This is the first book review I’ve written since being in secondary school, which…well, was a while ago, so go easy on me. I was inspired by a tweet a few weeks ago…
— DisasterWildCard (@LucyGoBag) May 29, 2021
There has been some chatter both online and offline recently about the ‘visibility of emergency management’. Professor David Alexander’s article last summer asked “where are the emergency planners?“. The Emergency Management Growth Initiative has been seeking to bring greater awareness. And there have been recent challenges to the narrative that ‘plans didn’t exist’ for the UK response to the COVID pandemic.
Generally, there’s a view from within, that that emergency management needs to be more mainstream, especially in the minds of political leaders.
Over the last 9 years I’ve also tried to use this blog as a way to bring greater visibility to emergency management issues; most directly in an early post about breaking out of the bunker, which is simultaneously the natural habitat of the Emergency Manager but can also be what holds us back as a profession.
It was with great excitement that I ordered Michael Lewis’ book The Premonition, about a group of like-minded (and like-frustrated!) individuals who know that something serious needs to be done about pandemic planning. The book tells how a small group initiated and then performed repeated course corrections to US pandemic planning in the face of indifferent, layered, and fragmented bureaucracies. Speaking about the Swine Flu pandemic of 2009 one of the cast notes “there was no one driving the bus” and that despite pockets of good work across the country, the formal bodies people looked to for leadership (the Centre for Disease Control gets an especially scathing review) were deeply dysfunctional.
The book repeatedly asks the question “What happens when the people in charge of managing the risks have no interest in them?”. Pretty much every time it circles back to passionate people fighting to be heard and finally breaking through (often to be un- or under-appreciated).
Like Love Actually, there are several intertwined stories at play. Initially, each of the main characters (they’re actually real people) are doing their own wonderful things in splendid isolation, solving local problems using local means. But characters are brought together through chance meetings, introductions or happenstance, and realise their collective power.
One observation is that for a Public Health Officer in the States, there is no defined career path. I’ve heard similar representations about Emergency Management. This is thought to represent a problem because it means such a diversity of approaches and backgrounds and therefore a lack of a common approach. However, I would argue that this allows multiple perspectives to be more easily readily and more organically, but agree that some standardisation could be beneficial.
Like in an emergency, rapid response is vital to control and reduce the impact of disease outbreaks. The response to outbreaks and emergencies often needs to be instinctive, Kahneman’s ‘System 1’ rather than the more considered ‘System 2’. As one of the protagonists remarks about a Hepatitis C outbreak “if we had waited for enough evidence to be published in journals then we would have already lost,” and similarly, later in the book talking about wildfire response, someone remarks “you cannot wait for the smoke to clear – once you can see things clearly it’s already too late.”
Active vs passive choice seems to be another recurring theme throughout The Premonition, reminiscent of the Trolley Problem:
In particular, there is a chapter that considers a response to potential health issues following a Californian mudslide and one of the stars of the book is described as “She processes information quickly and spits out a decision fast, that makes people nervous. You don’t find people like that in government.”
Considering the profession, or at least the decision-makers background, there is an observation that the Homeland Security Council was “staffed by military types who spent their days considering attacks from hostile foreigners, not the flu” and that this had the effect of cognitive narrowing, choosing to not see the things which were unfamiliar.
One of the characters talks about how they wanted to try to get the President, then George W Bush, to pay attention to the widespread impact that a serious pandemic could have across all society, not just healthcare. I was particularly amused that rather than formal submissions and briefings, actually what got the President interested was providing him with an annotated history book.
An intensivist doctor talking about touch clinical decisions remarks that “I felt like my best when shit hits the fan. I focus like a laser when everything is going to shit” and someone else mentions “You are going to make mistakes. The sin is making the same mistake twice and best is to learn from other people’s mistakes.”
The Premonition isn’t a popular science review of pandemic interventions and response strategies. Although, if there is a Hollywood adaptation (like Lewis’ Moneyball) then there would be parts for Selena Gomez to reprise her role in explaining dense public health theories and concepts. There’s an extended section which compares 1918 influenza pandemic interventions in Philadelphia and St Louis and supporting evidence which indicates “cities that intervened immediately experienced less disease and death” and further that cities which “caved to pressure from businesses to relax social distancing then experienced a more severe second wave.”
Lewis also presents research that concludes that you “couldn’t design a better system for transmitting disease than the school system,” which got me thinking about perceptions, and why there is a persistent view that closing schools is a bad idea? Surely it’s only a bad idea if it is done badly?
The book notes how we are notoriously bad at understanding statistics and complex dynamics. Exponential growth is hard for us to visualise beyond the first few steps. Lewis provides an example of folding a piece of paper 50 times being able to reach a distance of 70 million miles. It just doesn’t seem right.
What comes through most clearly is that more often than not this doesn’t come down to expertise or evidence. Success often is the result of people who work around the system. Individuals with passion projects that compensate for the failings and deficiencies of their organisations.
My own passion project has been to try and better surface and understand interdependencies between different systems. It’s easy to become a specialist in your own field, but to see how that connects and relates to other areas is less common. My Anytown project started off as a way to try and convey the ‘whole society’ impact of various scenarios. The Premonition covers some of this in a short section that identifies the pressures on the production of nasal swabs which are only manufactured in three locations worldwide and are in extreme demand during a pandemic.
However, Lewis also makes the observation that decisions can no longer be made purely on the basis of technical evidence and draws the book to a conclusion noting that “greater attention needs to be paid to how decisions might appear to a cynical public.”
There are some wild claims throughout, such as “The US invented pandemic planning in 2005”, which I’m not sure would stand up to much scrutiny. And I’m sure that trying to tell a history of COVID whilst we are all still living through COVID means there is more to be uncovered. But overall, The Premonition is an easy to read yet insightful book which casts light on, more often than not, the failings of government-level risk management and the commitment and passion of public health and emergency management professionals, noting that some are “so committed it’s more of a mission than a job.”
Next on my reading list: Catastrophe and Systemic Change by Gill Kernick