Epidemic Leadership. Larry McEvoy
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an organization rife with internal strife and external pressures. I had to familiarize myself quickly with a new organization, five thousand new colleagues, teammates, and opinions, and a city-owned health system in a national financial meltdown. Three days' worth of cash on hand stood between us and our debt holders' right to come in and run the place, and we had $320 million of bond debt tied up in the auction-rate bond market, which collapsed midyear, leaving us with worthless and burdensome debt and no bank willing to help us restructure it. Our compliance with federal guidelines was suspect at best, and the penalties for compliance violations were high and included incarceration of the “designated jailable officer”—me. Our finances were sagging after five years of investing in a new hospital with gorgeous brick and glass without replacing the numerous pieces of expensive technology that were reaching the end of their life cycles.
Nationally, we were entering a recession, which always decreases traffic to hospitals and clinics, and our city, strapped for cash as a sales-tax municipality, was hoping we would fund the city's budget, either by funneling cash flow or by selling the organization. All over the country, cities, states, and the nation itself puzzled constantly over how to fund health care, and I had landed in a town that wanted health care to fund the city.
We had no firm plan for working with physicians to improve and innovate the clinical care. Relationships with and between physicians themselves were poor, rife with manipulative competition, collegial distrust, and a long history of triangulation with the hospital's need to keep beds full. Within a month of my arrival, a patient told a nurse he was having a heart attack, and, despite repeated attempts by him and his family to tell us how ill he was, we only figured it out a few hours later when he died. The physicians blamed the nurses, the nurses blamed each other, and everyone blamed administration.
We had too much to fix and not enough time to do it. We had lots of policies and no consistent practices. We had lots of opinions and very little shared insight. People were hoarding clinical supplies in closets and above the ceiling tiles. We lacked operating processes, procedural rigor, and cultural alignment. We had chaos.
On top of safety risks, lagging results, and broken processes in the setting of a crashing economy, we had a more ominous problem. As I walked the halls and spoke with doctors, nurses, clerks, and pharmacists, I kept hearing we had a leadership problem. From leaders, I kept hearing we had “the wrong people.” I also kept hearing from people who had worked there a long time, who loved the place, and who wanted to be very good at their jobs. They took great pride in their professions and truly wanted to help people. When I asked them what they thought we needed to do to address the woes we were experiencing, I received a lot of head shakes, eye rolls, and muttering, but they all sent the same message: “This place can't change. Don't even try. It's been this way for years. You'll see.”
We had an internal lean coach named Jauna Werner who had arrived a bit before I did. She was skilled in facilitating shifts to lean thinking, but she was even more astute as an observer of all the little things that underpinned how a system was functioning. As she rounded through the organization, looking at operational processes and listening to people, she had come to an interesting conclusion.
“This place could benefit a lot from lean, but not yet. It needs therapy first. Maybe gene therapy.” We had all the hallmarks of a degraded ecosystem. Performance was sagging and widespread. Our ability to adapt was mired in entrenched frustration and apathy. Our biodiversity of thought and perspective had been winnowed to a few surviving patterns, and energy was low.
I spoke to and listened to hundreds of people. From a clinical perspective, I was fascinated with the ubiquitous combination of personal commitment and collective malaise. From an executive perspective, I sensed that we could fix all the policies, processes, and protocols we wanted, but until we got at the more foundational, lurking source of will in the organization, we would be wishing for results rather than creating them. I had a big whiteboard in my office, and after a month or so of scrawling on it with notes, pictures, and network diagrams in different colored markers, I wrote in big red letters with a circle around them, “CPD.”
The Epidemic Inevitable
Until COVID-19 shattered our veneer, many of us thought of epidemics as relics of the past, or at least something not particularly relevant to our day-to-day lives. We have an annual influenza epidemic, and in the twenty-first century we've already had epidemics of diseases with strange names: SARS, MERS, Zika. Ebola, the virus lurking in the equatorial forests of Africa, rose up and killed 11,310 people in Guinea, Liberia, and Sierra Leone between 2014 and 2016.1 That was then, though, we thought. It was so long ago and far away in an age when yesterday can be quickly forgotten. Our world kept whirring in a blur of Facebook posts, hypershort media cycles, and a million things to do and distract before COVID arrived. Possessed of our computers and networks, vaccines and antibiotics, constant video feeds and big data, it was tempting to see the deadly power of epidemics as old furniture in remotely historic eras—if we were even thinking about epidemics at all.
There were, indeed, catastrophic and legendary eruptions of disease in the past. Across history, infectious plagues have certainly decimated humanity—the biblical plagues, the Black Death, the flu epidemic of 1918. Smallpox, now officially eradicated, killed as many as 300 million people in the twentieth century alone,2 despite the fact that vaccination against it began in the early 1800s. Unknown millions of people native to the Western Hemisphere died after Columbus brought the disease to the New World in 1492.3 Those sweeping sixteenth-century North American epidemics, while hinted at by later smallpox outbreaks, remain largely invisible to our subsequent awareness as they weren't recorded. Instead, vastly reduced populations of Indigenous people defined the modern view of the Western Hemisphere's human numbers as more Europeans arrived later to a vastly underpopulated continent.4
Bubonic plague, the infamous Black Death, entered Europe in 1347 after the disease inserted itself into a year-long siege between the Mongol King Jariberg and Italian merchants at the outpost of Cappra. Once it reached mainland Europe, 25–50 million people died in five years, thought to be 50 percent of Europe's population at the time. Then, as now, adjacent unrest and violence flared up, as antisemitic sentiment and brutality boiled to the surface. Over 200 Jewish communities were massacred; 2000 Jewish people were burned alive in Strasbourg alone on Valentine's Day, 1349.5
COVID may have surprised us, but it shouldn't have. We had warning that epidemics were looming. For some years, epidemiologists, scientists, and military planners have been warning us of the destabilizing power of epidemics moving through our populations. Time Magazine's 2017 cover declared, “We Are Not Ready for the Next Pandemic,” and Bill Gates's now-famous TED Talk reviewed our urgent need to prepare for an era when tiny, anonymous microbes would sweep across our social stability and wreak upheaval. Before COVID arrived among us, Ebola, SARS, MERS, Zika, and H1N1 had already created significant havoc in the first fifth of the twenty-first century.
Epidemiologists tell us there are more epidemics ahead. Even now, while we grapple with logistic, economic, and political dimensions of the most widespread global health threat we have seen, policy makers, militaries, governments, health agencies, and intelligence capacities around the world are thinking about how to mitigate the devastation of “Disease X,” the hypothetical viral pathogen poised to destabilize civilization. They contemplate the odds and possibilities of the kind of things that spawn horror movies—World War Z, Outbreak, Contagion all being examples of out-of-control instability that deadly epidemics bring. Can you imagine a virus that moves like COVID-19 and has Ebola's death rate of 50 percent? Those future superpathogens and their destructive fallout are what haunt the epidemiologists and military planners.
Approximately 1.67 million viruses are known to human