Thursday, September 24, 2020

Doctors need to care: It's about the patients, not about you


 Recently, a friend of a friend had an accident and fell in her driveway. After two days of pain that did not improve, she went to an urgent care center where an x-ray was taken and the PA told her that there was no rib fracture and her lung had not collapsed, so she went home. The next day the urgent care center called back and said “whoops, there is a rib fracture and you do have a collapsed lung”. They said they’d call her primary care doctor, but didn’t. The patient tried to, but the doctor was on vacation. The covering physician refused to see her. So our mutual friend, who is a physician and surgeon who lives 1000 miles away, called someone who lived in the patient’s town to take her to the emergency room. There, they re-x-rayed her, and admitted her to the hospital, telling her that they would need to insert a small tube to remove the air (called a pneumothorax) from around her lung. The doctors said she refused the procedure, although she says she just asked some questions about it. She was admitted for “observation”, and given oxygen. In the morning, since the x-ray was no better, they said that they would have to keep her in the hospital, but this later was reversed on a visit from the resident on the hospitalist service, who said she could go home.

 Our mutual friend called the resident, asked about it, was told that it was OK to discharge her (quoting the “resident’s best friend”, the medical information website UpToDate®) and would not put the friend in touch with the attending physician. However, the patient was terrified about going home, especially given her accident, that she lived alone, that she had had her bad experience with the urgent care center, and that her physician was out of town. I suggested that our mutual friend might try to contact a hospital administrator to see if the attending physician could be reached. Then I got a message that there was a new hospitalist over the weekend, who happened to be a family physician, and who tried a novel approach: she talked to the patient, examined her, and reviewed the chest x-rays. After this, she decided to call a pulmonary specialist, and it was decided to insert a chest tube. The patient, with the proper treatment, improved and should get better.

 So probably the story will have a happy ending, at least from the point of view of ultimately getting the right treatment. The woman who was the patient may recover physically, but is unlikely to recover a lot of faith in what is amusingly called our health care “system”. The number of things done wrong were many, and most could be blamed on the individuals; the PA in urgent care who mistakenly thought that they could accurately read the chest x-ray, the provider in the emergency department who was apparently in too much of a rush to answer her questions and decided the fact that she had them meant she was refusing the recommended treatment, the hospitalist service who changed their mind about her need for hospitalization without explanation, the resident who would not contact the attending physician, and the attending physician who apparently did not want to be contacted.

 But to blame just the individuals would be incorrect, although we can be very enthusiastic in lauding the weekend hospitalist who decided to actually care for the patient. The system is critical here. I do not know that hospital, but I imagine the doctors in both the emergency department and on the hospital floors are stressed an overworked, and that the way they responded to the patient in question, while unjustifiable, was probably caused in part by that overwork and stress. The resident may have been the “point person” in contact with the patient, but the service attending was ultimately the one making the decision. Poor role modeling by attending physicians and senior residents is common and leads to poor behaviors by residents, who are often more concerned with their own workload or pleasing their bosses than providing proper patient care. In such busy situations, patients are often assessed quickly, and judgements are made not just regarding their medical problem, but their personality. Are they going to be a “good patient” – meaning that they will quickly accede to doing what I am recommending -- or are they going to cause me “trouble” and cost me time? That trouble can be real if the patient is aggressive, intoxicated with alcohol or other substances, or has a serious mental health diagnosis, but it is sadly true that the label “troublesome” patient can even be applied to someone who asks perfectly appropriate and reasonable questions about the treatment being proposed for them.

 Racism provides us with a bit of a metaphor, in the sense that there is both an individual and a structural (or institutional) component. Yes, behavior by individuals can be inappropriate and wrong and blameworthy. But if we leave it at that, if we do not understand the overall structure that encourages or facilitates such individual behavior, we will never solve the problem. We will never decrease or end racist behavior, and we will never ensure that patients get treated with the respect and concern that they should. Racism affects the medical system and medical education as it does the rest of society, but disrespect and self-centeredness can inhibit appropriate medical care even when race is not involved. Indeed, in this case the patient was a 70-ish middle-class white woman. One can imagine with what frequency, and to what degree, people are treated with disrespect – and poor medical care – when they are members of minority groups, poor, homeless, have a psychiatric diagnosis, are not clean and nice-smelling, are not coherent, are under the influence of a substance, etc. Of course, if one is a health care worker, one need not imagine it; one sees it all the time.

 As a family doctor, I would like to take pride in the fact that the “hero” of our story also was one. In fact, I will. I actually believe that the training of family physicians, and the emphasis on caring for the patient rather than a particular problem, makes a difference, and enhances the caring characteristics of the individuals who choose to enter this specialty. That is, I think it is more than a coincidence. However, of course there are wonderful caring physicians, including resident physicians, in every other specialty, as well as family physicians who are jerks. I just think that it is a smaller percent.

 Should there be any jerks in medicine? I have heard it argued that in some specialties, it is not necessary to have good “people skills”. In pathology, or diagnostic radiology, or even anesthesiology, where the doctor spends little or no time with living patients. Or in surgical and other procedural specialties, where technical skill, not “bedside manner”, is what matters. Sometimes I have acknowledged that this made some sense. Until I thought about the colleagues I have had in every specialty. And in every case the good ones cared about the patients they were involved with, whether or not they met them face-to-face.

 The pathologist or radiologist knows it is also their patient, and the use of their skills in the performance of their jobs may make the difference in a person’s life, or death. They care. Caring may not be the same as “people skills”; we recognize that some people have greater difficulty connecting directly with others, and are certainly not trying to create a profession full of hucksters and snake-oil salesman with false charm. But we do want one whose practitioners can convey concern, and caring, and at the minimum not disparage the people who are in their care.

 So, yes, I think that everyone admitted to medical school should care about people. And, yes, I think that we need to ensure that our medical education does not beat or role-model it out of them. Our residents need to have schedules and lives that are reasonable enough that, when they are tired or frustrated, they don’t act out. Our attending physicians need to be available.

 Even when you are tired or overworked, it is not ok to be cruel or insensitive any more than to be racist or sexist. After all, there is a reason that this profession exists, and it is not to provide a good life for the practitioners. It is to try to maximize the health of the people for whom it cares.

Tuesday, September 15, 2020

"If the only tool you have is a hammer..."

 “If the only tool you have is a hammer, everything looks like a nail”.

 This old adage has been applied in many contexts, and sometimes appropriately to the work of medical specialists, particularly those who do procedures. It is something that family physicians and other primary care doctors are only too well aware of; before referring a patient to a specialist equipped with their hammer, we like to do our best to make sure that this is the right tool for the job. Perhaps, metaphorically, the family physician has the full range of tools on their belt and can thus address most medical problems, but sometimes the complexity of the treatment that a patient needs requires someone with great expertise. Pushing the metaphor, a general contractor might think that a particular job needs a skilled electrician.

Sometimes, really a lot of the time, subspecialists are consulted for their opinion of a problem, because it is an area in which they have in-depth knowledge. This is not a bad thing at all, as long as that opinion is guided by the evidence that exists and not by the doctor having limited their knowledge to the extent that they know only one approach, or, worse yet, are guided by the potential to make money doing a procedure. This happens, but, thankfully, less often than it could. Most commonly, the issue is not lack of knowledge on the part of the specialist, or even greed, but rather a sense of what others expect of them.

If you present to a primary care doctor with chest pain that sounds like acid reflux, they’ll probably prescribe treatment for acid reflux, with caution about changes in the character or frequency of the pain. If the pain sounds a little more suspicious for cardiac angina, they might refer you to a cardiologist. After examination, history and physical, the cardiologist might think it is probably acid reflux. But – and it is a big but – because they are a cardiologist there is a good chance that they will maybe do more tests, expensive and possibly invasive, because, since they are a cardiologist, missing a potential cardiac diagnosis would look worse. Plus, even if the cardiologist is not greedy (or is even on salary, not paid per procedure) the organization they work for might want them to run profitable tests.

For the society, this means a lot of extra tests are done, and this is costly. For the individual, especially if they are uninsured or poorly insured with a big deductible or co-payment, it can be particularly costly. Plus, for the individual, it can be risky – few procedures have no risk of harm, and the more extensive and invasive the greater the risk. That said, they can also be beneficial or even life-saving. The key is to do them when they are necessary, or the evidence suggests that the probability of benefit outweighs the risk of harm, and not otherwise. Of course, we ourselves, patients (or, to use the English word, people) often demand an “answer”, even if the answer is not going to be clear and/or the methods for obtaining it not without risk. When I tell people that the results of their tests to rule out potentially dangerous causes of their symptoms are normal (I try to not use “negative”, which sounds, unsurprisingly, negative!) they often respond “But what is it?” I have to tell them that I still don’t know, but I have discovered it is not something that is really bad. That is always a good thing. Finding out that the cause of your symptoms is not cancer, for example, doesn’t tell you what it is, but it is  lot better than finding out that it is cancer!

Of course, this whole incentive to intervene, to do more sophisticated, high-tech, complex, invasive, and expensive tests or treatments, applies only to that segment of the population that is well-insured or rich. It is an incredible source of inequity, because a different set of decision rules is applied to different groups of people depending on their ability to pay rather than the medical need (or lack thereof). Yes, people with good coverage may get too many tests, which not only cost a lot and have some risk of harm in themselves, but also can snowball into needing to repeat tests or do more complicated ones if there is a suggestion of abnormality in the first set. [Think of the math in terms of something as “simple” as panels of laboratory tests. “Normal” is usually based on 2 standard deviations from the mean value in that lab, 95%, so 5% of normal people might have an “abnormal” test result. But if 20 tests are done – and their results are independent of each other – the probability that someone’s results are “normal” on all 20 might be .95^20 or about 35%!] This can result in harm to people with money.

However, it is still more common for people without money or good insurance to suffer harms because they do not get the testing and treatment needed. And, unsurprisingly in the US, racism enters into the mix; Black Americans are less likely to get recommended diagnostic and treatment interventions for heart disease than White, even when they are insured!

What can be done? Changing medical education to teach that interventions should be done based on the overall evidence, not evidence selected to lead in a particular direction, could help. This has actually improved; when I was in medical school most of the surgical literature, for example, was case series (“We did this procedure on X people, and this many got better and that many died or got worse”) without control groups or controlling for how sick people were. (A famous study in my medical youth compared surgical intervention for coronary artery disease with medical treatment. Surgical was better. Of course, all the people with other diseases that made them at higher risk for surgery were allocated to the medical treatment group!)

Another very big thing would be to make sure EVERYONE is adequately insured. Not more people, but everyone. And, best, with the same insurance, so there is no gaming the system to get the folks whose insurance pays the most. If everyone has the same insurance – most simply, improved and expanded Medicare for All, there is no financial reason to do, or not do, tests or treatments on anyone (this would not,of course, cure racism).

Also, more primary care doctors would be great. As research presented by Etz and Stange at the recent Society of Teachers of Family Medicine (STFM) conference, and published in the Annals of Family Medicine has shown, currently primary care sees 50% of all physician visits (500,000,000) with only 30% of the workforce and <7% of the dollars (and, for the academic researchers, 0.2% of NIH funding).  More primary care physicians, which would almost certainly result from (and probably require) a lot larger portion of the money spent on health care to be directed to primary care, would almost certainly lead to more equitable and higher quality care for everyone.

A highly-placed non-medical health care executive once asked me (a family doctor) why he would go to me with a prostate problem instead of a well-known urologist. Skipping over “how do you know it’s a prostate problem?” I said “I guess it depends upon whether you want surgery or not.” Oversimplistic, perhaps, since urologist might provide other options, but not entirely unrealistic. The urologist’s job may be, in part, to care for prostate problems, but their training is to operate. 

By the way, the executive had no follow up questions.

Monday, August 31, 2020

Hospitals compete for money, not the people's health. We need to stop this.

For decades, Santa Fe, NM, had only one hospital. St. Vincent’s was founded 155 years ago by the Sisters of Charity, but was taken over by the national Catholic corporation CHRISTUS in 2008. It’s a pretty good hospital with about 200 beds, for a small city of 85,000. A couple of years ago, the largest health system in New Mexico, Presbyterian, opened another hospital. It is a big building, but has only 30 beds, so its additional contribution is not primarily general inpatient care. Interestingly, while the hospital is on the far southwest side of Santa Fe, its main medical center building is directly across the street from St. Vincent’s. This is obviously not a coincidence, as it is now firmly in the center of the area in which people are accustomed to coming for medical care, establishing itself, at least for outpatient care, as a competitor.

The point that I want to talk about is not hospitals in Santa Fe specifically but rather competition among hospitals in general. This is not a problem in rural areas and small towns where the struggle is, rather, to hang on to their hospitals at all (often with just a very few inpatient beds, and almost invariably losing money). It may not be a big issue for mid-size cities like Santa Fe. It is a huge issue in the major metropolitan areas where most hospitals and doctors are, and where there are the greatest concentrations of patients (the medical term for what in English we call “people”).

In these areas, you will find that almost every big hospital (or “medical center” or “health system”) has a Cancer Center. And a Heart Center. Centers for Orthopedic Surgery and Sports Medicine are also big. And in the last decade Neuroscience centers have joined the ranks of “must-haves” for each of these centers. Of course, if they deliver babies, they certainly will have a Neonatal Intensive Care Unit. What is wrong with this? Are these not important, serious diseases that can and do kill a lot of people and need treatment? Am I advocating against treating, say, cancer?

Not at all. But while there are a lot of people with cancer, it is a finite number. Was the new Cancer Center just opened to a lot of hoopla at St. Elsewhere necessary because there were many cancer patients for whom there was not room in the Cancer Center at Downtown General, opened a few years ago, and now would have an opportunity to receive treatment? Or, just perhaps, is St. E’s hoping to attract many of the patients, and perhaps the doctors, who currently use DG to instead use their new, glitzy, state-of-the-art facility? Is it a simple matter of competition for a limited market?

If we had a medical care system that was based on the health care needs of the population, we wouldn’t have such redundancy of facilities; we would have enough for all the people who need care and not unnecessarily duplicate services. Downtown General might have centers of excellence in cancer and orthopedic sports medicine, while St. Elsewhere might be great for heart and neonatal care. And, since we are fantasizing about a system in which the driving force is the health of the people, let’s throw in primary care and mental health. But that doesn’t happen. And, in our hypothetical city, even with both cancer centers (and perhaps yet another at Doctors Medical Center), there will still be bunch of people who cannot receive care because they have no insurance or their insurance is poor (i.e., they are “underinsured”).

So, in addition to creating excess capacity, which creates major excess cost, competition in medical care services doesn’t meet the needs of all the people. The true driver of the health system, making money, creates at least three major sources of inequity:

  1. The services are only for the well-insured. Entire groups of poorly-insured people are excluded. The services offered by these special centers may be highly-profitable, but only if they get paid. They don’t make money providing care to poor or uninsured or underinsured people. 
  2. The services offered are those that are highly profitable, and most often this is for particular procedures. Yes, cancer is bad. So is heart disease. But the real reason for these centers is that these conditions are very well reimbursed by insurers, so the hospitals (and doctors) make a lot of money (provided the patients meet criterion #1, of course). For example, while chemotherapy drugs are ridiculously expensive, of course, making money for the pharmaceutical industry, the hospital makes money on the “administration fees” which are far in excess of the actual cost of administration. In addition, the creation of new “centers” are often driven by a single procedure. No one had big “Neuroscience” centers until the procedure for inserting a catheter into a brain artery to pull out a clot was developed. THAT is reimbursed incredibly well! All of a sudden every big hospital needed a “Stroke Center” and started competing (and paying a lot of money for) “stroke doctors” (who might be neurologists, neurosurgeons, or invasive radiologists) who could do this procedure. But poorly reimbursed services? No matter how much the people need them, don’t expect lots of new centers for primary care. Or mental health. Or even general surgery. Essentially, we discriminate not only against those who are poor or uninsured, we discriminate against those who are unlucky enough to have poorly-reimbursed diseases!
  3. The third great inequity is obviously geographic. If you live in a major metropolitan area, and are well-insured, you can have your choice of which hospital is the best for your problem. You consult US News, ask your friends, read the ads. But if you are in a small town or rural area far from such a city, it’s a long trip. And not worth making if you don’t have the money.

What can and should we do? In the long term, we need to eliminate the motivation of hospitals to compete for profitable services by putting them on a global budget, which is what is done in Canada as part of their single-payer health care system, called (interestingly) Medicare. And, of course, we need to cover everyone so there are no people left out because they are poor and uninsured, a universal health insurance system, not “cover more” but “cover everybody”. And by long term, I mean as soon as possible.

In the mid-term, we must change policies to much less dramatically favor certain procedures at the expense of others. Pay more for mental health and primary care. Pay less for cancer drug administration and sucking clots out of brain arteries. Stop making it so much more profitable to do knee surgery than gall bladder surgery. The availability for any kind of procedure should be based on the need for it, not how well it is highly reimbursed. That is a totally backward motivation, and dangerous to our health. This can actually be done by federal policy simply by changing how (US) Medicare values and pays for services. Because Medicare is the largest payer, it sets the market rate. Private insurers may pay more, but it is always “multiples of Medicare”; the ratio of what is paid for one medical service relative to another is set by the federal government.

And while we’re at it, let’s eliminate the universal tax-breaks “non-profit” hospitals get for anything that they do, which are mostly things that will make them money! As evil in many other ways as for-profit hospitals are, they are at least required to pay taxes, and go to the capital markets for capital expansion. No donations to a hospital should be tax-deductible if they are going to be used for a money-making scheme. Again, in Canada capital budgets are separate from operating costs. A hospital is not motivated to increase its operating profit so it can expand and build, to better compete with others. It must apply for additional capital funds, which will only be available if they serve a health need.

In fact, this is something we can do in the near term. As citizens and donors, we can demand that the next opulent fund-raising gala for our local hospital is not for the purpose of expanding money-making services, but rather to expand those services to those who cannot currently access them. The money raised should be earmarked only for, say, providing cancer care at our great cancer center to uninsured people. That would be something for which tax-deductibility is justified.

It is outrageous that our health system in the US is structured to maximize money-making and not health. But as in so much else in our society, those making the money have a lot of it to use to exert their clout. It is going to take a massive national effort by the people to make the changes that we need to have.



Monday, August 17, 2020

How the left is losing the COVID “war”

Guest post by Edgar Blaustein.  Originally posted at

Can the left already be losing the political war regarding the COVID pandemic?

A look at the political impact of the current coronavirus crisis in the United States, the United Kingdom and France, and what it might portend for the left.

Hail to the chief! Pandemic as legitimization

Donald Trump’s, Boris Johnson’s and Emmanuel Macron’s rise to power share key similarities: lack of legitimacy, and, for Trump and Johnson, appeal to nationalist sentiments (MAGA, Brexit). Trump through lies, luck, and electoral math won the Presidency with less than a majority of voters. Johnson won through lies on Brexit (no hard borders, more money for health services). Macron won with less than a quarter of votes in the first electoral round. Nevertheless, the winner takes all systems in all three countries gave the victor complete control of the legislative and executive branches of their respective governments. Though lacking legitimacy, all three wanted to think of themselves, as great war leaders such as Churchill, Roosevelt or De Gaulle.

Unlike the World War II leaders, our modern day chiefs have had the leisure over the last several years to choose their wars. Trump’s initial attempts failed, as he was outmanoeuvred by Xi Jinping and Kim Jong-un. Trump and Pompeo sounded the drums of war with Iran, but Iran, notably through attacks on oil tankers and a Saudi refinery, stopped US escalation.

Johnson’s chosen enemy was the European Union, framed as a faceless foreign oppressor, trying to grind down the plucky English. But “getting Brexit done” ran up against barriers: no hard frontier” between the Ireland and Northern Ireland, and the impossibility of assuring economically vital free trade with Europe without membership in the European Union.

Macron’s struggle was against “recalcitrant” sectors that opposed his vision of the “modernisation” of France, clinging to “outdated” notions such as progressive taxation, unions, worker’s rights, public services, or a public retirement system. Macron had won most battles, but the ceaseless conflict — with the gilets jaunes, trade unions, students — had taken its toll, and at the end of 2019, Macron’s government was visibly suffering from wear and tear.

At the end of 2019, all three leaders were in difficulty. And then came the coronavirus.

The birth of the war against a virus.

German President Frank-Walter Steinmeier said “This pandemic is not a war. It does not pit nations against nations, or soldiers against soldiers. Rather, it is a test of our humanity.”

And yet, the three leaders wound up framing their reaction to a health emergency as a war. But the path that led them to the war paradigm was far from direct. Indeed, in a first phase, all three initially downplayed the risk of the pandemic. In a second phase, they for a short while followed the “herd immunity” strategy, letting the infection run its course. And then in a third phase, all declared war on the coronavirus.

The three leaders hesitated, contradicted themselves, changed discourse, lied about the lack of personnel protective equipment, were contradictory on the subject of tests, all in frantic efforts to avoid assuming responsibility for massive unemployment and tens of thousands of unnecessary deaths. Trump’s “I take no responsibility” will certainly go down in history.

The three tried to frame their failures as responsible action to find balance between the health and economic impacts. As the double health and economic crisis deepened, they pivoted to “communicating”, a difficult task, since several countries — South Korea, Taiwan, New Zealand, Germany, Viet Nam, the Kerala state in India, among others — have demonstrated that rapid effective action on health, combined with a strong safety net for workers, leads to optimal economic as well as health results.

There appears to be no simple left/right divide that explains which countries have been most successful in meeting the crisis. Some rightist or extreme right governments — Poland, Germany, Austria, Australia or Japan — have done better in dealing with COVID, than the Social Democratic governments of Spain or Sweden. It does seem that women leaders, whatever their politics — New Zealand, Taiwan, Germany, Iceland, Finland — do better than men.

The countries that did not act rapidly have had to impose lockdowns, a blunt medieval pandemic control instrument that dates back to the time when humanity knew very little about the science of disease. Lockdowns are in no way progressive, although progressives must respect them when there is no better alternative, as in the case of our 3 countries.

The combined health and economic crisis in these three countries represents a severe threat to the legitimacy of their leaders. The depth of the crisis and the loss of legitimacy of the governments has led many leftists to imagine that we are on the brink of radical change, even the end of capitalism. The remainder of this article will argue that this is not the case, and that whatever our long term goals are, in the short term we should focus on more immediate achievable victories.

COVID is worse for the left than the subprime crash.

The 2007–2010 financial crisis was triggered by the collapse of Bear Stearns and Lehman Brothers, in the very heart of the capitalist financial system. The “shadow bankers”, who engineered the 1999 repeal of the Glass-Steagall Act walked away with hundreds of billions in profits made during the decade of the expanding bubble, while the general public paid for the crisis when the bubble burst. At the time of the subprime crisis, many people (author included) thought that the bankruptcy of the capitalist system had been made evident to the majority, and that the way was open for radical change. The crisis gave rise to the occupy movements, their European variants such as “indignados”, and in part to the Arab Spring and “Nuit debout”.

The actual results over the last decade were the opposite of radical progressive change. Economic inequality increased, the hold of bankers on public policy expanded, the influence of the right wing press increased. Authoritarian regimes have come to power over half the globe. Democracy, trade unions, free press … all declined. As Naomi Klein has argued (“The Shock Doctrine: The Rise of Disaster Capitalism”), capitalists are generally better equipped than progressive forces to take advantage of a major shock. Furthermore, the specific nature of the COVID crisis makes a radical change even less likely than was the case in 2008.

  • Capitalism did not cause COVID. Indeed, the modern capitalist system has contributed to the coronavirus pandemic, through globalisation-driven increases in travel, through accelerated exploitation of natural resources that increase interactions between wild animal populations and human activity, and through the neo-liberal sabotage of public health systems. Nevertheless, it is false, and harmful for progressive forces, to argue that capitalism caused COVID. Viruses, animal to human transmission, and long range trade all existed long before the emergence of capitalism.
  • COVID weakens intergenerational solidarity. The lockdowns strike most heavily on the finances of the youngest, whose professional and economic situation is often fragile. In contrast, older people, a majority of whom have a stable retirement income, suffer most from the health risk of the double crisis. This divide in material interests, coupled with the lack of close links between generations, has led to a political divide.
  • Weaken class solidarity. COVID divides workers by race, by class, and by type of work. The most obvious cleavage is between white collar workers who can telecommute, and essential blue collar workers who are exposed to sickness. Furthermore, since many of the essential workers are from minorities, this distinction is also of a racial nature: Black people are 4 times more likely to die than the general population in the UK, and 3 times more likely in the US.
  • Increase oppression of women. In normal times, many two income families “outsource” the principal domestic tasks: childcare, cooking, cleaning. This has ended under lockdown. Furthermore, with schools closed, home schooling is a new domestic task. It is no surprise that women have assumed a major share of this increased workload.
  • Physical distancing degrades the tissue of society. Staying 1 or 2 meters away from other people is a physical measure to prevent the spread of the corona virus. Breaking down social links is an unfortunate, and perhaps partially unavoidable, consequence. This frazzling of the tissue of society is harmful for progressives, since our main tools for collective action — demonstrations, public meetings, civil disobedience, strikes — are difficult or impossible for the moment. The rise of telecommuting will most likely make it even harder for unions to penetrate into tech related industries. Naomi Klein, in “How big tech plans to profit from the pandemic”, shows how the “tech bros” plans to make use of the crisis.
  • Justify the permanent surveillance State. “Test, trace, isolate”, while essential to fight COVID, nevertheless involve public intervention into the private lives of citizens. Successful programs in China, South Korea, Taiwan and Hong Kong all involved massive privacy intrusions. China, in particular, has woven the COVID tools into already existing, widespread programmes of surveillance of citizens lives. We can expect that these surveillance tools and powers will be used against progressives.
  • War on truth. Rightists have made a scale change in their war on truth. The chloroquine controversy, built on the basis of nothing, is just one example. Rightists no longer attempt to counter the truth, they simply bury it under a constantly growing pile of rumours, factoids and lies. Hannah Arendt, in “Lying in Politics: Reflections on The Pentagon Papers”, explains that the fog of lies aims to make both thinking and action impossible.
  • Democracy, pollution, climate. It is clear that different strands of progressive movements will have lost ground and lost momentum during the pandemic. For instance, President Donald Trump signed an executive order to ease up on businesses that make so called “good-faith” attempts to follow regulations during the coronavirus pandemic. This text will not detail the many other cases of using the crisis to weaken democracy, and to sabotage regulations on the environment.

It thus appears that the specific nature of the COVID crisis will leave the left in a weaker position than was the case after the subprime crisis.

We are not in a pre-revolutionary period

Six months ago, the UK, France and the United States were led by men who, even if they were stumbling, were strongly supported by at least a substantial minority that was enthused by their nationalistic, racist, xenophobic fear mongering. Certainly — as shown by Bernie Sanders, Jeremy Corbyn or Jean-Luc Mélanchon — there were also substantial minorities of mostly young people that give enthusiastic support to reformist candidates critical of capitalism. Nevertheless, the three radical reformists have all lost elections to more conservative politicians: Sanders lost to Biden, Corbyn to Johnson and then Keir Starmer, and Mélanchon to Macron and Le Pen. From these results, we conclude that the support for substantial reforms stems from perhaps 20% of the population, far from the overwhelming large majority that could be the basis for a mass movement for radical, post capitalist change.

The COVID crisis paradoxically weakened the political support for the three Presidents, while at the same time — for reasons outlined above — weakening the tactical capacity for action by the anti-capitalist left. In this context, the killing of George Floyd and the BLM and related movements swept across all three countries. From the point of view of the author, the BLM movements are radical in character, but reformist in their demands, mostly seeking limited reforms of a democratic nature: the right for people of color to live without fear of being harassed, beaten or killed by police. The achievements of the ’60s civil rights movement shows that this and related BLM demands are hugely important, and nevertheless achievable within the current political and economic system.

Since the end of decolonisation and the wars in South East Asia almost half a century ago, the left, with the exception of victories on women’s and LGBTQ rights, has lost more struggles than it has won. Today, over half of our planet’s inhabitants live in countries controlled by different types of authoritarian, xenophobic and racist regimes.

The left desperately needs short term victories to reverse the drift towards authoritarianism. While the current situation is not in general favourable for progressives, the specific nature of the COVID crisis in the three countries could lead to victories on specific objectives, such as the following.

  • Rebuild public health systems, and public hospitals.
  • Universal health care. Millions of Americans lost their health care when they lost their jobs. The spread of the virus in poor communities shows that health care must include undocumented workers and families.
  • Vastly increase international cooperation on preventive health issues. We cannot avoid a future pandemic unless all countries, even the poorest, have the capacity to rapidly identify and isolate new diseases. We need a strengthened WHO. Even the most closed minded of capitalists can understand that spending a few tens of billions per year to build up world health systems would cost much less than the next pandemic.
  • Increase protection of workers in times of unemployment, both through financial support, and effective retraining to allow workers to adjust to inevitable economic change. Again, a portion of capitalists would support such action.

The BLM movements show support exists for another category of actions, focusing on policing, and more broadly on systemic racism. Two types of measures should be within our reach:

  • Measures to limit police violence in poor communities, such as always-on body cams, new rules for use of firearms, end of choke holds, effective surveillance of deaths of people in police custody, some kind of control on abusive stop and frisk, or transferring some police functions to unarmed civilians. These measures broadly correspond to the slogan “defund police”.
  • Measures to reduce discrimination against minorities in employment and in the media. The actions of several large enterprises (for instance in the Facebook boycott) show that large parts of the capitalist class will support some measures.

Three other measures might be within reach.

  • a guaranteed of a job or of a basic income. This would be cheaper than the current hodgepodge of measures, and would be a more effective countercyclical Keynesian economic shock absorber. Unfortunately, opposition might come as much from some workers as from capitalists.
  • deepening of democracy, or at the least limiting of corruption.
  • perhaps a more progressive tax system. Possibly a one time special COVID wealth tax on multi-billionaires, to repay the public borrowing during COVID. Spain may create such a a wealth tax. Perhaps some kind of reparations for slavery.

We should use the opportunity of the weakness of our rulers to fight for significant and achievable short term goals. We need victories to strengthen progressive movements, to improve our capacity to win future battles. We must at the same time keep in mind our long term goals, and use the experience we gain in short term struggles to develop common ideas on our vision for the future, our strategies, our alliances, our tools and modes of action.

This text benefited from the generous help of Robert van Buskirk and Jérôme Santolini, who kindly contributed, even though they disagree with major portions of the text.

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