Some crises arrive all at once: a pandemic, a heart attack, a child in the ICU. Others arrive so slowly that we stop noticing them.

American healthcare has made real progress. But access has become harder, costs keep rising, and clinicians and patients alike can feel dehumanized by the systems meant to serve them. Many of us who work in health plans and care delivery have spent years improving quality and safety. We can point to better scores and good intentions. We can also see the distance between those measures and what people experience when they need care.

We have learned to live with things we should still find unacceptable.

Raj Panjabi’s new book offers a way to understand how that happens. I found myself thinking about a question at the heart of my own book, The Moral Alibi : How do people who want to do good become comfortable with systems that are not working?

A playbook for when systems fail us

Panjabi has seen crisis from nearly every vantage point. He fled Liberia’s civil war as a child. As a physician, he worked through Ebola in West Africa and COVID at Mass General Brigham. He later led health emergency coordination for COVID, mpox, and flu on the White House National Security Council. Today, he is a senior partner at Flagship Pioneering.

His book, Safer: A Playbook—Turning Fear into Action and Crisis into Community , begins with a question that has followed him since childhood: “When the people and the systems, including healthcare systems, no longer keep us safe, what can we do for one another?”

The book is organized around eight elements of crisis: denial, isolation, risk, change, conflict, vulnerability, adaptation, and persistent uncertainty. Each chapter combines stories, mostly from medicine and public health, with the psychology behind them. Each ends with a few practical tools. The central idea is that connection helps us withstand crisis. As Panjabi puts it, the opposite of fear is not bravery. It’s belonging.

The bias that hid his daughter’s illness

The most personal story in the book is the one that taught Panjabi the idea at its center. When his daughter was about a year old, she began sliding down the growth chart, eventually falling below the third percentile for weight. He assumed she was a picky eater. It took roughly six months—and swelling around both of her eyes—before she was diagnosed with dilated cardiomyopathy. She spent two to three weeks in a pediatric ICU and two and a half years on medication. She recovered and is now nine.

“I thought it was a character flaw,” Panjabi told me. While researching the book, he found a name for it: normalcy bias, the belief that what is true today will remain true tomorrow.

He argues that this bias is not a moral failing but an evolutionary inheritance. Our ancestors needed to react when a leopard leapt from a branch. But a brain that expected a leopard on every branch could not sustain that vigilance. We are wired to assume tomorrow will look like today. That helps explain why COVID caught so many institutions flat-footed, even after cases had been percolating for weeks.

Peacetime leaders in a wartime system

This idea feels familiar to those of us who run health plans and care delivery systems. In my view, too many healthcare leaders are operating with a peacetime mindset in a system facing wartime problems. We tend to see the crisis only when it becomes impossible to ignore.

Panjabi points to chronic disease, which drives the majority of U.S. healthcare spending. We wait for the heart attack, the tumor large enough to detect, the memory loss that signals dementia—and then we act.

“We’ve normalized the inefficiency, the inequities, and sometimes the ineffectiveness of our healthcare,” he said. At the Forbes Healthcare Summit last December, he made a similar point: “We have a sick care system that’s reactive, not proactive.”

Psychologists describe a “moment of liminality”: the threshold in a slow-moving crisis after which nothing can be as it was before. For COVID, that moment was March 13, 2020. American healthcare may be approaching its own, as the population ages and spending takes up a growing share of the federal budget. “We haven’t become aware of that tipping point yet,” Panjabi said, “although it feels like some days we are.”

You can see the same pattern in the debate over costs. “The one thing everybody agrees on is that costs are going up,” Panjabi said. “The other thing people understand, paradoxically, is no one wants care to go down.” His answer is to get ahead of disease. If we keep treating late intervention as normal, it will be hard to reduce costs without reducing care.

Panjabi also challenges the way we define risk. Clinicians are trained to think about biomedical risk, but transportation, language, and economic barriers shape health, too. As a National Security Council official, he weighed in on Medicare’s community health integration services, finalized in the 2024 physician fee schedule. He called them a small drop in the ocean. The harder question is why it took so long—and why so few institutions treat social support as core medical care.

Normalcy bias helps explain how we stop being surprised by a failing system. But that is only part of the story. In The Moral Alibi , I write about the explanations we reach for once we have seen enough to know something is wrong. The problem is too complicated. The tradeoffs are unavoidable. Someone else has to fix it. These explanations may contain some truth. They can also help us avoid asking what responsibility we still have.

That is how an abnormal condition becomes routine—and how routine becomes an alibi.

Panjabi offered several ways leaders can recognize a crisis before it becomes undeniable.

Name what is happening. “First of all, simply say this is not normal,” he said. It sounds simple. It isn’t. Naming a problem means giving up the comfort of treating it as inevitable.

Rehearse before the crisis. In the Situation Room, officials ran premortems and scenario simulations—ways to practice under low stakes before the stakes were high. Public health runs tabletop exercises for pandemic flu. Healthcare organizations could do the same for cost, access, and workforce burnout.

Make room for dissent. Intelligence agencies use red teams to challenge military planners’ assumptions. Panjabi suggested that leadership teams formally designate a dissenter, perhaps a CFO or COO. I pushed back. In many healthcare organizations, the person who challenges the consensus gets stomped out and pushed out.

Panjabi’s answer was psychological safety. Leaders have to invite disagreement and keep asking, “Have we heard from them yet?” That only works if people can speak honestly without being blamed for raising a problem.

Hold purpose firmly and plans loosely. In “Get Ready to Pivot,” Panjabi argues that in uncertain times, the better question may not be “What’s your best-laid plan?” but “What’s your next best experiment?” Plans need to change when reality changes. That requires listening to the people who see the problem first, including the ones an organization would rather not hear.

Leaders people will follow

Panjabi closed our conversation with a point about trust. Crisis breeds conflict inside teams. In “Find Common Ground,” he writes about the importance of humanizing authority.

“People don’t follow invincible leaders,” he said. “They follow leaders who are authentic.”

I agree. Leaders don’t have to know everything. But they do have to be willing to say when the system is failing, including when they are part of that system. That admission is uncomfortable. It is also where responsibility begins.

Panjabi’s book asks what we can do when systems meant to keep us safe fail. The Moral Alibi asks how we learn to accept those failures—and the stories we tell ourselves so we can keep going. Both questions matter in healthcare, where the distance between what we know and what we do can become its own form of crisis.

The water has been heating for decades. The first step is to notice it.