Mark E Keim

THE PROBLEM: PREDICTABLE SURPRISES

According to of the Harvard Business School’s professors Bazerman and Watkins, “predictable surprises are “disasters that catch leaders off guard even though they had all the information necessary to anticipate them.” These occurrences represent a “pervasive failure of leadership that holds grave consequences for individuals, organizations and society”.

There are six characteristic traits of a predictable surprise disaster:

  1. Leaders knew that a problem existed and that the problem would not solve itself.
  2. Organizational members recognize that the problem is getting worse over time.
  3. Fixing the problem would incur significant costs in the presence while the benefits of actions would be delayed.
  4. Addressing the problem typically requires incurring a certain cost while the reward is avoiding a cost that is uncertain, but likely to be much larger.
  5. Decision-makers fail to prepare for the predictable surprises because of the natural human tendency to maintain the status quo.
  6. A small vocal minority benefits from inaction and is motivated to subvert the actions of leaders for their own private benefit.

This manuscript compares the leadership challenges of the coronavirus pandemic to that of climate change. This comparison is offered as a case study for the need for risk management as a national policy that will address predictable public health emergencies in the US.

Knowing that the problem exists and that it won’t solve itself

The world has long recognized pandemic-related illness as a serious global threat.

There were three global pandemics of influenza during the 20th century: in 1918, 1957, and 1968. Most recently, pandemic-related research has grown substantially since introduction of the first trivalent influenza vaccine and the emergence of H1N1 in the 1980s.

In 2006, Congress recognized this grave threat and passed the nation’s first Pandemic and All-Hazards Preparedness Act. PAHPA I established a new Department of Health and Human Services Assistant Secretary for Preparedness and Response provided new authorities for a number of programs at the National Institutes of Health and the Centers for Disease Control and Prevention. Pandemic preparedness has, in fact, become a cornerstone of US disaster policy.

The world has also long recognized climate change as a serious global threat. In 1988, the United Nations established the Intergovernmental Panel on Climate Change to review the science of climate change, its social and economic impacts, and potential response strategies. By 2007, there was a global consensus regarding the extreme weather events that were predicted to occur with an increasing frequency and/or severity as a result of global warming.

Also by 2007, the Bush administration was already seeking to ratify a maritime boundary treaty between eight nations surrounding the arctic region that would allow for extraction of the oil, nickel and diamond resources that were known to be buried under the melting sea ice (which was then known to have already decreased by 20%).

Recognizing that the problem is getting worse over time.

In 2007, H5N1 influenza (“bird flu”) outbreaks in southeast Asia again threatened to become a global pandemic. By 2009, the US had also made its first declaration of national emergency related to a pandemic (H1N1 “swine flu”). Over a decade later, Congress continued to recognize pandemics as an imminent threat to the health and national security of Americans with passage of the 2019 Pandemic and All-Hazards Preparedness and Advancing Innovation Act (PAHPA II).

And yet, at the time of the 2020 pandemic, most Americans can easily recognize that the problem has worsened over time, particularly with respect to: stockpiling of critical medical equipment and supplies; hospital preparedness for surge capacity; bio-surveillance for active cases; accelerating medical countermeasures for outbreaks.

As early as 2013, the US Navy leadership voiced public concern regarding the impact of climate change. US Pacific Command Rear Admiral Samuel J. Locklear III then stated that, “Climate change is probably the most likely thing that is going to happen ... that will cripple the security environment, probably more likely than the other scenarios we all often talk about.’’ In the 2015 Paris Agreement, world leaders pledged to restrict the expected increase in global temperature to below 1.5° Celsius.

However, by 2017, global warming had already reached approximately 1°C pre-industrial levels. And the IPCC has also recently reported that 1.5°C could be reached in as little as 11 years — and almost certainly within 20 years without major cuts in carbon dioxide emissions.

Fixes incur significant costs with delayed benefits

Pandemic preparedness is not an inexpensive endeavor. The long-term management of a stockpile inventory requires an ongoing and steadfast commitment sustained over multiple political administrations. Like most risk management activities, the expected benefits are often delayed. It takes time to implement effective public health interventions and to then measure their effectiveness. This time lag does not align with the short attention span of policymakers and the public.

For example, the 2006 PAHPA I legislation established nine national Preparedness Emergency Response Research Centers to conduct research for public health preparedness and emergency response. This program was then entirely defunded in 2013 (in effect, after graduating only three cohorts). This is an obvious example of the lacking public and/or political will to delay gratification long enough to even measure any return on the public investment.

The transition from fossil fuel energy is also not an inexpensive endeavor. The transition to alternate energy sources will require significant investments across multiple sectors with delayed benefits. According to the IPCC, even if significant cuts were to begin immediately, we could delay, not prevent, 1.5°C of global warming.

The costs of preparing are certain. The benefits are likely (but not as certain).

While the public and policymakers are often well aware of the potential benefits of pandemic preparedness, the “rule of rescue” instead often serves to direct most allocations of the day. As a result, costs tend to become prioritized according to acuity or immediate likelihood, as compared to the potentially high societal impact.

White House advisor John Bolton recently justified his 2018 decision to disband the National Security Council pandemic response team as “streamlining” while responsibility for monitoring threats from infectious diseases was shifted to another group. The move has since been characterized as highly impactful upon the current state of pandemic preparedness.

And, just like the COVID pandemic, it’s difficult for us to fully appreciate the benefit of preparing for climate change until we are immersed in a global crisis with few options left. The benefits of a “normal” climate are more subtle, difficult to appreciate. Uncertainty regarding the future climate is also a difficult to communicate to the public. People tend to want a “black or white” answer, many times where one does not exist. The science and practice of risk communication has developed to address this common public health challenge. Once again, the certainty of cost appears to carry more psychological weight than uncertain benefit, regardless of the scale of the potential losses or downside that may occur.

Decision-makers tend to maintain the status quo, rather than prepare

For decades, the status quo for US public health emergency management was an ad hoc response delivered during times of national crisis. Then, during the late 1990s, US policy came to recognize public health emergencies as a significant threat to national security. In 2002, Congress established the CDC Public Health Emergency Preparedness cooperative agreement as the main source of federal support for state and local public health preparedness and response). However, during 2003 to 2019 the CDC’s funding for PHEP was cut by a third (along with other key HHS programs including hospital preparedness and global health security).

With respect to climate, there are many kinds of costs associated with fossil fuel use in the form of greenhouse gas emissions and other pollution resulting from the extraction and burning of fossil fuels. These negative externalities have adverse environmental, climate and public health impacts.

According to the International Monetary Fund, "fossil fuels account for 85% of all global subsidies," and reducing these subsidies "would have lowered global carbon emissions by 28% and fossil fuel air pollution deaths by 46% and increased government revenue by 3.8% of GDP."

But rather than being phased out, fossil fuel subsidies are increasing. The latest IMF report estimates 6.5% of global GDP ($5.2 trillion) was spent on fossil fuel subsidies in 2017, a half trillion dollar increase since 2015. The largest subsidizers are China, the United States and Russia.

A small vocal minority benefits from inaction and is motivated to subvert the actions of leaders for their own private benefit.

The most vocal minority to benefit from inaction related to pandemic preparedness is the voice of (albeit well-intended) fiscal conservatism that is often given strict interpretation when applied to public health programming in general, but even more so for low probability events, such as pandemic. However, actions that may be seen in the short term as saving money tend to become lost opportunities for a return on investment that could have been monumental and perhaps even existential.

There are a number of powerful and profitable industries and nations that are affected by US climate change policy, most obvious being the energy sector. In one of the most publicized examples, of such benefit, the Heartland Institute, a $5M/year conservative public policy think tank has been at the vanguard of climate change denial in the US over the past generation. This group receives direct support from the US fossil fuel industry.

THE SOLUTION: RISK MANAGEMENT

The common thread among all predictable surprises is the nature of the disaster risk – commonly characterized as “high impact/low probability events” (HILPE). HILPE share many of the same challenges. Their definitive characteristic is that though they are unlikely to occur, the impact is devastatingly high when they do. This relative infrequency often results in a lower perception of risk among the public and policymakers. However, countering the relative low probability is the high degree of societal impact that many of these events also entail. It then becomes necessary to include these hazards in our spending and policy priorities even though the timing and degree of their impact may be less certain. Again, it is this uncertainty regarding future costs versus benefits that complicate the risk communication efforts for all of these HILPEs. If the event does not appear certain to occur during this fiscal year (or earnings quarter), it is more likely to be prioritized much lower.

Of course, the common lesson among all of these disasters is that predictable surprises are best prevented altogether, (rather than reacted to). The losses are either too great to bear for our collective health and national security or our capabilities are not developed well enough to respond to the event in such a way that would be reasonably effective (e.g. no therapeutics or vaccine for a coronavirus).

Prevention is the action of stopping “something” from occurring, in this case disaster-related disease (including injury). This “something,” also known as “risk,” occurs when there is an exposure that could result in damage or losses. Prevention seeks to lower health risk before it actually occurs to become a “health consequence.”

ISO 31000, the international standard for risk management, applies the process of prevention in three successive steps: 1) risk assessment; 2) risk communication and 3) risk treatment. The first step in risk assessment is hazard identification – the process of recognizing and characterizing terms of potential impacts and losses. The second step in risk assessment is to prioritize potential hazards and threats according to impact and probability (the measures of disaster risk). The risk assessment also includes a well-informed cost-benefit analysis that will guide future decision-making. Risk communication is the action of sharing information regarding the impact and probability of the event (i.e. the risk) with the public and decision-makers for subsequent treatment of the risk.

Bazerman and Watkins described this same risk management process, in terms of three “key actions” that may be taken to prevent predictable surprises in the future:

  • Recognition – identifying emerging threats earlier
  • Prioritization – focusing on the right problems
  • Mobilization – building support for preventative actions

These key actions serve to assess and communicate the health risks associated with both pandemics and climate change. But of course, mobilization is a much larger effort than merely risk communication -implying treatment and lowering of the risk. It is the next step – action. As Leonardo da Vinci implored, “Knowing is not enough; we must apply. Being willing is not enough; we must do.”

It is within that final task of mobilization that leadership becomes so critical and that failure of leadership becomes so obvious. And it is that failure of leadership which also defines the final characteristic of a “predictable surprise”,when mobilization of national efforts is the primary raison d’etre among public health leaders.

But, are we, as the public, absolved from any responsibility for these predictable surprises? As Joseph de Maistre pointed out, “Every nation gets the government it deserves”, and as such, we can easily see that our own citizens and policymakers have a similar propensity when making the following choices grounded in human nature:

  • denial versus recognition of risk
  • short-term versus long-term gratification
  • certain costs versus uncertain benefits
  • status quo versus change
  • inaction versus action

Indeed, we are each responsible to an extent (especially those of you reading this that may also live in a democracy where the people are directly responsible for their own government).

So, finally it comes down to you and what you must do.

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