Map of life expectancy at birth from Global Education Project.

Thursday, June 15, 2006

State of Emergency

No doubt you have read by now about the Institute of Medicine report on the shortage of Emergency Department resources in the U.S. According to the IOM, ambulances are diverted from emergency rooms that are too busy to accept their cargo every minute.

AP reporter Lauran Neergaard writes "At the root of the crisis: Demand for emergency care is surging, even as the capacity for hospitals, ambulance services, and other emergency workers to provide it is dropping." Well, that's not exactly the root of the problem, it's the stem. The root is money, of course. Emergency rooms are not an economically attractive proposition for hospitals, mostly because they have to treat everybody who shows up with a genuine medical emergency, and some of those people don't have insurance and can't pay. They used to do "wallet biopsies" on people and divert them if they didn't have an insurance card, but it's harder to get away with that now. (Not that it doesn't happen.)

There's a further problem, which the AP report clearly acknowledges. Even if we did maintain adequate emergency department capacity for everyday demand, it would be insufficient for a disaster, whether it's a local catastrophe such as a nightclub fire, or a regional or worldwide infectious disease pandemic. Herein lies a classic problem for human societies, which I have discussed before. We tend to underinvest in preparations for catastrophic events of unclear or fairly low probability. Some people nowadays have even taken to presenting it as somehow a "progressive" position to denigrate concern about possible emergencies such as a flu pandemic, because it supposedly diverts money from immediate needs -- even though in reality, it doesn't. Apparently just taking up a bit of space in the public discourse is a crime.

The truth is that this is not a question of political ideology or leftism or rightism. It's just a puzzle. How much to invest in situations that would be extremely serious if they happened, the timing of which cannot be predicted, is a value judgment. We need to compile the best data we can, get as much information as possible, have an open, public discussion, and then make a decision based on democratic process. Emergency departments are expensive to maintain. Spending the capital needed to maintain capacity above everyday demand means, a fortiori, some form of social subsidy. Presumably, it ought to be more than zero, but how much? I'm not going to tell you the answer, but we need to think about it, and we need to act.

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