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Book Review: The Premonition by Michael Lewis

Book Review: The Premonition by Michael Lewis

Reading Time: 5 minutes

 

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…

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

Pandemic Anytown

Pandemic Anytown

Reading Time: 3 minutes

Remember that song you learnt at school… “the knee bone’s connected to the leg bone“? Well, that song tells us to think of the body as a system of interconnected and interdependent components which work together to form a whole. Make a change somewhere and the repercussions of that will be felt elsewhere.

Other metaphors are available: The butterfly effect. The domino effect.

For a whole host of reasons though, we often focus more on components over systems; and it’s important we do that.

It’s important that when we plug something into an electrical socket or turn on a tap that what we are expecting comes out.

But we should ask ourselves why that is important. It’s important because, owing to our highly connected modern society, when a component fails the cascading impacts of that can be felt far and wide. It’s not just inconvenient, it can sometimes have direct safety implications.

When an earthquake struck northern Italy in 2013, the NHS in the UK had a supply issue with dialysis tubing.

We’re seeing similar right now with the COVID pandemic. It’s not just the impact of people who contract the disease, but the far-ranging impacts and knock-on effects of social distancing and isolation, reduced international travel and changing perceptions of risk.

I started the ANYTOWN project in 2013 as an attempt to better understand and describe how a partial or total failure of a network can impact on other connected networks. In some circumstances, this can lead to a much larger range of impacts than just the initiating incident.

Previous blog posts about ANYTOWN cover a bit more of the background of the project. But I’ve been attempting to apply the same model to describe what we are seeing (and may see in the coming months) with COVID.

There is very little ‘real science’ to this. Previous Anytown work was informed by extensive focus group research. However, as this is a highly dynamic situation this is primarily my musings. I shared it on LinkedIn over the last week and I’m indebted to those who have made suggestions and offered feedback.

This is is a work in progress. It is biased towards my own experiences as a middle-class white man in his thirties in London. I appreciate that other people’s experience of COVID will be different. I want to reflect that in future versions, but at the moment it is a limitation that I have noted.

Here’s version 1.2 for you to explore…

Starting in the centre is the initiating incident, in this case, the pandemic virus. Although there may be some specifics to COVID I suspect many of the cascading consequences would be relatively similar across different global pandemic threats.

The next ring out from the centre describes the ‘first-order’ impacts that are/have been observed across a range of different sectors. So some of the first impacts that would be anticipated (and have played out with COVID) are the introduction of social distancing measures, reduced public transport use and increased handwashing.

Second and third-order impacts for each sector are then captured as you move further from the centre. The diagram deliberately doesn’t indicate timescales; I intended this to help understand sequence, not timing.

This is a bit of a thought experiment to see if the model would work having previously been geared towards ‘hard infrastructure’ systems failure. I think it does, but it needs some development. I’m incredibly grateful to those who have made suggestions (I haven’t checked that it’s ok to specifically credit them so acknowledgements to feature in a future version!) or have commented that they have found it useful.

It’s not the answer to the problem. Not by any means.

But hopefully, it’s a useful tool to help us all to think about how our increasing interconnectedness. Normally this is super helpful, but it can sometimes work against us. At a time when there’s lots of uncertainty about lots of things, perhaps this offers a bit of a glimpse into the future to help us be prepared.

Standard Recovery? Recovery Standards?

Standard Recovery? Recovery Standards?

Reading Time: 2 minutes

In two week’s time, I’m moderating a conference panel session entitled Standards in Recovery: Are we getting it right and what have we learnt from recent incidents? 

This blog is an attempt to organise my thoughts and set out my own views, rather than to reach any particular conclusions!

On the face of it, standards seem like a good idea in anything; normalising complicated processes or ensuring homogenous technical precision. However, you don’t have to look too far before you realise that the issue of standards is polarizing and fraught with challenges.

That doesn’t mean they can’t be useful, just that extra care is needed in their development and application, as well as the performance management which flows from them.

Standards came to prominence around the time of the Industrial Revolution, allowing manufacturing industries to regularise processes and reduce waste. Things we take for granted are the result of standards which have developed over long durations.

I can easily conceive of, and ascribe value to, standards for ‘technical’ things. Even if I’m not an expert in the subject, I can see why it would be advantageous to standardise things like:

  • How much electricity comes out of your sockets.
  • How bright your lightbulbs are.
  • How can you be confident your eggs are salmonella free.

I can also see that standardising language/terminology would be helpful in establishing a shared understanding.

However, I find it harder to see how a meaningful standard can be developed for the complex set of processes associated with emergency recovery. Like Alice falling down the rabbit hole, there is a seemingly endless range of questions and possible answers about what recovery is, and how it should be done.

So I turned to Lewis Carrol to see if he had any wisdom…

‘Would you tell me, please, which way I ought to go from here?’ asked Alice.

‘That depends a good deal on where you want to get to,’ said the Cat.

‘I don’t much care where –’ 

‘Then it doesn’t matter which way you go,’ 

Can we really know what we’re recovering from until an incident happens? If there isn’t a fixed destination for recovery, how will we know we’re there?

So, looking forward to the conference session, here are some of the questions that I’ll have in reserve for my esteemed panel members to respond to:

  • Just what is ‘recovery’ in the context of an emergency?
  • In their experience, when does ‘recovery’ start and finish?
  • What do you think a standard for recovery would look like?
  • Should a standard for recovery be specific or allow for flexibility? If it gives too much room for manoeuvre is it really a standard?
  • Have emergency responder organisations already adopted any of the standards out there? What has been their experience and how can we learn from it?
  • Is there a danger that standards become increasingly complex over time and require disproportionate effort to maintain and measure against?

What’s your perspective on these issues? My experience is that, as a profession, recovery is overlooked in favour of areas which are arguably easier to measure impact or seen to be more exciting.

Leave a comment or start a discussion with me on Twitter.

Rethinking Recovery

Rethinking Recovery

Reading Time: 2 minutes

It’s cliche, but recovery starts at the moment that something bad happens. If you fall down and break your leg, nobody says “oh, just wait a bit before getting medical attention”; you get the help that you need when you most need it.

recoveryIn a disaster, there is almost unanimous agreement that recovery starts as soon as the incident happens. I fundamentally agree with this, and in a broad sense even response activities can be classified as ‘recovery’ interventions of some sort. However, in the typically process-dominated world of emergency management (in the UK at least) this mantra that recovery starts at the outset of the incident is, in my opinion, both misinterpreted and over simplified.

Let’s revisit the broken leg scenario – yes you get help, but you don’t skip straight to physiotherapy…you need time to heal first.

As I’ve been working on the planning for Exercise Unified Response I’ve been frustrated by comments from colleagues insisting that because we have this mantra, that there should be recovery meetings from the outset. On one hand I agree with the philosophy, but on the other hand in practical terms surely you need to understand what it is you’re recovering from before you try to attempt recovery?

In my experience it’s rare that the precise impact of an incident is understood from the outset. Indeed, the likelihood of cascading failures and secondary incidents means that in some circumstances the initial incident isn’t even the biggest concern from a recovery point of view.

Provided that response actions are effective and appreciative of longer-term prognosis, I think you can afford to take a breath before formally implementing structures contained within your long-term recovery plan. In the emergency phase lots of decisions need to be taken in sub-optimal conditions. It’s surely doing a disservice to the objective of long-term recovery to take decisions which have wide reaching implications without a more well developed understanding?

I’m not advocating ‘not doing recovery’, if anything it’s one of the most important aspects. I’m just saying do we need to rush into recovery at the same speed as emergency response, or should it be more considered? Would it help to view everything that happens after the incident as ‘recovery’, but that recovery needn’t rely on the activation of a specific plan?  That sometimes the rigidity of the structures that have been developed can be a constraint?

There you have it, my first blog in ages, and I’m posing what I expect is a fairly controversial question! I’d be interested in your views about the practicality of when recovery can actually start!

30 Days, 30 Ways: Day 17

30 Days, 30 Ways: Day 17

Reading Time: 2 minutes

Recovery is often overlooked. Not just by members of the public but, in my experience, also by resilience practitioners themselves.

Thinking about what documents could be needed following an emergency in advance can make it far easier in the event of needing them; and that is the focus of today’s 30Days challenge.

House_Documents

1 Pt: Do you have a copy of important documents stored?  What types of important documents do you keep?

2 Pts:   Share some examples of how you can safely store important records and how often you update them.

The following are often suggested as important documents to keep copies of

  • Passport and driving license – important for identifying who you are! If your house has been destroyed how can you prove to authorities that it was your home?
  • financial Documents – proof of past income can be helpful in arranging access to loans if necessary, and proof of purchase of items or an inventory can assist with making insurance claims
  • Insurance documents – who know’s their policy number, or has actually read the small print? Having a copy can be useful to double check details
  • Other Personal Documents – this could include things like wills, family birth and death certificates, disability of medical records, educational records or certificates Payslips and Bank Account documents

In addition to these, I also have copies of my emergency contacts and documents with a particular sentimental value – such as photographs.

Where I can, I keep paper and digital copies. Automated backups to the Cloud are great for the times when your phone breaks or you delete a photo by mistake. However, I also have an external hard drive connected to my broadband router to provide another level of fallback. Currently my physical copies are not particularly well stored (i.e. not fire proof or water proof) but that’s something I’m slowly working on; and should I need it, the British Damage Management Association provides a useful source of advice on restoration of damaged documents. Keeping physical copies up to date is more challenging, but is something that I do from time to time, usually when it’s raining at a weekend and I don’t fancy venturing outside!

Speaking of rain, I’ve also been growing my own Rainy Day Fund over the last couple of years. Whilst not a document per-se it’s definitely something that I think could be very useful following an emergency, and could make recovery a smoother and less stressful process.