Making Choices in an Ocean of Uncertainty (Part 1)

The pandemic resulting from the spread of a novel virus, Covid-19, has pointed out many of the failures of not thinking, planning, or acting with an awareness of large systems and how they dynamically change over time. These failures occur every day in every system of support for people with disabilities, and they occur throughout the larger global complex adaptive system (CAS) that is our world. But we don’t normally see the failures except as small drops of irony. That is, we don’t see the ocean of uncertainty that is the reality of living out our lives in a Complex, Adaptive, System.

I don’t believe that any event in my life (over 7 decades) has shoved our collective face into these realities the way this virus has.

And in less than 3 months.

Much of this “in your face” quality of the pandemic is due to our “connected” world if connected is the right descriptor for experiences that can’t be avoided except in a sensory deprivation chamber, in a deep valley, underground, in Antarctica, with a face mask.

Pandemics always end, but while they are going on, they act like slow motion volcano eruptions, raining down ash on the just and unjust, rich and poor, and every other distinction we make among ourselves about our personal and social worth. Social, financial, and political choices that are usually buried or disguised become obvious. In the disability community, devaluing and destructive choices and matters of life and death become far more obvious and less hidden behind the walls of institutions and programs.

“Everything we do before a pandemic will seem alarmist. Everything we do after a pandemic will seem inadequate. This is the dilemma we face, but it should not stop us from doing what we can to prepare. We need to reach out to everyone with words that inform, but not inflame. We need to encourage everyone to prepare, but not panic.” — Michael O. Leavitt, 2007 From Telliamed Revisited

The dilemma that Leavitt describes is certainly a real one, but it is also a dilemma not just because of the impact of a pandemic, but also because those who have taken on the authority for telling us about an appropriate response have long-standing, deeply political, and financial reasons to pretend that they are in control of the pandemic and that their simple, mechanical (maybe these days data-driven), operational policies will win the day. Messaging to communities that have always believed that every problem can be solved through an operational plan, a bigger version of replacing a leaky faucet through a DIY video, makes it easier to massage away the cramps that result from economic, social, and political failure and those pesky long term consequences when they inevitably occur.

The “message is the massage”, as it were.

Pandemics have lots of explicit characteristics that make them difficult to manage using the mechanical, operational planning, and contingency planning that passes for prevention and safety these days:

• The dynamic process of a pandemic emerges from the relationship between people. Each and every contact has the capacity to spread the virus, but there is also no guarantee that the contact will, and in the immediacy of the contact, no way to tell what happened. There is no way to calculate the probability that any single contact will result in the spread, except over group and population averages that are nowhere near granular enough to track the actual dynamics of the pandemic. Your “track” of a pandemic is always well behind the reality because bugs are faster than we are and have a much longer track record of undoing our best plans for safety than we do for stopping them. This means that the evolution of the pandemic is, among other things, Fractal (everywhere at every level) and inherently uncertain.
• You can’t negotiate with a virus. You can’t intimidate a virus. A virus is like a tiny Terminator. That means that none of the standard political memes and longstanding manipulation techniques available for everyday use will actually permit social, political, and financial elites to manage pandemics the way they manage everything else of importance to them.
• Our society ordinarily uses the concept of Risk Management to deal with failure and disaster. Because the dynamic of a pandemic is a CAS, its actual path of destruction will remain uncertain until the current pandemic is over. Real Uncertainty is very, very different from calculable risk. In an uncertain ocean of possibility, every published Risk is wrong and is being used for some additional purpose besides authentically managing the actual pandemic.
• As Italy has discovered in Lombardy, being supremely confident of your individual and community’s economic strength, high health status,  and social superiority doesn’t stop the corpses from decomposing in their homes, or the stereotyped social worth calculus of global medicine from throwing whole communities under the train.
• So, in the rollup to the pandemic maximum (number of people affected, the peak of the Bell-Shaped Curve), all the numbers you are being told daily are underestimates (obviously). But it seems to me that most of the time people make decisions about their behavior on the numbers with which they are presented. How many people have been diagnosed today, and should I go to the store and buy food, or drop my child off at daycare one more day, or get drunk at the bar with my friends one more time? Our decisions are almost never made using an actual appreciation of the potential impact. Instead, we are conditioned to make choices that don’t match reality by the very efforts to educate us about what and how we should choose.
• Although this should be obvious, it isn’t the lethality of Covid-9 that is the greatest threat. Although this virus is somewhere around 20 times as lethal as the annual flu, it doesn’t come close to our ancestral pandemics.  The problem is that our healthcare system is designed around the industrial notion of Just-In-Time supply, treatment, and disposition. If everyone who got the virus had the mild version, we would be able to manage the number pretty much no matter how many there were. But 15-20% of those who become ill (some estimates are as high as 40% for risk of complications) need more than basic illness care. We are all in real trouble if that population shows up in the emergency room on the same day. If the critical care system collapses, it won’t just be people with Covid-19 complications who will die. People with other conditions that ordinarily would have gotten competent treatment aren’t going to get it.

This is why the strategy for managing the pandemic is to first contain, then mitigate the results, as in #flattenthecurve. The goal is to avoid completely overwhelming the healthcare system, under the motto, “Flatten the Curve”; it is not an attempt to prevent death, which can’t be done, but to spread it out so that system failure doesn’t dramatically increase the number who die.

#flatten the curve is a genuine strategy. It is a framework for making decisions about the two things we can never control:

• The unpredictable future;
• The eternal scarcity of resources.

#flattenthecurve creates a space of possibilities where we can build and implement operational plans that are consistent with this strategy. Many such plans are being rolled out now. Because the pandemic is fractal, the operational plans resulting from the strategy have to be fractal as well. At every level, there are things we can do to support the strategy. We don’t necessarily need to wait to be told what to do, as long as what we do in our own lives and with those about whom we care is driven by the constraints of the #flattenthecurve possibility space.

If we avoid the collapse of healthcare, we will not only minimize death in the short term, but we will create a timeframe for the longer term that allows for better choices.

Because, like all strategies, #flattenthecurve isn’t a complete answer to a pandemic (there is no complete answer to a novel pandemic).

If we minimize the total number of people who actually get the virus this time around, we leave open the possibility, in fact, the inevitability, of an annual/multi-year cycle of recurrence, much like the annual flu season. But we also will have time for a genuinely effective vaccine, drugs that interfere with the ability for the virus to enter lung cells and cause damage, improved access to (hopefully) more sophisticated and cheaper ventilator systems, and a much deeper experience of acute and long term clinical care for the fallout from the virus.

If everyone on the planet had gotten the virus in one bell-shaped curve, we might have 140 million dead, and be treating the long term effects for many years. And there would be no resources for the mitigation and management possibilities mentioned above.

A well-chosen strategy doesn’t eliminate the reason for its necessity. Rather, it enables you to manage the current and future states of the original trigger for the common good.

We have lost touch with the idea that we should think about the long term together, instead of simply maximizing our individual gratification in the short term. I hope this pandemic proves to be a tonic for our social foresight about our common threats.

Because, as bad as this virus will be, there are far worse novelties that could arise, and we don’t have any idea which one will surface next.

Working together to build real safety and flexible response must be the lesson we take from this evolving experience that we all share, and we need to use this experience to dramatically improve how we manage our uncertain future.