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.

Cost of health care increases poverty around the world, and in the US

The title of the press release from the World Bank, “New WHO and World Bank Group Report Shows that 400 Million Do Not Have Access to Essential Health Services and 6% of Population Tipped into or Pushed Further into Extreme Poverty because of Health Spending”, about says it all. Or does it? Certainly, it summarizes the core information provided by that study, and that is pretty bad. Even in a world whose population this year reached 7 billion that is a big number (nearly 6%), and remember that it is talking about “…essential health services—including family planning, antenatal care, skilled birth attendance, child immunization, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation.” This is not coronary artery bypass surgery (as essential as that seems to those of us who need it), or knee replacement (which may make it possible for us to walk with less pain), or even tight control of our diabetes (possibly less prevalent in populations that are chronically malnourished), still less entirely elective care.

We are talking about access to clean water and sanitation. We are talking about the fact that the greatest cause of death in the world is water and that most of those deaths are in children. We are talking about the absence of the most fundamental aspects of access to health, not to mention health care and medical care.  While not a focus of the World Bank report, in many places war makes it worse, adding to the lack of basic services an extraordinary need for major medical care. In his New York Times Op-Ed piece of June 21, 2015, Nicholas Kristof describes the chilling war being waged by the government of Sudan against its own people in the Nuba Mountains, with daily bombings of civilians. He describes the deaths and maiming of children, and the inadequacy of even the most committed physicians to help in the atrocious conditions that exist there. An 8-year old boy, who had just lost several siblings to the bombing, “showed extraordinary courage,” the lone doctor at the hospital remembers, “but he would scream every day from pain as his dressings were changed.” While he “persevered for weeks”, “flies were laying eggs in his wounds, and soon the burns were crawling with maggots. Dr. Catena says that he would cut out the maggots, and the next day more would return.”

Yes, most of these 400 million are not in the US, are in developing (a euphemism, perhaps) countries. But in the US there is great need also; every day in our cities we see people who have not had access to TB or HIV treatment, who have delayed care because they are uninsured and cannot afford the cost, until they are so sick that their treatment costs far more than it otherwise would have. We see women who do not come for antenatal care until very late in their pregnancies if at all, missing the chance to discover and treat relatively minor problems until they become major. Fortunately, it is uncommon in the US for them to not receive “skilled birth attendance” since the law requires hospitals to provide care when women come in in labor, but they often appear with no records of whatever prenatal care they may have had. An excellent post on the blog of Medical Care Section of the American Public Health Association (unfortunately, access is limited to APHA members), “For Medicaid enrollees, a choice: PCP or emergency department?”, by Sandhya V. Shimoga, describes the problems that Medicaid patients, particularly those newly covered by Medicaid expansion in those states that have done so, in finding primary care providers; they continue to have to use the ED instead, often (again) with conditions far worse than they would have otherwise had. This, of course, does not count the largely insured people in the US who elect not to immunize their own children, secure in the knowledge that most other people are and that they will have access to care if anything does go wrong. Which it often, by the way, does.

And then there are states like mine, Kansas, that have chosen not to expand Medicaid, so that people similar to those Shimoga describes in Oregon and California do not even have a choice. The people of this state, once proud of its education and health care, have seen their rate of uninsurance increase relative to the states which have expanded Medicaid (Kansas only state to increase number of uninsured: A how NOT to do it strategy, August 9, 2014). The “solution” backed by the Republican Party and state governors such as Kansas’ Governor Brownback, is to further decrease the number of insured people by suing on a wording issue in the Affordable Care Act (ACA, “Obamacare”) that might invalidate the federally-run insurance exchanges which have allowed low-income-but-not-desperately-poor people in states like Kansas to gain insurance coverage.

This is a bold strategy, likely to work as well as Governor Brownback’s experiment in reducing taxes on the wealthy and businesses in 2012, which left the state with an $800 million budget deficit this year (on a budget of only about $8 billion). Half was replaced with one-time funds (eg, raiding the state highway fund) and the other half, after a marathon legislative session that ended a month late, with the largest tax increase in state history. However, these were all regressive taxes, mainly a sales tax increase, that hurts the poor and middle class; the 2012 cuts stayed in place for the wealthy, so I guess in that sense it did work. Business pays less tax, and if you own your business (say, self-employed lawyers or doctors) you pay no state income tax although your employees do. Kansas spends less now than neighboring Nebraska, which has 2/3 as many people. Now if we can only get rid of those federally-sponsored exchange so even more people will be uninsured…

The World Bank report calls for universal health coverage. “The world's most disadvantaged people are missing out on even the most basic services," says one official, who adds that a “... commitment to equity is at the heart of universal health coverage.” The report said that 17% of people were pushed into poverty (<$2/day) and 6% into “extreme poverty” (<$1.25/day) by the cost of emergency health care. Few Americans make anywhere near that little, but the cost of living, and of health care, is much higher and the same trend exists here; medical expenses are the largest cause of personal bankruptcy (see Fox Business’ 2014 report).

“As more countries make commitments to universal health coverage, one of the major challenges they face is how to track progress,” says another World Bank official, commenting on the study. Of course, if a country, such as the US, does NOT make a commitment to universal health coverage, this is not a problem.

Except, of course, for the people without health care.

Shall we be callous or shall we be people? There is hope.

This is a repost from yesterday from my other, non-medical, blog "Life the Universe, and a Few Things". I have gotten some positive feedback on it, so have decided to post it to MSJ as well.


Charles Blow, who appears every Saturday in the New York Times, is one of my favorite columnists. He is terse and articulate. His column always features a fascinating graphic with data that presents additional insight into his topic. Sometimes his topic is overtly political, as when he recently wrote about the disappointment many, including African-Americans, feel in President Obama. Frequently it is about people, especially poor people, especially children, and the incredible challenges that they face in this land of “everything for the rich and squeeze the most needy”. His colleague, Nicholas Kristof, often writes about the plight of children in the rest of the world. Between them, we learn a great deal of about the desperate situation of so many, as in Kristof's On Top of Famine, Unspeakable Violence, September 25, 2011.

So, on September 24, 2011, it was uplifting to have a column presenting something good happening for these children, It Takes a Village. Blow describes his visit to the Dorothy Day Apartments on Riverside Drive in West Harlem, a “former drug den” converted in 2003 to housing for destitute and homeless families. Most of the adults were drug addicts or are HIV victims or mentally ill or all these. He writes about the cheerfulness of the design of the entire building (including the art gallery on the top floor with views of the Hudson River), of the yoga done by “wee little legs that barely have kneecaps” on mats placed in a courtyard that was previously 6 feet deep in garbage.  It has been successful by any measure – no teenage pregnancies, successful graduations from high school and entry into college, and done at a cost far less than “housing” people in prison, shelters, or mental hospitals.

Blow quotes Lady Bird Johnson saying “Where flowers bloom, so does hope”. I am reminded of the song (taken from a poem by James Oppenheim written in 1911) “Bread and Roses”, “Yes, it is bread we fight for, but we fight for roses too!” The poem is associated with the women who struck the textile mills in Lawrence, MA in 1912, and since the name of many projects and organizations, including an “integrated arts” high school in Harlem.  If I am disappointed in anything in Blow’s column, it is that he fails to mention who Dorothy Day was. Day, who died in 1980, co-founded the Catholic Worker movement in 1933, “a nonviolent, pacifist movement that continues to combine direct aid for the poor and homeless with nonviolent direct action on their behalf”. If anyone wonders if Catholics are focused only on anti-abortion, anti-contraception, and child abuse, or whether there are those practicing the precepts contained in the New Testament rather than greed, prejudice, and selfishness, the Catholic Worker Movement is a good place to start. We are very fortunate to have such a center, Shalom House, in my town of Kansas City, KS.

On the same page as Blow’s op-ed is one by Theodore R. Marmor and Jerry L. Mashaw, who are academics rather than columnists. “How do you say ‘Economic Security”?” discusses the situation in the Depression in 1934, and how the government was seen as the vehicle for helping those in need to achieve a dignified life. They talk about how the discussion has changed in the last 50 years. “In 1934, the focus was on people, family security and the risks to family economic well-being that we all share. Today, the people have disappeared. The conversation is now about the federal budget, not about the real economy in which real people live.“  They go on to say that “In 1934, the government was us. We had shared circumstances, shared risks and shared obligations. Today the government is the other — not an institution for the achievement of our common goals, but an alien presence that stands between us and the realization of individual ambitions. Programs of social insurance have become “entitlements,” a word apparently meant to signify not a collectively provided and cherished basis for family-income security, but a sinister threat to our national well-being.”

There were selfish bad guys with lots of money in 1934. But they were unable to control the debate, hard as they tried, with their control of the media (Hearst newspapers, anyone?). Somehow today they do. Occasionally, there is a burst of hope, the mass rallying of regular people to contribute to and work for Barack Obama in 2008, and the dashing of hope as this figure too seems to serve those with the most power. Marmor and Mashaw conclude  “Over the last 50 years we seem to have lost the words — and with them the ideas — to frame our situation appropriately. Can we talk about this? Maybe not.”

I’d like to say “maybe yes”. Maybe we can look at the Dorothy Day Apartments and the Catholic Worker movement and Shalom House and the dozens of groups called “Bread and Roses” and the thousands of organizations and millions of people who really want to make this country and this world a better place for actual people, and have hope. And, if we want to look back for inspiration, let me offer a few passages from FDR’s “Four Freedoms” speech of January 6, 1941:

“The basic things expected by our people of their political and economic systems are simple. They are:

Equality of opportunity for youth and for others.
Jobs for those who can work.
Security for those who need it.
The ending of special privilege for the few.
The preservation of civil liberties for all.
The enjoyment -- The enjoyment of the fruits of scientific progress in a wider and constantly rising standard of living….

Many subjects connected with our social economy call for immediate improvement. As examples:
We should bring more citizens under the coverage of old-age pensions and unemployment insurance.
We should widen the opportunities for adequate medical care.
We should plan a better system by which persons deserving or needing gainful employment may obtain it….

In the future days, which we seek to make secure, we look forward to a world founded upon four essential human freedoms.
The first is freedom of speech and expression -- everywhere in the world.
The second is freedom of every person to worship God in his own way -- everywhere in the world.
The third is freedom from want, which, translated into world terms, means economic understandings which will secure to every nation a healthy peacetime life for its inhabitants -- everywhere in the world.
The fourth is freedom from fear, which, translated into world terms, means a world-wide reduction of armaments to such a point and in such a thorough fashion that no nation will be in a position to commit an act of physical aggression against any neighbor -- anywhere in the world.”

Are we now such a different people that such aspirations are no longer possible? I hope not.

Fighting for freedom abroad -- and at home

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In two side-by-side Op-Ed pieces in the NY Times on Sunday, February 27, 2011, Nicholas Kristof and Frank Rich discuss apparently very different topics. Rich’s piece, “Why wouldn’t the Tea Party shut it down?”, can be described as “depressing-with-a-glimmer-of-hope.” It compares the current situation in Congress, with a new, empowered, Republican majority with 83 freshman and firm ideology, to that of 1995, when a similar class of mid-term-elected Republicans took control under Newt Gingrich with their “Contract for America”. The similarities are obvious, but he points to the differences as well. Structurally, these include the advent of FoxNews trumpeting the GOP line that this is all about cutting spending and reducing the deficit, and pressures such as Gingrich himself urging current Speaker of the House John Boehner to push ahead with this agenda. Importantly, it highlights the role of massive funding of this agenda by the secretive-but-being-dragged-into-the-open billionaire Koch brothers, whose financial self-interest is being massively served by the Republican policies of tax cuts for the wealthy, and even more by gutting of all regulation of the oil industry (EPA) and financial industry (SEC, IRS and others). As the House moves toward actually shutting down funding for the government, it hopes (believes?) that it can convince the public to blame the President.

What is the “glimmer”? First of all, this strategy did not work in 1995, when the Republicans, not Bill Clinton were blamed for the government shutdown. Second, in 1995 the economy was in very good shape, while now it is still a disaster. While the unemployed and fearing-unemployment portion of the public, may not want to pay taxes, they are their slightly-better-off countrymen both need and want the services provided by the government in that small sliver of discretionary spending (not counting Medicare, Medicaid, and the military) that is on the table. People want their Medicare and Social Security and Veteran’s benefits and are not going to be happy if the checks don’t come because the Republicans shut down government. Moreover, Rich notes that “…the latest Pew survey found that Americans want to increase, not decrease most areas of federal spending – and by large margins in the cases of health care and education.”

Republicans think that they can continue screaming “deficit” and Americans will ignore the fact that the cuts that they propose, targeting social programs they are ideologically opposed to (Head Start, Planned Parenthood, etc.), will not make any significant difference in the deficit, while the cuts they oppose, such as repealing the tax-cuts for the wealthiest individuals and corporations, would. Maybe people will. Hopefully, especially if the President can make these points clearly, they won’t.

Kristof, on the other hand, provides a tale of inspiration and hope-with-a-serious-measure-of-caution. In “Unfit for Democracy?” he challenges the “crude stereotype” that the peoples of the Middle East (along with those of Africa, China, and other parts of the non-western-European world) are “too politically immature for democracy.” He acknowledges the state failures of Yugoslavia after Tito and the Congo; he is aware of the fears that regime change led to civil war in Iraq, chaos in Somalia[1], repressive theocracy in Iran. I have had friends tell me that the uprisings in the Middle East are about economic opportunity, not freedom. I’m sure economics, in these very poor countries, are part of it, but people are bravely dying for freedom, and they are at home, and not in the military.

Kristof tells us of unspeakable tortures endured in Bahrain, of the bravery of the double amputee he met in Cairo who wheeled his chair to the front lines as Mubarak’s thugs attacked with “rocks, clubs, and Molotov cocktails, of people marching unarmed in Bahrain toward security forces who had opened fire on them the day before.” That while there have been bad, even horrible, outcomes when people have overthrown repressive governments, “countries usually pull through”. That the solution cannot be the continuance in power by the current corrupt and brutal dictators. This is a myth perpetrated by the very dictators themselves to justify their continuance in power, to justify both pocketing most of the money and oppressing their own people.

What is the relationship between these two stories? Tyrants in power share with elites in power the professed (and often believed) myth that those who they oppress are lesser peoples, inferior races, too “childlike” to manage themselves not to mention be “trusted” with managing their country. Bigotry and exploitation exist in a homeostatic relationship, one used to “justify” the other, in a history of atrocities, from the colonialist “White Man’s Burden” to Hitler’s attempt to exterminate all Jews in the Holocaust. This position characterized attitudes toward American Indians, black people, immigrants in the late 19th and early 20th century, workers and the labor movement, and women. It justified – in our country, built on the idea of freedom and democracy – not only discrimination, degradation, and intimidation, but violent repressive attacks on: American Indians (genocide), black people (slavery and Jim Crow), immigrants, workers, and even women.

Well, these days are not over. American Indians and Black Americans, as well as other minorities continue to be on the bottom rungs of our economic and social order. Attacking immigrants is the new paradigm, with Arizona and its continued escalation of ignoble and often unconstitutional laws being hand-in-glove with the iron fists of those such as the Sheriff of Maricopa County (a worthy successor to the evil Sheriff of Nottingham, Robin Hood’s nemesis on the old television program). Wisconsin moves to the front lines in attacks on workers, with its governor seeking to eliminate collective bargaining under the myth that it is about money, despite the complete accession of the public sector unions to the financial cuts (and despite the fact that it is their own money they are giving back).[2] An astute observer notes: “You look at what is happening in the Middle East where people long kept "under the thumb" are expressing their yearnings for freedom and then contrast that with the fomenting battles over pensions and collective bargaining here in the US. It doesn't take long to start asking "What is wrong with this picture?![3]" What indeed?

“In Egypt and Bahrain in recent weeks,” Kristof writes, “I’ve been humbled by the lion-hearted men and women I’ve seen defying tear gas and bullets for freedom we take for granted. How can we say that these people are unready for a democracy that they are prepared to die for?”

Most of us in the US, those who are not the mostly young and mostly poor and working class people deployed in the at-best-futile wars in Afghanistan and Iraq, are not in danger of dying from government-directed violence. But we are certainly in danger of losing the freedom as our rights are all sold off to the highest bidder, and we must stand against it.

[1] See also the article on the Somali pirates and what the response might be,
[2] See Rick Ungars piece on Forbes.com, “The Wisconsin Lie Exposed – Taxpayers Actually Contribute Nothing To Public Employee Pensions”.
[3] R. Aistrope, personal communication.
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