when we are in the middle of what we study
Comments as the rolling outbreaks of COVID-19 unfold across the world
woods.2 (at) osu.edu
The work in Cognitive Systems and Resilient Systems as well as in systems safety and disaster resilience around the world have looked at emergency operations in complex systems across many settings for a very long time. The events and studies have been scaling up over the last 20 years and now we are in the middle of a global scale event. We are experiencing ourselves many of the processes that play out for people caught up in these events – the noise, the uncertainty, confusion, the selfish responses, the mis-coordination, the exemplary behavior, the incredible endurance of those who find themselves at the front lines, the slow/stale reactions of the management and political classes, and the muddling through that is always part of these events whatever the scale.
Here are my comments as the situation has unfolded and emailed as part of discussions with colleagues.
April 3, 2020 Team USA steps up
My colleague Mike Rayo followed up Team Defense is about Help basketball metaphor with his own from volleyball. He writes:
“Sports give us plenty of guidance about teamwork, which we need right now! We need to think of ourselves as #TeamUSA, and we’re all suiting up. One important lesson comes from volleyball: You never call YOURS on a volleyball court … you call MINE. From a really good friend of mine, ‘Coach would have our asses [his words, not mine] if we just looked at each other and the ball fell in between us. You always call MINE. In fact, I once broke my nose because I and another player both called mine and never let up. No regrets.’ You can stay out of the action, or you can call MINE. Anything else just gets in the way.”
April 2, 2020 Moral action in pandemic 2
A discussion on the moral dimensions of responding to a pandemic with Sidney Dekker too. You may want to refer to what I wrote on moral agency on March 26 and in the 10 point piece (see link at March 31 entry).
March 31, 2020 Webinar followup: Team Defense is based on a system of help
In the March 30, 2020 webinar on Resilience Engineering and Covid-19 pandemic, a colleague asked how should society make the trade-off between the consequences of massive economic disruption versus the aggressive actions needed to turnaround virus transmission, reduce hospital overload, and minimize fatalities.
As is always the case in systems safety, efforts to prevent harm and deaths runs into pressures to reduce economic costs and increase productivity. The history of systems safety reveals a longstanding struggle to manage the trade-off. For the most part, we see an oscillation where a dramatic public accident shifts the balance toward investments to reduce risks. But the investment is usually narrow as discounting processes take hold — the lessons don’t apply to me because my activity is different or we are more careful than those people or that group. Even in the areas that make new investments in safety, the investment isn’t sustainable as pressure for optimality on economic criteria dominates again.
Resilience Engineering began with identifying fundamental trade-offs and basic patterns in how human systems across scales navigate the multi-dimensional trade space. Some patterns increase risks of breakdowns in adaptive behavior and others reveal key sources of resilient performance. Simply moving an operating point back and forth on one trade-off curve is ineffective.
The current situation in the rolling Covid-19 outbreaks across the globe reflects the science about managing and mis-managing the multiple trade-off dimensions. In particular, the current situation highlights the importance of anticipation — building the readiness to respond before a crunch happens despite the impact on usual practices that balance efficiency pressures. Otherwise, the risk of decompensation gets too high.
We see the consequences of waiting too long to act in several areas around the world. When jurisdictions miss the window of opportunity for aggressive action, the consequences get much more severe in economic disruption, more overstressed hospital systems, and fatalities which reflect higher excessive death counts.
Then various perspectives argue about a single trade-off dimension asking whether the consequences of economic disruption are worse than higher excessive death counts. Like the battle between safety vs economy in the history of system safety, the opposition between these two poles is both false and ineffective.
However the science about complexity and adaptation behind the above result is far from simple. We are in the middle of a crisis and how authorities and the public perceive the trade-off can and have delayed actions to turnaround transmission rate, led to overloaded hospitals, and rising deaths in those areas slammed by the patient surge.
How to explain and connect the science on complexity and adaptation to facilitate actions that reduce deaths and mitigate economic disruption? Sleeping on it, the metaphor that came to mind is team defense in basketball (maybe since we would normally be glued to the screen watching college basketball these last couple of weeks).
I asked one of our graduate students, Carmen Grande Pardo, who also happens to have been the starting point guard on the OSU basketball team and on international teams to explain how team defense is built up as a metaphor to understand how this virus is affecting our society, our economy, and our medical response. She writes:
“We all love sports. Basketball is one of the most popular sports in the world at the moment but the seasons are cut short due to the Covid-19 virus. However, we can use the sport of basketball as a metaphor to understand how this virus is affecting our society, our economy and our medical response.
Like any healthcare system, basketball has front end workers (the players and coaches), and blunt end workers (those in administration, basically anyone who has influence on how the team, season, competitions are run). Right now we are in an extended competition between Team USA (everyone in the country plays a role) and Team Covid (which has evolved a strategy that is working for the moment to infect large numbers of people given its transmission characteristics, lethality, time delays, etc.).
In Team USA’s basketball game against Team Covid, The players on the court for Team USA represent our nurses, doctors, respiratory therapists, and anyone who is working face-to-face with a patient to save a life, delivering care. The coaches represent our hospital supervisors, epidemiologists, infectious disease specialists, administrative health care staff, or anyone who is directing workers and making sure that our front lines are prepared and ready to play strong defense against Team Covid. Our scouting on Team Covid tells us that they are a very offensive-oriented team, meaning that our defense is going to need to be on point to stop Team Covid. We are going to have to be able to adapt and run some defenses that we have not even worked on, depending on what offense Team Covid decides to run and how they surprise us. We have been learning a lot of the plays that Team Covid likes to run.
In the beginning, we started with man-to-man defense. The person guarding the ball has poor footwork and the opposing player on Team Covid keeps driving to the rim. The person whose role is ‘help’ for Team USA has to make a decision: leave her person and help defend, or stay where she is to prevent a pass to the player she is guarding.
Given Team Covid has two easy scoring options, which move — stay or help — is the correct answer for the defender at that point? The solution can only arise from the plans and skills for team defense.
The helper will step up to double team the Covid player driving because the team defense plan/practice means a team member will recognize what is developing and rotate to cover the other Covid player. The team defense skills provide a way to cover both Team Covid scoring options.
Unfortunately, Team Covid has been scoring easy points because Team USA’s defense plans have been slow and weak. The lack of sufficient testing resources has blocked deploying the classic test, track, isolate defense. Team USA has needed to develop some alternative defensive plans and bring in new playing skills to slow down Team Covid’s momentum.
In our metaphor, Team Covid got ahead leaving our medical system to scramble to increase our resources to mitigate the virus scoring excessive deaths. We are improvising multiple ways to help the hospital systems from overload by finding ways to supply and conserve PPE (Personal Protective Equipment), shift care for non-Covid-19 patients to tele-health, drive-thru testing, and many more. All of the players and coaches are stepping up to provide help to the player under pressure. Building a new plan and capability for team defense relies on common effort, trust, adaptation, coordination.
But Team USA is still in a scramble and the whole team has to rotate in order to stop the Virus. The players, our front line health-workers, are working to offset Team Covid’s aggressive offense. They will be on the court as taking care of others is their passion despite the personal stress and risks from being behind. Our metaphorical coaches, athletic directors, trainers, etc. can make all the resources available to help our players succeed. Governments, leaders, supervisors can make all the resources available and expand the capabilities to protect front-line workers and provide the resources to treat severely ill patients.”
Ultimately the answer to the dilemma of economic disruption and excessive death is build team defense. Team defense is based on a system of help. When the help is missing or comes too slowly, the virus scores easy points and gets a big lead — spreading more widely, triggering new outbreaks across the world, generating more seriously ill, producing more overload on hospital systems.
Building and executing team defense brings many roles and levels of society together to coordinate help so the front line team can play well against Team Covid and adapt swiftly as the details on the ground shift. Team defense goes beyond the players on the court to include the front office, the referees, the fans, the league — every one. This is the need to build solidarity across all of the roles and layers to reduce excessive death tolls and to compensate for the economic disruptions that accompany building the team defense.
But as in our own systems safety work, we see other classes of responses – notably, defection from team defense as individuals retreat to selfish short term behavior and exploitation of the breakdown of team defense to pursue unrelated contentious policy, political and economic goals. So what will we see — solidarity or exploitation across the roles in society? Regardless, there will be those on the front lines who will struggle on, despite the personal risk, to care for the seriously ill no matter the help or lack of help from everywhere else.
March 31, 2020 REA Webinar Video and Links to 2 Short Papers on What Matters in the Rolling Outbreaks
March 28, 2020 Anticipation and Coordination; Links to Beyond Surge Capacity papers by Sheuwen Chuang
Adapting when faced with a beyond-surge capacity incident is essential for effective disaster response. Studies of sudden-onset, no-notice disaster show that emergency departments and hospitals engage in a massive ad hoc effort to generate adequate resources. They have to mobilize and reconfigure response capacity despite overload, uncertainty, and time pressure. The hospital’s ability to adapt effectively is based on anticipation in the face of uncertainty and on new forms coordination across roles and units to keep pace with the dynamic demands produced by the incident.
The anticipatory ability of individuals or an organization looks ahead to read the signs that its adaptive capacity, as it currently is configured and performs, is becoming inadequate to meet the demands it will or could encounter in the future. This produces interventions involving multiple parts of the care system to resolve resource limitations in real time.
Covid-19 moves across the world as a series of rolling outbreaks. This means different parts of the world do have time to replan ahead of whatever patient surge they will experience. I’ll cover how hospital systems are adapting ahead to generate and mobilize the response capabilities to keep pace with increasing stresses produced by the pandemic.
Among many studies of emergency medicine in mass casualty events see Sheuwen Chuang’s papers.
For an example of how the different levels of an organization adapt to handle the risks from a large scale extreme weather event see Dave Deary’s work.
These results follow the general stress-strain relationship from 2006/2008 (which provides a new way to represent adaptive landscapes). See
March 27, 2020 Video discussions with Seager and Alderson
The series of conversations with Tom Seager, Dave Alderson and myself are also available at the ISSST 2020 site. Look for a new on on moral actions in the pandemic with Sidney Dekker.
March 26, 2020 What is Moral Agency in this Crisis?
Moral agency in our crisis is about: can you do some thing to make difference, where that difference means reducing excessive deaths and supporting the people near or on the front lines who care for the sickest victims. If you can, then there is moral imperative to act to make that difference. [Afterwards we will find out more about what actions turned out to be more effective than others, but we are in the crisis and must act on uncertain information.] Acting against this principle, puts self above others and puts things above people, plus it means, the odds are, all the measures of performance in this crisis get worse.
March 25, 2020 Its all about the match or mismatch of response to demands over time
Multiple commentators (e.g., Levitt in LA Times) are pointing out the rate of infections will peak and turn around so things will be OK eventually.
The issue is what actions get the rate turned around — I keep repeating, get transmission rate below 1. One way that this happens is when the virus runs out of people to infect. If little is done, this happens when most of the population gets infected; those simulations are what have been saying 40 – 70 % of the population in ___ could end up infected. This becomes our baseline — the do nothing turnaround number in comparison to when interventions reduce transmissions below 1 . The people who have fought new infectious diseases say break the transmission quickly. If you do that, you turn around sooner – so your ratio for getting turnaround due to interventions is much better than the do nothing turnaround.
Actions affect this ratio. Which actions have the biggest impact on it? Again, standard infectious disease knowledge says: test (or equivalent)/trace/isolate combined with keep people apart depending on the virus’ bases transmission (2-4 for Covid-19). How well do other interventions work? Well we’ll see when the after-this-outbreak analyses are complete. But what matters now is some do better than others; Asian countries have had good at getting turnaround sooner than the do nothing number. Wuhan less so compared to other parts of China, Hong Kong, South Korea, etc (Taiwan mostly blocked the virus so they are different). Italy does not have a good ratio. Saying they all eventually there is a turn around and there is a sign that tells us when turnaround happens, ignores how actions make a difference.
The next thing we have said: it is about the match or mismatch of 2 rates — how actions expand the readiness to respond to patients needing hospitalization / ICU level care. If the latter does not match the growth of patients needing care, the overload increases bad outcomes. This is the excessive death ratio (or regression) — how many deaths occurred in a jurisdiction for a given policy or action relative to how many deaths were there for the best policy/actions. There will be a way to estimate the excessive deaths. So knowing that there will be a turn around says nothing about what the excessive deaths will be; acting to get a tiurnaround sooner will reduce excess deaths.
If we care for people needing hospitalization, meaning if we build enough response capability to provide appropriate level of care, how well do we perform? This will be a major contributor to excessive death calculations and the data wizards will be able to get a sense of how this part of mismatches between the 2 rates contributes to excessive deaths.
I have started to check different places to get estimates of what the range of excessive deaths can look like. The best give us a baseline and part of that is building the capability to treat the sick in ICUs given the numbers needing that level of care.
My original statement was what had been happening indicated excessive deaths could be on the order of 10x. Using todays numbers Wuhan’s estimate has dropped to under 4x. Spain right now is 7x. Italy is way higher than 10x (the estimates of death rate in the best controlled areas may drop also).
What we want to know is: how actions reduce hospitalizations (assuming most sick people get to a hospital or care facility) and how they reduce fatalities given hospitalization.
March 23, 2020 New video
March 21, 2020 New video
March 20, 2020 Message from Madrid
Another three-way conversation recorded
From a colleague with family in Madrid:
“I think it is very good that Ohio moved very swiftly; this was not the case in Madrid and the consequences are apparent.
It is also shocking how fast everything happened… almost no issue by the beginning of the spring break, but major issues by the middle of the spring break, including widespread air travel disruption.
Anyway, another good case study for you… major nonlinear effects, brittleness, lack of preparedness and understanding… ugly.”
“The crisis takes a much longer time coming than you think, and then it happens much faster than you would have thought.” Rudiger Dornbusch
Though this is just the signature of adaptive system breakdown – decompensation – and the need for anticipation despite the difficulties in acting ahead of definitive need to expand the readiness to respond. Need to monitor the change in rate of change – people aren’t plotting that (though some give us hints).
In discussions of disasters and response, we have noted for complex systems, that the reserves directly available get exhausted quickly as the disruptions last longer than planned for. Eg fuel to power backup power systems, etc. This means resupply comes into play in ways that are not thought through or prepared for. Not having enough PPE (protective gear) and exhausting the supply quickly as demand goes up for a prolonged period.
March 19, 2020 The time scales of the disease (lag) increase difficulty of acting early and building reciprocity
I think there is a basic confusion between stopping the current outbreak and what is the long term, endemic, state of the virus, interventions, and risks associated with the virus. We are in ‘stop the outbreak’ urgency while coping with the outbreak’s consequences for at risk groups.
Some of the confusion is due to multiple long time scales and global reach of the virus (some is due to oversimplification fallacies). Month(s) long process of stopping what is really a series of regional outbreaks that spread over the globe. What happens after this when the virus is established is not really relevant now: too many unknowns and too many issues with what interventions we will develop and deploy over the next 12 -24 months. Both are longer scale than we like to think about so they blur together. The 2 processes will overlap in time so it’s easy to conflate them. But they are different relative to what are productive actions and the 2nd longer process is influenced a lot by what happens in first outbreak control process and sequence.
Botching the outbreak control can mean the virus keeps infecting til most of the population in some regions have it – this is what the sim people are projecting when they say up to 70% of the population will be infected with the virus with millions of hospitalizations. This is defeatist and you get quackery like Boris’ advisor saying we will build herd immunity and claims this is OK as the virus spreads completely through the population.
China has broken the outbreak. Same for Taiwan, Singapore, & I think Korea (if there is prejudice it should be directed to the West for incompetence). The countries that have been successful (or nearly there) are in a post-outbreak monitoring for flare ups and defending against reinfections from parts of the globe where the outbreak is growing. Testing on massive scale and tracing has been the key. The outbreaks can be stopped.
The breakdown in decisive steps early across the West and some other areas (plus Brazil and we’ll see) plus the breakdown in testing and the inadequate supplies of protective gear mean the outbreaks will be larger and longer to stop across these areas.
Total breakdown of response in a region will move that region to the endemic end state much sooner, though without the interventions that will come.
The sequencing of regional outbreaks across the world will mean some barriers will stay up as part of post-outbreak monitoring for flare ups and defending against reinfections for regions that stop the outbreak. This means a variety of pre-COVID-19 normal will not return to “normal”. As an aside, as these 2 processes (sequence of regional outbreak control and endemic viral presence) unfold over the next 24+ months, we will see that little “returns to previous normal.” The pseudo-models of return to previous will be exposed as bankrupt on every dimension (but zombies of oversimplification rarely die).
Reciprocity type of relationships at many levels are important in this kind of situation (despite the isolation measures). Reciprocity also will be fragile. Breakdowns in reciprocity occur when: early on, leadership thinks imposing barriers will block outbreak spreading to their region; me-first behavior given the scale at which resources and counters are needed (as in reports of Trump trying to buy German company to guarantee supplies to US); during post-outbreak monitoring, groups/regions late in the sequence or lagging in outbreak control will be labelled as ‘bad’ and experience forms of social prejudice. Plus the usual scapegoating processes and segments of the previous leadership class deflecting anger to other out-groups to distract from their failures and to try to preserve their privilege (though there will be a some shifting of the composition of the leadership class given the scale and depth of disruptions).
Some groups/people will step up to the challenges (as we say, some people are the source of resilience). This is and will be front line clinical workers but also some other groups of people who will face risks to their person and families to provide care, resupply populations, and keep basic things running (who cleans the groceries/pharmacies that stay open in shutdowns; who delivers supplies to sheltered populations). Their efforts will be exhausting. Typically, we would expect that society will fall far short in supporting, compensating, appreciating these people until well after a new normal is achieved, if at all.
The US is representative what will play out over the globe as it has continental reach, with no internal borders, inadequate testing, with subpopulations and portions of the leadership class lost in conspiracies and delusions. Already underway is a sequence of regional outbreaks across the US which will spread out given the limits on social distancing as the primary means of reducing transmission rate to below 1. Prejudicial behavior is already evident. Clinicians already are steeling themselves to step into the breach. [Remember what that phrase denotes: bombardment would breach the defensive walls, the first groups to “breach” those holes would face intense defensive attempt to rebuff the assault with the first attackers suffering enormous casualties until resistance was broken as a sense of futility spread across defenders – “forlorn hope”). Others wonder how and why they are on the front line with duties of carrying on but at personal risk so that others can live more normally – as the mythical and apocryphal British redcoated sergeant says to the private prior to a battle against all odds, “because we are here lad, nobody else” see movie Zulu, Nigel Green as Colour Sergeant Bourne at https://www.youtube.com/watch?v=HUq8gXhI0y8 ]
March 18, 2020 Shortages of PPE
Another 3 way conversation recorded
Protective gear shortages:
Ohio Governor’s briefing says insufficient protective equipment (PPE) in state and actions to “conserve” supplies.
A colleague just got a story from a nursing friend: all the nurses received their ONE paper bag last night with their PPE in it which they were instructed to “reuse” for the duration of this outbreak. They only received 1 pair of goggles and 1 of the n95 mask (which is the flimsy mask most people dispose after a few uses if not the first). She quoted it as “dark times”. Since this PPE is crucial for limiting exposures and contamination’s within the hospital, this shortage will make clinicians jobs significantly harder as well as unpleasant. They referred to having to reuse the n95 mask as “disgusting” and “unsanitary”. In general, it feels like “an army war zone” right now!
March 17, 2020
I explain some of the relevant findings for this outbreak in an interview with Tom Seager who works on sustainability and resilient infrastructures at ASU, see:
March 16, 2020 How the Blunt End supports the Sharp End in a Crisis (Polycentric Governance)
Social scientist (@RebeccaGruby) asks Ostrom’s Polycentric Governance should say a lot about how to handle outbreak. She is correct and Resilience Eng. provides some results (from Resilience Engineering lectures on polycentric architectures):
Polycentric governance intersects with nonlinear layered networks in resilience engineering (eg Doyle):
1. how to be poised to adapt in advance of a future challenge?
2. how to facilitate adaptive responses as a challenge unfolds?
Ostrom’s Polycentric governance is a general finding: neither strictly hierarchical command architecture nor a completely decentralized flat network has sufficient adaptive capacity to overcome the basic risk of brittleness. Hard constraint for all systems & scales is “viability requires extensibility”. The discovery of graceful extensibility as a basic form of adaptive capacity required to overcome brittleness but it trades-off with pursuit of optimality. Thus, Ostrom really is posing a question: of the many architectures in between flat and command, what works well when & where? Those that build and sustain graceful extensibility. Another constraint comes from work on fundamental trade-offs: Need an architecture that builds in the ability to continue to adapt over longer cycles — to find new ways to balance constraints as change continues, especially since others adapt.
Initial challenges of this outbreak operate at continental & inter-continental scale #1: Societies with experience at previous outbreaks (SARS) have anticipated, mobilized & generated responses better than those without — a difference in proactive learning.
Once into a new challenge, what matters (#2)? Strategy in 4 parts
A. Empower decentralized initiative at Sharp End Layers, up close roles. …
B. Support reciprocity across roles as overload threatens by anticipating bottlenecks ahead.
C. Broad End Layers, distant ‘supervisory’ roles coordinate/synchronize over emerging trends to meet changing priorities. …
D. Horizontal learning & exchange will emerge spontaneously and informally across units/roles facing the challenges will emerge. Broad End Layers monitor for, facilitate, cross-check, & at least do not block this.
& our studies on adaptation in a large mass casualty event at researchgate
Ohio’s response demonstrates these moving forward.
Preparing for another interview:
failed to save the first 2 tries to do follow up to first (rambling) interview
List of possible points to discuss in interview:
- Steering through threats and obstacles: verb, not category
- Risk of saturation as patients and severity increases and threatens to overload response capabilities
- Deploy, mobilize, generate additional response capabilities – build readiness to respond in advance of patients needing hospitalization
- Steering through threats and obstacles at this scale means:
- Multi-party and multi-level steering that is synchronized to expand ability to keep pace with increasing demands
- At some point lets’ break up questions and responses: eg. Scale, anticipation – staying ahead of growth of need, overload issues, rationalizing away threat, not an episode but a novel event triggering a process that will go on over a longer time scale, natural experiment in US
- At continental scale and intercontinental scale: polycentric governance, vertical and horizontal coordination as learn ways to treat and expand and preserve response capabilities. How upper echelons generate and move resources to build effectivities, entrain/help synchronize responses across scales, remove blockages, …
- Anticipation paradox: generate a readiness to respond in advance of the patient needs
- How this threat adds load and constraints on generating response capability
- Isolation units – reconfiguration
- Protective gear in “hot” zone
- How to handle arriving patients who might have COVID-19, given non-COVID-19 medical problems will arrive too
- The nature of the threat affects clinicians providing care, thus reducing the ability to provide the needed care:
- time in hot zone limited,
- how to extend effective time in hot zone,
- clinicians become potential vector for transmission,
- workers who need to be quarantined reduce clinical response capability,
- sustained performance issues
- 8% of cases in Italy are healthcare workers
- Not just an episode
March 15, 2020 Satire to highlight we’ll solve it through “herd immunity” is crazy and unethical (or the anglo world has lost its mind)
The announced English government policy (already collapsing) that large gatherings do not need to be cancelled/banned and that schools do no need to be closed is hard to justify especially given NHS overload, presumably they wanted to try to reduce the economic losses of responding to the outbreak. Then they rolled out a justification claiming it was a scientifically based plan to build herd resistance to COVID-19 presumably by having the virus spread more widely among the groups who would have mild symptoms or recover without hospital interventions.
I find this whole thing remarkably unethical. I can hardly begin to lay out how crazy this is on so many levels and dimensions. Has the anglo world lost its mind?
Such a study requires approval by a human subjects review committee. Proposers of research do not get to decide themselves if their research plans meet safety criteria for people who participate in the planned research. I took the liberty of preparing the submission for Boris PM of UK:
Proposed research submitted for approval
Let a novel virus spread through a country of 66 million people to measure the speed and scale of development of herd resistance.
(1) Immune system resistance to the new virus will develop sufficiently quickly across 60% or more of the population in the current outbreak to build herd resistance.
(2) Immune resistance of greater than 60% of population will significantly reduce the virus’ mortality statistics by age group in some future outbreak of this virus.
What is a significant reduction?
Whatever reduction in illness/deaths that reduces fear in the population enough so that economic consequences are minimized.
Evidence basis for hypothesis?
Need to find a way to justify slow and inadequate responses to the current outbreak.
Consequences if hypothesis is supported:
Substantial mortality in age groups most at risk; collapse of NHS due to overload of patients requiring hospitalization. Reduce mortality and serious illness in a second wave of virus spreading through population in the future.
Consequences if hypothesis is incorrect:
Substantial mortality in age groups most at risk; collapse of NHS due to overload of patients requiring hospitalization.
Obviously, the proposed research project is exempt from further review and can proceed.
March 14, 2020 Adapting fast to cope with beyond-surge capacity events
Looking at the Italian doctors interview about his ICU getting slammed and trying not to be overwhelmed by the surge.
A lot of the stuff we talk about in general is evident in his experiences. It also parallels our study of a mass casualty response – the clinicians adapt to somehow make up a response that gets everyone through; the planning and plans contribute very little to the front lines.
Analyses are using the #s (estimates based on current experience) to show what overload looks like. Note the critical # – length of stay in hospital until sufficient recovery – it’s a bigger than normal #. This is part of knowing how recovery processes happen after hospitalization. The Italian physician’s account of their adaptations to treat the growing need shows how front line clinical work adapts as the need they directly face grows. These are very local and an open question is how well are these processes/lessons being shared and set up by hospital systems not yet loaded with COVID-19 patients.
The care issue shifts from a standard of care centered on each patient to a standard of care centered on handling the patient load — a set — while doing the best available for all patients (given the response resources mobilized) note how the Italian physician said this in effect. Simple example: in a standard of care centered on each patient, each patient gets a physician from the appropriate medical specialty while in a potential overload situation, physicians from other specialties are recruited in and work with the specialists – so that expertise is deployed to cover patient needs in new ways.
We see a strange loop effect in this case, as well as in the IT infrastructure/DevOps incidents – providing care undermines the ability to provide care as the clinicians needed for care are themselves quarantined or get the disease, increasing cases, transmission risks, and reducing the ability to meet care needs, as is happening in northern Italy.
The US is providing an extraordinary contrast: the incoherent non-system in US provides a variety of pathways for the virus to spread and as that happens the potential for overload is scary. Cross level coordination is the only way to generate new capacity ahead of need (this coordination also facilitates varies forms of horizontal sharing).
There is no way to know what is sufficient effort to generate new readiness to respond. This means, if enough capacity is generated given the actual experienced load, afterwards there will be the perception of inefficiency or unnecessary or wasteful or overreaction – exactly what I wrote about the sacrifice judgement in the 2006 Essentials chapter, though with examples at a very different scale.
Interview with WHO head on lessons from past outbreaks, Ebola.
Highlights how timing matters and need to act aggressively early — shows anticipation paradox. Also how the standard framing of decision making leaves out time; even he is caught in this framing, when he is supporting the fundamental reframing of naturalistic decision making – time (time pressure, tempo, keeping pace) always matters.
March 12, 2020 Anticipation paradox and initial conversation on what is going on from Resilience Engineering point of view
We can think about the current unfolding epidemic as a case at scale of the general systems issues we have been thinking/writing… about for more than a decade. We are part of a multi-national scale natural laboratory on managing a spreading disruption relative to saturating critical points in the response system.
Looking at this analysis from March 10 (attempt at visual analytics of the situation in progress):
The US looks like it will be the contrast for smaller nations that have kept a lid on the epidemic, especially since we are not testing at scale. We will see how much social distancing alone reduce can peaks in hospital/ICU load/overload.
And this is not an episode to be handled and then be done with — but rather a process as a novel virus becomes endemic around the world with a time course of fluctuations, change (the virus itself) and responses as it becomes a part of the diseases of the world.
The anticipation paradox is quite evident as COVID-19 outbreaks start to roll across the world, that is, effective counters require action in advance of the direct experience of the tangible consequences of harm but the ability to engage/mobilize/generate the needed response mechanisms can be limited without tangible harm (US’s inability to get large scale testing going). The delays (slow and stale) only serve to make later responses more disruptive and less effective. Anticipation requires acting that that builds future responsiveness without waiting for definitive information. The current situation highlights that the drivers of how the outbreak unfolds is the risk of saturating and actual saturation of critical points in the response system what are the critical points which will saturate and how does this effect ability to manage impact and reduce consequences. Politically paralyzed environments are particular vulnerable to falling behind the pace of the outbreak.
Discussion with Tom Seager:
Resilience perspectives on pandemics