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Figure and Ground - A Strategic Approach to Pandemic Risk

by: SusanC

Thu Feb 28, 2008 at 10:41:11 AM EST


( - promoted by SusanC)

Here's the pdf version, which to be honest is a lot more readable.
(Comments on UK National Framework for Responding to an Influenza Pandemic vNov 07, sent to the UK Department of Health in response to their public consultation.)

SusanC :: Figure and Ground - A Strategic Approach to Pandemic Risk
Preamble
The present generation is the first to have the opportunity to prepare the country against the consequences of an influenza pandemic.  It is a novel task requiring leaders to 'think out of the box'.  It is also an unenviable task of enormous complexity.  The UK government deserves to be commended for its willingness to repeatedly consult with the public and subject this complex, ongoing, and unfinished work to the scrutiny and criticism of any who cares to do so, with or without expertise or justification.  We as citizens can only do it justice by giving our best to the process.

The current iteration of UK National Response Framework while fairly comprehensive in traditional public health and social policy terms, suffers from some conceptual flaws (or at least inadequacies) which may have contributed to significant difficulties in proper characterization and articulation of the nature of the pandemic risk, and in shifting priorities from conventional health and social policy perspectives to encompass the complexities required in 2 additional domains, that of security and continuity of infrastructure in a global networked environment, and of managing the effects of public perception and the sum total of many individual decisions.  Not all risk areas are as amenable to intervention as others, but it is possible through some critical analysis to identify certain nodes that are most likely to have large effects.  The scale of the response needs to correspond to the sum total of risks from the different domains, not just the one under consideration.  Multiple interventions applied early and targeted towards such nodes is the preferred strategic approach to mitigation. Currently the recombinant haemagglutinin vaccine is the most viable option for providing us with a pandemic vaccine in 12 instead of 20 weeks; investing in and acquiring such a vaccine is a step that may be critical to the sustainability of our response and early recovery.  There are two 'show-stoppers' that the government needs to pay special attention to: the logistical challenges for antiviral distribution, and a realistic look at the likely level of healthcare worker absenteeism.  Both require community cohesion and public trust.  

In the Beginning, There was the Word

A pandemic is potentially such a devastating event to society that we must take utmost care at every level when considering how and what national policies should be developed.  While no consensus exists, there is at least a large school of thought in the cognitive sciences that suggests that the language we use have powerful effects on our thinking [1].  For example, the word 'framework' describes a structure rather than a plan of action to secure a goal (as implied by the word 'strategy', used in US national plans [2]).  Since a pandemic is not intrinsically a structural problem, this creates a mismatch between the problem and the direction taken to generate solutions.  Such mismatches can be the cause of great institutional hardships as all levels of government are constrained to work with the problem in the way that was originally defined by the leadership.

At the most basic level, the word 'framework' implies a passive, static, and institution-centric approach that is equated more often with bureaucracy, rigidity, and complacency than with result-oriented pragmatism, creativity, and competence. In comparison, the word 'strategy' is more likely to generate an agile, adaptive, and dynamic mindset more conducive to finding innovative solutions outside normal institutional memory.  It is a lesson leaders should take to heart.

In addition, while it is true that the right institutional structure or framework is important to optimize our response to such a major challenge, a pandemic is a novel problem for which we do not have existing solutions nor much experience in developing them.  We are learning by trial and error as we go along.  Until we find solutions that work, we really do not know what is the optimal institutional structure for such solutions to become effective.

Institutional structure, process, or framework should therefore be subsumed under and be made to serve the goal of finding solutions to our challenges.  In other words, solutions should precede structure and process, and not the other way round.  High-level strategies articulated by the national leadership can lead the way and jumpstart this change.

All this is much more than idle semantic play.  For example, in 2 years of daily conversations with online flu communities, the author has witnessed many instances of creative solutions that can and should be harnessed for the good of society.  However, the most creative people are also often the most free-spirited, and most do not belong to any organization.  While in theory government and institutions can reach out and discover 'best practices' and utilize them, in reality there is no common meeting place for the two sides.  Often no mechanism is available for non-affiliated private individuals to work with official institutions.  Trying to become eligible for the smallest grant program, for example, requires the individual to overcome enormous legal and financial barriers just to get in to join the queue.  

This problem - the need to put in institutional mechanisms to connect with and harness the creativity of nonaffiliated individuals - is finally only recently recognized by the US government, to their credit, but only after the Herculean efforts of a few individuals just to create the space for dialogue!  Still, it is better to have a solution or solutions trying to find a framework for dissemination, rather than having an empty framework with no solutions that will fit in it...

Words are made of powerful stuff.  We need to focus our energy and attention on 'mitigation' rather than 'response', 'preparing' instead of 'planning'.  Finally, the idea of 'readiness' needs to be introduced into our national lexicon as a matter of urgency!

But the most important word that we need to develop a comfortable working relationship with, is the word 'risk'.

Figure and Ground - The Pandemic Risk in Context


One cannot truly deal with a problem, or a risk, unless one can describe what it is.  There is however a common perceptual error that can trip up the unwary - the classic figure and ground conundrum.  The problem is most famously represented by the 'Rubin vase' (Fig.2).  When we look at the picture, do we see the vase?  Or do we see the profiles of 2 people facing each other?  Which is the figure, which is the ground?  And which is the more important to pay attention to?  (The answer, in this instance, is both!)

Similarly, when we think of pandemics, are most planners dealing with it as primarily a public health and healthcare delivery challenge?  Are they approaching it as strictly a well-circumscribed problem that needs only text-book solutions, or are they able to look outside of the problem at the landscape, the social, economic, demographic, and humanitarian context [3] within which 'the problem' is likely to unfold?  More importantly, are they deriving useful information from constantly switching between figure and ground?

Overpopulation, Globalization, and Risk Harmonization

Pandemics do not happen in isolation.  Epidemics have caused upheavals in human societies since time immemorial.  The next pandemic is likely to happen under conditions that did not exist in previous generations. Since the last pandemic in 1968, world population has doubled, the number of cities with population over 1 million has increased 5-fold, with megacities of > 10 million sprouting all over the world, often in the most impoverished countries. A pandemic unfolding in any large urban area will have instant and dramatic effects worldwide given the 24/7 news cycles.  Considered in that light, it becomes obvious that the problems resulting from a pandemic are much more serious than can be portrayed by the simple epidemiological assumptions that we make.  While an influenza pandemic is a classic public health crisis, it is arguable that issues arising from the 'landscape' may contribute more to the sum total of societal consequences than the epidemic itself. [3]

The government has issued a set of epidemiological markers or assumptions to guide planning.  While the general principle that response should be proportionate to risk is sound, the challenge lies in developing an adequate understanding and quantification of risk in the 21st century.  Traditional public health measures such as attack rate (AR) and reproductive number (R0) developed as tools in more sedate times need to be interpreted in the context of dramatically different demographic and socioeconomic environments today.

In addition, countries are increasingly connected to and dependent on each other in complex and efficient ways [4] the effects of which are harder and harder to discern.  This has created vulnerabilities that may remain hidden until a small event triggers a sudden systemic collapse. [5] A recent report from the World Economic Forum (Global Risk 2008) highlights 4 particular vulnerabilities of the global system [5], all of which can be triggered by a pandemic:
1. Systemic financial risk
2. Food security
3. Supply chain
4. Energy

It is sobering to note that in this same report on global risks pandemic influenza is rated 3 on a scale of 5 for likelihood in 2008, 4 out of 5 for economic impact, and the most severe 5/5 for number of lives lost.[5]  In other words, this group of eminent risk experts has come to a consensus opinion that a pandemic is both a significant possibility and one of the most severe and destabilizing disasters that can happen to human society.  This is in marked contrast to the UK government's assumption of 3% risk based simply on the fact that 3 pandemics have happened in the last century - an act of 'normalisation' that finds no justification in science or statistics - and the again unsupported expectation that many of the vital functions of society will be able to continue at 'normal business levels'.   Similarly, the projected GDP loss of 0.75% in a moderate pandemic is a far cry from the 5% estimate from the World Bank and the UN. [6] These gaps in risk estimates may have arisen from a totally restrictive, linear, binary view of the problem.

A New Approach to Risk
The National Framework is the most important document that guides policy decisions at the regional and local level.  Instead of the current 'laundry-list' approach, more emphasis should be placed on assessing and articulating broader risks and consequences (ie to explore more 'ground' in the figure-ground conundrum), to provide all levels of government with a more holistic understanding of the complex issues involved.  
Good lessons can be found by reviewing the dynamic approach to risk used in compiling the Global Risk 2008 report, [5] especially the significant changes in methodology from the 2007 one.  Interestingly, although "The global risk landscape at the beginning of 2008 is broadly similar to the risk landscape at the beginning of 2007." re-defining the risk landscape using social network analysis has produced a much more organic and realistic representation of the variety of risks that interact with each other, each of which can trigger and can be triggered in any number of ways by other risks in the global network.   In this instance, the various risks (or nodes in the illustration) make up the 'figure', while the network and characteristics of the various connections form the 'ground' or the context within which the risks may affect us.  Both components, figure and ground, nodes and connections, are important in our evaluation of risk.

Within this giant global network, pandemics are but one type of risk in a system that is increasingly fragile but efficient in distributing and harmonizing risk.  While such harmonization may serve to mitigate the risks somewhat, unfortunately any 'slack' is almost immediately taken up by activities generated by hyper-efficient market mechanisms assisted by technology, such that the system is increasingly vulnerable to sudden catastrophic unpredictable failures, even without a pandemic.

The UK as High Risk
The UK is one of the most globalized nations.  Because of our high degree of social, economic, and political connectedness [7] to the rest of the world, we are particularly vulnerable to any perturbations in the system. It is likely that the next pandemic starting in a distant country will bring serious secondary and tertiary consequences to our shores well before the virus arrives.  While some of these consequences are foreseeable and therefore somewhat susceptible to mitigation, (Fig 9) the timing, precise nature of the trigger, and the severity and extent of secondary and tertiary consequences are not. [5] The risk of sudden catastrophic or cascading failures of infrastructure will be present, ongoing, and unpredictable. Risk assessment for planning purposes must make allowances for scenarios that are potentially much more dire and more unpredictable than historical experiences from previous pandemics of similar biological severity may suggest.

Critical Uncertainties in Influenza Science

H5N1 is not like any other influenza virus.
Current pandemic plans take into account scenarios with a range of severity derived from the 3 pandemics of the 20th century.  However, what is troubling the world most is the H5N1 avian influenza virus, which by all accounts is not like any other influenza virus.[8]  While for this and other reasons one cannot predict or assume it is going to cause the next pandemic, neither can we make plans based on the assumption that the next pandemic will fall within the range of and be similar to any of the three pandemics in the 20th century that we do know about.



Limits to Certainty - The 'n=1' Problem

Most of what we know about seasonal and pandemic influenza comes from studies of these 3 pandemics and interpandemic influenza disease.  Note that this knowledge is all based on one single progeny of influenza viruses - descendants of the 1918 H1N1 and the reassortants derived from them in 1957 and 1968.  Even though by convention we name the viruses according to their surface antigens and thereby they appear to acquire distinct identities, the fact remains that all current circulating human seasonal influenza A strains retain 5 of the 8 gene segments that are direct descendants of the 1918 H1N1.  

H5N1 does not share such common ancestry. Do we know whether and to what degree our knowledge from human influenza infections can be extended to an avian H5N1 that has just acquired some human-adaptation to cause a pandemic?  Not really.[9]  In addition, there is no guarantee that the virus will change its characteristics should it acquire the ability for efficient and sustained human transmissions.[10]  The clinical pattern to date has been remarkably and disturbingly consistent[11] across geographical regions and even across subclades.  We simply do not know a) whether it has the capability of acquiring such changes, or b) how severe the disease would be if that were to happen.  [9]

The 1918 pandemic showed that it is possible for a purely avian virus to cross the species barrier into humans and cause severe pandemic disease without reassortment[12].  Since then, H5N1 is the only purely avian virus that has been known to repeatedly cause severe and fatal human disease on such a scale.  The high mortality especially for adolescents and young adults exhibited in H5N1 disease may well be a feature and not an idiosyncrasy of such primary infections.  Again we simply do not know the answer to that question. [9]

It could have been a lot worse? - 1918 mortality in a different light.
In addition, the W-shaped mortality curve of the 1918 pandemic, with a reduction to below interpandemic levels for older adults, has been interpreted as a possible indication that older adults in 1918 may have had some pre-existing immunity due to prior exposure to a virus circulating before 1889.  [12, 13]  If that is the case, the extremely high CFR (70-100%) in adults seen in Alaska and some isolated islands of the Pacific [14] may have been more representative of the effects of a pandemic from such an avian virus on a truly immunologically naïve population.  While there is no evidence that this was indeed what happened, such absence of evidence cannot and should not be construed as evidence of absence, only a reflection of our ignorance and the need to guard against complacency.  
We must remember that human scientists do not write the rules of biological behavior in nature - there is no rule against a population-depletion type of disease for Homo sapiens.  We put the world in grave peril if we forget that.


(see pdf version for a more readable chart)

IImpact on Children
As a corollary to that, there is the additional need to focus on the role in transmission and the consequences of a pandemic for children. [15]  Children are important for many reasons:
1. They tend to have higher attack rates. [16, 17]
2. Higher morbidity results in significant demands on medical attention. [16]
3. They are the early transmitters in a community outbreak.  [17, 18]
4. They spend long periods of time during a school day in some of the most population-dense environments that anyone can find. The following slides illustrate this graphically.  [19]
5. Social interactions between children involve far more close physical contact than for adults.   They also have poorer control over their behaviors, and their secretions!
6. Families today have fewer children compared to previous generations.  Child mortality has plunged dramatically in the last century, such that losing a child has become a rare and catastrophic experience.  Today's parents are far less able to tolerate any actual or imagined harm to their children.  

How much pain can we stand? A Look at Age-Specific Death Rates
Parental bereavement is widely considered to be the severest trauma that any person can sustain. The pain is unrelenting and the grief prolonged.  One bereaved parent is a personal tragedy.  A nation of bereaved parents is a source of national trauma and collective discontent.  The following slide shows the effect of a 1918-like pandemic on child mortality today (US figures) [20].

The Meaning of 1% - Figure and Ground Revisited
The real impact of child deaths are often obscured in the population data, and it is only when placed against the proper context, the age specific deaths against the background of very low childhood mortality in today's society, that the full extent of the impact can be elicited.  The following table covers the full range of planning scenarios as set out in the National Framework.


In an unmitigated pandemic with moderate (35%) to high (50%) attack rates and 1% CFR, the number of child and adolescent deaths will be more than what would normally happen in 2 decades.  This is the context, the background that we must turn our minds to, however uncomfortable it makes us.

A Confluence of Nightmares
Terrifying as these numbers are, a 50% AR and 2.5% CFR resulting in 7 decades of child deaths in one season is by no means the worst case scenario.   There is at least the theoretical risk of a pandemic caused by H5N1 with no alteration in current disease characteristics, [6] including the peak CFR of 75% for those aged 10-19.  In addition, if AR is partly a function of density of environment, then the kind of age-specific AR seen in the 1957 pandemic is entirely within the reasonable range of possibilities in our world today.  A combination of a high AR and high CFR within the same age group will result in unspeakably high death tolls among our young.  
The following table is generated from age-specific attack rates from the 1957 pandemic, and the age-specific CFR of a moderated scenario of a 20-fold attenuated H5N1 pandemic virus.  Even assuming such a large degree of attenuation, the clear 'bulge' of deaths in adolescents is breathtaking, in comparison to baseline death rates.  

No Such Thing as a Mild Pandemic
Changes in societal norms and public expectations, a general risk-averse culture, and the efficiency with which small individual actions by large numbers of people can become amplified, mean that even a mild pandemic today is likely to have consequences that surpass almost all other disasters in living memory.  A graphic example of what a pandemic at the lowest end of the government's planning figures (ie 25% AR and 0.4% CFR) would look like for a city like London was described in this online blog "There is no such thing as a mild (unmitigated) pandemic" http://www.newfluwiki2.com/sho...

What IS the Risk - A Strategic View
To summarize, then, a pandemic creates a very complex risk landscape, with broadly 3 major components:
a) the epidemic itself, causing morbidity and mortality, being transmitted rapidly in an epidemic wave in a community
b) in the background, a society that is hyper-efficient in and totally dependent on trade, communications, and financial services, and deeply embedded into a complex global network of interacting systemic risks, plus
c) the sum total of many individual perspectives, the personal considerations such as the safety of our children, job security, whether we have enough food in the ladder, or concern for our community that may drive our decisions in various ways.  Each of these decisions may not be significant but when multiplied by tens or hundreds of thousands can create additional perturbations to the system.  

These 3 components combine and interact with each other to produce what one might call a 'total societal burden' of risk that will impact the likelihood of catastrophic systemic failures and/or significant social instability.  Note that this does not measure the risk to an individual, but rather reflects, for the purpose of governance, the amount of vigilance and/or intervention needed to maintain continuity of critical functions and law and order..

Shifting again between figure and ground, one can say that a pandemic is a health crisis requiring responses such as diagnostics and antiviral distribution, re-configuration of our health services to deliver care to as many as possible, and provision of palliation to those we cannot help, to name a few health responses.  It is also a security and humanitarian crisis, requiring the diversion of national resources to ensure the continuity of government and critical infrastructure, and to provide the basic requirements to sustain life such as food, water, and shelter to communities affected by the knock-on effects of the networked risks.

All that is response.  However hard we try, the scale of the problem is such that there will be significant periods and/or many communities where our response will fall short, where pockets of systemic failure will cause perturbations to the whole system in addition to local instability and suffering.  How and to what extent we can find solutions to fill this response gap, is the most important job of planners and policymakers.

From Risk to Mitigation

Of the three components, epidemic, systemic risk, and individual actions, the middle one, the networked global system, is probably the least amenable to intervention.  As discussed above, as long as it remains functional and 'online', the system is hyper-efficient in re-distributing risks as well as benefits, with multiple mechanisms available for numerous players to siphon off whatever resources that governments or institutions attempt to pour in.  In the financial markets for example, such interventions as injection of liquidity by central Banks which in normal times may be able to make a difference in re-establishing market confidence and stability, is unlikely to have the same effect in the middle of a prolonged megadisaster that overwhelms the resources of governments all over the world.  
Unfortunately, such an assessment may well become a self-fulfilling prophesy, as governments with some justification refuse to sacrifice their scarce national resources for the illusive 'common good'.  Similar issues arise between private-sector entities as well, eg different power companies connected to a grid.  Mitigation of systemic risk is possible with extensive coordination at the international level.  Such cross-sectoral work is happening - the office of the UN Systems Coordinator for Avian and Pandemic Flu works with between 500-1000 different organizations.[3]  It is however a Herculean task which is unlikely to significantly change the risk environment any time soon.

The Need for 'Over-Kill'?
We are then left with the other two options, mitigation of the epidemic, and managing the effects of the sum total of individual decisions (some would call this the 'herd instinct').  The task is to find interventions based on either one or both of these domains that when combined are sufficient to counteract the effects of all 3 different domains combined.  This is a critically important concept to bear in mind.  
At the risk of stating the obvious, systemic risk causes problems that permeate throughout the system.  In contrast, both the epidemic and personal decisions are relatively localized events at any point in time.  This is what one might describe as a 'reverse leverage' challenge.
The scales are therefore heavily tipped against us, in that utilizing interventions at the local community level, one has to achieve very good results AND achieve them consistently in enough localities to counteract the effect of systemic stresses, whereas systemic disturbances can wipe out any gains achieved at the local level without warning!  

To succeed, interventions need to be proportionate to the sum total of the combined societal risks (see 'total societal burden' above), not just the risk in the category where the intervention is applied.  Nor should such interventions be assessed only according to the needs of the local community.  Local officials need to constantly keep an eye on the big picture, the 'ground' where the community (as the 'figure') stands, to ensure that the response is sufficient to meet the collective needs of the region or even the country!

Without adequate understanding of risk as explored in this paper, the type and degree of interventions needed will often look like 'over-kill', and advocates of such policies often stand accused of fear-mongering.   This kind of misunderstanding is prevalent, and much education and communication remains to be done to overcome such biases.

Mitigating the Epidemic

Stripped down to the bare-bones, an epidemic causes societal distress by a combination of 2 parameters, the AR, and the CFR. (ie AR x CFR = mortality, which is a marker for social distress).  In theory, we can attempt mitigation of either one or both of these parameters.
Antivirals
Unfortunately, our track record in reducing CFR for H5N1 infections is very poor.  [ref]  There is insufficient evidence for us to have any degree of comfort that early administration of antivirals will make a substantial difference in mortality, even assuming little or no drug resistance and assuming problems with distribution/access have been resolved.  (See below.)  

For the purpose of changing outcomes at the individual level, we should continue our current policy of dispensing antivirals for pandemic patients.  We should however be realistic in our expectations with regards to the degree of relief that can be obtained, since at the societal level, those who are sick and are now receiving antivirals are still sick, with all the ramifications for services and absenteeism.  In other words, the use of antivirals for treatment, without concomitant use for prophylaxis for contacts, cannot be relied upon as a tool for significant mitigation of the epidemic itself.
Mitigation targeted at transmission (and therefore AR) is the major intervention for epidemic control.  This one single component is so critical for pandemic preparedness planning that, in the words of a senior public health expert,[21] "the goal of every single decision is to reduce transmission", meaning that policy decisions that do not result in reduction of transmission are probably not good ones and should be re-considered!

Social distancing
The rationale for use of early, targeted, layered community social distancing measures including proactive school dismissal has been previously described.  [22-30] The (albeit indirect) evidence of effectiveness of social distancing measures in changing outcomes in the 1918-19 pandemic continues to accumulate.  [25, 28]. However the important point to note in the current context is the issue of natural avoidance behaviors.  As experienced during SARS and other epidemic disease [31], the desire to remove oneself from possible sources of infection is as natural a behavior as removing one's hand from a hot object!  Spontaneous social distancing will happen irrespective of official advice and however much or little the community understands about the nature of the disease [31].  Our ability to target this behavior and harness it systematically for the collective good will be one of the most cost-effective interventions we will use.  Getting maximum benefits requires planning and meticulous attention to detail especially the timing of implementation.  [29]

Vaccines

The following slide was presented recently in conference [32].


In addition to summarizing the 'multiple, layered, targeted' interventions that can be applied in combination, it proposes the use of recombinant vaccines relatively early in the epidemic cycle as a tool for mitigation.
In contrast to existing egg-based vaccines, cell-based vaccines can be produced in much larger quantities and in much shorter time-frames (8-12 weeks vs 20+ weeks).  Recombinant technology which produces a pure surface protein antigen with no viral components nor genetic material[33], is the most promising process out of all the different candidates in the pipeline.  It is receiving significant attention from the US government for good reason.  The early availability of vaccines even just for a portion of the population is the light at the end of the tunnel.  It is likely to be a significant morale booster not just for our citizens but also for overseas investors.  An early return of confidence and investments will provide the much needed jobs and finances for recovery and regeneration.

The Power of Autonomous Personal Decisions

In any outbreak of a novel and deadly disease, the public is likely to adopt avoidance behaviors.  Such behaviors can be utilized and incorporated into official social distancing policy.  Good public education can assist in spreading the message that such measures protect everyone, including those who have to go to work. [29,30]
The more challenging and potentially destabilizing behavior at the beginning of a pandemic is indiscriminate hoarding of materiel and panic buying.  The biggest problem from the policy perspective is that the fear of shortages is indeed justified.  Officials are in a no win situation, as any admission of the possibility of shortages will exacerbate the panic buying, while denials will cause further loss of trust.  The solution lies in public education well ahead of a pandemic.  The panic can be reduced if a substantial proportion of families have at least 2 weeks of food and other essential supplies http://pandemicflu.gov/plan/in...  at home.  The government should issue such guidance to the general public in the next round of official guidance development.  The engagement of the public as true partners is a requirement for social stability and not an optional item on the planning menu!

Parental Risk Perception as Most Powerful Driver

In the debate over social distancing especially school closure, those who are opposed often cite the effect of child-minding needs on staff absences and therefore continuity of operations.  In theory one can compute such absences and the cost to society and debate whether such interventions are cost-effective.  In practice, such computation ignores the issue of free will, and the fact that in an outbreak of a novel and potentially lethal disease, parental perceptions of risk to their children will in most if not all cases outweigh all other considerations, such that once their risk perception hits a certain threshold, irrespective of expert advice they are likely to take the precautionary measure of keeping their children home, even sometimes at the risk of losing their jobs.  (see box p14)
It is particularly instructive when a group of public health professionals who were unable to come to a consensus over school closure (due to issues with 'evidence', among others) when asked whether they will send their children to school in a pandemic, every one of them (ie 100%) answered No. [34]

Such is the power of parental instincts to override professional judgments!
This anecdote is also instructive for the reverse reason, that professionals need to be wary of their own inability to think like ordinary people in their professional decisions.  Many are likely to misjudge what the public would do, unless they adopt the habit of regularly stepping out of their professional identities, to step in the shoes of a member of the public.

Engaging Parents
Each individual decision by a parent to keep their child at home may have minimal impact for society.  Collectively, of course, the effect can be substantial.  Note that threshold values are by definition very powerful drivers (see box p14) and are unlikely to be overcome by the usual enticements such as extra pay or appeals to altruism.  Mitigation requires the building of mutual trust and the sharing of information well ahead of a pandemic.  In addition, officials need to be aware that in heightened states of collective anxiety, the public is likely to over-interpret any remarks made by officials or anyone deemed to be a person of importance.  The solution lies not in tighter control of information but in more detailed and repeated explanations whenever comments are made.
Despite the repercussions for staff absences, parental risk perception may be one of the most powerful forces that build community preparedness.  The vast majority of content contributors on internet flu forums are parents.  Once they have become informed of the risk and started to prepare their families, many are likely over time to realize that they are only as safe as their community is safe, and that they need to help their communities build resilience and redundancy.

These informed and engaged citizens are valuable resources http://www.newfluwiki2.com/sho... both for their preparedness and for the knowledge they have acquired.  Building a relationship of trust and sustaining an ongoing dialogue with these citizens may be one of the most cost-effective ways for government to ensure that come the next pandemic, when stores are empty, hospitals are full, and officials are called upon to make difficult choices, there will at least be a small group who understand and care sufficiently to extend a helping hand.  One never knows who will be at the receiving end of that...  

And Now for the Final Curtain - Two 'Show-Stoppers'!

Show-Stopper #1 Will Healthcare Staff Come to Work?  
The issue of potential staff absenteeism is most acute in the case of healthcare workers. [35] Published studies are likely to underestimate the scale of the problem unless they use anonymous surveys.  Internet forums provide a 'safer' environment where their real fears and conflicts are revealed.  This is an area of critical importance to societal stability.  What is needed is open and honest dialogue between employers and their staff, to help establish the conditions under which they feel safe to come to work.  Most officials are still oblivious of the risk.  The following 2 links to internet discussions are therefore required reading for officials and employers!  http://allnurses.com/forums/f8...
http://www.fluwikie2.com/index...

Show-Stopper #2 How (Not) to Do Anti-Viral Distribution
http://www.newfluwiki2.com/sho...  

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references
References:

1. Marlowe M, The Effect of Language upon Thinking, April 2004 http://www.bible-researcher.co...
2. National Strategy for Pandemic Influenza, White House Homeland Security Council, Nov 2005 http://www.whitehouse.gov/home...
3. Nabarro D, Assessing the Risk of a Worldwide Avian Flu Pandemic, synopsis of speech at National Emergency Management Summit, Jan 08. http://www.newfluwiki2.com/sho...
4. Friedman T, The World Is Flat: A Brief History of the Twenty-first Century, 2005.
5. Global risk report 2008, World Economic Forum
6. Nabarro D, Harrold PC, Progress and Impact of Efforts to Control Avian Influenza and Prepare for the Next Pandemic, New Delhi International Ministerial Conference December 4, 2007
7. Dreher A, KOF Index of Globalization 2007, Swiss Institute of Business Cycle Research
8. Peiris et al, Avian Influenza Virus (H5N1): a Threat to Human Health, Clin Microbiol Rev. 2007 Apr;20(2):243-67
9. Taubenberger. The next influenza pandemic: can it be predicted? JAMA. 2007
10. WHO Working Group Report: Influenza Research at the Human and Animal Interface, Sep 2006
11. Writing committee, WHO, Update on Avian Influenza A (H5N1) Virus Infection in Humans, N Engl J Med. 2008 Jan 17;358(3):261-73.
12. Taubenberger et al, 1918 Influenza: the mother of all pandemics, Emerg Infect Dis. 2006 Jan;12(1):15-22
13. Ahmed et al, Protective immunity and susceptibility to infectious diseases: lessons from the 1918 influenza pandemic.  Nat Immunol. 2007 Nov;8(11):1188-93.
14. Crosby AW, America's Forgotten Pandemic: The Influenza of 1918, Cambridge University Press, 2003.
15. Nicoll A, Children; Avian Influenza H5N1 and Pandemics. Arch Dis Child. 2008 Jan 11
16. Glezen WP, Emerging Infections: Pandemic Influenza, Epidemiol Rev. 1996;18(1):64-76.
17. Monto et al, Modification of an outbreak of influenza in Tecumseh, Michigan by vaccination of schoolchildren, J Infect Dis. 1970 Jul-Aug;122(1):16-25
18. Brownstein, et al Identifying Pediatric Age Groups for Influenza Vaccination Using a Real-Time Regional Surveillance System  Am J Epidemiol. 2005 Oct 1;162(7):686-93.
19. US Centers for Disease Control, Interim Pre-pandemic Guidance, Community Strategy for Pandemic Influenza Mitigation, Feb 2007.
20. Venkayya R, White House Homeland Security Council. CDC Community Mitigation Stakeholders' Meeting, Dec 2006
21. Burkle F, Plenary Session: "Measuring Pandemic Preparedness, Containment, and Effectiveness for Communities", Public Health Preparedness Summit 2008 http://www.phprep.org/agenda.cfm Bootsma & Ferguson, The effect of public health measures on the 1918 influenza pandemic in U.S. cities, Proc Natl Acad Sci U S A. 2007 Apr 6
22. Glass et al, Targeted social distancing design for pandemic influenza, Emerg Infect Dis. 2006 Nov;12(11):1671-81.
23. Hatchett et al, Public health interventions and epidemic intensity during the 1918 influenza pandemic, Proc Natl Acad Sci U S A. 2007 Apr 6;
24. Heymann et al, Influence of school closure on the incidence of viral respiratory diseases among children and on health care utilization, Pediatr Infect Dis J. 2004 Jul;23(7):675-7.
25. Caley et al, Quantifying social distancing arising from pandemic influenza. J R Soc Interface. 2007 Oct 4
26. Markel et al, Nonpharmaceutical interventions implemented by US cities during the 1918-1919 influenza pandemic. JAMA. 2007 Aug 8;298(6):644-54.
27. Mamelund SE (2006) Soc Sci Med 62:923-940.
28. Gottfredsson M, Halldórsson BV, Jónsson S, Kristjánsson M, Kristjánsson, Kristinsson KG, Löve A, Blöndal T, Viboud C, Thorvaldsson S, Helgason A, Gulcher JR, Stefánsson K and Jónsdóttir I.  (2008) Proc Natl Acad Sci USA 105:1303-1308
29. Chu S, A Race to Save Our Children, May 2007 http://www.newfluwiki2.com/upl...
30. Chu S, Comments on the ECDC Interim Guide to Public Health Measures to Reduce the Impact of Influenza Pandemics during Phase 6, Jan 08 http://www.newfluwiki2.com/upl...
31. DR Congo plague outbreak spreads  http://news.bbc.co.uk/2/hi/afr... Wednesday, 23 February, 2005, 13:18 GMT
32. Robinson R, National Pandemic Influenza Medical Countermeasure Programs, National Emergency Management Summit, Feb 08
33. Treanor J et al, Safety and immunogenicity of a baculovirus-expressed hemagglutinin influenza vaccine: a randomized controlled trial., JAMA. 2007 Apr 11;297(14):1577-82.
34. CDC Community Mitigation Stakeholder Meeting, Dec 06 http://www.newfluwiki2.com/sho...
35. Balicer RD, Omer SB, Barnett DJ, Everly GS Jr. Survey of local public health workers' perceptions toward responding to an influenza pandemic. J Healthc Prot Manage. 2006;22(2):1-14.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


Values (a short explanation)
In a free society, each person makes decisions based on a set of values and beliefs that make sense to them and no one else.  Values are powerful drivers of behavior. However not all values carry the same weight nor do they act in the same way.  

If you ask someone "what's important to you about your job", they are likely to give you a list of values or criteria such as:  Good pay, Short hours, Close to home, etc.  These values determine how much they enjoy or value their work, and whether they will come to work.  They remain relatively consistent as drivers of behavior under normal circumstances.  

If however you were to ask "everything else being equal, assuming you got all this, what is it that needs to happen for you to not come to work?" you start getting a different type of answers, such as
"My daughter is sick."
"My boss yelled at me."
"I got a burst pipe at home and I have to stay till it gets fixed."

These are what we call threshold values, values or criteria that are normally not in play, but which when triggered causes the person to discard all other values and act only on this single one.

For the person who is staying home cos her daughter is sick, if you were to ask, "you are staying home cos your daughter is sick.  What is it that needs to happen for you to change your mind and go to work instead?" you may get some answer such as "if my boss threatens to fire me,".  Here we are getting into a 'Stay-Go' loop, a set of alternating values that causes the person to decide to do the opposite of what they were intending.  Both the 'stay' and 'go' are threshold values, because they induce the complete opposite behavior based on a single value on its own, every time.

These types of values are very powerful drivers.  In the case of parents, anything that involves the safety of their children is likely to rank very powerfully in that selection.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
figures and boxes are in the pdf but not (as of now) in the diary


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

sorry - you had said it. now - some feedback
My very initial reaction is: I wonder how much of this will
- sink in and
- elicit
-- action or, even more powerfully,
-- a slightly modified way of looking at the issues.

I hope it gets read.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


[ Parent ]
it gets read n/t




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
I've read it once
and I'm tempted to read it twice more:
- for the insights (not necessarily your insights, it may be my insights, and I'll report back)
- for doable items

(I first wrote this as "maybe someone will ..." but changed it to "I", but of course I'd like the "maybe someone will ..." too.)

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


[ Parent ]
maybe someone will do what?
I'm going to challenge you, ;-D to a week of only writing in complete sentences, and answering ALL of your maybe's and questions.

Maybe then you can tell us more of your insights?

LOL



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Good presentation
SusanC,

 I like your presentation and thank you for making the PDF version available.

 Some more words that may or may not fit.

Kobie

 "doing" instead of "drafting"

A disaster is a horrible time for people to exchange business cards asking "So what do you do?"

 Here in the 21st century we have so much our grand parents only dream of that it would be emabrrassing not to be as resliant and self reliant as they where. They survived 1918 pandemic with little technology, refridgeratiorn, communication or mitigation. Each person, American, European, Russian, French, Italian, Swede, Austrailain, Asian, etc should now be able to live safely and comfertably through a three month pandemic. We should learn from the past but not have to repeate it. Nor should our children or our children's children have to make the mistakes we do.

 We are truly fortunate to see this one comming. As the pandemic slowly raises its ugly head and takes hold in one place after another each person, each business and each government should prepare or answer to why they did not. Our great grandparents and forefathers never really saw this coming. We do. Mathematicaly, epidemilogicaly, and in the news all the signs are here.

 Governments can harnas the public will and couriosity now while the public is still curious. "The time to fix a leaky roof is when the sun is shining" - John F. Kennedy. The cost of doing nothing is an unprepared populus un-prepared to respond. A populous requiring more attention and help duiring any emergency. A fully prepared popoulus puts less of a strain on local rescources and the country than an unprepared on.  


Insights
A powerful analysis. ..and as lugon says...tempting to read twice more for the insights and doable items.  

Some insights (or perhaps re-statements of Susan's words):

1.  [in the 'framework' vs 'strategy' discussion on page 1]

To a degree, how a problem/threat is defined, sets the boundaries for the solution set

2.  [page 2,  "...a pandemic is a novel problem for which we do not have existing solutions nor much experience in developing them.  We are learning by trial and error as we go along.  Until we find solutions that work, we really do not know what is the optimal institutional structure for such solutions to become effective."

With many unknowns, a traditional plan (often a linear progression of steps) is unlikely to match the threat.  Therefore a menu of 'options for consideration' might be more appropriate, as in the NPI charts.  One picks and chooses based on what's presented.  The price being a pretty in-depth knowledge of pandemics (so as to have a solid foundation upon which to make correct intuitive decisions when faced with something new), and the courage to act on this.

3.  [page 3,  "Finally, the idea of 'readiness' needs to be introduced into our national lexicon as a matter of urgency!"

For those in the public safety community, readiness would need to include 'demonstrated, measured capability', and not just 'plans.'

4.  [page 4,  "A recent report from the World Economic Forum (Global Risk 2008) highlights 4 particular vulnerabilities of the global system [5], all of which can be triggered by a pandemic:

1. Systemic financial risk
2. Food security
3. Supply chain
4. Energy"    

The potential critical infrastructure degradations/failures are drivers of instability.  A key task is to drive these towards stability.

5.  [page 14,  "The biggest problem from the policy perspective is that the fear of shortages is indeed justified.  Officials are in a no win situation, as any admission of the possibility of shortages will exacerbate the panic buying, while denials will cause further loss of trust.  The solution lies in public education well ahead of a pandemic."

The RMs with the tremendous variety of projects and toolkit, and InKy's 'Just-at-Home Resilient Living Parties" are model programs for just this.


great insights, thank you
To a degree, how a problem/threat is defined, sets the boundaries for the solution set

Right on.  Or, put in another way, how we define the boundary has great impact on our perception.  it's interesting when i was researching this stuff, with the figure-ground theory, people tend to take the smaller piece as the figure (understandable) and they tend to ascribe the boundaries as belonging to the figure.  Which is important because the ability to alter boundary conditions is a powerful intervention for change.  ie you look for opportunities to break down or change the bountdaries, but if you are restricted in your perception and understanding of the boundaries, then your options for solution are more limited



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
agree!
With many unknowns, a traditional plan (often a linear progression of steps) is unlikely to match the threat.  Therefore a menu of 'options for consideration' might be more appropriate, as in the NPI charts.  One picks and chooses based on what's presented.  The price being a pretty in-depth knowledge of pandemics (so as to have a solid foundation upon which to make correct intuitive decisions when faced with something new), and the courage to act on this.

which is why I said solution has to precede institutional structure, if we have any chance of finding innovative ones

The potential critical infrastructure degradations/failures are drivers of instability.  A key task is to drive these towards stability.

Yes, instability from whatever reason and/or CI continuity breakdown.  These are the bigger problems that need mitigation.

The RMs with the tremendous variety of projects and toolkit, and InKy's 'Just-at-Home Resilient Living Parties" are model programs for just this.

Yes.  I'm trying to get them to agree to this in principle first.  Note that the UK (and most other governments) have NOT come up with recommendations for personal preparedness/stockpiling.  the fear in high circles including the US, is to tell the cat out of the bag about shortages.  I'm telling them doing it now is less painful than doing it at the beginning of a pandemic.  Vested interests focused on quarterly returns will not agree with this concept.  Hence we have our work cut out.

I'm glad you feel this is important enough to read again.  I'm writing this not just for the UK, but also cos I believe even for this forum the time is ripe for us to go to a different level of thinking, of considering how global vulnerabilities are potentially more damaging to us domestically than the little bits that we have control over.  The various photos especially the top one serve to make that point.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
...
CI is critical because the people that depend on it are not as resilient as they once were, or could be.  if we make the people more resilient, the infrastructure becomes less critical - at some point in the future, it could once again be a nice-to-have, instead of the need-to-have it is today.

the CI mindset is a hard one to step outside of - rather than taxing folks by whatever means, collecting and funneling the funds through govt, and then raining the benefits back down to the people (with considerable loss in the system)...  imagine how much (and many) we could save...  if the people became more resilient, and govt moved more toward making people aware of problems they can fix themselves, vs the govt taking on the responsibility of fixing those problems for the people (which will always result in imperfect and mis-matching solutions)..

imagine....  ;-)


[ Parent ]
Pandemic planners urged to tap grass roots
I did not see this CIDRAP article last year when it came out, but it is pertinent to this discussion:


Pandemic planners urged to tap grass roots
Maryn McKenna  Contributing Writer

Apr 17, 2007 (CIDRAP News) - Governmental plans for an influenza pandemic are missing an important opportunity to improve US preparedness, according to two new reports: They are not reaching out to communities and grass-roots groups that could refine plan details and increase public support.

Meanwhile, ad hoc communities and preparedness alliances are forming-in the real world and online-with minimal input from government planners. And, confirming the reports' concerns, some members of those communities say they have networks and resources to offer to official efforts, but are frustrated by their inability to make themselves heard.

The first report, "Community Engagement: Leadership Tool for Catastrophic Health Events," was published Apr 4 by the Center for Biosecurity at the University of Pittsburgh Medical Center (UPMC). The report, which sums up the findings of a 27-member panel convened by the center during 2006, asserts that official planning incorrectly assumes the public will panic and create a "secondary disaster."

"The civic infrastructure-comprised of the public's collective wisdom and capability to solve problems; voluntary associations (both virtual and face-to-face) that arise from shared interests or a public good; and social service organizations that look out for the well-being of various groups-is essential to managing a mass health emergency," the report says.

"US homeland security and health emergency policies, however, do not adequately reflect the civic infrastructure's proven contributions in catastrophes. Nor have most top officials yet realized the potential value for local and national communities-and for themselves-of preparing knowledgeable, trained networks of constituents who can mobilize in a crisis."

More than stockpiling
In an interview, lead author Monica Schoch-Spana, PhD, a senior associate at the UPMC center and chair of the panel, said that official planning addresses civic divisions-states, counties, cities, and towns-and then makes a long leap to individuals and households. In that leap, she said, the plans ignore the many relationships that knit together civil society and that could be used to enhance preparations before a crisis and disseminate information and organize action during one.

"If you just define citizen preparedness as stockpiling, you are only giving people limited options," she said. "There is a wide range of contributions that citizens can make, to prepare for, respond to, and recover from extreme events."

The second report, "Citizen Engagement in Emergency Planning for a Flu Pandemic," was published Apr 13 by the National Academies Press and sums up the findings of an Institute of Medicine workshop held Oct 23, 2006. It says that seeking community input about policy decisions and setting up channels through which residents can talk back to government has been critical to the success of recent environmental-action and public-health campaigns and should be folded into pandemic planning as well.

The report quotes Jason Corburn, assistant professor in the urban planning program at Columbia University, New York City: "Engaging community members and their knowledge about how they move through the world, and what they know about their disease management and exposure risks in their community, can contribute to better science and policy."

Tapping communities' self-knowledge, rather than dictating to them, ought to be an essential component of pandemic planning, said noted risk communication expert Peter Sandman of Princeton, N.J. (Sandman serves as deputy editor of CIDRAP News' sister publication, CIDRAP Business Source Weekly Briefing.)

"The rational planning unit is the neighborhood," he said in an interview. The ideal planning unit "wants to be geographically compact, it wants to be something with more storage capacity than individual homes, and it wants to be something that, when government has its hands full, can be autonomous."

But few top-down pandemic plans have approached neighborhood organizations or examined the potential of neighborhood gathering places such as firehouses and American Legion halls, he said.

There's more - worth reading or even re-reading.


[ Parent ]
yes they are absolutely right
The UPMC, especially Monica Schoch-Spana, has been doing stirling work with community engagement.

Here are some links

UPMC report Working Group on Community Engagement in Health Emergency Planning

BTW the CIDRAP article erroneously reported the IOM meeting as the Oct 23 one.  These are 2 different meetings - an IOM one on Sep 19-20, which was compiled into a report, and a National Academies one on Oct 23, see below.)  

The IOM meeting Ethical and Legal Considerations in Mitigating Pandemic Disease agenda and slides are  here, while the meeting summary was published as a  book report by National Academies press.  You can read the whole thing for free online.  You can find  the quote on Flu Wiki by searching my name. I think it's on page 24 or something like that.  I didn't know they quoted that till much later.  lol.  Shows that it CAN be worth your while getting into these things and speaking, cos once it's on the record like that, you can use the quotes!

The National academies Disaster Roundtable on Oct 23 2007 was Citizen Engagement in Emergency Planning for a Flu Pandemic.  I gave a presentation there on FW, the hive mind, etc, and 'Who will tell the people', slides available on that page.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Thanks for the links - I'll take a look :-) N/T


[ Parent ]
just FYI, for everyone, the pdf is much easier to read than the diary n/t




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


and contains all the pics. n/t




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Unlucky things do not go bad
SusanC,

 I do not wish ill on anyone or anything.

 We are lucky that most bad things never happen for we do not prepare for any of them.

 Yet, how safe people drive after a ticket or accident. How carefull they are after a glass has dropped and broken. How well they eat after they are diagnosed with heart disease.

 I wish there was some way to put this in your .pdf that would change people for the better.

Kobie
"the answers we find or hold are not always for us, but for others. An answer kept is not different from a winning ticket never cashed. Both will expire" - kobie

 


you don't have to put it in THIS
paper.  -0( It was written for the UK government, to make a few points.

There are so many things that come to mind, but we can tell it to so many other people besides./

Your thoughts, wherever they are written, can and will spread.  We just have to keep writing, write them well, put out the arguments coherently.  I've been doing this for 2+ years.  In the beginning, nobody knew to read us.  But now, a lot of important people do read what we write.   Not everything, and not all the time.  And they don't always do what we suggest.  But it's still an improvement from before.

It's a long hard slog.  But you do see results.  So keep at it!  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
Clear our minds.
SusanC,

  I like to think "a lot of important people do read what we write.   Not everything, and not all the time.  And they don't always do what we suggest.  But it's still an improvement from before. "

  They do not have to do what I say. I am doing this for the first time. Building upon the past as it fits the present and future.

  I can learn from the past, I just can not re-live it.

  I understand you point :o) The words do not have to make your paper. We just have to strike at the problem and see what sparks. Hopefully good sparks do catch in the minds and hearts of others. That will shed light upon the real problems.

 Many governmetns and business push COTS (consumer off the shelf) solutions. Sigh, yet those same governments do not seek us - those who make COTS.

  We the people build the factories, set the pace of many things as well as pay for it all through purchanses and taxes. I understand TPTB want to have a workable solution but as teh Admiral said "how can they lead people who are unable to follow?"

  I feel the captian of the ship says "Rough seas are ahead. We have a plan for you all to build life boats if we need them"
 I ask - "have anyone ever built these life boats?"
 Captian says no.
 I ask "So how do you know they work or that we can build them?"
 Captaiin says "because a group of passengers many years ago did and we have even better technology"
 I ask "does this new technology work in a storm?"
 Captain said "It might. We have not tested it yet nor has it been hardened agaist the storm. It is kinda finiky on dry land"
  I ask "So you want us to go about life untill you tell us to drop everything for several months adn do something we are unprepared for?"
 Captian smiles "Spot on! Glad to see we still hire the best and brightest.
 I say "But sir your crew is just 130 and we are over 1,200. We have engineers, professionals, chemists, moms, dads, etc. The whole lot. Can we help?"
 Captian says "No, itis our job. BTW do not bother me nor my crew we have work to do and will give you our answer later."
 I aks "Sir can we test your answer"
 Captian puts his hand on the doorknob, "We have a plan, we might get a few of you to help run a test but no. Good bye. Go have fun and act like nothing is comming. It is bad for moral."

Kobie


[ Parent ]
Had a chance to read
I had a chance Friday evening to read through the paper - you've advanced powerful points.  Thank you for working this issue at all levels, from government papers to ReadyMoms booths.  

[ Parent ]
you're welcome, ;-)
Thank you for working this issue at all levels, from government papers to ReadyMoms booths.  

Well, this is a big problem, as we all know, and we need to work at it at all levels.  The challenge is most people, whether officials or grassroots, tend to stay within their comfort zones or the area that immediately concerns them.  

To solve this problem requires everyone to step out of their comfort zones and embrace wider issues.  

The metaphor of figure and ground applies as much to grassroots as to national leaders.  We cannot hope to achieve the breakthrough needed to make a difference in the preparedness of each of our communities, unless we all contribute to the wider process.

The global aspect may seem daunting to any single individual, and it is.  However, the world, all of humanity, is only made up of individuals.  If we collectively, through our technology and globalization, can create such success and interconnectedness that has dramatically changed life on this planet, we are also capable of nudging it towards better outcomes.

My motto is 'Never say never'.  A better world always starts from the vision of one insignificant individual.  

My question is, what is yours?  ;-)



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
What is "risk harmonization"?
Within this giant global network, pandemics are but one type of risk in a system that is increasingly fragile but efficient in distributing and harmonizing risk.  While such harmonization may serve to mitigate the risks somewhat, unfortunately any 'slack' is almost immediately taken up by activities generated by hyper-efficient market mechanisms assisted by technology, such that the system is increasingly vulnerable to sudden catastrophic unpredictable failures, even without a pandemic.

I've Googled this term and see it is used a lot in risk management, but cannot find a definition.   What does the above paragraph mean?

GetPandemicReady.org - non commerical website with practical ways for families to prepare.


it means the risk is spread out
throughout the network.  What you get is an efficient reduction of risk for the risk area, but you also get increased risk for everyone else.  The issue is unpredictability.  

Imagine being connected to millions of people in such a way that if anything happens to any of these people, that risk comes to you as well, instantly and efficiently.  

Now, the larger the number of people, the more likely each individual risk when spread out becomes a  very minor or even unnoticeable issue.  That's the upside.  The downside is a) you have no say, no control, over what risk comes to you b) therefore you won't be able to see it coming, and c) if the same issue is causing problems for a lot of people simultaneously (eg stockmarket crash causing people to be suddenly less wealthy than they thought they were), then the effect can be very dramatic, and may have larger secondary and tertiary consequences just because of how efficiently it is spread.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
not just spread out, but also evened out. n/t




All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
equalization of risk
is not, a priori, necessarily a good thing.

Neither is "harmonization," regardless of how attractive that might sound on the surface.  ;-)


[ Parent ]
nobody said it's attractive
nor good.  In fact, the thesis in this paper is that harmonization is a major source of our increased risk, that we need to take into count.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
the way that harmonization increases systemic risk
is complex, but generally it is because of transmission of risks to areas that would not have been exposed before, and also the efficient way with which any redundancy or slack is removed by profit-taking (see explanation below http://www.newfluwiki2.com/sho... ) or other similar actions.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
is it "harmonisation" as in "vibration that makes things worse"?


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
don't know, ;-)
I'm sure it's not as esoteric as you describe it.  More like the kind of harmonization of policy we get for the EU.  



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
What I pictured
(This could be completely wrong, but I'm fond of it, anyway.)

I pictured systems and risk networks as intersecting webs - like spider webs - in different planes that connect to one another.  The dragonfly that barrels into one web quakes all the others - everything connected is affected, and sometimes torn asunder.


[ Parent ]
that is a great metaphor
and no, not wrong at all.  They really are intersecting webs.  Consider this.  How many people do you know personally, that you would consider friends?  That's one network. Family?  That's another network.  Work acquaintances?  Neighbors?  Parent's of your kids' friends?  How many networks are we connected to, each one of us, in our interpersonal relationships?

In addition to physical/interpersonal networks, you are also connected by interests to all the people who have similar interests as you, whether or not you communicate with them.  What would life be if you are no longer able to watch your favorite sport on TV?  That is one connection.  What about connections based on trade/finances?  How many companies do you pay every month, for EVERYTHING that you spend money on?  How many companies supply services or products to you?  And how many other companies are they connected to?  And so on, and so forth.  

The thing is, what differentiates us from most life forms on this planet, is our ability to organize into complex systems that can achieve much more than the efforts of an individual - think what the life of a caveman was like, without such modern connectedness.  I'm sure even a caveman had substantial differences in his experience of 'life', than the most evolved chimpanzee!

It is our connectedness that defines us a species, more than anything else.  And yet, in a pandemic, the virus is going to utilize such connectedness to wreak havoc.  It is the connectedness that gives meaning to our human experience.  What kind of effects are we likely to see, when such a fundamental cornerstone of our existence is ripped away from us and torn apart?  Can we re-create a meaningful society when it's all done?  I'm sure we can, but at what cost, if we are unprepared, weakened, impoverished, and defeated, at the core of our being?

We must work to keep people's spirits up, but it will require at the most basic level a degree of forgiveness for those who have failed us.  Such forgiveness will be very difficult if the general perception remains that the people should have been told, but weren't....



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
to explain the rest of the paragraph
any 'slack' is almost immediately taken up by activities generated by hyper-efficient market mechanisms assisted by technology,

We have in our globalized economy, primarily in the financial markets but in other systems as well, built in very efficient mechanisms for different players (institutions, companies, individuals, governments) who are clued up, to use automated processes to take profit from any small advantage.

Let me give a very simplified example.  Let's say you are a currency trader, and your whole job is to buy the US dollar when it's low and sell when it's high, and make money from the difference in price, or the 'spread', however or wherever you can find it.  Usually this spread is a very small number.  You can find an example here, of the very tiny difference in price you might be able to find http://www.taxfreegold.co.uk/f...   (although it isn't the right one for this context, I'm using it to illustrate the order of magnitude only.  Forex is a very complicated business.)   With 1 pound sterling (UK money) you can buy 1.9887 dollars, and then use $1.9882 to convert back to 1 pound.  In that trade, you have made $0.0005.  

Now this might look like peanuts to you, and it is, but if you are a trader with a financial house, you are liable to be trading with hundreds of millions of dollars, and you don't have to be very senior to do that!  

However the problem for you is, where do you go and find that little bit of spread?  The foreign exchange market is the biggest of all financial markets, with the amount of money changing hands every DAY, in the order of 3 TRILLION of so!  http://en.wikipedia.org/wiki/F...

You are looking at millions and millions of dollars pouring in and going out minute by minute, how can you possibly keep track of things to find a way to buy and sell at the right time?

The answer is you can't, not without technology.  What you do is use powerful computers (and hire the math geniuses fresh out of college) to do extremely complex calculations at high speed, to allow you to find those opportunities.  Not only are you doing it, but so is every other trader all the way round the world.

In such an EFFICIENT system that let's you find such miniscule profits and gives you the signal in real time so that you can trade accordingly, then any kind of 'slack' or 'redundancy' or opportunity is not going to lie around for long.  It will get snapped up very quickly by whoever has the most powerful machine and the top math whiz kid in the house!



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
another example of risk harmonization
is climate change.  People, communities, and countries by their activities, increase the amount of gas emissions that exacerbates climate change.  However, the effect of this type of pollution is not experienced like other types of pollution.  

Whereas for example, smog and related health risks caused by various pollutants are experienced as relatively localized risks, the emission of greenhouse gases such as carbon dioxide does not result in local pollution (nor even 'local' climate change!) but rather is dangerous to the whole planet by effects that are operational only at the global level.

Thus, the benefits (eg of industrialization) are felt locally, while the adverse effects or risks, are 'harmonized' around the world.  This creates huge challenges in mitigation, as the threat is seen as both being too big and being too distant, and one's efforts as being too minor to make a difference.  This is a lethal formula for complacency.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
your idea of harmonization
implies substantial involuntary reduction in the free agency for individuals.  

There is great peril ahead for individual freedoms when policies such as "harmonization" are promoted.


[ Parent ]
i don't read "harmonisation" as something someone forces
but as something that occurs naturally within the nature of the network.

i.e. it's not a policy as far as I understand.

Air is shared in a closed dancing place, whether individuals like that fact or not.

It's easier to walk away from such a place than it is to walk away from a planet.

I'm interested to see if SusanC's take on it is different, as "risk harmonisation" was not in my vocabulary so far.

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


[ Parent ]
It's a political term
or, let's say one born in the political arena. It's not a term either born of or embraced by American and British cultural tradition.  

[ Parent ]
harmonization
A chilling concept if there ever was one. Let's harmonize language, then we can all communicate more efficiently. Let's harmonize our governments, then there will not be war. International law will strip us of our sovereignty.

Cooperation and compromise do not, in and of themselves, demand "harmonization". Informing consent does not either.
Harmonize in that I understand the risks but allow me the right to control my own destiny as far as those risks are concerned. Yes, we are interconnected. And yes, what we do as individuals has an impact on our communities, our society and on our world as a whole. Inform me how what I do has an impact on others and I will adjust my behavior if and only if my conscience dictates that my behavior needs to be changed.

We must be very careful that we do not allow acute world situations to blind us to the greater concept and threat that exists.

Just my 2c but when someone brings up the concept of harmonization my eyes become wide open in awareness. This thread has chilled me to the bone....

Please explain the context in which you are referring to "risk harmonization".


Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
it's a 'political' term??? since when?
Help me out here.  I haven't encountered it except in management studies, environmental hazards, and in the financial markets, etc.

Here's a list returned by doing a simple search with google http://www.google.co.uk/search...

It's not a term either born of or embraced by American and British cultural tradition.  

Really?  I refer again to the google list, all in English and looks to me it's being used by both American and British folks in many contexts.  Unless of course I mistake your meaning, and that you are implying we should not be using certain words and phrases on this forum for fear of starting a political debate, in which case pray enlighten me how specifically we on this forum ought to be policing the words we use to express certain ideas, given there are those who do not have English as their first language, and there are others who are somewhat challenged in their writing skills.  Are we now to pass certain literacy tests before we can write without attracting such feedback?  I'm just curious, seeing that you are a mod on a different forum, what yardstick you would use to measure whether certain words (not ideas, mind, just the words) are deemed to be political or not political?

But if you're not implying anything like that, then it's fine, each to our own.

Also, btw again out of curiosity, how would YOU describe the issues that are being expressed by this phrase which I took from the Global Risk report 2008, compiled by a team of international experts and management gurus.  I know I'm not an expert on risk, so all I can do is copy what phrase those experts use.  But if you've got a better suggestion, I'm all ears.  And, as always, by all means use your own words



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
some risk harmonization benefits
Harmonized systems that promote greater safety because the promotion of consistency educates, and encourage compliance to an agreed upon standard or method of operation, no danger in that. This helps to streamline trade and reduce costs. When we begin to speak about harmonizing individual actions....I think that this is where I bristle. I just need more clarification here.

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
oh yes I absolutely agree
implies substantial involuntary reduction in the free agency for individuals.  

that IS where the danger lies.  I wrote about it in various places, all over the original paper and in the subsequent posts that I wrote.  However, just to clarify

your idea of harmonization
this is not MY idea; I don't know where you get that impression.  ;-)  It's what I learned when I read all those reports from experts, as a phenomenon already in existence.  Like climate change.  It is certainly something I worry about (again for those who haven't, read what I wrote in the paper, I know it's long and difficult to understand and I apologize, but it was written for bureaucrats/government so that's how it needed to be) and would rather we have less of.

There is great peril ahead for individual freedoms when policies such as "harmonization" are promoted.

I'm not sure anyone is 'promoting' it as policy, as far as I can see.  I'm certainly wary of it, but I haven't come across it as POLICY being PROMOTED by someone, in this context of RISK harmonization.  But of course you may know something that I don't in which case please enlighten us.

I am certainly the last person to be PROMOTING it, since I busted my a** for a whole week non-stop to warn everyone AGAINST it!



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
...
"I am certainly the last person to be PROMOTING it, since I busted my a** for a whole week non-stop to warn everyone AGAINST it!"

Thank you for clarification.

Pray for all people and rulers
1Timothy 2:1-4

(Extending the culture of life.)

http://preparedcitizens.wordpr...


[ Parent ]
you're welcome ;-)
also, I meant a whole week writing the paper, in case someone misunderstands



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
UK Civil Contingencies Secretariat
http://www.homelandsecurityeu....

Their website is http://www.ukresilience.info/  and in the main page there's this:
Latest on UK Resilience
   * HIGH PROFILE RISKS
         o Avian Influenza (Bird Flu)
         o Flooding
         o Foot and Mouth Disease (FMD)
         o Human Flu Pandemic

Following the link to Human Flu Pandemic there's this:

Pandemic Flu

Influenza pandemics are natural phenomenon that have occurred from time to time for centuries - including three times during the last century. They present a real and daunting challenge to the economic and social wellbeing of any country, as well as a serious risk to the health of its population.

Emphasis mine: "as well as" ... "health".

Main point is "socioeconomic real and daunting challenge". Health?  Oh, yes, pandemics are health problems too! ;-)

You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.


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