Ebola and Organizational Behavior

Graham Allison's Essence of Decision is a remarkable book with almost universally applicable insights. I don't own the book, but enough of Allison's writing is available online to cite usefully here. I'll be pulling various quotes from a 1968 article by Allison, currently located at the RAND Corporation's site.

If you can't get around to reading the book, the paper seems worthwhile.

Let me summarize the key points of Allison's organizational process model, as I understand them:

• Organizations are designed to be able to coordinate the actions of multiple people to accomplish things that would not be able to be done independently.
• Organizations are very often blunt instruments: they rely on standard procedures, whether explicated or implicit.
• In approaching new problems, they tend to look for similarities to older problems, and often act by analogy.
• Those procedures and organizational habits are very difficult to supplant, though it can be done in limited cases.

Feel free to skip ahead to Organizational Behavior and Ebola Treatment if you're not interested in Graham Allison; I provide a bit more context for that summary in the next few paragraphs.

Allison's Essence of Decision looks at the Cuban Missile Crisis through three lenses: the rational actor model, in which governments make decisions like chess players; the bureaucratic political model, in which government decisions are driven by institutional positioning and self-interest; and the organizational process model, in which the capabilities of organizations govern government decision-making. Allison demonstrates that all three models are useful for analysis, but it largely serves as a corrective for analysis that relies entirely on the rational actor model. If you're not thinking about bureaucratic politics or organizational behavior when you're analyzing decision-making, you're missing a ton of texture.

For my purposes today, the organizational process model is the most useful. Allison points out that part of the way that the US detected the missiles in Cuba was because Soviet soldiers had put red stars on their buildings that were visible from their roofs; it was standard operating procedure to do so at a Soviet site. (Another example: the spy satellites saw soccer fields. Russians played soccer; Cubans played baseball. A really good deception program would have accounted for that, but organizational behavior was what it was.)

On organizational capabilities, Allison writes,

Many organizations must be capable of performing actions in which the behavior of hundreds of individuals is carefully coordinated. Assured performance requires clusters of established, rehearsed standard operating procedures for producing specific actions, e.g., fighting enemy units or constructing military installations. Each cluster comprises a "program"... which the organization has available for dealing with a situation. The list of programs relevant to a type of activity, e.g., fighting, constitutes and organization repertoire. The numbers of programs in a repertoire is always quite limited. When properly triggered, organizations execute programs; programs cannot be substantially changed in a particular situation. The more complex the action and the greater the number of individuals involved, the more important are programs and repertoires as determinants of organizational behavior.

He continues,

Where situations cannot be construed as standard, organizations engage in search. The style of search, and the solution in any particular case are largely determined by existing routines. Organizational search for alternative courses of action is problem-oriented: it focuses on the atypical discomfort which must be avoided. It is simple-minded: the neighborhood of the symptom is searched first; then, the neighborhood of the current alternative. Patterns of search reveal biases which reflect special training or experience of various parts of the organization, expectations, and communication distortions.

Lastly, Allison wrote, "Government leaders can intervene and disturb organizational propensities and routines. Central direction and persistent control of organizational activity, however, is not possible." Allison was writing about government, but really, we're talking about the impact of an external force on an entrenched organization via coercion, cajoling, etc.

Organizational Behavior and Ebola Treatment

So, we know that organizations can have strong capabilities, but they also have severe limitations.

Let me pose my theory of what happened at Texas Presbyterian Hospital, from a Graham Allison-organizational process perspective.

A patient who claims to have been to West Africa comes in with symptoms resembling a bad virus. He has a very high fever, but people really haven't been paying much attention to the news, and they're not inclined to think hemorrhagic fever unless the patient is... you know, hemorrhaging from the eyes, vomiting blood, etc. So they assume "sinusitis" and send him home with antibiotics, just in case it was bacterial.

Personal aside: I was once hospitalized with sinusitis. This wasn't an unreasonable diagnosis, based on the symptoms. I felt like death, had a very high fever, and ended up spending five nights in the hospital. Sickest I've ever been.

Two days later, he comes back, obviously very sick. They're now thinking Ebola, and they got the diagnosis right.

Hospitals use "standard precautions" in dealing with infections to avoid sickness, as well as to avoid spreading infections between patients. (See the sad case of Ignac Semmelweis and puerperal fever for their importance.)

Hospital workers and administrators know that Ebola is serious, but they also know that they have "standard precautions" to follow. The initial thinking is that the precautions will work, provided that they're careful. They work, after all, on the most comparable virus we know about: HIV. And on a gut level, the two are similar: they are not airborne, thankfully. They are spread through contact with bodily fluids. And they are very serious.

This was the first error, though. While HIV and Ebola are comparable on a surface level, there are some significant differences. Ebola is actually more contagious; HIV does not survive outside of the body for longer than minutes, but Ebola can survive on surfaces for much, much longer. (Believe it or not, most people catch the flu the same way they could, in theory, catch Ebola: contact with infected surfaces and then putting their fingers in their mouth, or nose, or eyes. The flu is airborne, but it's really the contact with surfaces that causes most cases, if I understand it correctly.)

Moreover, while HIV destroys the immune system, Ebola overwhelms the entire body. A late-stage HIV patient is most vulnerable to an opportunistic infection that a person with a fully-functioning immune system would fight off. Ebola just reproduces and reproduces until the body basically excretes it from all points of exit.

The HIV analogy is not good enough.... but the procedures come from the HIV analogy.

This basically seems to be what happened. The Dallas Morning News writes:

The 3-day window of Sept. 28-30 is now being targeted by investigators for the Centers for Disease Control and Prevention as the key time during which health care workers may have been exposed to the deadly virus by Duncan, who died Oct. 8 from the disease. 

Duncan was suspected of having Ebola when he was admitted to a hospital isolation unit Sept. 28, and he developed projectile vomiting and explosive diarrhea later that day, according to medical records his family turned over to The Associated Press. 

But workers at Texas Health Presbyterian Hospital Dallas did not abandon their gowns and scrubs for hazmat suits until tests came back positive for Ebola about 2 p.m. on Sept. 30, according to details of the records released by AP.

Seems like standard precautions were in place, rather than biohazard level 4 precautions, as Ebola really warrants.

Now we're hoping for luck. Not only are the health care workers at risk, but other patients in the hospital that the health care workers dealt with are also at risk.

The story continues. They eventually realized that standard precautions were not enough, so they started putting on more gear. But it appears that there was a failure in training, or just flat inexperience; US hospitals do not deal with this level of infection. Most really sick people in hospitals have cancer or organ failure, not infectious disease. That's a good thing, but it means that organizations don't really know how to handle those cases that do emerge.

As the patient got sicker, the hospital implemented standard operating procedures for critical care. I'm not a health professional, but I assume it's something like this:

- Able-bodied man's kidney's start to fail? Get him on dialysis.
- Airway obstructed/breathing problems? Tracheal intubation.

With a late-stage Ebola patient, these procedures are incredibly dangerous. The later into the disease a patient is, the more contagious they are. But these are the standard operating procedures in critical care, and this is what the hospital implemented.

So we had a systemic, procedural failure at Texas Presbyterian, brought about by procedures that were not equipped to deal with the nature of the problem they faced. Note that this problem isn't even remotely due to the activities of health care workers. They were implementing procedures. It is the job of management to ensure that procedures make sense for the circumstances that line workers face.

What should be done going forward?

Only the government could have changed these procedures. It was never something that a conventional hospital was going to be able to handle. That's the critical failure here; the workers at Texas Presbyterian were left out in the cold, when they actually would have required some assistance from our medical establishment.

First and foremost, Thomas Frieden should be fired at the end of this crisis. He is just now striking the right chord, in terms of what hospitals should be thinking with Ebola. But for weeks, he has downplayed the risks faced by American health care professionals. When Frieden says, "One of thing we want to emphasize is virtually any hospital in the country that can do isolation can do isolation for Ebola," that's a signal to hospitals that this isn't a big deal. Over and over, literally for months, we have heard that "Western infection controls" should be able to stop Ebola. We haven't heard the necessary message: that Ebola is extremely dangerous, and is very contagious in late stages, and that health care workers are very much at risk.

Moreover, this isn't just a messaging problem. CDC hasn't been taking it seriously enough, if a nurse involved in the treatment of Thomas Duncan was allowed to fly before the end of the incubation period. They genuinely do not seem to have a grasp of the risk of what they are dealing with. It is classic overconfidence.

In general, this "everybody be calm!" message has been coming from every official we've heard from, presumably to prevent a panic. This backfires, though, when the reassurances prove wrong; people become (rightfully) skeptical of what they hear from those officials. And frankly, there are worse outcomes that a few people panicking.

Next, we really do need to step up procedures for decontamination, and we need to roll out a lot more training on it, fast. It is possible that we're going to see more cases, maybe even enough to swamp our ability to send CDC teams out to handle treatment.

Additionally, we may need to consider restricting critical care procedures. If someone is so sick from Ebola that they need kidney dialysis, we just may not be able to provide the care in a way that will keep our medical professionals safe. This is a sad potential reality, but it may well be true. For severe Ebola cases that do not show signs of improvement, we may need to shift to palliative care rather than our era's preferred model of heroic medicine. I am not an expert on the subject, but I hope that someone, somewhere, is having this conversation.

Lastly, people need to stop mocking those who are worrying about Ebola. Vox.com, voice of the glib Left-leaning establishment, put out a graphic like this a few days ago:

This glib approach is so, so bad. It signals to people that they don't have to worry. But they should worry, at least a little bit.

Part of why we haven't been wiped out by something like Ebola is because people who appropriately worry about things have acted appropriately. It's the same thing with the notion of the "arc of history" or whatever. Human action shapes the arc. It's not just something that happens, and assuming that the "arc" will carry us to where we want to go is just incredibly naive.

The "go team" approach is the right one, because CDC specialists will have a better chance of implementing the proper procedures for infection control. But, again, this is too late for the health care workers who are now at risk. And they were utterly, utterly failed by a hubristic establishment. Chris Hayes, correct again.