I have some complicated thoughts about the problem that is convulsing the world. I have noticed that people who have shared similar thoughts have gotten some negative and even outraged reactions from people who don't grasp the subtleties. I'm going to directly confront some problems that people tend to avoid -- let's call them psychologically aversive.
First the real emergency consists of the risk that the health care system will be overwhelmed. Here is the first complication that many people do not want to confront. The idea of "flattening the curve," ceteris paribus, still means that the number of people who will ultimately become infected is pretty much the same as it would be if we don't do anything. It has to be that way because, until there is a vaccine, which won't be for a long time, the only way this ends is when we achieve herd immunity -- when enough people have become infected and hence have immunity that the virus can't efficiently spread. Josh Kovensky at TPM explains it at greater length. One implication is that we have to expect the social isolation measures to last for a long time, much longer than most people probably expect. So that's a whole lot of pain.
Another point -- and this is really just for context, I'm not arguing the ethical issues -- is that the only reason we fear overwhelming the health care system is because it is possible to save the lives of very sick people using the expensive and scarce technology of ventilators. We know that the large majority of infected people don't get very sick, or sick at all. It's just that approximately 10% (maybe a bit less, it's looking now) who need hospitalization. If this were 1918, and there was nothing we could do for them, flattening the curve wouldn't matter. We'd have the same number of deaths if we just let the epidemic take its course and be over with quickly. But since we can do something, we (whether consciously or not) invoke the rule of rescue -- the ethical perception that if there is a specific, identifiable individual in extreme need we have an obligation to do whatever we can to save them.
But -- and this is the part we aren't supposed to talk about -- there are obviously enormous costs to the measures governments and private employers are taking. In public health, we always consider the costs as well as the benefits of interventions, but in this case, nobody seems to be doing so. One ought to ask of any intervention, "Is it worth it?" We aren't supposed to ask in this case because of the instantaneous, really instinctive answer, "Don't you care about saving lives? People are going to die!" Well yes, but if we create massive unemployment and bankrupt countless small businesses, and precipitate a global depression, what will happen? The answer is that people will die. Some will become homeless. Some will become despondent and commit suicide. People will turn to alcohol and drugs. And society as a whole will have less resources. Tax revenues will crash and it will become more difficult to provide basic health care to people, as well as other public services, infrastructure maintenance, quality education.
And the people who are most harmed by these measures are low-wage workers, notably in the hospitality and travel industries. They are already living hand to mouth and now they have no income. It's easier for people with salaries whose livelihoods will continue to make these decisions.
It isn't callous or sociopathic to ask these questions. It is compassionate and responsible. I'm not saying I know the answer or that governments really are grossly overreacting. I'm saying nobody seems to be thinking about it. Reducing the number of people who ultimately die from Covid-19 is not the only, singular goal of public health policy to the exclusion of every other concern. Sometimes there aren't any good answers and we have to accept some bad outcomes. Sometimes we can only make hard choices. I'm not sure people who are now speaking very authoritatively are thinking about that enough.
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4 comments:
Whew ... and whoa ... that is a whole big bunch on which to chew.
Like philosophers ... you know, those people who, as Colin Hoover (my friend Betty's grandson) so wisely said, "think hard about hard things" ... we have to ask these questions: How best for all to handle this crisis? How do we triage treatment based not only on the immediate needs of individuals, but on the greater good? No, these are not callous questions. And: What is the best long-term approach for humans everywhere? Talk about difficult questions.
It seems to me that every person in each country needs to be tested at this point, since we have no idea who's carrying an infectious disease that may have as many as ten low-symptomatic or asymptomatic human hosts for each person who presents symptoms. As David Ho said on the Rachel Maddow show two nights ago, if we aren't testing, we're "running blind." With testing of everyone in the U.S., draconian preventive measures might be obviated.
We're so used to thinking about things in terms of financial cost, and cost to the predominantly wealthy skin-color/class, instead of considering human life quia omnis as our priority. For all those "literalist" supporters out there, let's adopt the TRULY literal meaning of the Declaration of Independence's phrase, " ... all men are created equal." Because times change. As the highly literate hypocrite Thomas Jefferson wrote,
“I am not an advocate for frequent changes in laws and Constitutions. But laws and institutions must go hand in hand with the progress of the human mind. As that becomes more developed, more enlightened, as new discoveries are made, new truths discovered and manners and opinions change, with the change of circumstances, institutions must advance also to keep pace with the times. We might as well require a man to wear still the coat which fitted him when a boy as civilized society to remain ever under the regimen of their barbarous ancestors.”
And he--who had an enslaved woman as wife, and kept his own children as slaves--along with many other founding fathers, and mothers, was as barbarous as they come.
Rome didn't end because of "barbarians." The barbarians were within, as with our country.
So one last quote, from Mahatma Gandhi, when he was asked what he thought of Western civilization: "I think it would be a good idea."
CARPE DIEM, but for god's sake, let's get it right for once. Carpe diem--QUIA OMNIS.
As in, mankind. Everybody.
So a good strategy would be to let the infection spread just fast enough to keep all the ventilators in use? That would reduce social isolation to the least harm while still minimizing the death rate.
Sadly, given the status of this nation, the need for ventilators will outstrip the supply for quite a while.
We won't have serious discussions about issues like this until most people understand the following 3 things:
1) Reality is too complex to be dealt with by someone operating at the level of a grade schooler.
2) Reality is too complex to avoid all disasters even when the best and the brightest, with access to ample resources, run things. Because shit happens.
3) However, the frequency and seriousness of the disasters that happen are almost certain to be less in the second case.
Chucky,
I hear the criticism of the president, but I haven't heard the criticism of the policies he's put in place.
Which policies advanced to stem the spread of the virus do you disagree with and how do you think the candidate that lost might have handled it better?
Wow that's easy. Other than the initial restrictions on travel from China (which were ineffectual) he didn't do anything until this past weekend except dismiss it, call it a hoax perpetrated by the media and Democrats, and claim that it would miraculously disappear in a few days. Also, he disdained existing effective tests made abroad while the CDC tried to come up with its own test which didn't work.
While some of what is happening now may be an overreaction, we'd be in much better shape if more had been done earlier. Instead he pretended it didn't exist because he can't think about anything but himself and he's an insane idiot. I obviously can't what the counterfactual would be of a Clinton presidency but she is smart, thoughtful and level headed. It would have been a good idea to restrict large gatherings early and roll out an aggressive effort to identify cases, do contact tracing and isolate infected individuals, but that would have required adequate testing resources. It's too late now for that alone to work.
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