I’ve blogged before about the importance (and absence) of a true lessons learned processes in emergency management. The current system of debriefs and action plans is something. But it’s not everything that we need.
One of the most primitive ways that we share information, and pass on important lessons, is in the form of stories. Admittedly that’s far less measurable than some RAG-rated entries in a database. But potentially it’s powerful.
My latest project is to collate staff experiences of response to an incident, but through less traditional mediums, their own artistic interpretations of their memories and then to collate that into a zine. It’s a bit of an experiment to see if there are different ways to tell the story of a response, rather than limit that to the narrow confines of a debrief and it’s report.
With that in mind, I set out last weekend to go to London’s largest zine collection for a bit of inspiration.
Along the way I stopped in to a bookshop and one of the recommended reads was The Silence by Don DeLillo. A short novella rather than a mighty tome.
Superbowl Sunday, 2022. A couple wait in their Manhattan apartment for their final dinner guests to arrive. The game is about it start. The missing guests’ flight from Paris should have landed by now.
Suddenly, screens go blank. Phones are dead. Is this the end of civilization? All anybody can do is wait.
My interest was piqued.
However, I have some bad news. This was not an enjoyable read. Other than a few fleeting references to the situation (and it’s still unclear exactly what happened – cyber hacking? power loss? geomagnetic storm?) it wasn’t really about the incident. Worse, I’m not really clear what it was about. Or what message it was trying to convey.
Critics have lauded the book as ‘stylistic’. However, it feels like the author simply developed an algorithm to say the ‘right’ apocalyptic fiction words regardless of what order those words appear in, and at the expense of any kind of plot.
There is dialogue, but rarely are there conversations, just a series of loosely connected statements. I have never met anybody who speaks like this, and yet here are a collection of people who all do. I found it incredibly hard to read, so it was fortunate that it was short at just 144 pages.
I would not recommend this book. You can find a million better things to do.
The one positive; I learned a lesson to avoid this particular style of book, and I learned that lesson through the power of a story.
Book Review: Catastrophe and Systemic Change by Gill Kernick
Gill lived on the 21st floor of Grenfell Tower between 2011 and 2014. We all have our own recollections of the morning of 14 June 2017. Like many of us, Gill watched the Tower burn. Unlike many of us, her former neighbours were amongst the 72 people who tragically died. Her book is dedicated to them.
In part, the book is an exploration of the systemic issues behind why we don’t learn from disasters. Kernick has worked in high hazard industries and brings examples from there as well as from other disasters to show repeated failures to bring about post-disaster change. But her book is also intensely personal, and in parts reads like a diary, like she is making sense of her own emotions and thoughts, and processing all of this during a pandemic when other learning is also falling by the wayside. I didn’t expect the book to make me emotional, but it did.
Before discussing what I found particularly resonant about the book, a little disclaimer. I’ve been involved in the response to Grenfell since the early hours of that night in 2017. I’m still involved now. The Grenfell Tower Public Inquiry is continuing. For those reasons, I won’t be commenting on chapters 1 and 2 which consider the specifics of Grenfell, but will focus on the themes of learning and systemic change.
The book catalogues failed opportunities to learn. There is a whole swathe of documents, reports, investigations, inquiries and research that show that despite assurances rarely do ‘lessons identified’ translate to ‘lessons learned’ at either the scale or pace required. And this continues, on 24 June 2021 at the Manchester Arena Inquiry, there was considerable discussion about the collective failure to learn lessons from an emergency exercise.
Right there on page 6 my frustration is in black and white “the system is designed to ensure we do not learn”.
My biggest personal professional frustration is the repeat lessons. To ‘learn’ something, again and again, is to demonstrate that it is not actually being learned or addressed sufficiently. I’ve worked in organisations where the focus is on putting in place systems and processes to ‘help’, but which all too often just result in shuffling bits of paper around.
Kernick draws a distinction between piecemeal change (which involves looking at the system and making changes within it) and systemic change (which considers the conditions and cultures within which the system operates). She asserts that systemic change requires disruption of the status quo, but observes that kindness can be more disruptive than aggression.
We live in a complex, messy, often unpredictable world. I think it gives us a sense of comfort to think that we are ‘in control’ and can forecast what will happen in a given situation, but the reality is that emergent behaviours and complex dynamics between systems mean that we are only just scratching the surface.
To operate effectively in an increasingly complex world, Kernick suggests that governments need to change how they approach public engagement. I’d go further; this is not limited to engagement, governments need to embrace flatter, more organic structures for emergency response and move beyond ‘command and control’.
Emergencies and disasters often have high levels of uncertainty. This calls for what Kernick refers to as ‘the democratisation of expertise’. None of us individually have all the answers; we need to work together to make sense of a situation and determine a course of action. It’s an unspoken principle that runs through emergency management. That’s why we have COBR, once described to me as “Whitehall in miniature”, which brings together a bunch of people to find a collective answer. The same applies to Local Resilience Forums and Strategic Coordinating Groups. They are structures that allow knowledge and expertise to be pooled.
And those structures need to be more representative of the communities they serve. We need people with different lived experiences to shape a response that will be better for everyone.
Kernick moves then to consider the role of accountability and scrutiny in Government. The conclusion generally seems to be that structures for scrutiny are okay, but the willingness or ability of governments to act on that scrutiny is low. There is no structure that can compel public inquiry recommendations to be addressed. Similarly, the Prevention of Future Deaths reports and rail industry incident reports and many others too. They all swirl around, unaddressed, in a soup of known issues ready to boil over the next time there is an incident.
So, why don’t we learn? It’s a question I come back to a lot and which this book has helped me to explore. Through the book Kernick goes on a journey about learning, expressing what initially seems to be curiosity, but then becomes increasingly frustrated and ultimately becoming incredulous. I’m not quite at that stage just yet, but I do think that there is a requirement to turn the mirror on ourselves and really examine the conditions and beliefs which we hold on to, which might be stopping us from making more progress.
And so, we come back to where we started, that systemic change requires “a tribe of disrupters” and I hope this book galvanises emergency managers across the land to be braver and to disrupt with kindness.
The Disaster Tourist by Korean autjor Yun Ko-eun tells the story of Yona, who’s worked for Seoul-based travel company Jungle for 10 years, offering package holidays to destinations in disaster zones.
When she tries to quit after a #MeToo incident, her boss tries to buy her silence with a free trip to Mui, a remote Vietnamese island home to one of the company’s least popular disaster tours. In return, all she needs to provide is a full report on how to improve the itinerary.
To begin with, all seems okay. She joins 5 other people on the trip and has a bit of an adventure out to see some volcanoes. But things start hotting up when she becomes trapped on the island and begins to figure out what is happening around her – a tale of surreal conspiracy and powerful corporate entities plotting to stage a plausible disaster.
First published in Korean in 2013 but translated into English in 2020 by Lizzie Buehler sometimes it feels like the characters are a bit thin; we hear nothing of Yona’s life outside of work and her love story comes across as just lukewarm. Of course, as an emergency manager, I also naturally took issue at the use of ‘natural disaster’ throughout (see here for why natural disasters don’t exist).
There were also sections of the book, later in the story, which I found myself reflecting on in ways other readers perhaps wouldn’t. As emergency managers we develop similar stories for training exercises, and the faceless/nameless identities of the characters in those exercises seemed all too familiar whilst reading this.
It’s a short book at just 180 or so pages. I read it to a background of TV news showing Hurricane Ida making landfall in Louisianna, which seemed especially resonant. As Yona herself contemplates “disaster lays dormant in every corner, like depression. You never knew when it might spring into terrible action”.
The Disaster Tourist is thought-provoking throughout (especially as an emergency manager) but I suspect it takes on a slightly different relevance for everyone now contemplating post-pandemic travel.
And finally, it’s unlikely that other readers would draw a similar parallels, but this section seemed prophetic having been written in 2013…
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.”