms exhibit less of symmetry, and whose features have a very wild and savage appearance. Neither in these Músgu courtiers, nor in the common people, had I observed any of those becoming ornaments, especially those iron arm-rings, which I have mentioned in describing the Marghí.
Ádishén had shaved his head, in order to give to himself the appearance of a Moslim, and wore a tobe; but of his companions, only one had adopted this foreign garment, all the others having their loins girt with a leather apron. In order to keep themselves on horseback, they have recourse to a most barbarous expedient. They make a broad open wound on the back of their small sturdy ponies, in order to keep their seat; and, when they want to ride at full speed, they often scratch or cut their legs, in order to glue themselves to the horse’s flanks by means of the blood which oozes from the wounds; for, as I have stated above, they have neither saddle, stirrups, nor bridle, and they use nothing but a simple rope to guide their animals. They generally carry only one spear, but several “góliyós” or handbills, the latter being evidently their best weapon, not only in close fight, but even at a distance, as they are very expert in throwing this sharp and double-pointed iron sideways, and frequently inflict severe wounds on the legs of horses as well as of men. Some of their chiefs protect their persons with a strong doublet made of buffalo’s hide, with the hair inside.
Tuesday, Dec. 30.—This was the last day’s march which our expedition was to make towards the south, or rather south-east. For the first ten or eleven miles we kept through dense forest, the thick covert of which rendered it difficult for us to make our way, while the
restless and vicious Bórnu horses, crowded together and hemmed in by the thicket, repeatedly came into most unpleasant collision; and here again I was much indebted to my massive stirrups, which bravely kept their ground against bush and man. The whole forest consisted of middle-sized trees, the kókia being predominant, while scarcely a single tree of larger size was to be seen. It seemed very natural that all the wild animals should flee before such a host of people; but I was astonished at the scarcity of ant-hills, notwithstanding the great degree of moisture which prevails in these extensive levels, and which is so favourable to the existence of this insect. Our march the whole morning had been straight for Dáwa, the village of the Túfuri or Túburi, a section of the great tribe of the Farí or Falí, of which I have spoken in a former part of my narrative.
There had been a great deal of discussion in the last day’s council as to the expediency of attacking this place, the subjection, or rather destruction of which was of great importance, not only to Mʿallem Jýmma, but even to the Fúlbe settled in the eastern districts of Ádamáwa in general. This party at last had gained the upper hand over the greater part of the cowardly Kanúri courtiers; but at present, when we approached the seat of this tribe, who are well known to be warlike, and when the question arose whether we should engage in battle with these people in three or four hours’ time, it became rather a serious affair. When, therefore, after a march of four hours, we reached a beautiful fresh meadow-water or “ngáljam” overgrown with rank grass, surrounded by large spreading ngábbore trees, which pleasantly diversified the monotonous forest, we made a halt, and while the horsemen watered their animals, an animated “nógona,” or council, was held in the shade of a beautiful fig-tree. Here it was decided that, at least to-day, we should not march against Dáwa and the Túburi, but were to change our course more to the eastward in the direction of Démmo. It is probable that the vizier on this occasion promised to his friends, that after he had taken up his headquarters at Démmo, and deposited safely, in the fortified encampment, the spoil that he had already made in slaves and cattle, he would march against Dáwa; but unfortunately, or
rather luckily for the inhabitants, it was not our destiny to visit that interesting and important place, as I shall soon have occasion to mention.
During our halt here I contemplated, with the most lively and intense interest, the rich and animated scene which presented itself before my eyes,—a mass of some thousand horsemen, dressed in the most varied manner and in the most glowing colours, with their spirited chargers of every size, description, and colour, crowded together along the green margin of a narrow sheet of water, skirted by a dense border of large trees of the finest foliage.
After a halt of about a quarter of an hour we were again in the saddle, and pursued our march, but now in an entirely different direction, keeping almost due east, and crossing the shallow watercourse, which stretched from north to south a little below our halting-place, the place where we crossed it being quite dry, and full of holes caused by the footsteps of the elephant. The wilderness for a while was clearer; but after a march of about two miles we reached a very thick covert, where it was found necessary to send out scouts, in order to see if the enemy was lying in ambush. It is a great pity that these poor natives do not know how to avail themselves, against their cruel and cowardly enemies, of the fastnesses with which nature has endowed these regions. Of course these immense forests, which separate one principality, and I might say one village, from another, are themselves a consequence of the want of intelligence and of the barbarous blindness of these pagan tribes, who, destitute of any common bond of national unity, live entirely separated from, and even carry on war against each other.
Scarcely had we made ourselves a path through the thicket, when we reached another meadow-water, which at present, however, looked rather like a bog, and offered some difficulties to the passage of the horses. Having then for some time kept upon dry ground, about noon we had to cross another swamp; but beyond this the country became open. Having now reached the place of our destination, the banners were unfolded, the drums beaten, and the
greater part of the cavalry hurried on in advance ready for fighting, or rather for pillage, for no enemy was to be seen. Immediately afterwards we reached the village of Démmo, and marched slowly along, looking out for the best place for encamping. Numerous deléb-palms became visible behind the shady acacias, when suddenly we obtained sight of a broad shallow watercourse, larger than any we had yet seen in this country—more than two miles in width, with a considerable sheet of open water, where two pagan canoes were seen moving about.
Greatly interested in the scene, we closely approached the edge of the water, which seemed to be of considerable depth, although a number of hungry Kánembú had passed the first open sheet, and were fishing in its more shallow part, which divided the open water into two branches. From beyond the opposite shore a whole forest of deléb-palms were towering over the other vegetation of lower growth, as if enticing us to come and enjoy their picturesque shade. The direction of the watercourse at this spot was from south-west to north-east; and, according to the unanimous statement of those who had any knowledge of these regions, it joins the Serbéwuel, that is to say the upper course of the river or “éré” of Logón.
Here we stood awhile, and looked with longing eyes towards the opposite shore; it was a most interesting and peculiar scenery, highly characteristic of these level equatorial regions of Africa. What an erroneous idea had been entertained of these regions in former times! Instead of the massive Mountain range of the Moon, we had discovered only a few isolated mounts; instead of a dry desolate plateau, we had found wide and extremely fertile plains, less than one thousand feet above the level of the sea, and intersected by innumerable broad watercourses with scarcely any inclination. Only towards the south-west, at the distance of about sixteen miles, the low rocky mount of the Túburi was seen.
But not less interesting than the scenery of the landscape was the aspect of the host of our companions, who were here crowded together at the border of the water. Only very few of them had
