America Normalized a Broken Healthcare System. Raj Panjabi’s New Book Explains How.

NEW YORK, NEW YORK - DECEMBER 04: Raj Panjabi speaks during the 2023 Forbes Healthcare Summit at Jazz at Lincoln Center on December 04, 2023 in New York City. Photo by Taylor Hill/Getty Images

Some crises arrive all at once: a pandemic, a heart attack, a child in the ICU. Others unfold so gradually that they become background noise.

American healthcare has made genuine gains. But access has grown harder, costs keep climbing, and both clinicians and patients often feel dehumanized by the systems meant to serve them. Many people working in health plans and care delivery have spent years trying to improve quality and safety. They can point to better scores and good intentions. They can also see the gap between those measures and what patients experience when they need help.

The result is a kind of learned tolerance. We live with conditions we should still find unacceptable.

Raj Panjabi’s new book offers a framework for understanding how that happens. His argument resonates with a question at the center of The Moral Alibi: How do people who want to do good become comfortable with systems that are not working?

Panjabi has witnessed crisis from almost every angle. 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, opens 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 stakes are difficult to overstate. The United States spends more per capita on healthcare than any other high-income nation, yet it struggles with access, affordability, and outcomes. Chronic disease drives the majority of spending, and an aging population is putting new pressure on Medicare and the federal budget. Those trends make prevention and early intervention more urgent—and make the industry’s habit of reacting late more costly.

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

The most personal story in the book is the one that taught him that lesson. 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 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 said. 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. Early humans needed to react when a leopard leapt from a branch. But a brain that expected a leopard on every branch could not sustain that level of 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 spreading for weeks.

The idea feels familiar to those 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 consumes 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.”

The same pattern shows up 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 late intervention remains normal, reducing costs without reducing care will be nearly impossible.

Panjabi also challenges how 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 why 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.

How leaders can spot a crisis before it is undeniable

Panjabi offered several ways for leaders to recognize a crisis before it becomes impossible to ignore.

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 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.

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 do not 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.

This article was originally published on Forbes.com.