Prior to the "Challenger" disaster in 1986 the people who ran the space program thought they knew it all.
Then bad things happened:
-- The space shuttle's big booster rocket's O-rings and sealant got chilled overnight
-- "Challenger" blew up a minute-and-change after coming off the launch pad
-- A creepy cover-up ensued that Nobel-winner Richard Feynman was instrumental in busting, and generally
-- No one quite trusted technical management quite the same way again
That is known as Deming's Law. Authored by quality control innovator W. Edwards Deming. What is possible is different from what managers deliver. A difference as wide as the gap between getting into orbit and getting blown to pieces."All Problems Are 85% Management"
This 85% rule is also said to predate the Judeo-Christian Creation. (Obviously.)
Today the management situations at WHO HQ and at CDC are different from what was happening at NASA in 1986. "Challenger" was launched over sharp objections from engineers, related to the O-ring seal. It is fundamentally unimaginable that either WHO or CDC would let similarly degraded equipment go into use, risking a major outbreak or a pandemic.
Still, there are other players. Other people get involved. These include politicians and managers of hospitals. Purchasing officers. Managers of transportation operations. Police Chiefs. State level Cabinet officers. Governors. These folks can go into denial. They can refuse to cooperate with Federal projects.
The usual suspects. And Lord knows, there are enough boneheads out there.
I have a question:
What can bad managers do to us? What, if any, parts of the response system can be degraded? What could a management malfunction cause to be ignored? What normal-seeming behaviors produce sabotage?Where are the "O-rings" in our Ebola response system ???
At Texas Health Presbyterian hospital in the Duncan case it became clear that management had failed to install an emergency system. There was no Hot Button. No bull horn. No way for patient intake personnel to bump up priority on a high threat case.
Their protective gear for nurses left skin exposed. Yeah, there's boneheads.
One can imagine a "Walking Dead"-style zombie or an ISIS raider walking in and being asked to sit over there and fill out an information sheet. That medical system didn't allow for true emergencies apart from calling police.
Assume for framing that we are considering a scenario where EBOV has jumped to the United States and kicked off a small outbreak with a dozen cases. For comments, that has already happened. Model: the Patrick Sawyer event in Nigeria.
Where are things likely to go wrong from human failure?
For another example of the 85% Rule, we use tons of antibiotics in agricultural applications. What goes wrong there is that drug-resistant pathogens get to use pigs to do their genetic adaptations. Don't blame the pigs.
Is there any way that Ebola could get to animals?
We're in New Jersey and the Christie Administration is perfectly happy to suppress/deny reports that West Nile infected mosquitoes abound in the area adjacent to the new Zanadu/Zanapoo/American Dream mall. The better to connive pay-offs for granting a casino license.
What happens next summer, if somebody like Christie gets involved, say, for a situation where Ebola gets to a fruit bat population?
Who in a position of power can screw up and trigger an Ebola-related "O-ring" event ??? How can independent quality control be carried out? Who if anyone is going to watch the people in power?
Put what you have here and we'll see about getting research going for follow-up.
My best to le trump l'orange. But this is all there is for now.