The Smell of Success Success is like an aroma. You can smell it, but chances are, you can't see it, feel it, or capture it. Like a shell collected from a beach of a thousand shells, some things take on greater meaning when examined alone far from the shore. That's when you first notice the depth of color, the sculptured edges, the grains of sand still clinging to an inner lip. It's much more now alone than it was on the beach. Just about anything holds a lesson if you keep turning it.
What of success then? Hard to pick up like a shell from the shore. Much harder to turn on the kitchen table. Success is like vapor. A trophy is a symbol of success. It is not success itself. Success is more like an aroma. You can smell it, but chances are, you can't see it, feel it or capture it. It drifts in and then away like the scent of newly cut grass. Within minutes, it's hard to be sure it was there at all. "Smell that?" you ask, "Smells like rain. Can you still smell it? No, now it's gone." Maybe you didn't smell it after all. And what of the smell of success?
The question comes up now in early June, 1994. In my hotel room, I reach for the TV remote and there it is, inescapable on any channel - landing craft and the backs of helmets silhouetted against a smoky shoreline. Down go the ramps and out they swarm. Some fall, already wounded or worse. D-Day 50 years ago. One documentary on Normandy ends; I flip to the next. A new angle each time. And this has the smell of success. It is authentic.
The Normandy invasion was an undertaking of proportions and complexity not seen before or since. On the beaches in France, history was shaped for the many decades that followed. Glamorized and sanitized, it has moved with inevitability to legend. For a generation of Americans, it became the defining moment in a defining decade that saw America become a world power. It engendered the confidence that helped the nation achieve world leadership in every major industry including health care. D-Day provided lessons aplenty for managers interested in the true character of success. Lessons too for those involved in remaking health care in America. Here then, are 27 of those lessons.
Success can only be defined in retrospect. The soldiers on Omaha Beach didn't know they were at a turning point. Success is usually impossible to recognize at the time of its occurrence. All they knew was that they were part of something big. It could have easily been, from their perspective before, during and after the invasion, a big disaster. Only the slow but inevitable collapse of the German army and the fall of Berlin made Normandy a success. Until that point, it could have been just a horrendous waste of men and arms at the wrong place at the wrong time. Only with the benefit of perspective was success definable. Here's what Churchill had to say about the decision to launch the invasion on June 6. "In retrospect, the decision rightly evokes admiration. It was amply justified by events, and was largely responsible for gaining us the precious advantage of surprise. We now know that the Germans thought an invasion on the 5th or 6th of June would not be possible owing to stormy weather which might last for several days."
Success requires that the important drive out the urgent. Ultimately, fire fighting without aim divides attention and resources. A clear, consistently stated ultimate purpose must be articulated. For the Allies, that objective was clear - to take Berlin. But there were different roads to Berlin. Stalin had tried persistently to get the Allies to shift their forces to reinforce Russian efforts in the east. Despite disappointments, Roosevelt, Churchill and Eisenhower stayed resolutely on the road that led through France.
Success depends on a combination of flexibility and rigidity in exquisite balance. The Allies were firm in their commitment to take the Allies into France first. Yet, when they hit Omaha Beach and all the plans went down in a hail of bullets, it was self organizing American soldiers who moved ahead on their own accord and crossed the seawalls. Pinned down on Omaha Beach, they were mostly leaderless. The withering fire from the Germans above had been so destructive that it killed most of the officers. Finally, a young officer who could tolerate no more carnage stood and shouted, "Two kinds of people are staying on this beach; the dead and those who are going to die." With that, men who before had been paralyzed on the beach for hours, moved out. In the next 24 hours 175,000 men and 500,000 vehicles came ashore. Meanwhile, the Germans suffered from their own rigidity. They were unable to unleash elite Panzer tank corps because they had to wait for permission from their central command.
The American character was dramatically demonstrated at Normandy. George Will spoke to that character: "Confusion is normal in combat and was extraordinary among the parachute forces dropped past the beaches on D-Day. But the flexibility of the confusion suited a strength of the American character... American forces excelled when required to organize themselves into small groups and then improvise their tactics." Historian, John Keegan, says what the American paratroopers did was in character for Americans: "Like pioneers in an unknown land, ignorant of its language and landmarks, uncertain of what the next thicket or stream-bottom might hold, confident only in themselves and their mastery of the weapons in their hands, the best and the bravest among them stifled their fears, marched forth and planted the roots of settlement in the soil that was there for the taking."
Success makes liars of leaders who promise victory in the face of uncertainty and complexity. Eisenhower admitted after the invasion that he had written two letters. One a letter of congratulations. The other read as follows: "Our landings…have failed to gain a satisfactory foothold, and I have withdrawn the troops…If any blame or fault attaches to the attempt, it is mine alone."
Success often comes from unlikely sources. Who would have bet on a privileged child of the New York upper crust for grit, resolve and useful manipulation? Who would have predicted that he would be, as Gary Wills has suggested, rated among "the top three or four chief executives of our history?"Few would have put their money on so unlikely a choice as Franklin Delano Roosevelt. Like Lincoln, who denounced abolition until he felt there was popular support for it, Roosevelt was described by Wills as a man who "would make many deals with the devil in order to keep his hold on those who might respond to his call." How did a man of such soft beginnings become such a toughened and effective handler of the American spirit? The answer says Wills is found in his legs, or his lack of them. What is taken for granted by so many of us, an easy amble from one place to the next, was for Roosevelt an immense struggle. Polio taught him to move up stairs by pulling himself a step at a time with his powerful arms. He had to be carried to and from bed, lifted in and out of the bath and dressed by aides. His "fireside chats" were designed to allow him to avoid podiums where he might fall. Deathly ill in 1944, he attempted to show himself strong and capable by taking an open car ride through New York City in a pelting rain. Unknown to the public who saw him, were the Secret Service stops along the parade route where he was "stripped, wrapped in a blanket, given a rubdown and a shot of brandy, then dressed in warm clothes." According to Wills, "The final mystery is that this physically impaired man made his physical characteristics so comforting to the nation facing hardship and war. People drew strength from the very cock of his head, the angle of his cigarette holder, the trademark grin that was a beacon of hope."
Success sometimes demands that you endanger the things you have valued most. The French officers aboard Allied battleships found themselves compelled to lob shells into their homeland, into peaceful pastures and onto graceful chateaus.
Success is always easier to plan than it is to deliver. In The Young Lions, Irwin Shaw described vividly the difference between the plan and its execution: "A battle exists on many different levels. There is the purely moral level, at the Supreme Headquarters perhaps eighty miles away from the sound of the guns, where the filing cabinets have been dusted in the morning, where there is a sense of quiet efficiency, where soldiers who never fire a gun and never have a shot fired at them, the high Generals, sit in their pressed uniforms and prepare statements to the effect that all has been done that is humanly possible...
"...To a General sitting before the maps eighty miles away, with echoes of Caesar and Clausewitz and Napoleon…matters are proceeding as planned, or almost as planned, but to the man on the scene everything is going wrong. When he is hit or when the man next to him is hit, when the ship 50 feet away explodes…it can only appear to him that he has been involved in a terrible accident…it is inconceivable…to believe that there is a man eighty miles away who has foreseen that accident…and who can report, after it has happened…that everything is going according to plan."
Success is just one link in a chain. Even if it's the master link, one link in a chain is quite useless without the rest of the chain. Normandy would not have been possible without riveters in St. Louis, code crackers in London and spies in France. Each relied on the other in a web of mutual success. There would have been no success at Normandy if it hadn't been preceded by success in Detroit, success in North Africa and Italy then followed by success at the Battle of the Bulge.
Success must have some boldness in it. What distinguishes success from the everyday acts of getting through life? Is getting out of bed in the morning to be counted as success? For most not. When does mere achievement cross the line to become success? It has to do with the immensity, complexity and formidableness of the task. And, of course, it has much to do with how many people view the challenge as important. Lieutenant-General Sir Frederick Morgan spoke to the immensity of the challenge at Normandy: "The prospect of launching an invasion out of England was little short of appalling. There was no precedent in all history for any such thing on the scale that must of necessity be achieved here."And when it was done, even Josef Stalin who had wanted those same troops focused to the Russian front had this to say: "The history of war does not show any such undertaking so broad in concept, so grandiose in scale, so masterly in execution." Such boldness brings to mind the personal credo of Jack London:
"I would rather be ashes than dust,
I would rather my spark should burn out in a brilliant blaze,
Than it should be stifled in dry rot.
I would rather be a superb meteor,
With every atom of me in magnificent glow,
Than a sleepy and permanent planet."
When pro quarterback Ken Stabler was once asked what London's credo meant, he responded simply, "Throw deep."
Success is often made of very ordinary things. When Eisenhower was asked to name the most valuable tools in the Allied arsenal at Normandy, he did not name tanks or battleships or fighters. His list included the jeep, the 2 1/2-ton truck, the DUKW landing craft, the C-47 transport plane and the bulldozer.
Success requires both leadership and followship. In an article in Newsweek, Paul Fussell spoke to the challenges of leadership and the lessons of Normandy: "After hours of motionless horror, what finally got them moving off that deadly beach? 'Leadership,' of course, But what is it? Did it take the form of exhortations, example, commands, threat of punishment? Imagine a wet strand of spaghetti on a slippery surface. Push it from the rear and it goes nowhere. You have to pull it from the front. But what if the leader shouts "Follow me!' and no one does? Why do men sometimes follow and shout enthusiastically too? Something called character must be apparent in the leader. The followers must like him and want to be like him - or want him to like them. When it's all over, they want him - private, sergeant, lieutenant or even General Eisenhower - to clap them on the shoulder and say he's proud of them."
Success often blinds the future to the past. For most of us who grew up after World War II, democracy appears to have been one wave of inevitability beginning with the Greeks and surging forward to England, France and, of course, America. But as Arthur Schlesinger, Jr., has commented: "Basking as we do today in the glow of democratic triumph, we forget how desperate the democratic cause appeared half a century ago. The Great War apparently proved that democracies could not produce peace; the Great Depression that it could not produce prosperity. By the 1930s, contempt for democracy was widespread among elite and masses alike."
It was an era, Schlesinger points out, that could have seen democracy succumb to "…a single leader, a single party, a single body of infallible dogma, a single mass of obedient followers… It's impossible to fathom the depth of ambivalence with which America entered the enterprise that led her sons to the bloody beaches."
Success does not wait for the evidence of virtue. Those who look to Normandy or any other great human undertaking for evidence of consistent bravery or altruism will be disappointed. Success sweeps along cowards and charlatans as well as heroes and saints. The jails of England were full of soldiers who refused to join the invasion. Many inflicted wounds on themselves. There were crooks and profiteers in the shadows of D-Day, just as they have always lurked around great moments. But their presence doesn't remove the virtues of success. Many a wise leader has harnessed the greed and cowardice of his fellows to achieve some great and decent purpose. Leaders intent on leading only the chaste and the decent will wait a very long time for the hour to arrive. A line from Henry V has oft been repeated in connection with Normandy: "Gentlemen in England now a-bed should think themselves accursed they were not here." Many were not there. Those who were could not afford to wait for the missing to appear if they were to craft success.
Success sows the seeds of future failures. The Americans triumphed at Normandy, later stumbled in Korea and Vietnam. What worked in France, the massive deployment of men and material supported by carpet bombing, did not work in Southeast Asia; Mao Tse Tung's strategy was very different than the Germans, "When the enemy advances, we retreat. When the enemy retreats, we advance. When the enemy encamps, we harass."
Success often cannot be achieved unless it is preceded or accompanied by failure. The Americans who arrived at Omaha Beach disembarked into a blunder of colossal proportions. The German guns above the beach were to have been destroyed by bomber raids and naval shells. Both overshot their target. The guns blazed away. American bombardment was to have created craters so arriving soldiers would have secure cover in the sand. No craters were to be found. To gain victory over Germany, both Roosevelt and Churchill knew they could lose Eastern Europe to the Russians and to Communism. General Charles De Gaulle, in a BBC appeal to the people of France, made failure out to be part of the pavement on the road to success: "France has lost a battle - but she has not lost a war! Believe me when I tell you that nothing is lost for France…The means which have defeated us can bring us victory one day…Whatever happens, the flame of French resistance must not and will not be extinguished."
Success is sometimes built of doing what others have convincingly established as impossible. At Normandy, America's world leadership was secured by courage but also by the nation's capacity to produce vast amounts of material and deliver it to the beach. As the Smithsonian commented: "On the home front, we were asked to train every ounce of energy on the war effort. From conserving kitchen grease, to facing down Hitler on the weapons production line, everyone from housewife to retiree was called on to pitch in. Support the troops overseas and help assure victory." At the time World War II broke out, America was already recognized, according to Alistair Cooke, "as masters of mass production." But of what? And of what quality? Air Marshal Goering assured Hitler that there was nothing to fear from American industry and technology. "The Americans," said Goering, "cannot build airplanes. They are very good at refrigerators and razor blades." "Hitler," according to Cooke, "confronted Americans with the sort of challenge to which they respond like catapults; a dare to beat the unbeatable, to choke the world's champ with massive doses of his own medicine." In 1943, American factories turned out 86,000 planes. Henry Kaiser had never built a ship before and his workers knew less about ship building than he did. They, like he, referred to the "front" and the "back" of a ship. Their first Liberty ship took 244 days to build. Soon they were being built in 4 days.
Success often ebbs before it flows. A wave breaking on the beach always recedes and then you wait to see how big the next one will be. The same bad weather that caused the Allies' bombers and naval batteries to miss their targets also made the invasion possible. The Germans did not expect the attack to come in such foul weather.
Success is not replete with marvelous consistency. It bends and reshapes to meet the circumstances. Roosevelt once reflected on his own inconsistencies while governor of New York: "Those who seek inconsistencies will find them. There were inconsistencies of methods, inconsistencies caused by ceaseless efforts to find ways to solve problems for the future as well as for the present. There were inconsistencies born of insufficient knowledge. There were inconsistencies springing from the need of experimentation. But through them all, I trust that there also will be found a consistency and continuity of broad purpose." Once the world moved to war, Roosevelt, still a master of the useful inconsistency, was resolute about one thing, according the Schlesinger, "to one way or another, rid the world of Hitler."
Success is often not pretty. In seeing the silhouetted rush of men to the distant beach in black and white photos and films, it is not possible to tell some of them had lost control of their bladders, that many had vomited all the way to shore, that the water they stepped into was churning red and scattered with body parts. What one sees is only the determined drive stripped of fear and uncertainty.
Success sets off a chain of events that create other successes not easily discernible. During World War II, like wars before and after it, tremendous breakthroughs in medicine occurred. Indeed, some of the most significant medical advances in history including sulfa drugs, triage trauma care and aseptic technique can trace their origin and development directly to the battlefield. The physicians who built the American medical empire cut their teeth on World War II and then got their training through an ingenious program called the GI Bill.
Successful innovation comes only from the things you try that work. The floating tanks at Normandy sank. The gliders full of troops somersaulted on landing. But the portable harbor imagined by an Englishman in his bathtub and tested in his pond worked. It would later prove essential in moving vast numbers of men and material ashore. A.P. Herbert praised the innovativeness that built those floating bays in a poem called The Harbour:
"Give thanks for the wild inventors, give thanks for the fearless wits,
Who set themselves to a riddle that never was put before;
Give thanks to the faultless seamen who ferried the crazy bits,
And fashioned a mighty harbour, in storm, on a hostile shore."
Success will sometimes be diminished after it's been achieved. Eisenhower was constantly hounded after the war by critics who charged he could've ended the war sooner. The Russians still look to battles on their own fronts as the levers of success, while diminishing the importance of the events on the coast of France.
Success can outrun itself. Having broken free of the beach, the Allied invaders outran their supply lines. Success can cause you to forget your homework. To begin to think that you have caught the scent of success and have it securely in your pocket. You smelled it today. Surely it will be there tomorrow. Of this you become confident and then overconfident. And that is your undoing as success drifts out of your grip just as you begin to think you've closed your hands around it.
Success is defined by the circumstances. What worked in one situation often will not in others. Field Marshal Montgomery won a legendary battle for the British against Rommel at a place in North Africa called El Alamein. He won by dogging an adversary that was quickly outrunning its supply lines. Shortage of fuel did Rommel in just as surely as Montgomery. But the same plodding doggedness proved a liability when Montgomery took a month to bring down a strategic French town he had promised to take in a day.
Success still depends on the few as much as it does the many. It is popular today to cast success as the result of empowered players at every level contributing each in their own way. But the battle at Omaha Beach became so precariously balanced that General Omar Bradley was ready to withdraw. Then, minutes away from canceling the landing of the remaining troops, word came through that a handful of men had begun moving out. Combat historians can still name the 47 men who turned defeat into victory. To support them, a few old battleships dating back to Teddy Roosevelt's administration began to pound the cliff tops above the beach while a handful of destroyers, in order to provide cover, moved in so close their bottoms were rubbing rock and sand. A few made success for many.
Success depends on the little things as much as the big. Once the Allies broke out of Normandy, the Germans certainly offered them stiff resistance, but it wasn't Panzers that were the biggest impediment to their continued progress. It was gasoline. Or more precisely, "jerry cans," the square cans that carried fuel. Rather than send the cans to the rear to be replenished, Allied soldiers threw them into the bushes when they were empty. So the charge to Germany ran out of gas and with it the hopes of ending the war by Christmas.
Success and quality are siblings who travel in the same compartment. Those who think of success and think too of quality will find them very much alike. Because what is quality if not success in moving, for some defined but fleeting moment, closer to perfection? And what is success if not for some equally fleeting moment having set a mark worth hitting and hit it?
Health care is on the beach. It's a beach in many ways like Normandy. It's wide and its impediments are well dug in. It can only be crossed with massive levels of focused attention and human capital. It requires the ability of leaders to meld varied backgrounds, capabilities and perspectivesinto common purpose and unified effort. It is beset by powerful political and economic undercurrents as well as old rivalries. As at Normandy, success will trigger an avalanche of consequences, most of them good, some of them bad, many of them unknown and unknowable.
But it is also a different beach. Normandy and the liberation of Europe were more important. The stakes were so much higher. The smell of consuming disaster was much more in the air. But Normandy had the benefit of definable goals. Rome, Paris and then Berlin. It was easier to declare victory and the fighting done. When Eisenhower, Bradley and Montgomery ordered their troops to move out, it was likely they would obey. Success in health care is harder to define. It is a target that's constantly moving. No one in health care either on a national or a local level has the clout to make forces march in order. American health care remains largely leaderless with no easily identifiable set of commanders the various armies have shown any willingness to follow. There is no Roosevelt or Churchill. No Patton or Alexander.
Where is the unifying call? Isn't there something here that is broad enough and deep enough to strike a resonant cord? We know that it's not universal coverage. It's not the right of physicians and hospitals to earn at the same level as they have in the past. It's not capitation. Or lower cost alone. So what is it? What is the battle cry?
It should not be surprising that this crusade has not been joined by those with the greatest ability to make it succeed - those who deliver the care. Unfortunately, this campaign started with the presumption that the troops were themselves the enemy. They were called to attack themselves. Although the acclamation of "best health care in the world" went too long unquestioned so too has the complaint, "the system is broke." When trying to stir action, many an opportunistic politician cried "crisis."
Instead of taking the high road, we've gone at health care like a mob armed with clubs and accusations determined to beat the other guy and his side into bowed submission. We're quick to complain that health care is too expensive while pointing the finger in the other direction. Should an MRI that's running at less than full utilization really be a national embarrassment? Compared to what? We went to the moon on more dubious possibilities (and should be proud we did). Is health care too expensive or just too limited in its ability to prove its worth? Are chronic and catastrophic illness such uninspiring foes? Are we now so divorced from our confidence and altruism that we'll back away from going the next step? If much of America's health care problems are related to lifestyle, then why not take lifestyle on. Cigarette manufacturers are headed out of town on a rail and smokers are finding the space allocated to their habit ever more confined. It didn't take a government mandate or some high minded prohibition to accomplish this. It took C. Everett Koop, advertising executives, educators and an informed public to do it. As Churchill once said, Americans can always be counted on to do the right thing once they've exhausted all other alternatives. Is it possible to unleash American ingenuity, entrepreneurial spirit and civic mindedness on the disconnectedness and discontinuities that keep health care from achieving a new era of miracles?
It's time to ask what success will smell like in health care. To recognize that all the consolidation, linkages, standards and information systems are merely mechanisms, not success in themselves. When we've built a system with doctors, hospitals and insurers pulling in the same direction, we will not have succeeded but merely caught up. We'll have in our hands at last tools we need to succeed. But we best not fool ourselves into thinking that we've won when we've only made it off the beach. American health care remains at a crossroads just as the world's democracies were at a crossroads 50 years ago. A spot in the road not unlike the one described by George Gordon, Lord Byron:
"Twas on a summer's day - the sixth of June.
I like to be particular in dates,
Not only of the age, and year, but moon;
They are a sort of post-house, where the fates
Change horses, making history change its tune.."
Let's hope that we can charge over the seawall to realize the motto of the Royal Tank Regiment by moving: "Through mud and blood to the green field beyond."