Chapter 1: Decisions and Implementation

At 5:04 P.M. on October 17, 1989, a large earthquake struck northern California. The earthquake destroyed or severely damaged several sections of freeway and a number of freeway off-ramps, as well as a portion of the San Francisco Bay Bridge. The vivid pictures of the damaged section of the bridge and the collapsed freeway section in the East Bay, which accounted for most of the fatalities, were flashed around the world. Most people recall that repairs to the bridge began immediately, and since the work was literally done around the clock, the bridge was reopened about six weeks later. What most people do not realize, even many living in the San Francisco area, is that some 18 months later, the opening of the San Francisco Bay Bridge was the only completed repair. Not one other damaged highway structure, not one off-ramp, not one other section of freeway had been repaired a year and a half after the quake. Indeed, in the case of the other two major portions of roadway that had been closed by the quake-the so-called Cypress Structure in Oakland and the Embarcadero Freeway in San Francisco-there was still no decision on exactly where, how, or whether to make repairs.

Technical or engineering complexities do not account for the delays, nor do they explain why the Bay Bridge was repaired while nothing else was. San Francisco's and California's response to the earthquake presents a situation that is repeated often in both public and private sector organizations-a paralysis that reflects an inability to mobilize sufficient political support and resources to take action. Confronted with a problem, in this case-or opportunities, insome other instances-organizations are often unable to get things accomplished in a timely manner. This inaction can have severe consequences. The continuing closure of the Oakland section of the freeway costs some $23 million per year in extra transportation costs and fuel, while the continuing indecision about the repair of the freeways and off-ramps in San Francisco has cost much more in terms of lost business in the city.

It is, perhaps, not surprising that there is delay and indecision when the issue is as inherently ambiguous as the location and repair of roadways. Even in cases of life and death, however, there are failures to effectively mobilize political support and get things done that have serious consequences. Consider the chronology of the discovery of transfusion-transmitted AIDS, and the subsequent delays in getting anything done about it:

In March 1981, an "Rh baby" received a transfusion of blood provided by a 47-year-old donor at the Irwin Memorial Blood Bank in San Francisco.

In July 1981, epidemiological evidence led many members of the medical community to conclude that the so-called Gay Cancer was a contagious disease, spread by both sexual contact and through blood.

In September 1981, the child who received the transfusion in March was sick, suffering from immune dysfunctions; the donor, also sick, went to his doctor at about the same time and noted that he was a regular blood donor.

In December 1981, Don Francis, an epidemiologist at the Center for Disease Control (CDC) wanted to put blood banks on the alert. He argued that if the disease spread like hepatitis, it would be spread by blood transfusions.

In January 1982, the CDC learned that hemophiliacs were dying from a disease with symptoms similar to those spreading through the gay community, and that transfusions seemed to be the mechanism of transmission.

In November 1982, Dr. Selma Dritz, assistant director of the Bureau of Communicable Disease Control at the San Francisco Department of Public Health, was concerned about protecting the integrity of the blood supply; she had documented, at least to her satisfaction, the first case of AIDS transmitted by blood transfusion.

The reaction by the blood-bank industry was denial. "The first public announcement that AIDS might be in the blood supply brought an angry reaction from blood bankers in the East .... Dr. Joseph Bove, who . . . served as an officer of the American Association of Blood Banks, went on network television to say flatly that there still was no evidence that transfusions spread AIDS. Privately, some blood bankers thought the CDC was overstating the possibility . . . to get publicity and, therefore, more funding.

On January 4, 1983 (more than a year after it was first suspected that AIDS could be spread by blood transfusions), at a meeting of an ad hoc advisory committee for the U.S. Public Health Service, Don Francis of the CDC was angry. "How many people have to die?" shouted Francis, his fist hitting the table again. "How many deaths do you need? Give us the threshold of death that you need in order to believe that this is happening, and we'll meet at that time and we can start doing something."

In March 1983, the hepatitis antibody screening sought by the CDC was rejected because of opposition from the blood banks, although donor screening was introduced to try to eliminate high-risk donors.

In May 1983, Stanford University Hospital became the only major medical center in the United States to decide to begin testing blood for evidence of AIDS infection. "The rest of the blood industry was stunned .... Some said it was a gimmick to draw AIDS-hysteric patients to Stanford from San Francisco hospitals."

In January 1984, the blood industry was continuing to stonewall. The cost of AIDS screening would be high; moreover, the industry was afraid of what it would do to both the supply of donors and the demand for blood from nonprofit blood banks. "In early January, Assistant Secretary for Health Ed Brandt set up a conference call of blood bankers and CDC officials to discuss the AIDS problem. The upshot of all the talk was no new FDA policy; instead the blood bankers agreed to form a task force to study the issue." 5 The careful...