Monday, April 20, 2020

Pandemic mismanagement: Fear, inequity and -- maybe -- hope?

Like almost everyone else, of all political persuasions, I imagine, I am furious. What and whom we are furious about or with varies, of course, with how we see the world, what we value, and whether we have a “reality-based” outlook. To a great degree our perception is affected by what we want to be true, rather than what necessarily is true, and our short-term desires rather than any long-term sense.

As a physician with a great interest in and concern for public health, I am very concerned (!!) about the horrible way that President Trump and his administration prepared for a pandemic (not at all), reacted to the first evidence of one (denial), finally moved into a response (incompetently), and have yo-yo’d (good word for them) back and forth between making tentative positive moves and stepping back. Trump’s own statements are pretty accurately parodied by a meme making the rounds with him as Captain of the RMS Titanic. But we now have a response team, headed by Ivanka and Jared, with folks like Mark Meadows, Wilbur Ross, and Steven Mnuchin, so everything should be OK. Or not. We will, as Masha Gessen tells us in the New Yorker, not know the moment when democracy dies. We can have armed rallies demanding ‘reopening of the economy’, and even calls for insurrection if he loses the election, by folks like Franklin Graham.

So far, the coronavirus does not appear to be intimidated.

Predictions for the duration of this pandemic and the way in which it will change society and human behavior in the US and around the world are both dire and probably accurate. The most distressing news has been the unsurprising degree to which it has had its greatest negative impact upon the most vulnerable: the poor, minorities, elderly, and those who cannot afford to not go to work. The most inspiring aspect has been the degree to which it has highlighted the contributions of not only heroic health care workers, but all essential workers, the majority of whom are women, especially non-white women, and are generally underpaid. Among the essential workers are NOT included CEOs, hedge fund managers, political pundits, and other mostly-male, mostly overpaid roles. Walter Scheidel gives us mixed news in his New York Times piece ‘Why the Wealthy Fear Pandemics’; back to at least the 14th century, it brings about social disruption and tends to increase the relative power of workers to demand better wages and working conditions. However, he cautions, that while “more often than not, repression failed…none of these stories had a happy ending for the masses.”

But it is not just the far-right, the GOP, and Trump who are not responding well to this crisis. The Democrats have been much better, but that’s a low bar. They still insistently miss the point that a national health program would have put us in a much better position to respond to this pandemic, and at the very least have eliminated the probably of bankruptcy for many of those receiving treatment. It almost certainly would have decreased the number of people staying away from treatment because of fear of the cost. Bernie Sanders said this throughout his entire campaign, and has just said it again in a NY Times Op-ed:
We are the richest country in the history of the world, but at a time of massive income and wealth inequality, that reality means little to half of our people who live paycheck to paycheck, the 40 million living in poverty, the 87 million who are uninsured or underinsured, and the half million who are homeless.
These ideas are absolutely as correct now as they were before he left the race. We need a national health system.

Most recently (April 18, 2020) the case is made by economists Anne Case and Angus Deaton, who continue to be amazed at the fact that ‘America can afford a world-class health system: Why don’t we have one?’. They note that
In March, Congress passed a coronavirus bill including $3.1 billion to develop and produce drugs and vaccines. The bipartisan consensus was unusual. Less unusual was the successful lobbying by pharmaceutical companies to weaken or kill provisions that addressed affordability — measures that could be used to control prices or invalidate patents for any new drugs.
The notion of price control is anathema to health care companies. It threatens their basic business model, in which the government grants them approvals and patents, pays whatever they ask, and works hand in hand with them as they deliver the worst health outcomes at the highest costs in the rich world.
And make this blunt and totally accurate statement:
The American health care industry is not good at promoting health, but it excels at taking money from all of us for its benefit. It is an engine of inequality.

It is not good at promoting health. That is a bad thing. It is good at taking money from all of us for its benefit. That is a corrupt and inefficient, as well as bad, thing. It is an agent of inequality. For most of us, that is a bad thing.

And yet it persists. And its enablers include the Democratic leadership, which resolutely continues to refrain from challenging the profits of the insurance and pharmaceutical industries. They sometimes talk about how it’s a bad thing, but then so does Trump, and sadly it seems that Trump is often more sincere. The latest proposal for spending money on protecting people by the Democratic leadership is to pay for people’s COBRA (this is where you can continue to keep your former employment-based health insurance for a time when you are laid off by paying the whole premium yourself). A good thing if you were going to lose your health insurance, for sure, especially if now, not working, you can’t afford to pay not only what YOU were paying but also your employer’s contribution. Not a bad start. But, somehow, one would hope for a better, more proactive, more comprehensive, and most important more effective solution to this crisis than just paying money to insurance companies!

The media has talked about the Democratic Party and its presumptive nominee, Joe Biden, coming a bit closer to the universal health, single-payer, Medicare for All (#Medicare4All) proposals endorsed by Sen. Sanders; a recent NY Times article tells us that ‘Biden's new proposals include expanding Medicare, government insurance for Americans over 65, to those 60 and older.’ Bold! Not! Yes, it is good that people who are 64 years old will not have to risk their lives waiting to turn 65 – that would become the province of 59 year olds! It certainly would not begin to solve the problems of the health system that are apparent to all of us, not just to Case and Deaton. It leaves the uninsured uninsured, the underinsured underinsured, the folks bankrupted by co-pays, deductibles, and surprise bills (especially those from catastrophic costs, mainly a problem for the middle-income with employer-based health insurance, per the Commonwealth Fund) bankrupt, and the insurance companies fat and happy.

It is not a solution, and the only thing audacious about it is that Biden and his campaign even dared to put it out there. We are told, by all the candidates who have dropped out, by all the liberal pundits, even by progressives, that if we want to defeat Trump and incipient fascism, we have to all come together and vote for Biden. If we do, we need to see meaningful movement to put the interests of the people ahead of those of the healthcare-industrial complex, as leaders like Alexandria Ocasio-Cortez have called for.  We need to see meaningful proposals from the Democratic standard-bearer.

In fact, we need to see him. Anyone seen Biden recently?

Saturday, April 4, 2020

COVID-19 and protecting healthcare workers

The world, and the US, have entered unchartered waters in recent history as a result of the COVID-19 epidemic. Obviously, the deaths of people who would not otherwise have died is the most important. The real economy (forget the stock market) is a disaster; in this country 3.3 million people applied for unemployment insurance benefits one week only to have it double to 6.6 million the next – the previous high was less than 700,000. The responses of governments – national, state, local – to the epidemic, and the degree to which they rely on actual science, is another huge issue.  Here I seek to address one part of the crisis, one tension, the protection of health care workers, including doctors and nurses.

For starters, we have the issue of the actual health of these individuals. The reason for placing special emphasis on the protection of them is not because they are better or more important people than others, but because we need them to care for the sickest of us, those whose illness means that they cannot safely “shelter in place”, and need to come to urgent care centers, doctors’ offices, emergency rooms, and hospitals. Health care workers, particularly in hospitals, are personally more vulnerable because they have ongoing, repeated exposures to the virus. Greater levels of virus, from one or multiple exposures, increase the risk that a person will not only become sick, but become sicker, as discussed in ‘These Coronavirus exposures might be the most dangerous’ by Joshua Rabinowitz and Caroline Bartman in the NY Times April 1, 2020, and healthcare workers in hospitals have repeated exposures.

In addition, of course, we need these people to care for the sick, because they are the ones with the skills and training to do so. Thus, they need to be protected as much as possible. The news has been full of stories of this not happening, of hospitals not providing necessary Personal Protective Equipment (PPE) to its providers, and even punishing those who bring their own (with the bizarre idea that it is not fair to the other workers who do not have it). Our healthcare providers need to be protected, not punished for identifying flaws in the system (Nicholas Kristof, April 2, 2020, ‘”I Do Fear for My Staff,” a Doctor Said. He Lost His Job.’). Doctors, nurses, and other healthcare workers have often been lauded by the public (the practice of applauding out the window, begun in Italy, is especially touching), but punished by their employers. (Others, such as Capt. Brett E. Crozier of the aircraft carrier USS Theodore Roosevelt, are also being punished by their bosses for doing the right thing.) And these people are, although health professionals, also people, with families and with risk (Sandeep Jauhar, ‘In a Pandemic, Do Doctors Still Have a Duty to Treat?’. Heroes are great, but dead heroes are still dead, fired heroes are still fired, and dead or sick healthcare workers cannot provide care to others.

One of the most elementary pieces of PPE is in great shortage: the effective N-95 masks that every healthcare worker, certainly those in the hospital, should have on all the time. Some of this is because our overall national response has been anemic, and production has not ramped up quickly enough, and some is because hospitals have adopted the “just in time” approach to acquiring equipment popularized by corporations like Toyota and Ford. It may work for cars, and it may be profitable and efficient for hospitals in normal times, but like so much of our “normal” capitalist system it is fatally (quite literally) flawed when stressed by a real crisis. This fault has been augmented by individual profiteering -- well over a month ago the staff in my local Home Depot laughed when I asked about them; they told me they had all been bought up when COVID-19 began in China, by “entrepreneurs” who sold them to Chinese on eBay. True? I can’t know, but there sure were none available. One thing that the rest of us can do is to ensure that essentially ALL new N-95 masks should be available for healthcare workers, especially those in hospitals. Other people should not be wearing, not to mention hoarding or scalping them. Don’t get some to wear when you go out. Stay home. Especially if you’re symptomatic. Stay away from others. Social distancing is something we can practice, and healthcare workers cannot. What about other masks, “surgical masks”? They won’t protect you much if at all from acquiring the virus, but may help (if you can find them, or else use a bandana) protect other people from getting the virus from you if you are infected but asymptomatic. Of course, if you are symptomatic, you should not be going out at all -- unless you are so sick and short of breath that you urgently need to go to the hospital, in which case, wear a mask.

Sometimes this balance between our own self-interest (I need to go out and an N-95 mask protects me) and society’s interest (healthcare workers need the N-95 masks) is difficult, but it is decision that should not be hard. You, me, or our family members, may be the ones who would have been cared for by that doctor or nurse if they weren’t lying in the next bed because they didn’t have the mask we wore to the grocery store.

But some other decisions are harder, like deciding who should get access to a ventilator when there are far too few for everyone who needs one. In their generally good opinion piece (April 1, 2020), Protect the Doctors and Nurses Who Are Protecting Us: They need immunity from lawsuits and prosecution for triage decisions, Cohen, Crespo, and White argue for laws to protect doctors making difficult decisions protection from lawsuits or criminal charges for making them. This is a very good idea. They make two very important points. The first is that there need to be formal criteria established for triaging access to scarce resources so that we do not just have individual doctors making individual decisions, but rather following well-thought-out guidelines. The other is that those decisions need to be legally protected. They cite   
A Maryland statute [that] makes health care providers “immune from civil or criminal liability” for actions they take “in good faith” during a declared “catastrophic health emergency.” According to the Maryland Attorney General’s Office, this statute immunizes clinicians who follow state-approved ventilator allocation protocols, “regardless of the negative consequences arising from the withdrawal of a patient’s ventilator.”
This is a good idea, and one that should be adopted by all states.

But these writers also note that “Denying some patients short-term ventilation, against their wishes, will probably cause them to die when they might have gone on to live long and healthy lives with the treatment. But it will also make limited numbers of ventilators available to other patients who are more likely to survive.” Fortunately, this is not yet really the situation we are in, having to decide which “people who might have gone on to live long and healthy lives with treatment” should be left to die. But we will be, and are in places like New York, in a situation in which decisions will have to be made that deny some patients who would NOT have gone on to lead long and healthy lives ventilation to allow their use for other patients who are more likely to survive.

People who have pre-existing terminal diseases from which they would have died anyway, or those with dementia who are never going to have normal healthy lives (and cannot make their own decisions) will be, and should be, the last people to receive ventilator treatment. Hopefully, this will not be “against their wishes” (or those of their family, if their dementia makes it impossible for them to express those wishes), because they recognize the sense of this. When people have a terminal disease, and/or are suffering from dementia, coming to grips with dying and when it is time to say “enough” even if there WERE sufficient ventilators, is something that should have been addressed already, by the patient, family, and physicians. Of course, none of this argument should suggest that criteria other than pre-existing health status and the likelihood of a full recovery should be considered in allocating resources; certainly not income, wealth, insurance status, race, disability of any kind that is not associated with an expectation of dying soon, or even age in and of itself.

COVID-19 has affected, or will affect, (as the southern hemisphere enters winter) the whole world. We are all in it together. In fact, of course, we are always all in it together, but the pandemic has exposed the flaws in individualistic arguments. I am not going to write that we can “beat this” because I don’t know, but we can behave in wise and responsible ways to keep the terrible consequences a little less terrible.

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