The Checklist Manifesto_ How to Get Things Right - Atul Gawande [37]
The most straightforward thing for the group to do would have been to formulate and publish under the WHO name a set of official standards for safe surgical care. It is the approach expert panels commonly take. Such guidelines could cover everything from measures to prevent infection in surgery to expectations for training and cooperation in operating rooms. This would be our Geneva Convention on Safe Surgery, our Helsinki Accord to Stop Operating Room Mayhem.
But one had only to take a walk through the dim concrete basement hallways of the otherwise soaring WHO headquarters to start doubting that plan. Down in the basement, while taking a shortcut between buildings, I saw pallet after pallet of two-hundred-page guideline books from other groups that had been summoned to make their expert pronouncements. There were guidelines stacked waist-high on malaria prevention, HIV/AIDS treatment, and influenza management, all shrink-wrapped against the gathering dust. The standards had been carefully written and were, I am sure, wise and well considered. Some undoubtedly raised the bar of possibility for achievable global standards. But in most cases, they had at best trickled out into the world. At the bedsides of patients in Bangkok and Brazzaville, Boston and Brisbane, little had changed.
I asked a WHO official whether the organization had a guidebook on how to carry out successful global public health programs. She regarded me with a look that a parent might give a toddler searching the dog’s mouth for the thing that makes the barking noise. It’s a cute idea but idiotic.
I searched anyway. I asked people around WHO for examples of public health interventions we could learn from. They came up with instances like the smallpox vaccination campaign that eradicated the scourge from the world in 1979 and the work of Dr. John Snow famously tracing a deadly 1854 London cholera outbreak to water in a public well. When the disease struck a London neighborhood that summer, two hundred people died in the first three days. Three-quarters of the area’s residents fled in panic. Nonetheless, by the next week, some five hundred more died. The dominant belief was that diseases like cholera were caused by “miasmas”—putrefied air. But Snow, skeptical of the bad-air theory, made a map of where the deceased had lived and found them clustered around a single water source, a well in Soho’s Broad Street. He interviewed the bereaved families about their habits. He made a careful statistical analysis of possible factors. And he concluded that contaminated water had caused the outbreak. (It was later discovered that the well had been dug next to a leaking cesspit.) Snow persuaded the local council to remove the water well’s pump handle. This disabled the well, ended the spread of the disease, and also established the essential methods of outbreak investigation that infectious disease specialists follow to this day.
All the examples, I noticed, had a few attributes in common: They involved simple interventions—a vaccine, the removal of a pump handle. The effects were carefully measured. And the interventions proved to have widely transmissible benefits—what business types would term a large ROI (return on investment) or what Archimedes would have called, merely, leverage.
Thinking of these essential requirements—simple, measurable, transmissible—I recalled one of my favorite public health studies. It was a joint public health program conducted by the U.S. Centers for Disease Control and HOPE, a charitable organization in Pakistan, to address the perilous rates of premature death among children in the slums of Karachi. The squatter settlements surrounding the megacity contained more than four million people living under some of the most crowded and squalid conditions in the world. Sewage ran in the streets. Chronic poverty and food shortages left 30 to 40 percent