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EDITORIAL

Situational Awareness

Inequity

Weinstein, Dr. James N. DO, MS

Author Information
doi: 10.1097/BRS.0000000000003638
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... In this Covid19 pandemic the expedited scientific publishing process for some manuscripts has been subject to tarnished reviews allowing the national press to be a megaphone for misinformation …. The impact of misinformation effects all people but unfortunately some more than others

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” — Dr. Martin Luther King, Jr.

“Poverty is not an accident. Like slavery and apartheid, it is man-made and can be removed by the actions of human being.” — Nelson Mandela

THE PATH FORWARD

In a world stricken by the worst Pandemic since 1918, the worst recession since 1933, and the worst riots since the 1960s how can situational awareness help us move forward as a global society.

First, we should all realize in times of crisis lie opportunities. The ability to move from crisis to opportunity is never simple. Situational awareness is essential to contextualizing the moment and framing ones’ response in said context. This is, of course like many challenges in ones’ life, easier said than done. Leadership is critical. Absent leadership contextualization and appropriate framing, confidence and more importantly direction towards betterment will be missed and or mishandled. There is plenty of blame to go around but herein lies part of the bigger problem. Finding someone to blame provides a focus but not a cure. Finding answers is more important; finding truth is necessary to find a cure. Knowing one's diagnosis is usually the first step in finding what can be an “evasive cure”. In this pandemic we have a diagnosis, “severe acute respiratory syndrome coronavirus-2” (SARS-CoV-2), Covid19, a formidable opponent. A cure remains as a hope, not a reality.

Amidst the current pandemic, single center studies, mostly observational in nature, with limited follow up, have been rushed to the head of the line for early publication in well-established journals. Such was the case of a Northwell health study Richardson et al (April 23 FLARE), calculated mortality rate of 88%. A retraction of sorts suggested the true mortality rate was ∼24%, this going from 9 of 10 to I in 4 dying? Most of us remain unclear about what the actual % dying is. In the absence of facts, the debate continues re: testing, actual Covid19 related deaths vs. other causes; masks vs. no masks; the whole debate around Hydroxychloroquine, the population based rates of death across various hospitals, despite many attempts by all sides to explain varied positions. Dr. Martin Landray, deputy chief investigator of the “Recovery trial” and professor of medicine and epidemiology at Oxford University says regarding Hydroxychloroquine, “It doesn’t work.” Such reporting is a potential source of, if inaccurate, harm that cannot be understated. What is the basis? Is there an RCT for Covid19? Today there are some small RCT's and larger observational studies all with usual flaws. These are only examples of reports, that daily, flooded the airways and have contributed to the ongoing chaos and distrust. Knowing that some 20% Covid19 positive patients can be asymptomatic is yet another one of the covariates that makes almost all that has been stated questionable. Aren’t we therefore resigned to herd immunity by a vaccine?

Situational Awareness

Situational awareness, the perception of environmental and or surrounding elements and/or events with respect to time or space, comprehended in real time, and projected out over time. Simply perceiving one is happy or sad sounds simple but in context may be hard to read and/or be obscured by protecting oneself from an uncomfortable reaction, avoiding reality and misplacing necessary responsiveness with unnecessary lack of appropriate response. When our daughter died at age 12, I tried to keep a “stiff upper lip” for my family and friends. Today, years later I remain uncertain how to respond to what changed my life and that of my family, forever. Of course, if one is not situationally aware, normal unawareness and/or perception of discomfort becomes all too normal; avoiding what is true to protect oneself. Today, we are experiencing the inequities of affliction within and across race that are likely structural problems that are, in many cases, easier to avoid, not to be talked about, hidden in the corner for another day, only to be confronted by the grim realities of structural bias and in some cases true racism.

Strong words (e.g., racism) or accusations of prejudice often put one in a defensive, fearful posture making it hard or impossible to communicate the underlying issues. If you wish to have productive communication, what we say and how we say it matters. The current ecosystem chaos is in many ways due to a lack of situational awareness and in some cases simply reflects a level of frustration, a boiling point in waiting. As a nation we are experiencing a reawakening of a painful history, heightened by a pandemic that sees no color but never-the-less is more lethal to those of color and or non-white Hispanics, as well as others across the globe who are disadvantaged by socioeconomic circumstances. To not be situationally aware of the context in which all is currently framed, is to miss the forest through the trees. Context matters and yes, we have made some progress but debate and disagreement about progress, for whom and in who's eyes matters. Be careful how you evaluate what others are experiencing, your rose-colored glasses are likely not representative of others reality.

Situational awareness plays an important role in successful decision-making across a broad range of situations, including inequities and/or simpler public and/or private relationships, some of which involve extremes, the protection of a human life, and/or one's property. Lacking situational awareness has been identified as one of the primary factors in accidents attributed to human error. Just the other day, while driving, I witnessed and oncoming car ignore or miss red light. That same car crossed a double yellow line and passed on the left, almost causing a serious accident, just before missing the stop light. Wearing a necktie, especially during Covid19 seems like a lost art. Non-zoomed weddings, church services, and funerals remain as situations where a tie seems sensible. Being unaware, in general is often, a bad excuse.

One might ask; is it that you are unaware or is it that you, in fact, do not care? It is a bit harsh to imply that one does not care, but different people have different expectations in varied situations, sensing what is right and/or expected in various situations is simply, respectful. That said, trying to be respectful, aware of ones situation in the current context and with appropriate contextualization is an important part of the equity equation; being perceptive, understanding, and comprehending ones surroundings while projecting in a humble and respectful manner what seems important to others with whom you are speaking and or others who may be listening is simply the right thing to do. The equity equation financially is Equity = Assets – Liabilities. The bigger the assets the greater the equity less any liabilities. This is important but misses the need when considering Social Equity where the best is a result closer to 1.0.

For me, social equity requires an awareness and respect of the situation you find yourself in at a moment in time, being in the moment, not your moment but the moment of those you are with or interacting with. Therefore, I propose the following equation: 

Here social equity as a ratio is best when closest to =1.0. It is dependent on one's situational awareness and respect for the situation one finds themselves. If you are not situationally aware, social inequity increases as ones’ respect does not measure up. The more respect one has for others, in each situation, the greater is ones’ social equity.

COVID19

Covid19 has challenged the world's situational awareness. Great nations have struggled to comprehend the magnitude and impact of this pandemic. In the United States leaders have tried hard to understand what they are hearing and trying even harder to translate this to us, everyday humans, who are just trying to get through the day(s). Now some months later, we remain, not surprisingly, in a steady state of uncertainty. So how might we make sense of the current situation? Are we seeing a Covid19 spike, or was this to be expected based on known populations at risk, failure to socially distance for some, and/or bad luck for others? All can be true, and all are happening. Nursing homes, meat packing plants, migrant field workers, and many others who simply must work or be in a higher risk environment, to survive or make ends meet, cannot socially distance. In some instances, especially with age of 80 plus and/or known health risk, for example, diabetes, heart disease, COPD, hypertension, cancer, and/or kidney disease one is at greater risk. The fact that asymptomatic carriers of the disease exist, in and of itself, provides a challenge to all and makes true and sustainable flattening the curve of this disease difficult. That said, we know younger people, as carriers, are at much lower risk for mortality. Pregnant women of color are also at greater risk.

Sensemaking

Klein et al,1 distinguish between situational awareness and sensemaking. Situational awareness is about the “knowledge state” with current data, inferences drawn from the data, or predictions that can be made using these inferences. Sensemaking is about the process of achieving certain outcomes. Sensemaking is viewed more as a continuous effort to understand connections (which can be among people, places, and events) in order to anticipate their trajectories and act effectively, rather than the state of knowledge underlying any particular situation. Endsley2 points out that as an active process, sensemaking considers a subset of the processes used to maintain ones’ situational awareness. In the vast majority of the cases, situational awareness is instantaneous and effortless, proceeding from pattern recognition of key factors in the environment—the speed of operations in activities such as sports activities, driving, flying, and/or manning an air traffic control unit practically prohibits such conscious deliberation in the majority of cases, but rather reserves it for the exceptions. Endsley2 also points out, that sensemaking is backward focused, forming reasons from past events, while situational awareness is typically forward looking, projecting what is likely to happen to inform effective decision processes and how those processes impact others. In most of ones’ life's events we need both, situational awareness and sensemaking. Some will choose a side as part of the, wholly unnecessary, politics of Covid19 while others will pray for their fellow humans, seeking a cure, a vaccine, and/or a time when social distancing is but a memory. I am in the latter group but only with active situational awareness and reflexive sensemaking, based in prior experiences, allow me to understand both approaches. My hope is, that we as a nation, and as a world, will become, because of Covid19, much more situationally aware of the inequities that have and do still exist and recognize the tremendous opportunities, to make some real and sustainable changes.

A recent Aspen Ideas3 report on education reform concluded that “in any collective human endeavor there comes a moment; a moment when we know so much more about what to do; a moment when collective voices align around a common purpose; a moment when we can make the possible real.”

For improving healthcare inequities following this Covid19 pandemic, that moment is now. Words are not enough; they do not substitute for action. We need action.

In the end if we are to be successful against this invisible virus, and we must be, contextualization, in the greater context of the multiple constituencies impacted is neither simple nor can it be ignored. One size does not fit all, and those who wish for a one size fits all approach are doomed to fail. Those who are not situationally aware and are not sensing the environment they are in will also fail. This is a global moment where listening can, for the moment, be more important than acting. Consequences of the virus are ever more present and understood. As a disease, Covid19 can and will continue to kill some of our most vulnerable here at home and across the globe. As an economy's worst nightmare, this virus has caused many untoward consequences. We know for example social distancing as an all-in strategy is important, but this is complicated by ignoring many ongoing illnesses that can’t wait for a cure and/or are made worse as a consequence. Mental illness, child abuse, sexual abuse, strokes, heart attacks, and many others are not waiting for this virus to clear, in some cases they have been missed and or ignored.

As a nation and as a global society we must unite as one while recognizing the many differences, some earned, and some acquired. In all cases whether earned or acquired, only seeing the differences is unacceptable and only serves to deter much needed cooperation and harmony for true success. Therefore, we must come together in a real team effort. For some it is too late, for most we can and must come together. Let us forgive those who rushed to publish less than adequate data in trying to help those in need. There has been enough suffering, healing is now needed. Like a great orchestra, we all play different instruments, we are unique individuals, we speak many languages but when given the same sheet music we can come together and create a beautiful symphony. We simply play our part, understanding the situation we are in, all the time, sensing our stand partners, and greater orchestral symphony members playing their instrumental part of a greater whole. With every note, the need to play a beautiful peace in synchrony is an exemplar of a great societal need. Let us come together to LOVE and HELP thy neighbor.

Through situational awareness and sensing within the context of time, we can come together to solve for inequity and social injustice in ways we’ve yet to imagine. Please join me in this effort and let freedom ring. Now is a special time, let's not let it pass without real change and sustainable results.

References

1. Klein G, Moon B, Hoffman RF. Available at: http://self.gutenberg.org/articles/Situation_awareness#:∼:text=Klein%2C%20Moon%2C%20and%20Hoffman%20distinguish%20between%20situation%20awareness,predictions%20that%20can%20be%20made%20using%20these%20inferences. Accessed: July 16, 2020.
2. Endsley MR. Available at: https://humanfactors101.com/topics/situation-awareness/#:∼:text=36%29%20Situation%20awareness%20is%20therefore%20a%20product%20of,two%20key%20differences%20between%20this%20and%20situation%20awareness. Accessed: July 16, 2020.
3. Aspen Ideas. Available at: https://nationathope.org/wp-content/uploads/2018_aspen_final-report_full_webversion.pdf. Accessed: July 16, 2020.
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