Introduction from David Somekh, EHFF Network Director
After our Newsletter n.6 last month which also doubled as our first COVID-19 bulletin, we offer here four thought pieces. The theme is different kinds of learning so far from the pandemic, which link to EHFF’s principal mission, that of supporting transformational change for health and healthcare in society. Shawn Day looks at the role of logistics in dealing with a crisis. Lars Munter thinks about the implications for city planning of the lessons we might be learning. I attempt to tackle the thorny question of statistics and whether we can learn anything from the figures streaming at us on a daily basis! Finally Sean Conlan reminds us that ‘Small is Beautiful’, linking alternative economics to what might come after the immediate crisis starts to settle.
On Plans and Institutional Momentum
Everyone loves a good plan. It gives direction, sets expectations, lets us know what’s coming next. It makes everything seem manageable. The problem with plans is that we have trouble letting go of them or allowing them to evolve with circumstances. Best project management principles tell us that the most effective plans are iterative and respond to changing circumstances. As Helmuth von Moltke, the 19th C military strategist reminds, ‘no battle plan ever survives contact with the enemy’ – nor should it.
During this global COVID-19 crisis, there is an ongoing debate over the effectiveness of different strategies adopted by governments to deal with the spread of this highly infectious disease. Strategy, tactics, ‘battle’ and the mobilisation of populations to marshal resources for the ‘war on COVID’ remind us that we often portray crisis management in military terms. Needless to say, it’s more than metaphorical. Throughout history, nations have risen to the challenge of war. Differing cultural, social and economic realities often lead to differing strategies. We look to history and past experience for answers.
The art of war?
We developed our healthcare plans in peacetime. The strategies, tactics and most importantly, how we manage our logistic supply are predicated upon normalcy. There are contingencies and emergency preparedness processes. This is not to sell our healthcare services short. These plans are possibly excellent, but they are facing new circumstances and great unknowns for which they were not constructed. We have built systems to fulfill these plans. But we know from organisational behaviour that bureaucracies and administrative delivery systems are intended to deliver stability. All too often, this creates behaviour that attempts to preserve the plans in place. Again, having a plan makes us feel safer and better informed. We believe that we can address complexity and engineer behaviour.
The problem is, humans are tough to engineer, and as we have learned, we are a fragile and frail lot. We have a multitude of objectives and motivations and many conflict with one another and with broader societal needs.
Dealing with contingencies is something entirely in conflict with many established bureaucracies, conditioned to achieving normalcy and stability. Plans to maintain stability don’t do well when they attempt to manage the unknown. It doesn’t fit into the plan, and this very often impacts quickly on the logistics chain – often the most complicated aspect of the battle.
Napoleon and logistics
Napoleon asserted that ‘amateurs discuss tactics, but professionals discuss logistics’. What Napoleon knew and demonstrated is that effective logistics win campaigns. The great strategists know that you can lose battles but learn from them and still win the campaign. You often need to lose to win – you have to respond to immediate circumstances and quickly assess the situation and modify tactics, strategy and plans to absorb this learning.
In academia, there is a similar disconnect between plans and objectives. Research projects demand a concise and well-framed proposal – to get funded. The problem arises when the proposal is directly repurposed to become the project plan to deliver the research. The proposal was designed to get funded. It does not necessarily have any relevance to how to conduct the project.
The human inclination to have a plan, any plan, unfit for purpose or otherwise holds true in too many sectors of society. It’s habitually human. The problem is we need rapidly evolving plans to carry out sophisticated logistical responses to the COVID-19 crises. Unfortunately, this often goes against our human and institutional tendencies.
In the UK, during both world wars, strong leadership recognised this institutional failure. During both national crises, rapid response meant moving outside the existing systems and often drafting an outsider to subvert the usual bureaucracy and put effective logistics operations into effect. Although our front-line healthcare workers are making the ultimate sacrifices to win the battle, they are suffering from a lack of supplies and appropriate personal protective equipment (PPE). This is not through negligence, but simply because logistics systems are predicated upon stability and are often by construction unprepared for emergencies. As a result, they are unable to react with agility, or as von Moltke posited, bend with the storm and respond to a fluid a situation.
During World War II, Winston Churchill turned to Max Aitken, Lord Beaverbrook, to deal with the unprecedented challenge of wartime aircraft production – especially during the Battle of Britain. A media mogul who found repeated success in the private sector, Beaverbrook cut corners, re-channelled supplies, set up parallel processes and made many enemies amongst military as he developed new efficiencies and got material and supplies to precisely where they needed to be. He was not constrained by politics or existing systems predicated upon rigid hierarchies. Beaverbrook had a single objective – maximise production to offset spiraling losses. With a clear agenda and objective, he tailored processes to meet a new reality and to re-invent these processes daily to respond to changing circumstances. He wasn’t looking for a long-term position (and frequently sought to resign) nor was he building an empire designed to be sustained. He focused on solving an immediate problem – one that was not part of the plan.
His success demonstrated that the existing logistic services in their rigidity were incapable of meeting the needs of the crisis simply because they were not designed to evolve with changing circumstances. They functioned relatively well – until they met the enemy.
Instability and innovation
Especially in Western Europe, our governments attempt to provide us with stability. We have increasingly become convinced that this is in our interest. Although not necessarily opposed to our interests, it is most clearly in the interest of the party in power. As a result, bureaucracies have evolved to support governmental interests and not necessarily serve the society it represents.
Instability may well be in society’s best interests. Instability often conditions to an ability to deal quickly with changing circumstances and ultimately deliver resiliency in an evolving world that faces many great unknowns. Realising that we know less than we may think we do reminds us of our fallibility and reaffirms our need to seek resilience and that bureaucratic stability weakens our ability to deal with crises springing from the unknown.
We find ourselves in times of great unknowns. The terrifying threat of a global pandemic with an unknown cure means we are indeed in a battle for the lives of our citizens. We have to question whether our logistic lines are appropriately capable of delivering the front-line supplies that our healthcare soldiers need. Examples from the past remind us that the circumstances we face are unique but that how we face them is something that we do know. Fresh, focussed thinking from outside blinkered systems often has mobilised new processes to meet social and human rather than our systematically generated ones. Eisenhower once said ‘Leaders win through logistics’. To not to re-invent and evolve our supply chains to deliver the materials our healthcare workers need and to fight the battle, we are all engaged in is to ignore the lessons of history.
Healthy by Design – or designed for future infections?
“Corona heralds new tasks for urban planning and design across Europe. With cholera forgotten, it’s time for an upgrade to 21st century microbiology”. Article by Lars Münter written for International Federation for Housing and Planning – http://www.ifhp.org – as part of a collaboration to explore the future of resilient, healthy cities.
“What is the most effective vector for infectious pathogens? Humans. Who do we usually cohabitate with, in our modern dwellings? Humans. Does this mean we have done what we can to reduce the risk of transmission between us? Not quite – much to our current chagrin. So, what does this mean for cities and spaces in coming years? In the US, cities from New York to Seattle are asking similar questions, while planners in and around Asia are also grappling with these issues.”
(for the rest of this article, via the link below, you can visit the IFHP website)
At the time of the lock-down in the UK in late March, we at EHFF had a discussion about how we could contribute as a European organisation in this time of crisis. As we now know, many NGOs like ourselves then started posting regular bulletins or newsletters sharing information from their perspective. E.g. our partner organisation EPF, the European Patients Forum (https://www.eu-patient.eu/COVID-19/covid-resource-point/). Our own idea was to use our links across Europe to get a perspective which could support exchange of learning between different stakeholders.
So, we decided to collect data (e.g. by joining the initiative by our German partner Healthcare Futurists ‘FasterThanCorona’ https://www.fasterthancorona.org/ ) and that work continues. Although originally only in Switzerland, Germany and Austria, they aim to extend the request for data to Anglophone countries shortly.
As all futures organisations do, we also used our horizon scanning to gain an early overview of what was happening, to see what patterns were emerging.
Although there is an understandable degree of distrust of public information, especially in a time of crisis, we were struck by what appeared to be a regular stream of what we felt was responsible and in depth reporting by many media outlets, which allowed tracking of developments not just in Europe but in other highly relevant areas like Taiwan, Singapore and New Zealand.
Nevertheless, very early on a Danish colleague, Paul Bartels, sent us a pre-publication copy of a paper from Stanford University, from Prof. John Ioannidis ‘Coronavirus disease 2019: The harms of exaggerated information and non‐evidence‐based measures‘ now available as https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7163529/
Although it makes worthwhile points, his stance is still that of an academic – in essence: we need scientific proof before we can conclude anything definite.
Learning point 1: we do know already that there are all sorts of non-sinister reasons why the figures currently published are at best an approximation to what has really happened. Depending on what country or what health system is reporting, each may differ over and above, a) the number of confirmed serious cases (usually having needed hospitalisation) and b) confirmed deaths in hospital. These are if you like, the easy figures, but how accurately (or even, roughly) do they reflect what is actually happening in each area? We know that nursing or care home numbers may or may not be included but the value of these depends on the availability of testing at those sites and it’s also known that because recording systems vary, numbers may not be synchronous. Only where ‘track and trace’ associated with comprehensive testing is in place (not many places in the world, although things are gradually improving) can we have some confidence in those figures. Add in the lack of properly validated antibody tests to detect the extent that citizens in the population may have had mild or even asymptomatic exposure to the virus, we have no idea about
the prevalence of contact with the virus in whole populations.
Learning point 2: Pronouncements by governments that ‘the curve has been flattened’ or ‘the peak has been passed’, or ‘we have a step-plan to exit the lock-down’ are more motivated by political expediency (the concern to rescue a badly impacted economy, pressure from the public to improve their quality of life after weeks deprived of normal liberties) than factual data.
Even the much touted indicator, the ‘R’ number is suspect in this scenario – does R>1 mean that subsequent deaths are acceptable? The issue is honesty – can a government be brave and honest enough to admit, that this is a hard-headed calculation about the common good, some people will continue to die, there is no ‘winning the war against the virus’ but expediency requires that, for the greater economic and social public good, we must take some risks?
Our observation is that the latter is probably appropriate provided that the lessons have been learnt which will make sure a resurgence of the disease, the so-called second wave, is mediated by preparedness – adequate resources for comprehensive testing and tracking, better provision of intensive care resources, adequate stores of protective clothing for staff in health and social care settings (both essential) but also perhaps more investment in better health education. The finger-wagging scare tactics we have seen in some places- ‘do as you are told, or people will die’ is proven to be a less effective approach than professionally led, sustained health education. All the above have one common feature – investment. Once the panic is over, can we trust governments to behave responsibly and make that investment? All we can do is hope.
In a subsequent thought piece we’ll consider the WHO Europe Health System Resource Monitor https://www.covid19healthsystem.org/mainpage.aspx , set up in early April and what we might learn from it that allows us, despite the limited value of the statistics, to draw some learning from comparing responses to the pandemic around the world.
Small is Beautiful?
When E.F. Schumacher wrote his influential treatise on economics in the early 70’s of the last century, it is unlikely that he was thinking of how a virus only about 120 nm (nano metres) could have such a profound impact on so many
aspects of our lives – from the personal to the macroeconomics – in the space of a few months.
Our world under a different sky:
The early panic buying of toilet paper (!) in western society gave way to more subtle shifts in consciousness in a world of new contexts and behaviours. More time at home has led to the revival of old and the development of new activities – evidenced by shortages of baking materials – flour, yeast – and the rapid growth in online activities commercial, educational and developmental.
The realisation that no work commute and obligatory virtual meetings actually can make for a better lifestyle, has set the foundation for profound workplace changes in the future. For those fortunate enough not to be directly impacted, the slower pace of life, absence of traffic and noise, and the changes in human behaviour have all led to greater awareness – of breathing oxygen, of hearing the birds sing, seeing the stars, of our place in nature and in the cosmos. Ornithologists have noted that birds themselves are more relaxed, while hits on bird-watching sites have more than trebled. Although nature itself has not changed very much, humans are limited in travelling, have more time and therefore are much more aware of what is around them.
Public and social gatherings of all types from sports to the arts have been curtailed, and while many artists and musicians have taken to online platforms, these initiatives have led to questions about how we recognise and reward our artists for their work, who benefits, and indeed the place of the arts in our lives.
However, these forced limitations on our lives are having other perhaps deeper consequences. The full impact of the virus on mental health, loneliness, domestic violence, addiction, or our physical health for example, has yet to be determined. Add to this, dramatic changes imposed on our witness of life’s passing stages such as marriage and death as well as rituals and religious observations. The unfolding consequences of approaches and actions on how to resource the protection of vulnerable sections of the population, such as the elderly and the very young shines a light on fundamental ethical questions for society. Is it an accident that in Ireland, for example, large numbers of Nursing Home staff are ‘agency workers’ typically non-nationals?
The virus has also shone a light on a variety of leadership approaches in different countries. Invariably our politicians all claim to be following ‘scientific advice’ or more bluntly ‘the science’. The gravity of decisions made – including limitations on movement, development of tracking methods, allocation of very significant resources (regionally, by group..) how older people are treated and even sharing of resources with other countries – often evade scrutiny or deny debate by invoking various excuses such as legal advice, constitutional obstacles etc. In so doing the very basis of our democracies is threatened.
Another threat on the horizon:
While the catastrophic economic consequences with collapsing businesses and uncertainty in employment continues to unfold, more subtle but equally serious changes are taking place. The accelerating pressure on traditional media, particularly newsprint, as advertising revenues free-fall seriously threatens the voice of independent journalism. This has brought into sharp focus the global dominance of particularly Google and Facebook. In Ireland, which is typical of other western European countries in this respect, these two companies alone collected an estimated 40% of total advertising spend, and are believed to control more than 80 % of the online advertising market. This dominance makes it unlikely that smaller players can break into and survive in the new online world. As we emerge into the next post-pandemic phase, there is the greatest need for the transparency and scrutiny which a diverse and healthy communications sector facilitates.
Can global disaster lead to lasting changes for the better?
There is also an underlying current of reflection emerging on the opportunities of building totally new economic and social approaches. Articles linking the causes of the pandemic and particularly its rapid spread with our traditional approaches to supply-chains, global commerce, cheap travel etc., are also turning an eye to innovative approaches and reflections on GDP dominance, reliance on economic growth, and how better to monitor health, well-being and quality of life.
Fifty years on, E.F. Schumacher and his thinking are more relevant than ever.
Seán Ó Conláin 04.05.20