Micro-Macro Connection

Social Structure and Catastrophe

People’s dependence on social structure is illustrated most clearly when they face calamitous, life-threatening situations. In 2010, 33 Chilean miners were trapped 2,300 feet underground for over 2 months. They all survived and most were surprisingly unscathed after the ordeal. Sure, their physical survival required impressive levels of individual stamina, the diligent efforts of rescuers, a constant flow of food and supplies, effective medical advice from doctors at the surface, and some really good luck. But without the well-organized subterranean social structure they created, they never would have made it.

Early on in the crisis, the trapped miners determined that every decision they made, no matter how large or small, would be put to a majority vote. They developed a clear authority structure, with every individual assigned to a particular role, such as food organizer, medic, pastor, environmental assistant, communications specialist, and media director. They designated places for eating, exercise, and waste disposal. They split into three groups of 11, each with its own leadership and assigned tasks. They abided by a regular daily schedule that included meals, showers, exercise, “house” cleaning, and chores done in three shifts around the clock (J. Franklin, 2010). To many observers, the remarkably good shape the miners were in when they emerged could be attributed to all this organization. Social structure literally helped save their lives.

Let’s turn the clock ahead to the spring of 2011 and the massive Japanese earthquake and tsunami that devastated the country’s northern coast and killed tens of thousands of people. Many villages were wiped off the map. One such place was the tiny fishing hamlet of Hadenya in the town of Minamisanriku. After the tsunami hit, homes were wiped away and loved ones disappeared. Bridges were washed out, vehicles crushed, boats stranded. Electricity and cell phone services were nonexistent. Two hundred and seventy survivors huddled in the frigid cold at a hilltop community center. They had very little food, no fuel, and no news from the outside world. It took nearly two weeks for the military to finally reach them. But they were all alive. Like the Chilean miners, the people of Hadenya realized that the only way they could survive was to create their own social structure, quickly reorganizing themselves along the lines of the original community:

Almost as soon as the waters receded... they began dividing tasks along gender lines, with women boiling water and preparing food, while men went scavenging for firewood and gasoline. Within days... they had re-established a complex community, with a hierarchy and division of labor, in which members were assigned daily tasks.

They had even created a committee that served as an impromptu government body for this and five other nearby refugee centers.... Representatives from the centers met daily to swap supplies and assigned tasks. (Fackler, 2011, p. A11)

It soon became apparent that Hadenya wasn’t unique. Refugees in scores of other small hamlets all along the coast created similar makeshift organizations to aid their survival. The groups were so successful that when the local government began to plan for the eventual relocation of all the survivors into temporary housing miles away, officials realized that the spontaneous group organizations might have some lasting use:

[The mayor] said the town had originally planned to put people into housing as quickly as possible. Now he thought it best to keep these organizations intact, to help people adapt to new and different living environments.

“They are like extended families,” [the mayor] said. “They provide support and comfort.” (Fackler, 2011, p. A11)

But social structure is not always a savior during catastrophes. It can sometimes overwhelm individuals’ best efforts to exercise their will. Take, for example, an even bigger tsunami disaster that hit seven years earlier, killing more than 200,000 people in South Asia and Eastern Africa and leaving millions homeless. Ordinary people all around the world pledged to help the victims, alongside promises of billions of dollars in aid and military assistance made by 19 nations. Close to 30% of U.S. citizens donated money to the cause, and another 37% indicated that they intended to do so (Lester, 2005). Two weeks after the disaster, the charitable organization Save the Children had received more than $10 million in donations over the Internet alone. In a typical month, the organization receives between $30,000 and $50,000 (Strom, 2005).

But such spectacular individual benevolence was hobbled and almost crushed at the organizational level. When two dozen government and aid organizations arrived in the hardest-hit regions of Indonesia a week or two after the tsunami hit, they found that looters and black market traders had already descended on the wreckage. Some devastated areas had yet to see any relief workers, while others were swarming with doctors and nurses. Moreover, the presence of foreign military and relief workers soon created resentment in the Indonesian government. In response, it imposed travel restrictions on foreign aid workers, citing security concerns, and demanded that all foreign military personnel leave the country within three months. In one of the hardest-hit areas, Banda Aceh, relief organizations found themselves in the middle of a civil war, operating alongside paramilitary rebels (officially regarded as terrorists by the U.S. government) and an Indonesian military known for its corruption and rights abuses (Wehrfritz & Cochrane, 2005). Despite the presence of thousands of caring and generous individuals who came to help, these structural factors conspired to slow down the relief process.


The U.S. Health Care System

Consider the U.S. health care system, one of our most important social institutions. Think about the vast networks of organizations that are necessary for a single patient in a single hospital to receive treatments. First of all, the hospital is tightly linked to all the other hospitals in the area. A change in one hospital, such as a reduction in the number of patients treated in the emergency room or the opening of a new state-of-the-art trauma center, would quickly have consequences for all the others. The linkage among hospitals enables the transfer of equipment, staff, and patients from one to another when necessary.

To be accredited and staffed, the hospital must also connect to formal training organizations, such as medical schools, nursing schools, and teaching hospitals. These organizations usually affiliate with larger universities, thus expanding the links in the network. And, of course, the American Medical Association and various licensing agencies oversee the establishment of training policies and credentials.

To survive financially, the hospital must also make connections to funding organizations. Hospitals have traditionally been owned and operated by a variety of governmental, religious, nonprofit, and for-profit organizations. They must operate under a set of strict regulations, which means they must also link to the city, state, and federal governmental agencies responsible for certification, such as the Joint Commission. Add to these relationships their links to the medical equipment industry, the pharmaceutical industry, food service providers, the legal profession, charities, political action committees working on health care legislation, patients’ rights groups, and most notably health insurance companies, and the system becomes even more complex. Indeed, the recent highly contentious debate over and subsequent passage of health care reform legislation was essentially a fight to protect competing economic, political, and personal interests.

The vast network of organizations within the health care system must also work together in response to broader societal demands and crises. For instance, in the wake of the 1995 Oklahoma City bombing, the attacks of September 11, 2001, and the anthrax attacks in the fall of 2001, the Institute of Medicine (2003) published a report warning that the nation’s mental health, public health, medical, and emergency systems were not equipped to respond to terrorism. At the organizational level, gaps exist in the coordination of agencies and services, the training and supervision of professionals, and the dissemination of information to the general public. The report concluded that only a multilayered approach—involving the federal Departments of Health and Human Services and Homeland Security, state and local disaster planners, and relevant professionals in all areas of health care—could stave off potential catastrophe.

But despite the health care system’s complexity, size, and importance, when patients go to a hospital they don’t see it as a node in a vast network. Patients are obviously much less interested in the hospital’s organizational links than they are in whether their nurse is friendly, the food is good, or their doctor treats them honestly and compassionately. Yet in a 2003 study, one out of three doctors reported purposely withholding information from patients about potentially helpful treatments because those treatments weren’t covered by the patient’s health insurance (Wynia, VanGeest, Cummins, & Wilson, 2003). The needs of the larger system can sometimes clash with an individual’s health care needs, making even face-to-face interactions problematic and, possibly, even detrimental to the patient’s health