Lessons from COVID-19 on Boundary-Setting and Systems Change

I’m a lifelong Dodgers fan, and I watched elatedly as the Dodgers stormed the field a few weeks ago after winning their first World Series since 1988. I left the TV on to watch the celebration. I love seeing the joy and tears on the players’ faces, watching them hugging their loved ones, listening to the fans cheering. That’s right, fans. They were playing in a sort-of bubble in Texas, where the rules around large gatherings are looser, and there were some fans in the stadium, most of them rooting for the Dodgers, so it felt like a home game.

In the course of the celebration, the sportscasters reported that Justin Turner, the Dodgers steady third-baseman and long-time leader, had tested positive for COVID-19, which was why he had been abruptly pulled from the game and isolated in the eighth inning. Hearing this left a pall on the celebration. It was a stark reminder that this was not normal times, and it led to many questions. Who else on both teams had already been exposed? Would they be okay? What if the Dodgers hadn’t won, and there was another game scheduled the following day? Would they have played?

Then Justin Turner came back onto the field to join his teammates for their celebration. He hugged his teammates and family members, he took off his mask, and he participated in the team photo. My sobriety shifted to shock, then unhappiness. What the heck was he doing?! Why wasn’t anyone stopping him?!

It took a few weeks, but Turner and Major League Baseball’s commissioner, Rob Manfred, finally released statements explaining what happened. Turner had apparently asked to step onto the field with his wife (who was isolating with him) for a photo. In his statement, Turner wrote:

I assumed by that point that few people were left on the field. I was under the impression that team officials did not object to my returning to the field for a picture with my wife. However, what was intended to be a photo capturing the two of us turned into several greetings and photos where I briefly and unwisely removed my mask. In hindsight, I should have waited until the field was clear of others to take that photo with my wife. I sincerely apologize to everyone on the field for failing to appreciate the risks of returning to the field. I have spoken with almost every teammate, coach and staff member, and my intentions were never to make anyone uncomfortable or put anyone at further risk.

According to the ESPN article on the statements:

Manfred said teammates “actively encouraged” Turner to leave his isolation room and return to the field, adding that “many teammates felt they had already been exposed” and were willing to tolerate additional risk. Manfred’s statement said Turner believed he received permission from at least one Dodgers employee and that an unidentified person incorrectly told him that other teammates had tested positive, “creating the impression in Mr. Turner’s mind that he was being singled out for isolation.”

MLB previously chided Turner for breaking protocol, adding that Turner “emphatically refused to comply” when asked to leave the field. But Manfred acknowledged Friday that the league “could have handled the situation more effectively” by assigning a security person to closely monitor Turner and quickly transporting him to the team hotel.

“Mr. Turner has publicly recognized that his conduct was wrong and has expressed remorse for that conduct,” Manfred wrote. “I have spoken to him personally and I know that he is extraordinarily upset by the incident. By all accounts, Justin is a leader in the clubhouse, a contributor to his community and a responsible person who was instrumental in the Dodgers diligently following the health protocols all season long.”

I think this was a good outcome, and I applaud everyone involved. There was no single person at fault. It was a collective responsibility, and everyone owned up. The next step is to learn from this and to improve the system.

I live in San Francisco, where our local leaders have moved cautiously in accordance with public health officials and scientists, and where there’s been a culture of compliance and support. People wear masks for the most part, and folks are generally well-intentioned in supporting differing tolerances for risk.

Still, it hasn’t been easy. I’ve felt more cautious than many of my peers, and I’ve drawn some boundaries around distancing and being outdoors, which has meant not doing a lot of the things that my friends want me to do. Everyone has been supportive in principle, but I constantly feel that support tested in practice. People ask to go on a distanced walk, and then they walk right next to me, or they wear their masks below their noses. People gather outdoors, and then it gets cold, and they say, “Why don’t we go inside?” Even though I’m generally good at protecting my boundaries and I’m not conflict-averse by any means, I’ve given in more than once. I feel like I’m constantly fighting a number of forces and tendencies — many of them based on my own longing for normalcy — and afterward, I always feel crappy and scared. But I don’t blame anyone. I know it’s hard for everyone, and I can’t imagine living in other places right now where there’s violent disagreement around what the norms should be.

Last month, my sister shared this comic by Ali Solomon that exactly encapsulates how I feel about all of this. Check it out. It’s brilliant.

Last May, Atul Gawande wrote a wonderful article about how we might safely transition out of lockdown based on what he had learned from his hospital’s practices. He wrote:

These lessons point toward an approach that we might think of as a combination therapy—like a drug cocktail. Its elements are all familiar: hygiene measures, screening, distancing, and masks. Each has flaws. Skip one, and the treatment won’t work. But, when taken together, and taken seriously, they shut down the virus. We need to understand these elements properly—what their strengths and limitations are—if we’re going to make them work outside health care.

And later in the article:

As I think about how my workplace’s regimen could be transferred to life outside the hospital, however, I have come to realize that there is a fifth element to success: culture. It’s one thing to know what we should be doing; it’s another to do it, rigorously and thoroughly.

In my professional life, which is fundamentally about systems change, we get so caught up with finding high-leverage strategies, it’s easy to forget that nothing works in isolation. And among the different combinations that are necessary for success, culture is almost always one of the required strategies. As we’re experiencing right now in a large-scale, visceral way, culture change is really, really hard, even when everybody is aligned and has the best of intentions, which is rarely the case.

Reflecting on Some Incomplete Scenario Thinking from 2011

In August 2011, Kristin Cobble, Rebecca Petzel, and I had a planning meeting for Groupaya, the consulting firm we would start several months later. As part of that, Rebecca led us through some initial scenario thinking, which consisted of brainstorming certainties (trends we thought were almost certainly going to happen by 2016) and uncertainties (trends we thought were possibilities).

Here were the initial lists we brainstormed:

CertaintiesUncertainties
  • Economy really crappy in 2015
  • Mobile dominance
  • Africa will be online
  • Design firms flooding into the business (good design the price of entry)
  • Communication and Advertising Firms coming into the business
  • There’s a backlash against “collaboration”?
  • There’s a backlash against “social”?
  • Earthquake in San Francisco
  • Skilled, cheaper consultants coming here from developing countries
  • Knowledge work in the US in the decline
  • Knowledge work undervalued in the US
  • Net Neutrality
  • Trust in Internet services? Things like Wikipedia, AirBnB, eBay rely on trust
  • Institutional clamp down or continued democratization
  • Middle East political situation
  • U.S. “Arab Spring” coming?
  • Backlash against rationalism; rise of fundamentalism
  • Large factory consulting firms hijacking our business

Our “Certainties” list wasn’t very good. The economy was not “crappy” by conventional metrics in 2015, although we were continuing to feel the impacts of widening inequality. And we didn’t really see communications firms come into the business.

Our “Uncertainties” list was far more interesting. We no longer have net neutrality, at least at the federal level. Trust in several social media (Facebook and Twitter in particular) is down, and deservedly so. And reading the bullet point, “Backlash against rationalism; rise of fundamentalism,” now makes me want to cry.

I review these notes every few years out of curiosity and sentimentality, and I pulled them up again last month as COVID-19 was wreaking havoc on our lives. A few things come up for me when I look at these:

  • It’s possible to have an interesting scenarios conversation without a lot of prep. We were clearly already connected to a lot of interesting people and perspectives, which was how stuff like “backlash against rationalism” made it onto our list. (Kristin contributed that one based on conversations she had had with her friend and former colleague at Global Business Network, Eamonn Kelly.)
  • Prep would have helped broaden our perspectives and address some blind spots.
  • Pandemic wasn’t on the list of uncertainties.

The biggest thing that comes up for me is that we never truly benefited from the power of scenario thinking, because we treated it as a one-off. Imagine if we had returned to this list once a year, even without any additional prep, and talked through the possibilities. What might have come up? How might this have changed our thinking? What might we have done differently as a result?

This is a regret I often have about my own past work, and it’s something I find with consulting work in general: We barely benefit from the work (which is often time- and resource-intensive), because we never revisit it. There are lots of reasons we never revisit it, but the most common one is that we’re going too fast. I’ve been able to correct this with my own work (although it took several years and lots of focus and failure), and I continue to try to help others do the same. It’s been really, really hard, which is sad, because it’s so beneficial.

Watching the Grand Princess Leave San Francisco Bay After Its Quarantine

On my walk to Baker Beach this afternoon, I happened across the Grand Princess leaving San Francisco Bay after a 14-day COVID-19 crew quarantine.

On any other day, I would have barely paid attention. But these are not ordinary times. So I stopped, and I watched, and I wondered, as the sandpipers played by the crashing waves, unaware of the strange things occupying my mind in these strange times.

My New Favorite COVID-19 Dashboard

TL;DR I’m now using this dashboard as a way to make sense of what’s happening with COVID-19. It’s still too soon to draw any conclusions about how well the U.S.’s interventions overall are working.

I started trying to make sense of the COVID-19 growth rate data myself on March 13, 16 days ago. I learned a lot along the way, and my daily ritual of looking up numbers and updating my spreadsheet has been strangely calming. Here’s my latest graph:

Three observations when comparing this to last week’s graph:

  1. Italy’s growth rate seems to be flattening, which is a positive sign
  2. U.S.’s growth curve continues to rise at a steady rate; more on this below
  3. Even though China and Korea’s growth rates have been steady for a while now, it’s not zero. They have this under control (for now), but it’s far from over, and it won’t be until we have a vaccine, which folks keep saying is at least 12-18 months away.

My friend, Scott Foehner, chided me last week for saying that the results are lagging by about a week. He’s right. Based on Tomas Pueyo’s analysis (which I cited in my original blog post), the lag is more like 12 days. This is why the Bay Area shelter-in-place ordinance was for three weeks — that’s how much time you need to see if you’re containing your growth rate.

Shelter-in-place in the Bay Area started on March 17, exactly 12 days ago and four days after I started tracking. California’s order started on March 20. Other states followed after that, but not all.

It’s hard to make sense of all this when aggregated as a country. I’ve been wanting regional data for a while now, but have felt too overwhelmed to parse it out myself. Fortunately, other people have been doing this.

One of the positive outcomes of me doing this for myself for the past few weeks is that it’s given me a better sense of how to interpret other people’s graphs, and it’s helped me separate the wheat from the chaff. It’s also made me realize how poor data literacy seems to be for many media outlets, including major ones. They’re contributing to the problem by overwhelming people with graphs that are either not relevant or are not contextualized.

One media outlet that’s been doing a great job, in my opinion, has been The Financial Times, thanks to John Burn-Murdoch. Inspired by John’s work, Wade Fagen-Ulmschneider has produced this excellent dashboard, which has provided me exactly what I’ve wanted. (Hat tip to Rashmi Sinha.) I may stop updating my spreadsheet as a result, although I might miss the ritual too much.

Wade’s dashboard is pretty configurable overall, although you have limited control over which region’s data you’re showing. Here’s the closest equivalent to what I’ve been tracking:

And here’s what I’ve really wanted to see: the state-by-state data:

What does this tell us about the interventions so far? Again, not much. It’s too soon. Check back in another week.

I’ve seen some articles floating around with graphs comparing California to New York, crowing that sheltering-in-place is already working here. That may be the case, but it’s still too early for us to know that, and it’s irresponsible to point to a chart and suggest that this is the case. There are lots of reasons why New York might be doing so poorly compared to California that have nothing to do with interventions, density being the obvious one. Regardless, history has proven that even a few days can make a huge difference when it comes to containing epidemics, and I feel incredibly grateful that our local leaders acted as quickly as they did.

I think there are two questions that are on people’s minds. One is about hospital capacity. I’ve seen various attempts to model this, including the Covid Act Now site I mentioned last week. The one I find easiest to browse is this dashboard from the Institute for Health Metrics and Evaluation. They publish their model, which I haven’t even attempted to parse yet. (I doubt that I have the expertise to evaluate it anyway.) It suggests that, even if our current measures have flattened the curve in California, we’ll still exceed our capacity of ICU beds needed in about two weeks, although we should be okay in terms of general hospital capacity.

The second question is how much longer we’ll need to shelter-in-place (or worse). Even if we flatten the curve, lifting shelter-in-place will just get that curve going again unless we have an alternative way of managing it (e.g. test-and-trace). I haven’t seen any indications of when that will happen, so we’ll just have to continue to be patient. I feel like every day is a grind, and I’m one of the lucky ones. I can’t imagine how folks on the frontlines and those far less fortunate than me are dealing right now.

Updated COVID-19 Numbers (March 20, 2020) and Thoughts

Update: A new iteration is now available:

My morning ritual for the past week has been to update my COVID-19 spreadsheet and ponder my chart. Here’s the latest:

On the one hand, if you compare it to last week’s chart, it’s not a happy result for those of us in the U.S. (Italy’s curve might be flattening. We’ll see next week.) On the other hand, remember that this is a lagging indicator. This past week’s line was essentially pre-determined by what happened the previous week. Earlier this week, the Bay Area instituted shelter-in-place. Shortly thereafter, California made it state-wide, and New York and Illinois followed suit after that. We’ll see if this has any noticeable impact next week.

I made one slight tweak to the graph (adding labels to the axes; thanks to Kate Wing for the gentle scolding). I’d like to change the gridlines on the x-axis to every seven days, but can’t do that in Google Sheets. Not a huge deal. I’d also like to experiment with a log 2 graph (versus log 10) on the y-axis to more easily show how many days it takes for new cases to double, but again, can’t do that from Google Sheets. Again, not a big deal. I’d also like to do a region-by-region analysis, as suggested by many others and made possible by David Janes’ data, but haven’t gotten around to that yet.

I started doing all of this as an exercise in self-care. I wanted to understand what was happening, and I found what I was reading to be not just largely unhelpful, but actually debilitating. This has helped a lot. There is something very calming about looking up numbers, plugging them into a spreadsheet, and pondering the results, even if the results aren’t very good. (Come to think of it, this also played a huge role in helping me achieve better work-life balance, so it might be a pattern.) I haven’t been able to avoid the media as much as I hoped, but it’s helped me make sense of what I’m seeing and ignore articles and missives that are generally unhelpful or worse. It’s also validating when folks who understand this stuff far better than me are coming to similar conclusions.

I’ve loved seeing friends and others play with the data as well. One of the best websites I’ve seen is Covid Act Now, which shows state-by-state projections based on hospital capacity and what we understand about different interventions. They’ve also shared their model openly, and they’re posting the right disclaimers. (Good rule of thumb: Be skeptical of anyone who claims certainty about their conclusions unless they’re an epidemiologist, and even then, take everything with a grain of salt.)

I’m also inspired by everyone working on the front lines — from health care workers to domestic workers — and to those who are doing their part to support those who are. (Hat tip to Jon Stahl for sharing the amazing work that Carl Coryell-Martin instigated, for example.) Stay safe everyone, stay at home if you can, and be well.