← Back to Insights
September 14, 2021
David W. Johnson
Outcomes Policy
4-Minute 4sight Blogs Dispatches

September 11th and the Importance of “Proving Negatives”

Here’s a thought experiment.

Imagine if the Federal Aviation Administration (FAA) had enacted a regulation in the late 1990s that required commercial airlines to harden cockpit doors. This regulation would have prevented the September 11th terrorists from crashing planes into the World Trade Center towers and the Pentagon. It would have saved thousands of lives and prevented widespread social and economic dislocation.

Now imagine the airline industry’s pre-9/11 reaction to incurring the cost and inconvenience of hardening the cockpit doors of every one of its commercial planes. It would have been vehement, vociferous and venemous. 

Persuading stakeholders to invest in strategies that prevent potential catastrophic events is exceedingly difficult. The exercise is theoretical. There are no specific events triggering support for preventive actions. This puts policymakers in the position of “proving negatives.” How to show that failure to make investment “x” (e.g., hardened cockpits) will lead to catastrophic event “y” (e.g., airplane hijacking and destruction) when no such event has ever or may ever occur.

This thought experiment illustrates the conundrum that proving negatives imposes on policymakers. After September 11th, it was obvious that hardening cockpit doors would prevent perpetrators from taking control of flights in midair. No one, least of all the airlines, objected to the costs and inconvenience required to harden cockpit doors.

Without a September 11th-type event, it would have been almost impossible for the FAA to marshal sufficient political support to establish that regulation. The threat level was the same pre- and post-9/11. The difference was mindset. Prior to 9/11, the nation lacked the collective imagination and will to perceive and prepare for this new type of threat. After 9/11 was a different ball game.

Author Nassim Taleb addresses this proving-negatives conundrum in his 2007 best-selling book, The Black Swan: The Impact of the Highly Improbable. Since then, the term “black swans” has become synonymous with improbable events that have extremely high impact. Nassim used the September 11th attacks as an example of a black swan event, and emphasized the need to have robust response capabilities in place to minimize their negative impact.

In her 2016 book The Gray Rhino: How to Recognize and Act on the Obvious Dangers We Ignore, author Michelle Wucker describes “gray rhinos” as predictable, high-impact events that policymakers ignore because they’re complex, inconvenient and/or fortified by status quo behaviors. Wucker cites climate change as an example of a charging gray rhino.

It’s debatable whether the September 11th attacks were foreseeable. What isn’t debatable is that preventing catastrophic events is the essence of effective risk management. The potential for catastrophic events of either the black swan or gray rhino variety magnifies with complexity, interconnectedness and dynamism. 

Complexity, interconnectedness and dynamism are the very characteristics that define modern society. Therefore, the foreseeable gap between desirable and catastrophic outcomes is the widest it’s ever been. 

With regard to healthcare, for example, what will Americans do: 

  • advance healthy lifespans in the 100s and beyond through application of scientific wellness programming based individualized genetic profile; or
  • tolerate rampaging chronic disease that reduces national life expectancy; or
  • both of the above 

It’s anyone’s guess, but healthier lifespans are within America’s grasp if we have the collective wisdom and wherewithal to make investments that optimize health. America’s responses to COVID illustrates how high-impact events shape societal well-being in both positive and negative ways.

The United States was unprepared for the COVID pandemic and has experienced grievous consequences as a result. America’s poor and marginal populations have disproportionately suffered. At the same time, the embrace of virtual healthcare services and the ability to develop effective vaccines quickly are examples of the type of robust responsiveness that Taleb believes are necessary to cope effectively with high-impact events.

As the nation observes the 20th anniversary of the September 11th attacks, it is essential that Americans acknowledge and address the increasing role that uncertainty plays in our national affairs. We must have the imagination to consider how both predictable and unpredictable events can shape our future. We also must have the will to prevent avoidable catastrophes and the wherewithal to respond robustly to catastrophes we cannot prevent.

Nowhere is this need for more imaginative and responsive leadership more important than in healthcare. The combination of advancing data technologies in combination with advancing genetic knowledge means that healthcare will change more in the next ten years than it has in the last one hundred years.

Never has Ben Franklin’s maxim that “an ounce of prevention is worth a pound of cure” been more applicable. Franklin used this phrasing to emphasize the need for better fire prevention in Philadelphia. Fires can and do occur. Preventing fires is the highest priority. Containing fires that do emerge is also imperative. In both cases, having the imagination and ability to “prove negatives” is prerequisite for minimizing fire damage. 

Read all dispatches from Dave Johnson here.




About the Author

David W. Johnson

David Johnson is the CEO of 4sight Health, an advisory company working at the intersection of healthcare strategy, economics, innovation. Johnson is a healthcare thought leader, keynote speaker, and strategic advisor to organizations busting the status-quo to reform our healthcare system. He is the author of Market vs. Medicine: America’s Epic Fight for Better, Affordable Healthcare, and his second book, The Customer Revolution in Healthcare: Delivering Kinder, Smarter, Affordable Care for All (McGraw-Hill 2019). As a speaker, Dave plays the role of rebel, challenger, industry historian, investor and company evaluator to push audiences forward. (Watch bio video.) Johnson applies his 25+ years of investment banking in healthcare to identify ways the healthcare industry must change to deliver better care. He received a Masters in Public Policy from Harvard Kennedy School, an English degree from Colgate University, and served in the African Peace Corp service. Join over 10k+ healthcare executives who read our weekly insights and commentary on www.4sighthealth.com. His third book, Less Healthcare, More Health: The Prescription for a Happier, More Equitable and Productive America, will publish in 2024.

Recent Posts

Default Image
4sight Friday | April 19, 2024
4sight Friday | GoFundMe Healthcare Is Not the Solution | Don’t Cry for Acquired Physician Practices | Why… Read More
By April 19, 2024
Stop Weeping for Physician Practices
4sight Health published a blog post last month in which I said it was disingenuous of physicians to… Read More
By April 17, 2024
GoFundMe Helps Some Pay for Healthcare, but it’s an Awful Solution
During the chaotic runup to the 2020 elections, President Trump nominated Judge Amy Coney Barrett to fill Ruth… Read More
By April 16, 2024