The media is beginning to run the autopsy on our pandemic responses. (Although to be fair, outlets have been Monday morning quarterbacking from Day 1.) What exactly is the plan for the next pandemic? Of course, the real problem is that in dealing with the future, there's no plan at all.
We should begin with the words of a noted epidemiologist, Mike Tyson,
“Everyone has a plan until they get punched in the face.”
He succinctly captures the problem with plans, like those developed in the early 2000s for the next pandemic that we threw out the window in the early days of COVID-19. At the risk of extending my metaphor for just one more sentence, in planning for the next pandemic or natural disaster, we need a way to beat back those blows to move from defense to offense. Business academics have a word for that, ever since Clayton Christensen described disruptive innovation – resilience.
Let’s put planning on pause and consider how we might make our health systems more resilient so they can bob and weave in the face of challenges. Our health systems are “complex adaptive” organizations of labor, resources, and workflows, and to be resilient, they must
- Prepare for and effectively respond to crises
- Maintain core functions when a crisis hits
- Reorganize as conditions require
Resilience is not a static thing that can be pointed to, held, or copied; resilience emerges from the experience of its workers, workflows, and changing resources. Emerging is not always the result of specific designs, but resilient organizations' studies suggest some signposts we should seek.
When faced with a novel disease, we must first recognize that its impact extends far beyond where it is first seen. COVID-19 was not contained in Wuhan nor New York, or New Jersey. Responses need to be orchestrated from the national overview to the local actors.
Like an immune response, we need to send health “warriors” to the conflict. But in a system where States control licensure and public health, and the Federal government has resources, we need to establish legal and policy guides for who responds and is accountable. There were no established means to credential physicians and nurses quickly from States with resources to States in need. The current legal wrangling over mandates at every level of government speaks volumes as to is to be held accountable. Ask them; it is always someone else.
Finally, you need “a strong and committed health workforce,” those that show up for the difficult and dangerous. For COVID-19, our healthcare warriors did show up, every day and every night, with the PPE that could muster. Bless them all.
Resilient health care systems are a bit paranoid, looking over their shoulders, waiting for the “other shoe to drop.” Because they are always looking to the event horizon, they are not complacent. We were. To be prepared, we need maps of our “human, physical, and information assets that highlight areas of strength and vulnerability.” Hospitals had an intrinsic understanding of those assets, but not in a form that could be readily shared with other hospitals or the state agencies tasked with coordination. It took days before New York’s Governor had any idea of the daily bed counts, admissions, and ICU beds.
Resilient organizations must adapt to the changing conditions on the ground in front of them.
“Adaptability is the ability to transform in ways that improve function in the face of highly adverse conditions.”
For that, they “need people who are agile, comfortable with ambiguity, and able to move and change on a dime.” They change what and how they are doing in response to the conditions and data. They change quickly. Our healthcare systems turned lobbies into wards, wards into ICUs. They tried every therapeutic approach they could, including hydroxychloroquine and different ventilators. They discarded those treatments that did not work, like hydroxychloroquine, and promoted those that did, like steroids. But in many instances, the changes were not quick. Some like the blanket use of steroids waited upon data, but in other cases, institutional inertia (red tape) slowed the process. That is why infected patients were returned to nursing homes rather than to the USS Mercy, a 1,000-bed hospital ship that cared for 182 patients in 3 weeks.
Adaptive systems, to change quickly, need to involve all the necessary interests and stakeholders. We failed repeatedly. In addition to the nursing home problems, which we might argue was a misunderstanding in the heat of the moment, we cannot say the same for reopening schools. In what universe does the Board of Education in New York determine how schools will reopen without discussing it with the teachers or the parents? Not bringing everyone to the table cost our children a year of their education.
Pandemics, like natural disasters, require a range of services and expertise. You need medical knowledge, the expertise of manufacturers, logistics, and most importantly, accurate knowledge and understanding of the people and place you are trying to impact. To paraphrase Tip O’Neill, all pandemics are local (and global).
Resilient systems “think and act horizontally,” meaning across many groups of experts, and they actively break down isolated silos of information. They share and quickly disseminate information, which is “best achieved by having a designated focal point in the health system.”
COVID-19 did see COVID czars, advisors. President Trump mobilized our manufacturing resources to supply critical materials and accelerate vaccine development and production. But this collaboration was a traditional federal, top-down hierarchy. The free movement of information across multiple groups allows the resilient organization to “quickly assess situations and make good decisions that incorporate input and communication from throughout your business,” or, in this case, our nation.
Resilient systems “delegate leadership responsibility and authority down the chain of command. They give decision-making capability to frontline troops and provide the resources for rapid execution.” Here we failed. Justice Louis Brandeis said that states “are the laboratories of democracy.” They are and should have been the “laboratories of the pandemic.” To a degree, we moved the focus of leadership to the States. We see still today in the varying policies and timelines towards mandates. But the States failed to shift the focus down to our frontline troops, our local public health officials, and the community members that influence and lead.
Trust and Responsibility
Resilient organizations foster trust and hold themselves accountable. Nothing has been more difficult in the pandemic than these entangled concepts. Resilient organizations “actively weave accountability into the fabric of the culture. And it starts at the top.” No one has been held accountable. Not Governors Cuomo or DeSantis, not Dr. Fauci or America’s Frontline Doctors. No one will be held accountable other than your particular political foe.
Transparency, a foundation of trust, is about “making clear decisions, the rationale and the decision makers behind them.” Because of our inability to quickly disseminate information to all stakeholders, we could not transfer the “best available evidence from research to policy,” and we frequently failed to deliver a “clear and timely” message. Those failings were fueled by our education, which taught us little about understanding “the science” and its uncertainty; and by our belief that a sound bite or meme informed more than it inflamed and misled. What we knew and know about COVID-19 changed over time, but our institutional messaging and responses were nowhere near as agile as the virus. Our leadership chose to argue about what we should have said rather than what we should be saying now, at the moment. Our leaders use this moment to garner power and votes, not lead.
Resilient organizations need to finance their efforts – “the ability to draw on financial reserves and/or to undertake public borrowing.” That we were able to do. From income relief to the extension of unemployment benefits, rent abatement, funding vaccine development. We did manage to bolster the safety net while fueling efforts to mitigate the pandemic.
A final grade
For those of you who have not read or heard The Anthropocene Reviewed, “John Green reviews different facets of the human-centered planet—from the QWERTY keyboard and Staphylococcus aureus to the Taco Bell breakfast menu—on a five-star scale.” I will shamelessly steal that device for a moment.
On the three levels of resilience
- The capacity to transform our health system to respond – 4.5 stars
- The ability to adapt and deliver the same care with fewer or different resources – 3.5 stars
- The absorptive capacity to continue to provide basic care while dealing with a pandemic – 3 stars
On the four capacities of management
- The capacity to collect, integrate and analyze knowledge and information – 2.8 stars
- The capacity to anticipate and adapt to uncertainty and surprise – 3 stars
- The ability to manage interdependence across multiple constituencies and needs – 2 stars
- The power to “build or develop legitimate institutions that are socially accepted and contextually adapted” – 1.5 stars
Average 2.9 stars We can do a lot better. How would you grade these measures of a resilient system? Those grades provide the roadmap of how to improve. Because when we are once again punched in the face, we need resilience, not a plan.
Sources: 5 traits of resilient organizations Harvard Business Review
What is a resilient health system? Lessons from Ebola The Lancet DOI: 10.1016/S0140-6736(15)60755-3
Health systems resilience during COVID-19: Lessons for building back better World Health Organization
Health system resilience: a literature review of empirical research Health Policy and Planning DOI: /10.1093/heapol/czaa032