Ebola: Let The Pilots Lead Us

Flying is, contrary to the cliché, very dangerous. Dynamically-speaking

It is so dangerous that pilots do a methodical series of checks before every flight. And they have many "fire-drill" style procedures to follow in case something goes wrong during a flight (for example, the stall procedure).

Because these checks and methods are in place, air travel is quite safe. Statistically-speaking..

I make this point because I want to reveal the dangerous illusion of thinking in a statistical manner rather than in a dynamic manner when it comes to disasters. You think in circles when you think statistically. You look at things as giant lumps, from a distance, but you don't open them up and get into how they interact and operate. And you need to do that to understand disasters.

Driving is more dangerous than flying, statistically, because it's so much safer than flying, dynamically. Because it's so safe to drive, dynamically, we have a lackadaisical attitude toward it. Thus, it becomes more dangerous overall -- statistically. (Who here drives a car with  the kind of safety checklist and emergency training a pilot uses while flying? Nobody. You just get in your car and go without too much thought.)

When you understand what pilots do, you see how statistics lie. Air travel IS dangerous. If your engine goes while you're driving, you can pull over, call a tow truck, et cetera. If your engine goes while you're flying, there's a good chance you'll die. Because of that, you make damn sure your engine won't go!: you check it before each flight; you put switches and gauges in the cockpit to give you precise control over the engine; you design the aircraft with multiple engines so one can go down and you'll still survive, and so on.

Likewise, you need to think dynamically when you think about disasters. You need to think more in terms of immediate cause-and-effect, less in terms of abstractions and removed statistics. Otherwise there's a good chance you'll kill people unnecessarily.

Lets look at some dangerous illusions being caused by statistical, abstract and circular (non-dynamic) thinking patterns about this ebola situation...

Illusion: "More people die from influenza (cancer, smoking, etc) than from ebola."

Hello? If ebola were as widespread as common influenza (just an example), what do you think things would look like then? Yes, that's right: we'd have something like a zombie apocalypse on our hands. So while, statistically, common influenza (cancer, smoking, etc) is more dangerous (now), in dynamic terms these things are nowhere near as dangerous. A person who catches ebola has a 90% chance of dying within one month if they don't receive medical attention! Even with medical support, that fatality rate drops to only 50%! AND it is highly contagious! So stop making that stupid comparison!

Illusion: "We can handle ebola because we have plans in place"

Few things create the illusion of preparedness more than having a "disaster plan". In fact, veteran disaster responders even have a term for this: "the Paper Plan Syndrome". This is detailed by Dr Erik Auf der Heide, whose online book Disaster Response: Principles Of Preparedness & Coordination is a worldwide standard reference manual. (I actually met Dr Auf der Heide a number of times: he was on the Advisory Board of Code Orange, which I was a key designer of.)

Most people misunderstand the purpose of any plan, including a disaster plan. The purpose of a plan is NOT to be a book that you start to read once a disaster starts (or for that matter to be read even before a disaster). The purpose of a plan is for you to write it! Once you're done writing it, you may as well throw it all away -- except for the "cheat sheets" in it -- because, trust me, you won't be reading it during a disaster.

There are a few corollaries to this...

If you haven't written the plan, you've learned nothing. You haven't gone through the planning process, so your paper plan is as useful as a 50-year-old telephone book: good for the recycling bin, but not much more.

What is happening now trumps what you wrote in the plan! As they say, no plan survives contact with the enemy, so your plan -- again, except for the cheat sheets -- is pretty much useless. Throw it in the garbage, and start to look at the situation as it is now. If anything is going on now that contradicts the plan -- like for example, if ebola is starting to spread beyond the confines of Africa -- you need to throw away your plan and look at the situation with your eyes open. Ebola is not playing the part we wrote for it in our screenplay. Though the script we wrote is a thriller, where the heroes all live at the end, ebola might instead be reading from an apocalyptic horror story. Guess which of these two stories is going to come true?

Illusion: "We can 'screen' incoming travellers for ebola"

What does "screening" mean anyway? Can you tell me? If I add the word "enhanced" to the front of that -- "enhanced screening" -- does it really change anything?

This is what I have read, and I pay attention to red flags like this: some "screening" has consisted of the airline giving a flight of passengers questionairres to fill out. But, at the destination, all that has happened is the questionairres have been collected then left unread in a pile somewhere. So is this doing anything?

Here's another article on the limitations of screening.

The word "screen" is one of those hand-waving terms that sounds good but really means nothing. As we all know, an airport is full of people who really really want to get on that flight and go wherever they're going. They have nowhere to stay tonight; they have plans for tomorrow; et cetera. There is immense emotional pressure to just let people through. So what are passengers going to do? How will they think? Yah, maybe I have ebola... but I'll just go to the doctor if I get sick. (Let's hope they do in time.)

We need to look at this problem in tangible terms, not with meaningless abstractions like "screening". The reality is there is little barrier to travel now. If you have ebola in Africa, it might cause you a bit of trouble getting to New York, Hong Kong or wherever, but not much more than that.

Illusion: "Travel bans don't work because the sick will get through anyway"

Sure, with a travel ban in place infected people will get through. A few. But a lot fewer than will get through with no travel ban in place.

Think of a disease's transmission rate as an interest rate. A small change doesn't mean much on the surface, but when you understand that contagion is potentially exponential -- that it acts like accruing interest in a bank account -- what that means is a small change early on will snowball into a larger savings over time. In this case, a larger savings of lives.

Illusion: "A travel ban will impede us because it will cut off West Africa"

A red herring. When we speak of a "travel ban" what we mean is NOT the complete and total prevention of all air traffic. Instead we mean controlled access. Of course we need flights in and out of West Africa. We can still provide air travel to an infected region, but it would be tightly-controlled, essential-only travel.

Illusion: "Our higher levels of general sanitation will protect us"

Yeah, okay, we do wash our hands more than they do in Africa. But who washes their hands regularly when they go to a crowded nightclub? That's all it takes for a major outbreak: one symptomatic, infected person at a crowded nightclub. A perfect time and place to spread the disease.

Illusion: "This disease will kill [X] before we get it under control"

Really? How do we know there is any upper limit to the number it will kill, save for 50% of the population of the earth? In theory, it could kill that many. Statistically, we can probably assume we will get it under control, but I need to point something out: we're in uncharted territory here. We have no idea how many people this will kill before we get it under control. (Assuming we can get it under control and it doesn't become endemic, like AIDS.) Anybody who says otherwise is just pulling stuff out of thin air.

Illusion: "Ebola will never break out in North America (Europe, etc) the way it has in Africa because we have more and better healthcare, we have isolation wards, and so on."

Okay, it's true: we have all that stuff. So we'll think again in that statistical, circular manner. We'll just get in the car and drive without bothering too much with the details.

But now let's unpack this...

Do you know what an isolation ward is? Let's start with an ordinary ward. An ordinary ward is a wing of a hospital with a nursing station and a bunch of rooms, 1, 2 or 4 patients per room (about 2.5 patients per room on average).

You can turn an ordinary ward into an isolation ward. But there's a cost...

• You need to empty everybody out so that you have one patient per room.
• All the doctors, nurses and techs need to wear PPE (personal protective equipment) before going into the ward, and in particular before going into each room. Wearing PPE essentially cuts a person's work effectiveness in half, by the way: it's hot and exhausting to work in PPE. (It must be hell doing so in tropical Africa.) Not only is your labour supply cut in half, you also have to source the physical PPE itself, cleaning it and so on.
• Each room ideally needs negative pressure, which means that as you open the door, the ventilation system is sucking air into the room (helping contain the virus), venting it out the ceiling (through a hepa filter elsewhere, so you aren't spraying live ebola virons out into the air). You need to retrofit this somehow, if you have more patients and need to build more isolation wards for surge capacity.
• Every time you move a patient, you need to accompany them with security.
• Housekeeping is now a huge issue here. (And, while we're on that, think of the housekeeping burden that will be placed on victims when they are faced with the possiblity that their homes are now ebola-contaminated... even if they survive the disease!)

Now think of how much of a burden that is. Especially when you think of how taxed our hospitals are right now.

So while it's true we do have isolation beds, how many do you think we have? Perhaps 1000 in all of North America? I don't know the exact number. I can tell you one thing: not many. If we had the same number of cases in Africa here in North America, I'd say our hospitals now would be stretched to breaking. And we still haven't even topped 10,000 cases worldwide yet.

Now compare this to Spanish Flu. Millions got this disease. Do you think we could ramp up isolation to deal with that many?

Now also add in one more factor. What happens to those non-infected patients who are displaced by ebola? The ones with cancer, diabetes, whatever other disorders and ailments who now can't get a bed because entire hospitals are being turned into ebola hospitals. Some of them will die now, from lack of adequate care, whereas before ebola they would have survived. You need to add that to the casualty load.

And I want to add one final thought. And this is possibly the scariest thought. As you're ramping up all of this massive response, ebola is killing off your healthcare providers! Currently it's killed about 50% of the healthcare providers who have gone in, even with all the PPE! The personal protective equipment seems to only delay the inevitable.

AND ebola is attacking your source of supplies. How are you going to supply your hospital if its supply chains are now being infected by either ebola itself or just the fear of ebola?

I'll tell you what will happen. The same thing that happened in 1976 in Zaire, the first major ebola outbreak. The healthcare providers will simply flee the hospitals. That's how it was "contained" then. In true zombie apocalypse fashion.

What I Say: Let The Pilots Lead Us

So let me bring this full circle.

Healthcare providers, for the most part, want to take care of everybody. And thank God for that: we need them to be that way in ordinary circumstances. Some of them are "high-tech, low-touch" (i.e. hard-ass emergency responder types), but most are "high-touch, low-tech" (instinctively wanting to help everyone).

This means most of them are poorly suited to making the kind of brutally hard decisions you need to make when facing the dilemmas of a pandemic. And such a decision is that we may now need to pull back and act defensively.

I attended some Hospital Disaster Life Support courses in Washington DC. HLDS is a course that takes non-emergency healthcare providers and trains and drills them in a mass casualty situation (hospitals rely on their non-emergency people to be the reinforcements for the ER in times of disaster). What I saw reflected that most aren't well suited to making the kind of hard, defensive decisions you need to make in a disaster. In a normal situation, you put them in front of a patient and they will move mountains to help that patient. That's great, when you have a normal patient load (even during "routine emergencies" in the ER). In a disaster, however, their instinct to do that means they give lots of care to the first few people. Then when they look outside and see the huge waiting lines of people seeking care, they realize, usually too late, that they won't be able to cope. They've helped the first few tremendously, but they've killed a huge number of late-comers in so doing.

But the pilots know this kind of situation. They know the hard realities. Pilots live with apocalypse all the time. One bad landing can be an apocalypse to them. They ARE "high-tech, low-touch" -- and we need that now.  They know that if you go beyond the point-of-no-return without enough fuel for the long haul that you WILL crash and burn. So they don't mess around.

That's what we're doing now. We are messing around with this. It's a dragon we have by the tail, but we aren't adjusting to this reality.

But the pilots seem to understand. The airlines are ceasing flights into many of those areas. Nominally out of concern for the well-being of their crews. But also, I suspect, because they sense they may become the conduits which spread this disease globally, which they don't want to be. And thank God for that. We need them to do that now: a defacto travel ban. Even though they don't have any training in medicine, they know how to calculate a fuel load to get them over a long ocean haul without crashing into the abyss.