• Sounding the Alarm: The Lessons of ‘Crimson Contagion’

  • As the COVID-19 virus continues to blindside the world’s health care systems, markets, and governments, people facing drastic consequences are scrambling for clarity as to why officials have been so unprepared. In response, leaders around the globe are offering answers like “this is unprecedented” and “we have never seen anything like this before.”

  • But the truth is, they have.

  • Beginning in January and culminating in August of 2019, the US Dept of Health and Human Services simulated a large-scale, pandemic flu outbreak. The simulation, called “Crimson Contagion,” included two table-top exercises, a seminar and a functional exercise “to examine issues related to response structures, information exchange, coordination of resources, and policy decisions.” The goal was to focus specifically on “whole-of-community response and policy issues of workforce viability; critical infrastructure protection; economic impact; social distancing; scarce resource allocation; prioritization of vaccines and other countermeasures; available (or potentially available) funding streams or mechanisms to fund the response; and medical surge operations.” (Source: Crimson Contagion 2019 Functional Exercise Draft After-Action Report” October 2019)

  • The exercise involved participants from 12 states, including New York and Illinois, as well as representatives from local and state governments, FEMA, the US Dept of Health and Human Services (DHHS), and the Centers for Disease Control (CDC).

  • In the simulated scenario, the virus originated in China and was brought back to the US by tourists who had visited China and began their return home before becoming symptomatic. The virus spread rapidly through human to human transmission, with adverse symptoms that required hospitalization, especially among vulnerable populations.

  • After the final exercise ran in August 2019, the DHHS circulated a draft report to key decision makers in October 2019, with urgent warnings about systemic vulnerabilities revealed in the exercise. Below is a summary of some of the findings:

    • Statutes for how the crisis was to be handled were vague and often conflicting

    • Disparate information management systems made it difficult to “establish and maintain a national common operating picture.”

    • Standards of care varied wildly between local, state, federal and tribal entities, with insufficient plans to make up for gaps and differences

    • “Current medical countermeasure supply chain and production capacity cannot meet the demands imposed by nations during a global influenza pandemic.”

    • “States experienced multiple challenges requesting resources from the federal government due to lack of standardized, well-understood, and properly executed resource request process.”

    • Widespread confusion over how to handle school children and school closures “Inconsistent use of terminology regarding vaccine types and stockpiles caused confusion among response partners at all levels of government.”

    • Insufficient means to rapidly manufacture essential supplies, equipment and medicine, including respirators and ventilators.

    • And finally, “Currently, there are insufficient funding sources designated for the federal government to use in response to a severe influenza pandemic.”

  • As a result of decisions made and coordination among participants to fight the pandemic, approximately 110 million simulated US citizens contracted the virus, 7.7 million required hospitalization, and 586,000 died.

  • What happened?

  • For over a decade, systemic problems with pandemic response readiness have been widely known, resulting from simulations, models and reports delivered in the wake of the H1N1 and Ebola crises. Several senior leaders in the US government took part in these previous exercises, acknowledged the reports, understood the dire consequences of not taking action and were mobilizing to address the shortfalls. However, by mid-2019, none of these senior leaders remained active, and the National Response Framework that had been set up to specifically address pandemic readiness had been dismantled. Furthermore, while Crimson Contagion finished up in August 2019, with urgent warnings from participants to mobilize quickly, that information and urgency didn’t make it up the chain of command or to relevant policymakers.

  • The power of simulations comes from their ability to create a “memory for the future.” Especially useful for rare but disastrous events, simulations are able to embed lessons learned and motivate behavior change in ways that traditional classroom instruction, reports or guidelines cannot. Moreover, for these large-scale simulations, involving stakeholders at all levels, simulating urgent or potentially disastrous scenarios creates a strong institutional memory. But that institutional memory, just as memory for individuals, can be lost.

  • As the COVID crisis began to unfold In real life, the US government suffered from not having the structure or people that had direct experience with the simulated consequences, and not being able to feed lessons learned through relevant channels or embed them in new response systems. AS a result, the US experienced a patchwork of delays, miscommunications, shortages and lagging information flows that have exacerbated an already unprecedented problem. By the time the crisis was ramping up in early March 2020, the consequences looked eerily similar to the situation Crimson Contagion participants had played out just 6 months earlier.

  • But even with a vacuum of senior leaders, why didn’t the lessons from H1N1, Ebola, and these simulation exercises become part of the institutional memory? Simply running a simulation exercise and distributing the findings is not enough. How that information becomes incorporated as part of the institutional memory is critical. Too often, low to mid-level organizational members are able to see more intimately the true costs of disruptive or disaster scenarios, whereas senior leaders are forced to weigh the costs of readiness with the likelihood of risk, while also maintaining a confident and upbeat projection to outside (and often inside) stakeholders.

  • Institutions also have blind spots about how information is retained and deployed, both at the individual and institutional levels. Many institutions unconsciously act on the belief that simply having and disseminating information is enough to embed necessary changes, relying too often on procedures, reports and guidelines to create change. But just as an athlete must engage in routine practice to embed key performance learnings and behavioral modifications, a rigorous set of management practices and stakeholder buy-in are needed to create a new institutional culture of practice.

  • Response Readiness for Organizations

  • While what we’re currently facing seems to be a health crisis, it’s become evident that this is actually a systems crisis. The people who will solve the immediate healthcare needs are doctors, nurses, epidemiologists and immunologists. But the people who will be critical to determining how well we face the next global catastrophe are systems analysts, senior managers, and futurists.

  • Many have suggested that the current crisis is a dress rehearsal for an even larger, more virulent pandemic that may be lurking in the future. After the COVID crisis subsides, one hopes, we will have a generation that holds the planetary memory of this event to be better prepared to deal with what may come. But in the immediate aftermath, one wonders how this will change the way we view risk in organizations? How will we build better systems, better institutional memory, and ensure that information flows, decisions and risk transparency are optimized?

  • When the world is open for business again, organizations will no doubt be examining their disaster response plans in terms of immediate safety, black swan events and existential threats. But they should also be examining more common, overlooked disruptions based on ongoing, unanticipated risks. It’s likely that as organizations start reviewing their response plans, they will find similar systemic vulnerabilities to what has been revealed by the pandemic: confusion over accountabilities, unclear roles, insufficient coordination protocol and a lack of resources.

  • The Way Forward

  • There is no doubt that what we have been through is unprecedented. While we are seeing mistakes, delays, and overwhelmed, unprepared decision makers, we are also seeing incredible acts of generosity, rapid frontline action, global caregiving, and swiftly evolving adaptive responses on the part of citizens and policymakers. Can we harness and focus that adaptive energy to build better coordination and decision systems that will help reduce the threat of similar future risk? Can we use the lessons of Crimson Contagion to create new ways of working within our organizations – especially those who are continuously exposed to disruption and change?

  • The first step is being willing to acknowledge that these risks are real and that we remain unprepared. The next is to invest in the tools that will make a difference, creating not just a series of recommendations, but a commitment to deep understanding among key stakeholders. The final step is a commitment to embed the key learnings from what has been revealed by these tools, no matter how sobering, into the routine practice of the organization.

  • In making these three commitments, organizations will take a huge leap forward, creating a sustainable institutional memory that will not only reshape their future, but ensure they have one.