A recent experience while attempting to depart from an equatorial country made me reflect on why workarounds happen. As I checked in to my flight, the airline staff asked to see my yellow fever card while entering my passport information. Qu’est que c’est, carte jaune? I didn’t have one. Without one, I was told, they could neither check me in nor allow me to board the flight depart the country. I would need to find a clinic that would vaccinate me and give me a yellow fever card. At 9PM it was 2 hours from my flight and I mentally prepared to miss my flight and spend the next 24 hours navigating the healthcare process in this country and getting a vaccination. An older gentleman appeared and waved me towards the arrival hall across the street, telling me there was a medical office at the far end. “It should be no problem” he told me without explaining further. Not wasting time, I took off across the street, parking lot and to the far end of the arrival hall.
There was no sign of a medical office, but two young people in airport uniforms were standing against an information booth and chatting. I asked about the medical office for yellow fever vaccination. The young man asked for my passport, copied some information on a small pad, told me to wait and climbed the stairs with my passport. A few minutes later he returned and shuffled me down the other end of the arrival hall to a cafe where he presented me with my passport and a small yellow booklet. I paid him the processing fee of $50. He told me he was thirsty and asked whether I could spare any money for some coffee. The going rate for coffee was established to be the American currency remaining in my wallet, or $15.
The outcome was satisfactory but the process left me wondering. As I learned after my return, the World Health Organization (WHO) recommends that people traveling to countries where there are yellow fever-bearing mosquitoes get vaccinated 10 days in advance. It was fortunate for me that the entrepreneurial young man had the wherewithal to backdate my vaccination to November 2012.
Certain countries require their citizens to have proof of vaccination of yellow fever when traveling to at-risk countries. The purpose is to contain yellow fever and prevent human-to-human transmission. Enforcement, or checking for the yellow fever card, falls to the airlines that may be somehow financially liable if a passenger does not meet the requirement. A similar process exists for visas to certain countries, such as for U.S. citizens traveling to China or Brazil. Airlines check multiple times that the traveler has a current visa in order to avoid paying to ship them back home, should they be without visa be denied entry to these countries. The yellow fever card process is well-intentioned, yet did not work nearly as well as the visa process.
Why do workarounds happen? This is an important question because practically every value stream in the real world is just a net of workarounds. The ideal process delivers what we want, when we want it, directly and without error. This hardly ever happens because we want things that are not immediately available, and not flawed. We are not necessarily wrong to want these things, only wrong to believe that the universe, or any value stream within it, owes us this. However, we can endeavor to straighten out our processes and make them smoother, less wasteful and more people-centric. This takes concerted effort and constant maintenance, things we don’t always have time for day-to-day. So workarounds happen. Here are some reflections on possible reasons why, based on my yellow fever card adventure and from the perspective of the people who work in the process to enforce the yellow fever vaccination requirement:
1. Causality blindness. There is a clear difference between checking for the yellow fever card before departure to the at-risk country, upon arrival there, and upon attempted departure from that country. The point of cause of infection is the mosquito within the country, so there is zero added value in checking for the yellow fever card upon departure.
If the traveler does not have proof of vaccination because they have not been vaccinated, they have already been exposed to risk. There is no longer anything that can be done about this situation. The only places where prevention can happen is before departure in the home country by denying boarding for the non-vaccinated traveler, or upon arrival where the same traveler could be denied entry to the country and exposure to risk. Some workarounds happen because people who set policy do not take an end-to-end process view with an understanding of cause and effect.
2. Consequence asymmetry. The negative consequences of non-compliance on the part of the person enforcing the rule is clear, while the benefit is only vague, indirect and long-term. Specifically, the airline may be fined or forced to cover costs for a non-compliant passenger, while receiving no direct benefit by advancing the containment of yellow fever.
3. Cause non-locality. There is a strong need to take quick local corrective action, while true root cause countermeasures have points of cause that are distributed, distant and/or beyond the ability of the local enforcers to influence. This is common in processes and situations where delayed action can threaten life and well-being, such as healthcare. The process may be broken, but the belief is that there is no time to stop, gather the people who can make the decision, and redesign the process.
4. Solution complexity. The correct solution is more complex, or far less convenient than the quick, easy solution. This was the case with my experience. There are several orders of magnitude of complexity between paying my new friend $65 and spending 10 more days in transit while the vaccination took effect.
5. Feedback failure. When the yellow fever vaccination process fails for people like me, and we are able to find workarounds, these failure episodes are not normally reported to the people who set the policy at the WHO, the Center for Disease Control (CDC) or local airport administrators. Likely this is because these people do not go to the gemba and walk through the process, trying to check in to a flight without a yellow fever card, to discover the workaround. When policy makers and officials visit the country, they should slip out, go undercover and check how well their policies are serving the world in practice. Test the hand-off points and look for failure modes.
6. Standards incoherence. Workarounds are likely to happen when multiple standards exist for the same process with specifications varying from absolute (requirement) to optional (recommended). This is the case for yellow fever. The risk classification for yellow fever was changed by the CDC in 2010. However, this does not mean that the policies of all countries affected were updated in regards to entry and exit requirements. Ambiguity breeds workarounds.
7. Noncompliance incentive. I have heard that in some places there are incentives for not following the standard. For example, officials in some countries may stop individuals and demand to see proof of vaccination (recommended or required) and demand cash payment to remedy the situation if the documents are not in order. When this is done opportunistically, targeting individuals who are likely to have a high incentive to pay, not know the rules, and mainly for the purpose of supplementing the income of the officials, it results in a non-standard process or workaround. The purpose of the process (containment of disease through vaccination) is not achieved and the condition is not corrected due to a financial incentive to maintain the status quo. A prevention-oriented process would focus on checking at the point of entry, point of departure or simply informing people visually of the requirement.
Certainly there are other reasons why workarounds happen but these can be generalized and applied to practically any country, industry or setting. They should be used in building awareness and dialogue about these conditions so that we can correct them.
For the cautious traveler, here is the list of countries at risk of transmission of yellow fever. Please check whether vaccination is recommended or required with you travel agent, airlines, consulate or embassy.