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As health professionals prepare for a second wave of the pandemic, a Harvard epidemiologist discusses the injustices arising from rationing medical equipment in America.
It was small comfort, but I hoped we had dodged one important bullet in the first wave of the coronavirus crisis, even as 84,000 people have been slain. We have not yet seen widespread rationing of life-saving medical equipment. One exception was a National Public Radio report on the rationing of intensive care unit dialysis machines at hospitals serving working-class people of color in Queens.
The report said such rationing had not yet hit “less adverse environments,” such as NYU Medical Center in Midtown Manhattan. Nor were there reports from America’s first hotspots of rationing of other last-measure equipment, such as ventilators. It looked like we were avoiding what doctors faced in some parts of Italy, where physicians denied ventilators to older patients at the outbreak’s peak.
My main fear was that when this crisis came to the United States, the disparity between Queens and Manhattan would replay itself all over the nation. Schemes using point scales to penalize older Americans and prioritizing those in better prior physical condition automatically would put marginalized groups, including people of color, the poor, the disabled, and the old at a huge disadvantage.
When such schemes were announced early in the US fight against the pandemic, there was an outcry in some cities and states from progressive health professionals and public health and health care workers of color. One example is Massachusetts, where the state dialed back its point system to mollify critics.
The point system remained, but with less emphasis on long-term survival, which by definition works against racial groups with less average life expectancy. The University of Pittsburgh rationing model borrowed by many hospitals and states underwent a similar adjustment,limiting life expectancy judgements to whether death was expected only within five years, even if they survived the ventilator.
I myself posted a petition on Change.org, that I sent to the few medical figures the Trump administration allowed to the briefing podium in the national COVID-19 response, infectious disease expert Anthony Fauci, coronavirus response coordinator Deborah Birx and Surgeon General Jerome Adams. I proposed a lottery as I believe that no point system can account for the vast disparities or privilege this nation has allowed to fester that bring a person to a COVID ward.
Given the implicit bias that has been well-documented in health care, I frankly had little confidence that the system would respond with equity to many possible scenarios. For instance, should an otherwise healthy, high-income 27-year-old white COVID-19 patient who defied social distancing by frolicking on a beach get priority over a low-income 72-year-old person of color who was infected by an asymptomatic grandchild while living by necessity in a multi-generational home? Should white women with average life expectancy of 81 years get priority over black men with average life expectancy of 72 years or black women of 78 years?
My fears have been reignited as more than 40 states are reopening for business. As if it was not enough of a disaster that the Trump administration ignored coronavirus until it crashed the economy into a wreckage not seen since the Great Depression, the White House and most states have launched one of the most risky public health experiments in the nation’s history: reopening states for business even though the virus continues to rage in most of them.
It is as we are inviting a rerun of 1918 flu pandemic. How soon our leaders have forgotten that it was the second wave of the 1918 flu pandemic that killed most of the 675,000 American victims.
As of May 13, according to Reuters, only 14 states had met a key guideline from the Centers for Disease Prevention and Control (CDC) for opening back up: a two-week downward trajectory of coronavirus cases. Though President Trump has pined since March to “open this country up,” most of the public had the patience to wait for evidence of downward trends. Two thirds of Americans thought it was too soon to reopen the economy in a May 7 Pew Research Center poll.
That is likely because vast numbers of Americans know they are at elevated risk of complications from COVID-19. A CDC-supported study estimates that nearly half the United States population, 45 percent, is particularly vulnerable because of cardiovascular disease, diabetes, respiratory disease, hypertension or cancer. Tom Inglesby, the director of Johns Hopkins University’s Center for Health Security. recently told Fox News that if you added up the elderly with everyone else with underlying conditions, “There really isn’t any clear way to separate” them from the “rest of the country.”
But under financial pressure not seen for 90 years, governors are digging for dollars while families are still digging graves. “We just decided not to talk about the public health data anymore,” Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told the Washington Post.
Deciding not to talk about the public health data is a massive victory for President Trump, whose presidency is monstrously built on rejecting science. He has repeatedly contradicted scientific advice of his own coronavirus task force and has displayed appallingly little public empathy for spectacle of the dead while patting himself on the back for a “spectacular job.”The most aggressive states in reopening are conspicuously those that Trump won easily in 2016, where governors display as little regard for public health as the president.
For instance, Mississippi Governor Tate Reeves announced a reopening of barbershops, beauty parlors and gyms on the very day the state announced a record high in new cases. Copying a top Trump’s mantra in this crisis, Reeves said, “We are reaching the point where the (economic) damage to these families are disastrous as the virus. We are headed to the point where the cure could even worse than the disease.”
Reeves forced the reopening even though Chokwe Antar Lumumba, the African American mayor of Jackson, Mississippi’s capital, said it was way too soon. The state is part of the national picture in which African Americans, burdened with higher-than-average underlying illnesses stemming from the structural racism of housing, pollution, food availability, health care and virus-risky service-sector work at stores, meatpacking plants and health care, have died from COVID-19 at grossly disproportionate rates.
While African Americans make up 38 percent of Mississippi’s population, they account for 54 percent of the state’s COVID-19 deaths. Lumumba said, “It’s a bad decision to freeze economic progress, but a worse one to sacrifice human lives.”
Virtually all public health experts say this sacrifice is not worth it as you cannot have a lot of commerce with corpses. Nothing has changed in the last three months that would make African Americans or Latinx any less vulnerable to a second wave. In fact, they might even be more vulnerable.
The Harvard Global Health Institute estimates that only nine states are at or near acceptable coronavirus testing levels and none of the nation’s 10 most populous states are among them as of May 7.
Yet, as a Union of Concerned Scientists analysis pointed out, many governors are ordering people back to work like serfs or face the loss of their job and unemployment benefits. President Trump ordered meatpacking plants to stay open as “critical infrastructure,” even though the Midwest Center for Investigative Reporting has charted 54 industry-related COVID-19 deaths and 14,000 infections. Seven out of every 10 meat packers are Latinx and African American.
Now layer this with the growth of COVID into much whiter suburban and rural areas. Early in the pandemic, white Americans, 60 percent of the national population, were only 48 percent of the population in counties with a high incidence of COVID, according to the Brookings Institution. But in two of the last three weeks of tracking, white people were 62 percent and 65 percent of the population in new counties joining the ranks of high incidence.
“A greater expansion into smaller towns with fewer hospitals or medical professionals is of high concern, as is the impact on less-well-off white and racial minority populations, especially those with preexisting conditions,” Brookings said.
Actually, I have a high concern that a greater expansion of COVID into areas with fewer hospitals or medical professionals may have a great impact on people of color. For instance, three of the most aggressively reopening states, Georgia, Texas and Mississippi, have the nation’s lowest levels of physicians per person. If the second wave really does become as grim as 1918, that could create the drama of families rushing from farm country to already-overwhelmed urban hospitals in the cities. Do white rural families get extra sympathy for driving 150 miles for a shot at a ventilator?
These are real questions, based on the rashness to reopen the economy against all public health evidence, and because there are actually no uniform ethics in place to govern the prioritizing of critical care. An analysis published last month in the Annals of Internal Medicine found that many academic medical centers had no approved policy at all, let alone those that have point systems.
The analysis said, “Beyond ethical arguments for and against each of these criteria, the variation among policies is itself problematic, because it may result in injustice.” It said some policies “contend that age should be considered without specifying how.” It said “some policies exclude disability discrimination but categorically exclude patients with certain preexisting conditions from receiving mechanical ventilation. Policies that rely on triage teams’ or officers’ judgement may introduce implicit bias or discrimination.”
Finally, the analysis said that few policies “specify blinding mechanisms to prevent those making triage decisions from access to information about patients that is ethically irrelevant, such as the ability to pay or race. A related concern is the lack of specification in some policies of how triage decisions may be appealed or how they are retrospectively reviewed to ensure consistency and fairness.”
I proposed a lottery because conscious and unconscious discrimination makes any point scheme a crapshoot for the marginalized. I am not alone.
In the May 15 edition of the Journal of the American Medical Association’s Online First, the chief medical officer for the San Francisco Health Network and two other co-authors others offer a lottery as “the fairest way to allocate a very scarce drug among eligible patients,” in the arena of COVID-19 medications.
That commentary said that even with a lottery, hospitals should constantly review data to assure that “facially neutral policies for allocation do not in practice result in unfair disparities that harm groups that are already disadvantaged.”
That is a sign of how concerned progressive health researchers and practitioner are about disparities creeping into life-and-death decisions. Between devastated communities of color being ordered back to often unsafe work, the rapid erosion of social distancing, the rise of COVID in whiter parts of America, and the inconsistency in critical care policies from hospital to hospital, medical leaders need to think anew about who gets a ventilator when we truly are “all in this together.”
Michelle D. Holmes is an epidemiologist at the Harvard School of Public Health and Associate Professor of Medicine at Harvard Medical School & Brigham and Women’s Hospital. The opinions expressed in this article are solely her own and do not reflect the views and opinions of Brigham & Women’s Hospital or Harvard University. Her Change.org petition for just rationing in coronavirus care can be found at: Change.org/JustRationing.
Copyright 2020 Michelle D. Holmes.