Nobody asked me…

My primary job as a physician is to preserve life. It is not a war with death. There are no weapons or enemies or battlegrounds. My job is a negotiation with death. We sit together, death, the patient, and I, discussing, mediating, talking, crying. I take this part of my job seriously and I am often frustrated by the systemic and social factors that force me to fight death with limited time and limited resources. If we name death the enemy, we resign ourselves to a lost war. If we accept death as an inevitability of life, we may manage to greet it in peace.

There has been a lot of talk lately about whether the economic costs of our COVID-19 response are worth the human benefit. I understand where some people are coming from when they ask these questions. They see the human costs of economic depression and want to carefully weigh these against the human costs of the virus. They are negotiating. Much like my conversations with grieving families, deciding whether or not to let their loved one rest in peace.

Some of us are negotiating earnestly and thoughtfully, considering our children’s futures, our neighbors’ unemployment, and the lives of our community members. Some of us are negotiating selfishly and fearfully, considering our stock portfolios and our personal inconveniences. Most of us are probably considering all of these things. I never said the negotiations were easy. I just said it wasn’t a war. We aren’t enemies.

There are no simple answers to these questions. There are too many predictions and conjectures and unknowns. There is no mathematical calculation that will tell us what to do.

In that vein, I offer below some things to consider. I do not address the monetary value of a human life, since I could dedicate an entire blog post to the economics, utility, and philosophical ramifications of said topic. I also don’t find it especially prudent to make rash economic predictions. We don’t know what will happen. We don’t know how many new skills people will learn while at home. We don’t know how many company leaders will prioritize their communities over their wallets. We don’t know what kinds of things we will do to protect each other. 

It feels like we have two options: do we continue with protective public health measures or do we stop? But there are more than two choices. So in lieu of specific numbers or clear answers, I complicate the question more. You’re welcome.

The Economy with a capital E

The Economy is falling apart, right? Everyone says it is. All the economic graphs are showing down sloping lines. Politicians are trying to sell off their stocks. The government passed a stimulus bill. People are being laid off. The Economy is complicated. I fear that sometimes people in power use the term Economy with a capital E to confuse people. 

A reminder that for most Americans, fluctuations in the stock market mean diddly-squat. Two-thirds of American households own either just a retirement account or no investment accounts at all. Retirement accounts are long term investments that can weather shorter storms pretty well, especially if the owner can be flexible on the timing of their retirement. I’m not going to get into the macroeconomic theories of how the rest of our assets and incomes and wages are tied to the stock market. They are, sort of, but not indelibly. There are also plenty of things that the government does or could do to stabilize and protect those links, such as stimulus packages and lowering interest rates. The point is that if you imagine our total national economy as merely the stock market, you’re missing reality for a whole lot of people. 

And the reality for those people is unpredictable. For example, unemployment predictions for the coming year have been wildly imprecise, between 10% and 32%, depending on who did the calculations. In the same way that our predictions about the death toll from this virus are wildly imprecise. There are too many unknown variables right now. It might be really bad. Or we might recover alright. 

The Economy with a capital E is not something people thoughtfully discuss, it’s something people yell about on TV. If we want to solve a problem, we have to name that problem first. Some of those problems are named below. But the problem is never as simple as The Economy. 

The Economic Effects of the Virus Itself

Shelter in place orders and forced business closings have been generally regarded as the main cause of a looming economic meltdown. This is a tremendous simplification. Even though the stock market is a flawed proxy for everyone’s economic well being, let’s briefly take a look at it.

This image was taken from Google on 4/2/2020 and shows the peak of the recent downturn of the Dow Jones Industrial Average on February 21, 2020.

The line is going down. Not good for stocks. But look where it started to plummet: late February 2020. I’m sure that seems like a lifetime ago, but think back. Washington State was basically the only place in the U.S. with COVID-19 cases. No one had died yet. No one was working from home yet. No businesses were shut down. Cruise lines were still operating. Toilet paper still lined the shelves. Sure, perhaps the stock market was responding to the looming public health measures. But it was mostly responding to the looming threat of the virus.

The virus itself has real consequences. Rapidly infecting large swaths of the work force with a two week illness is not good for businesses. Killing off a large chunk of consumers is not good for business. Overwhelming hospitals and creating widespread panic is also not good for business. None of this is good for business! I agree. But I’m not sure the bulk of the bad is coming from protective public health measures. And I’m not sure that being bad for business should be our most pressing concern about the virus.

These Economic Effects are Hardest for Small Businesses…

A lot of my favorite local eateries are small establishments within walking distance from my house. I love these places and the sense of community they establish in my neighborhood. They are usually individually or family owned and operated and that means they usually have limited savings. Some of them have managed to sustain a takeout business. A lot of them have reduced hours or menus or locations. Many of them have simply closed temporarily.

There are two points to consider here. The first is how to protect the enterprise itself so that it survives this pandemic. The second is how to protect the employees who likely won’t be paid while they are laid off.

One way to protect their economic interest would be to just let them reopen. Call off the public health watchdogs and fling their doors open. I’m guessing many people would still not feel comfortable going to these establishments, now that they understand the risks. So business wouldn’t be great anyway. Reopening right now would also put their employees at risk of contracting COVID-19 or spreading it unknowingly to others.

But there are more than two choices. Individuals are still resiliently supporting local establishments by ordering takeout. Freezing rent and mortgage payments is a huge way to support local businesses since their largest overhead cost is usually rent. The loss of income trickles up to larger banks that are supposed to have larger reserves and can handle a longer stint without income. We expanded some unemployment benefits for workers, though we should be doing more to bail out these individuals who work for themselves or own their own businesses.

Even if we lifted restrictions today, business will be bad for months. We’re going to need a longer term plan to support each other. 

…and Even Harder for Vulnerable Individuals

When we think of The Economy, we think of businesses. But the reason we care about The Economy is because of individual people. We shouldn’t ignore the business infrastructure, but we should not focus on it either. The folks most affected by the economic impact of this pandemic are vulnerable individuals with limited savings and no job security. They will not be helped by interest free loans to large corporations. They don’t have generous paid sick leave or work from home programs. They will lose their health insurance when they are furloughed. And they have no one powerful to advocate for them. 

Canceling our protective public health policies still leaves them at risk for medical bankruptcy and job loss from a COVID-19 infection. It just lets us ignore it easier. Perhaps large corporations could pay some interest on their stimulus package handout and fund hazard pay and sick leave for grocery store workers and food delivery folks and janitors. Or perhaps our politicians could take a pay cut to fund these programs. Or use the money they made on their hastily sold stocks. There are more than two choices.

The Cost to Other People

There is a misconception about who will be affected by overwhelming the healthcare system with chaos and disaster. Many people who are frustrated by these lockdowns want to “take their chances.” Even if it was possible to allow individuals to “take their chances” without affecting other people, they should at least understand the ramifications of this choice. Overwhelming the health system with COVID-19 means that you won’t have your elective surgery for a long time. You’ll have to wait and suffer. It means that your father, suffering from his first surprise heart attack, will be greeted by an overworked and overwhelmed provider in the ED who has twenty other patients who need them. It means that when you get in a motorcycle accident, living your best life, there will be fewer providers making more difficult choices. I’ve seen some pretty heroic things in the trauma bay to bring people back to life. That’s not going to happen. There won’t be enough of us. 

And, ultimately, you, unnamed forty-something with your financial newsletter, anonymous thirty-one-year-old political blogger hosting COVID parties in NYC, faceless well meaning twenty-two-year-old gone stir crazy with nothing to do, you, you, you are NOT invincible. Your chances are worse than you think. And even though, right now, I find you stupid and reckless, your life has value.

And we do not make our choices in a vacuum. We cannot “take our chances” without making other people take theirs. If we’re going all economic, this is called an externality. A cost that you created but do not suffer. You’re right, you may be fine, I don’t know.  But your brother or classmate or neighbor or mother or friend or teacher or colleague or the stranger you never knew may not be fine. They don’t want to take their chances. Asthma is an “underlying illness.” So is diabetes. I can name ten twenty-year-olds right now who are healthy and spry and still very vulnerable to this disease. Especially if they don’t have a doctor or a ventilator. 

We do not get to decide that nursing home residents and grandparents and disabled folks are less valuable. We don’t get to decide that other people will die so our stock portfolios are saved. We don’t get to force other people to choose between their jobs and the lives of their loved ones. There are more than two choices.

The Cost to the Healthcare System

The overwhelming priority of my hospital right now is to prepare for the inevitable surge of COVID-19 patients. That is clear to me from our actions and from an explicit email I received from my department chair yesterday. Hospitals in New York are already overwhelmed by cases, with people being triaged in tents and staff shortages across the burroughs. This is the state of our healthcare system with protective public health measures. If we lift them too soon or without care, it will be so much worse. 

The consequences of overwhelming the healthcare system are disastrous and far-reaching. First, we will see an increased case fatality rate for COVID-19. A majority of people get better on their own, but about 20% of people require hospital care to survive the virus and 25% of those people will require intensive critical support like a ventilator in. Even if we make loaves and fishes out of our supply of equipment and spread our staff as thin as possible, it will be impossible to handle an unmitigated surge of COVID-19 patients. People will not have the care they need and they will die unnecessarily. Life is a negotiation with death, but there’s no need to be reckless about it.

The lingering effects on our healthcare infrastructure from COVID-19 are harder to predict. This is eating up a huge amount of time and resources. We aren’t focusing on other research or improvement projects. Our staff is burning out at higher rates. And it’s likely that a significant number of us will die from this virus. 

It is expensive to train a physician in the US. It’s four years as an undergraduate, four years as a medical student, and three to seven years or more for residency training. A lot of our specialized workforce goes on to additional fellowship training. Most of this cost is shouldered by the trainee, but hospitals and the Centers for Medicare and Medicaid Services (CMS) foot part of the bill for residency and fellowship training. I’m not going to put a price on a human life, but on top of that abstract cost, for a dead physician, we’ve wasted additional hundreds of thousands of dollars in investments. Take that, stock market. Think we have a doctor shortage now? Wait until COVID-19 rampages through our medical staff. Even if we liberalize funding and space for training medical students and expedite credentialing processes for foreign trained physicians, we may notice lingering effects of this pandemic on our workforce for years to come. 

There is one flickering light I can see at the end of this tunnel. Your healthcare team is pissed. We’ve been angry that our patients have to worry about insurance and payments when seeking care, but now we’re enraged. We’ve been frustrated by the administrative and financial control on clinical decisions, but now we’re enraged. We’ve been aggravated by the regional and socioeconomic differences in health outcomes and hospital policies, but now we’re enraged. Our healthcare system is an utter disaster. It has been, for decades, and is one of the reasons our response to this pandemic has been slow and frazzled and ineffective. 

After COVID-19 burns through our healthcare system over the next year, after we’ve done our duty to care for our communities, after we’ve buried the bodies, we will be faced with more than two choices. We could build the same system back up, leave people uninsured and vulnerable, leave your clinical decisions in the hands of business executives and pencil pushers, and accept the egregious disparities in outcome and approach. Or we could imagine and build a better world from the rubble. 

Better yet, we could start to rebuild now, instead of just patching holes. We need to ensure that all of us have adequate coverage for health care costs. Right now. We need to change how we pay for healthcare, to make sure systems are rewarded for taking care of their communities and not just performing procedures. Right now. We need to start valuing preventive medicine more than we value surgery. Right now. We have so many choices. 

Another Flickering Light

We’re going to have more opportunities to look up from the rubble and consider our choices. I can see the realization washing over folks now, as they sit at home with ample time to think. You’re laid off from your job and now you have no health insurance? This isn’t right, we think. Grocery store cashiers and janitors are paid how little? They’re at the mercy of their corporate overlords? That isn’t right. Wait a second. Did we just hand over half of our taxpayer funded stimulus bill to huge corporate entities? Don’t they have enough savings and assets to weather a small decline in business? Shouldn’t they have to pay interest? Why is our system so unforgiving for individual folks and so generous with business conglomerates? This is not right.

It is not right. Do not let a CEO successfully lobby for their benefit at the cost of your family’s safety and well-being.  Do not elect crooked politicians who cared more about making money off of the ventilator shortage than they did about you and your community. Do not let the oligarchy in this country tell you that there is not enough for everyone, while they hoard their own wealth like a dragon on its pile of gold. Do not let them tell you that people must die for us all to survive, while they hide out in their McMansions and want for nothing. Do not let them turn us against each other with fear and greed. This is not a war. We are not enemies.

We can’t help but compare the looming economic slump to the Great Depression. They call it Great with a capital G for a reason; it’s infamous. We also can’t help but compare this pandemic to the Spanish Flu in 1918. It was the last pandemic to really affect the U.S. after all. But the influenza virus was not what peaked in 1928 before the stock market crashed. It was income inequality.

This simplified chart was created by the New Yorker from detailed data in this article.

Choosing not to support small businesses, protect our communities, or save our neighbors does not mean we could not. Choosing not to dismantle the economic and social systems that allowed this disaster to flourish does not mean we could not. Choosing not to come together and build a better world does not mean that we could not. With great power comes great responsibility. We have great power, more than we ever realize. And we have a responsibility to be generous, patient, thoughtful, and brave. 

We have more than two choices. Do not look at the rubble and despair, look around you and imagine a new use for the stones.