Humans are about as savvy at assessing risk as they are at predicting the weather. And while we have models that have the predictive capacity to inform better public policy for events like pandemics and natural disasters, politicians get more credit for handling preventable crises, than they do for preventing a crisis in the first place. Civil servants aren’t given thanks, increased pay, or Congressional Medals of Freedom for crises averted. Nuclear regulators working for the Department of Energy for decades aren’t lauded for preventing the dissemination of nuclear material to dangerous non-state actors. Those doing the important work of minimizing and managing risk are often unseen, and worse yet, dismissed as the-sky-is-falling prognosticators or “Debby Downers”. It is time we reevaluate our perception and relationship with risk management.
Wishful thinking is a dangerous human emotion and one that has, as it turns out, tragic consequences. Economists, like Nouriel Roubini, predicted the Great Recession of 2008, but industry analysts and regulators dismissed his cogent warnings as alarmist. Similarly, the Trump administration was warned as early as November, that SARS-2 or Coronavirus landfall was imminent, however, in a January 22 press conference Donald Trump confidently noted: “We have it totally under control. It’s one person coming in from China. We have it under control. It’s going to be just fine.” Mr. Trump’s history of bankruptcy—he has filed six in total—is indicative of maximizing gains by assuming considerable risk on the front end, while leaving shareholders to absorb losses on the back end. In this case, the American public is the proverbial shareholder. And just like in bankruptcy proceedings and weather-related events, the fallout is largely going to absorbed by the most vulnerable members of society.
Bad weather, like long-tail events, are inevitable, and just as windows have storm shutters, so too should we have the necessary measures in place for when untimely, but nevertheless inevitable events come our way. The results are in, and the US continues to lack the basic resources it needs to adeptly deal with this global pandemic. Nurses are wearing trash bags in lieu of protective gowns, physicians are reusing surgical masks, patients that need continued observation are being sent home, ventilators are in short supply, and hand sanitizer is about as available as rare earth metals. A risk portfolio that is normally handled by the federal government is now being shouldered by individual states and the private sector. This, however, is not something new. For decades, government services and programs have quietly been replaced by privatized enterprises. Services as fundamental as public works, law enforcement, military training, prisons, and crisis management are now increasingly being performed and administered by private companies. If the Trump administration’s response is indicative of anything, it is an unwavering belief in the efficiency and efficacy of the private sector to solve problems, hence the incomprehensible resistance to the Defense Production Act.
The fundamental problem with this thinking is that there aren’t incentives in place for non-government actors to address public health issues. As I mentioned in a previous article, there hasn’t been an FDA approved class of antibiotics since 1984. And while almost 20,000 people die annually as a result of antibiotic resistant pathogens, there isn’t an appetite in the private sector to develop new antimicrobial drugs. Instead, pharmaceutical companies focus on erectile dysfunction, psoriatic arthritis, auto-immune diseases, diabetes, and other chronic lifestyle diseases that require continued “treatment”. Treatments imply a revenue stream, and so Big Pharma justifiably focus’ their energies on blockbuster drugs that require ongoing use. In fact, many diseases and disorders, like type-2 diabetes, that are a drain on our healthcare system, do have cures, they just aren’t drug related. Type-2 diabetes has much more to do with income inequality than most public policy makers are willing to discuss. Research from York University in Toronto found that living in poverty can double or even triple the likelihood of developing type-2 diabetes, and that “72 percent of patients said they lacked the financial resources to follow the kind of diet needed to keep their diabetes in check.” Income inequality is a strong determinant of many lifestyle diseases, like obesity.
You may have heard on the news that African Americans have suffered disproportionately in this crisis. Counties that are majority black have three times the rate of infections and almost six times the rate of deaths as counties where white residents are in the majority. African Americans live in more densely populated neighborhoods, have higher rates of heart disease and diabetes, and are less likely to have access to medical care. It is no secret that African-Americas live in food deserts. If you live in a black neighborhood, not only is living a healthy lifestyle more difficult, it is also more expensive and time consuming. A US Department of Agriculture study found “eight percent of African Americans live in a tract with a supermarket, compared to 31 percent of whites.” In Mississippi—which has the highest obesity rate of any state—”over 70 percent of food stamp eligible households travel more than 30 miles to reach a supermarket. So not only is fresh produce not affordable, it’s just not available to most poor Americans.” The alternative is the 7/11 diet, which is a dangerous cocktail of sugary carbonated drinks and foods that are high trans fats and preservatives.
Countless physicians have mentioned in news coverage that patients with comorbidities are much more likely to die of complications related to COVID-19. Though this terminology is helpful for doctors, for most of the American public, you might as well be speaking Swahili. For clarification, morbidity is the “condition of being diseased” and comorbidity is simply more than one disease existing concurrently in the same patient. Type 2 diabetes and obesity is one example of a comorbidity, that is, they often present simultaneously in patients. In a preliminary New England Journal of Medicine memo on the Coronavirus, “the vast majority of deaths (94%) occurred in patients with underlying conditions.” So, while many are saying that “we are all in this together”, the reality is that that observation is largely coming from people and families viewing this crisis from 30,000 feet. Many of the wealthy and famous members of society, according to the LA Times, are flocking to concierge physician services where Coronavirus tests can be purchased al la carte. They are also paying food delivery workers paltry salaries (largely through Amazon Prime) to assume the risky proposition of bringing them their food. This doesn’t square with the “we are all in this together” narrative.
This brings me to another point about risk. What terrifies most people isn’t exactly rational. I have had the great opportunity to dive with sharks, repel down slot canyons, jump out of airplanes, and yes, even bungee jump off a gondola. And while those experiences certainly were thrilling, statistically speaking, they really weren’t dangerous. Many people have told me, man the things you have done are absolutely looney—you really are as mad as a hatter! My stock response is, maybe you ought to consider putting down that burger and fries, and tread cautiously in your bathtub. I am a big fan of a good burger and fries, but the fact remains that 23.5% of people die of complications as they relate to heart disease—the leading killer of Americans. Number two on the list, cancer—of which colorectal and prostate cancers account for almost half of all deaths in men—is correlated with even moderate consumption of red meat. And yet you never hear anyone say, “Put that burger down, you maniac!” Much like dismissing the clear and present dangers of individual lifestyle choices, as a society, we are collectively dropping the ball on the next big long-tail risk: climate change. And the misplaced confidence that the issue will resolve itself, or that we can easily innovate our way out of the problem, more than misses the mark.
I had the benefit of getting to know a risk management expert while in Australia for a virtual reality project. We employed a very nice chap named Lucas Trihey to help manage our descent into one of Australia’s most remote slot canyons. I asked him, why do accidents happen to so many experienced alpinist and mountaineers. His answer was both unanticipated and illuminating. “Confidence is a killer”, he said. Confidence in certain contexts can be very useful. For example, talking in front of an audience—while one of most feared social scenarios—isn’t one that is likely going to result with a loss of life, that is, unless you are a really terrible public speaker. In a low risk, high thrill situation like public speaking, confidence can improve performance and lead to better outcomes. In the context of mountaineering, climbing, distance running, and canyoneering confidence can be the difference between living to climb another day and dying of hypothermia. Confidence can be the variable that pushes you to the summit when the objective indicators are telling you to turn around.
Lucas went on to tell the story of Aron Ralston as an example of misplaced confidence. If you are not familiar with his name, you are probably aware of his story. Between a Rock and a Hard Place was an autobiographical book Ralston wrote (later adapted by Daniel Boyle into a film staring James Franco called 127 Hours) about a canyoneering accident that he endured while in Utah’s Canyonlands. An experienced canyoneer, Ralston got his arm lodged between you guessed it, a rock and a hard place. He spent the ensuing hours trying to dislodge his arm, but with no success. Eventually Ralston faced a grim dilemma: either amputate his own arm or die of exposure. Ralston proceeded to amputate his arm with a multi-tool and was rescued shortly thereafter by hikers. That said, he violated the cardinal rule of any person planning an outdoor excursion: let someone know where you are going. And this is where confidence is clearly a liability. Had Mr. Ralston been less experienced, he likely would have gone canyoneering with another person, or at the very least, let someone know where he planned his excursion. Any Boyscout will tell you this, and yet, a seasoned adventurer didn’t check the most fundamental of boxes.
We need to reevaluate the way we look at risk as individuals and as a society. If we don’t check the right boxes, our consequences as a society might be as dire collectively as they were for Ralston individually.
So how does this relate to burgers and fries, or government management? As it turns out, a lot. Every government has a risk portfolio, and their job is to weigh those risks to society and provide safety mechanisms for when the worst does happen. Some of those risk, like the proverbial burger and fries, will seem innocuous in nature but have profound societal consequences. Risk management is decidedly unsexy, and isn’t something that captures the public imagination, but if we don’t take this as a wake up call, we might very well end up with a global situation that is even worse then what we are dealing with today.