It's not just about the emergency. It's about restructuring society so we have the ability to deal with crises.

A recent article by Jennifer Sinco Kelleher and Terry Tang from the Associated Press, highlighted in Medscape, is called “Omicron Explosion Spurs Nationwide Breakdown of Services”, and is one of many pieces documenting how this extremely contagious (if possibly more mild) variant of COVID-19 is continuing to overwhelm not only healthcare, but almost all areas of our society:

Ambulances in Kansas speed toward hospitals then suddenly change direction because hospitals are full. Employee shortages in New York City cause delays in trash and subway services and diminish the ranks of firefighters and emergency workers. Airport officials shut down security checkpoints at the biggest terminal in Phoenix and schools across the nation struggle to find teachers for their classrooms.

It goes on. One of the major flashpoints has been whether schools should reopen, often ostensibly pitting parents (who not only are feeling overwhelmed with having to supervise their children’s online education, but often have to go back to work themselves and have no one to watch their kids) against teachers (who are reasonably terrified of contracting COVID infection – and transmitting it to their own families). Of course this is overly simplistic; parents want their children to be safe and remain non-infected, and teachers want children to be educated – often this is not only their job but their calling! Michelle Goldberg in the New York Times argues that American Federation of Teachers (AFT) President ‘Randi Weingarten Still Wants Schools Open’, as she wrote a month ago. But there are many who are determined to pander to their political bases (like Oklahoma senator Tom Cotton, whom she cites) by creating bogeymen to attack.

But it has been, in case you haven’t noticed, a very stressful two years. The schools may affect a huge number of people, but so does healthcare. Kelleher and Tang emphasize the impact on healthcare, including my old hospital, the University of Kansas in Kansas City, where

The number of COVID-19 patients at the University of Kansas Hospital rose from 40 on Dec. 1 to 139 on Friday. At the same time, more than 900 employees have been sickened with COVID-19 or are awaiting test results — 7% of the hospital's 13,500-person workforce.

Paramedics are working 80 hours a week. There are simply not enough skilled people to do the work. And it is getting worse as more and more of them get sick. The always-overtaxed staff in our healthcare facilities has become more and more overtaxed by the increase in demand and the decreased number of workers. ‘"Everybody's working 'round the clock, 12-hour shifts” says New York City’s sanitation commissioner, and it is true in many fields.

It is tempting to say that this is, in large part, a result of “chickens coming home to roost”, of two generations of cutbacks in staffing and “just in time” supplying, of corporate consolidation and downsizing and increasing profits to please investors by overworking those who are left, of rewarding this with huge salaries to the C-suite executives. Well, it is, largely. We have been though a long period of rapacious exploitation of the workforce, and it is a big part of why there was nowhere near enough “flex” in the system to accommodate the huge demands of the COVID pandemic.

The news has also featured stories about the increasing power of workers, given the current labor shortages, and a few recent strikes that have been won. This is good, but it is not enough. Many hospitals have lost staff; nurses have not only stopped coming to work but have even left the profession. Not all of them would still be there if they were being paid higher wages, but it would help. It has been interesting to see that hospitals are willing to pay agencies huge amounts of money -- $100-200 or more an hour – to get “travel nurses” (nurses who will travel from where they live to your town for the more money) but not to significantly increase salaries for full-time nurses. This is part of an overall approach that sees the pandemic as a temporary blip – we can pay these high daily rates for a while, but really do not want to increase actual salaries in the long term. Reward those doing the work? Isn’t that communism?

Indeed, this is kind of the approach that the government has been taking overall; Trump or Biden, Republican or Democrat, trying to say “this will soon pass”, we can get back to normal, we can “open up”. It pleases folks who are frustrated at being at home and being on Zoom and not eating out or clubbing or whatever to hear that. Until they get sick. It must please some of the members of the Tucson Racquet and Fitness Club, who despite a county indoor mask mandate and a request from the management continue to wear masks indoors, do not -- like the two young women who held a 45-minute maskless conversation 10 feet from my machine today. Until they get sick. Probably not until they make someone else sick, since they won’t know. The county is not enforcing the mandate and the Club and stores are afraid to; supermarket managers talk of verbal and physical assaults on their employees. The stock market really likes the idea that things will get back to normal, since “normal” has been a rising market; plus all the richest investors make money either way.

Of course, people with some jobs have been hit harder than others. Those who must be physically present at work have been unable to “phone (or Zoom) it in”. And healthcare workers, doctors, nurses, and others, have been exploited by a culture which knows that they will sacrifice much for the welfare of their patients, and is willing to push it to the max. Or more. This is not ok. There is no reason for any healthcare system to be making money (whether it is called “profit” or something else in not-for-profits) or paying its executives huge salaries while the staff is getting sick, doing double shifts, burning out. It is not just about paying people more (although often this is important); it is about a paradigm shift that recognizes that long-term commitment to those doing the work needs to be the priority. It is about having enough workforce to be able to cope with increased demand when it happens.

Reminder #1: The entire structure is geared to the goal of increasing the wealth of those who already have the most and have the most power.

Reminder #2: This is not how it should be.

COVID-19 is hard and horrible and exposes existing gross inequities in our society. But don't drink the snake oil

The COVID-19 global pandemic is hard. It is just a little bit hard for those of us who can work from home or are retired, and live in lowish-incidence areas with a high outdoors/people ratio who can go for walks, and just have to worry about not going to the gym or our hair getting shaggy, or whether to try to go to the store to get things to cook or get takeout, or being able to see our children and grandchildren in faraway places. It is harder for those who live in more congested and affected areas, and really hard for those who have lost friends or family to the disease, or have had it themselves.

I read the NY Times, published at the epicenter of the US pandemic, and am torn up by the suffering of so many there. It is really hard if you are not any of the things I mentioned in the first sentence; if you have a very low-paying job and no savings and either cannot work and get paid or have to go to work because you are essential, despite the fact that no one ever told you that before – or certainly paid you as if you were. It is showing us not only which workers are essential even if very low paid, it is showing us which are absolutely not even though highly paid, like the manipulators of finance in the legal gambling casinos of Wall St. An article by a NYC subway conductor in the NY Times says “we are not essential; we are sacrificial”. It is really hard if you have pre-existing conditions such as diabetes, obesity, chronic lung disease, or all of them. Nursing home patients were the initial victims and remain the hardest hit.

It is really, really hard if all these things come together. If you are a low-wage health worker in New York, or a farmworker (documented or not) picking vegetables and fruit and living in dangerous conditions at the best of times, or a Native American on a reservation where services are meager and the virus is spreading. The two counties of Arizona including the Navajo reservation have just about 2.5% of the state’s population and 15% of its COVID-19 cases. If you are a racial or ethnic minority, whether Asian and being blamed by the President for the virus and harassed and worse by people on the streets, or Black or Latinx, and having your usual differential level of risk and harassment exacerbated, not mitigated, by the virus.

The virus has not affected countries across the world, or parts of countries, or communities equally, but the pandemic is far from over. The rates of infection are not fading; the NY Times coverage frankly says ‘The reality of the coronavirus in the U.S. is an unrelenting crush of cases and deaths.’

More than a month has passed since there was a day with fewer than 1,000 deaths from the virus. Almost every day, at least 25,000 new cases are identified, meaning that the total in the United States — which has the highest number of known cases in the world with more than a million — is expanding by 2 to 4 percent daily.

Rural towns that one month ago were unscathed are suddenly hot spots. It is rampaging through nursing homes, meatpacking plants and prisons, killing the medically vulnerable and the poor, and new outbreaks keep emerging, an ominous harbinger of what a full reopening of the economy could bring.

As New York, which has the largest burden of cases, sees plateauing and even decrease it brings down the national rate, but if NY is excluded, the rate is continuing to rise, moving more and more into the rural states and counties who have seen the least, and, despite their frequently suffering from poverty and drug addiction and unemployment, have sometimes deluded themselves into thinking this was a big-city problem.

Both the Trump administration and independent (e.g., University of Washington) sources estimate that the deaths from COVID-19 in the US will be at least double what has been previously predicted, up to 120,000. This is not coincidentally associated with the relaxation of public-health motivated controls including social distancing mandates, business closures, etc. The states that are taking the “lead” in this regressive movement are mostly in the South and Midwest, have Republican leadership, and are creating a macabre natural experiment to demonstrate how bad public policy can kill.

Despite the morbid, if accurate, predictions that come from his own administration, and that the administration has set federal guidelines for reducing restrictions based on decreasing rates of cases and deaths and increased testing, the President himself has provided a different message. He has overtly lauded the “opening” of states that have not met these criteria, visited a mask factory in Arizona without wearing a mask. and encouraged the shocking, stupid, and dangerous demonstrations by overwhelmingly white, armed men against the appropriate restrictions in states with Democratic governors such as Michigan. These folks may think that they look cool and tough, but in fact what they look like is the yahoos they are. It is impossible for me to look at a photo like this and not imagine what would happen to these demonstrators if their skin were a darker color. It doesn’t take much imagining, and it is an awful reminder of our ongoing racism that they are allowed to do this.

With all of the hard-to-terrible impact of the pandemic, it is also hard to resist the temptation to latch on to hope in the form of new magical miracle treatments, cures, tests, vaccines. It is clearly hard for the President, who enthusiastically touted the wonders of hydroxychloroquine before there was real evidence of whether it was truly beneficial – and the evidence came in overwhelmingly negative. He also, of course, has suggested the benefits of “disinfecting” the body with chemicals or UV light. These would seem as ridiculous as they in fact are, except for the folks who drank fish-tank cleaner because it had chloroquine, or ammonia or bleach, or did Tide-pod enemas. As much as I rue it, there are a large number of Americans who view his pronouncements as gospel, and act on his every suggestion.

In addition, the complexities of the science are hard for most people to understand, and the uncertainties can seem unbearable. What level of antibodies are produced by natural infection? Do they protect against reinfection? If they do, how long will this immunity last? Can their antibody-containing plasma be used to effectively treat other sufferers? We don’t know, and won’t know, until we know. That takes time.

Another recent article in the NY Times, said

Researchers and politicians in China, the United States, Germany, Britain and beyond have latched onto antibodies as a potential solution to the virus and an outlet from containment measures. But that talk, always ahead of the science, has grown more muted in recent weeks. With the research refusing to cooperate, experts in Italy say the promise of antibodies may not be what people have imagined. At least for now.

This needs to become the new mantra for essentially every medical and scientific intervention for the novel coronavirus (officially “SARS-CoV-2”). Our talk can be ahead of the science when we are expressing our hopes and desires, but we cannot allow these hopes and desires to become something we act on until we have real evidence. Too much has already been disappointing, or misstated. “Compassionate” use is sometimes advocated, but we had better be sure that our compassion does not create more problems for people than they already have. Hydroxychloroquine does, certainly drinking disinfectants does; high-dose vitamin C is water-soluble and thus may not – unless you are a stone-former; vitamin D is fat-soluble and you can overdose on it.

A moving article in the NY Times about Rep. Alexandria Ocasio-Cortez, whose district includes the hardest-hit areas of the hardest-hit city (including, with sad irony, the neighborhood of Corona in Queens), addresses the challenges of the community and the sadness it engenders in her, in her constituents, and in us. It says ‘The wreckage in her community has made a darkly eloquent case, she said, for her agenda of universal health care and less income inequity. “This crisis is not really creating new problems,” she said. “It’s pouring gasoline on our existing ones.”

She is correct. We need to move forward not following snake-oil salesmen but resolving to address the structural problems that have made this crisis worse than it had to be.

Battling for Biomedical Supremacy? How about improving the people's health?

In an editorial on August 30, 2015, the New York Times discusses the “Battle for Biomedical Supremacy”, looking at the practice of what they call “poaching” of biomedical researchers by one state or university from another. Their main focus on the receiving end is Texas, because it has the highest profile of spending really big money to recruit researchers from universities in other states, and its main concern is (unsurprisingly) New York, which has more medical schools than any other state, and especially private medical schools with big endowments and big research programs to be “poached”. They raise the issue, but I am not (after reading it a few times) quite sure what their position is and I am afraid that they may not be either, since usually the position of the Times editorialist is clear. It seems to be saying “Well, New York needs to join this, but not spend too much public money on it.” But the editorial certainly does not condemn the practice.

I am not sure that I am wholly against it, either. Biomedical research is important. Researchers who can get better jobs (higher paying, more money to support their work) should not generally be criticized for accepting them. People have that right. On the other hand, from the point of view of the institutions that are being poached from, there can be not only feelings of sadness, betrayal, and anger, but in many cases financial losses that result from money they spent to recruit these “top researchers”, and now is down the drain, or so it seems. Sometimes these researchers are signed to contracts, just as physicians who bring in lots of money for a hospital are. These contracts for physicians may contain “non-compete” agreements, which (try to) restrict the area in which a physician leaving their employment can practice. They are more enforceable when they are more local, preventing them from going over to direct competitors, but not when someone is moving from NY to Texas. And the competition in biomedical research is much more national than the competition for direct medical care. On the other hand, if you hire mercenaries, you run the risk that someone will offer them more.

So it can increase the income and resources for the individual investigator (and his/her “team”) and can increase the status of the successful university, and might (in some cases) impact directly or indirectly on the economies of the local area, and thus state. Whether it is “worth it” from a direct financial return-on-investment (ROI) point of view probably depends upon the individual situation. It is almost never financially “worth it” directly; universities (medical especially) almost always lose money on their research endeavors even when you don’t factor in multi-million dollar recruitment packages; most “wet-lab” (biomedical) research (as opposed to say, community based or epidemiologic research) costs a lot more than even the sum of the “direct” dollars from the National Institutes of Health (NIH) and the indirect dollars (often 50% or more of the “direct”) that is supposed to help support the infrastructure. Add in another $5, $10, $20, $40 million more and you have a really hard time coming out anywhere close to break even.

But so what? The money for biomedical research has to come from somewhere; the usual source is NIH, but if states want to sweeten that, why not? After all, there are privately funded research institutes (the Stowers Institute in Kansas City is a local example); why not state, as well as federal. There are some concerns in that the federal (NIH) funds are the result of a competitive peer-review process, while these state funds are often just awarded to researchers based upon cachet. Still, if the state believes it has a chance for direct or indirect economic benefit, maybe it should “go for it”.

The bigger issue is not whether biomedical research should occur or who should support it, but why there should be competition for which university or state gets the big researchers. Does this facilitate biomedical researchers finding out more about how to treat or cure disease? I guess if more money is available, more progress could be made. But the bidding wars between universities and states seem to me to be more about local glory and (if lucky) economic development than real advances in biomedical research. It is similar to states and localities trying to lure employers by tax breaks, which may sometimes cost more than the economic benefit. Or, in the case of the Kansas City metropolitan area which straddles two states, luring companies back and forth across the state line (so that employees don’t even have to move) in what seems not-even-break-even mode (considering the cost of tax breaks). There may sometimes be benefit to science or the public good from relocating researchers and their laboratories but certainly not at the level and frequency it is occurring, and not enough to justify the huge expenditures. Often there is little or no new value being generated, but rather a shifting of resources from one place to another, maybe with a little loss in the process. However, this is how much of our economy works; the stock market and most of the financial industry – moving money around, skimming off profit (HUGE profit – the profiteers here are most of the richest of the billionaires) without creating any real value for the society.

Even more important is the implication that this is benefiting people’s health. If we wanted, as a society, to actually benefit people’s health, there are a lot more direct, effective, cost-effective and rational ways to do so. This, of course, could partly be providing financial access to health care for everyone regardless of their socioeconomic or other status, including those who have been left out of the ACA expansion because they life in states that have not expanded Medicaid, because they are undocumented, or because the level of health insurance that they can afford on the exchanges doesn’t meet all their health needs. A single-payer health system, Medicare for all. It also could mean enhancing geographic access, for those who are in rural areas or underserved urban areas, by using whatever is necessary (like financial incentives) to get doctors and hospitals to service these communities. It could also mean increasing the number and percentages of health care providers entering our most needed specialties, such as primary care, either by direct subsidy or by stopping the skewed and counterproductive reimbursement of subspecialists at much higher levels. (In Denmark, I discovered, general practitioners usually earn more than subspecialists! It is all about policy, not about the market.)

But, even more narrowly, talking about research, there is the question of getting out the therapies that research has already shown work, and are effective, and often cost-effective, to the people who need them. Continuing to do more research and find out more things is great, but actually having a national (or even state) system to ensure that the important discoveries are disseminated and implemented, is a greater priority. There are many common conditions, such as diabetes, for which we have treatments that are simply not available to many people, for many of the reasons above. Some of the unavailability of effective treatments are cost (the rapacious prices and profits charged by drug companies), but there are also treatments that are unavailable because – well, we don’t know why. While we continue to do more research on discovery, we need to do even more on efficacy, and fidelity, and finding out how to get our people to actually have improved health. Competition for researchers without increasing value is as wrong as it is in any arena.

The most effective treatments need to be available to all, the ineffective to none. We don’t need biomedical supremacy of Texas over New York, or California universities over those in Massachusetts, or even in the US over the rest of the world. We don’t need one university to “win” over another. We need better health for all our people.