I am not sure everyone is familiar with the concept of the last mile, no I am not speaking of that final walk on death row, but about the final mile in delivery systems; like Amazon, or roadways or healthcare. Andrian Bejan has written a good deal about an evolutionary principle that suggests we evolve to move faster. Water seeps from the ground to form rivulets that become streams and ultimately rivers. And as the water moves through each of these conduits, it moves faster and faster. He claims that much of our anatomy, especially blood vessels (my favorite) and the bronchial tree are ‘designed’ by evolution to provide the rapid dissemination of blood or air. You can recognize the design by its tree-like shape.
But consider the reverse pathway, from the river back to the soil and especially when water percolates back into the earth, the last mile. It is slow and uneven. Think of getting off the highway, through the town, into the country – down roads without clearcut names and that perhaps have not been maintained as well as others. Those roads lead to interesting places, but that last mile is slow and uneven.
Healthcare is also subject to these laws of logistics. Journals used to be the rivers of medical information before they were supplanted by on-line preprints and reports in the media, mainstream or social. Same for conferences. But for healthcare, the last mile has seen little change. Yes, we have seen ‘innovation’ in urgent care centers or pharmacy-based doc in boxes, but that has more to do with convenience than addressing the fact that medical care at the face-to-face level remains a bespoke service – slow and uneven. Now bespoke services are customized that is partly why they are slow, and bespoke services are delivered by an individual with varying degrees of expertise and efficiency, that is why they are uneven. So, disparities in care seem inevitable.
Our daily bespoke service lies within a watershed, within the last mile of healthcare’s logistics. Watershed are by their nature slow, water seeps and percolates through the soil, governed more by the topography (steep or flat) and terroir (loose or tightly packed) then driven by gravity. The watershed, our metaphorical last mile, can explain the exasperation, frustration and occasional ill-mannered interactions of health professionals and patients alike. And the heterogeneity of pockets of excellence abutting abysmal practice. The broad strokes of governmental and corporate intervention concern themselves with downstream interests, with aggregates – the greater incidence of poor health and healthcare for the economically challenged, less educated, stressed – those the government and corporations view as a needful underclass. But these aggregates have an upstream source; they come from a diversity of watersheds, territories less explored, understood or attended. In the same way that a watershed’s topography is the source of flow, the environment of our daily practice is the root of those healthcare aggregates. There are few shortcuts and more obstacles so far upstream in healthcare. Health is a cofounder – it monitors the resilience within the watershed. Our health is a result of our watershed, not its measure.