The worst of the surge seems to have come and gone in New York City; so far, the damage there seems to have taken the form of a bad, but not worst-case scenario, partly due to the efforts to avoid a worst-case scenario. This article from Harvard Business Review describes what was done at Elmhurst Hospital in Queens, at the center of the epicenter. Don’t think of the New York situation as one of “dodging a bullet.” Think of it more as a case of donning a bulletproof vest at the last minute as the gunman got a shot off, being hit in the torso, then being hit in the thigh, with the second bullet missing the femoral artery by inches but still lodged there. The patient probably won’t die; he’ll just be crippled for awhile. And the gunman is still on the loose.
I haven’t had the chance to write up a comprehensive follow-up to my first post on the situation in New Jersey back on March 31. Rest assured that things are worse here than they were then. The surge here has begun, but is still mostly in the future: mass death will be our Easter present. We probably won’t be crucified or resurrected; we’ll just get the shit kicked out of us, and be left bleeding–less Golgotha than the Garden of Gethsemane. Yes, it could have been far worse, but it also could have been far better.
I’m struck by the remarkable prescience of my brother’s prediction back in mid-March. Would we, I asked him, face catastrophe? No, he said. Would we have the same outcome as Italy? Not quite, he said. His exact words (besides the ones I quoted) were:
We’ll be like Italy on the front end, but like America on the back end.
In other words, facing the pandemic with as little preparation as Italy (and far less excuse), our initial response would resemble Italy’s (as it did); but having far greater resources than Italy, and a better capitalized health care system, we would do a better job of picking ourselves up off the floor, stanching the bleeding, and mopping up the blood (as we have). But there definitely would be blood to mop up, more than most people would be capable of looking directly at.
Neither of us relied on sophisticated statistical models, or presumed to make precise statistical calculations. We discussed the issues and came to a consensus based entirely on qualitative judgments: the United States was headed directly for an outcome like Italy’s; it was imperative to avert that outcome; to some extent, the outcome was inevitable; to some extent not. Now was the time to act, and act quickly.
We didn’t cite Neil Ferguson. I cited Tomas Pueyo pretty late in the game, but made no mention of his statistical methods, just of his overall strategy, “the hammer and the dance.” We expressed no derision for this or that academic discipline (whether our own or any other), and engaged in no self-indulgent Monday-night quarterbacking, a month after the fact, about what should have been done, or could have been done, or might have been totally awesome for someone else to have done. I didn’t even say (in the title of the post) that we were headed for disaster; I said we were flirting with it. And we were. We still are.*
That wasn’t good luck. It was a deliberate decision. It was enough to grasp–as Pueyo rightly argued–that we faced the real prospect of the systemic collapse of our health care system by a sudden influx of critical care cases, that that outcome was unacceptable, and that it had to be averted fast. In that context, it was a pointless waste of time to get lost in methodological thickets. There would be enough time for that, but March and early April wasn’t the time for it. People had to take this pandemic seriously, and act accordingly. Not just clinicians. Not just government officials. Everyone. That prediction and prescription have been vindicated.
In some ways, New Jersey might be the further test case. If we make it, you can breathe a sigh of relief. If we don’t, brace for impact.
But the salient fact here is that our making it, one way or another, was and is a matter of both acting and speaking so as to change the outcome. If you think we were wrong, feel free to tell me how. Tell me what we should have said or done that we didn’t say or do, given the knowledge available to the modal clinician and the modal citizen, with all inputs and path-dependencies what they were around March 9, 2020. If you can, I’ll blow you a socially distanced kiss.
Otherwise, perhaps the inference to draw is that there was nothing better to do than more or less what was done by government officials, clinicians, workers, and (yes) activists in New York and New Jersey. I’ve followed the situation in New Jersey in greater detail than the one in New York, so I’ll leave it to New Yorkers to judge the performance of their government et al. But the State of New Jersey–and most of its residents–acted commendably.** A lot of people owe Phil Murphy, Judith Persichilli, and Patrick Callahan and their subordinates their lives (along with the likes of Mike Maron, the people at 3M, at H&P Sewing, at Shop-Rite, at JBWS, and so many others). I’d certainly rather be governed by people like Murphy et al than by the top ten authors at Bleeding Heart Libertarians.
My brother’s been on duty at Valley Hospital for the past several days, sending me late night missives when he can. (One keeps “odd hours” when one has friends and relatives in different time zones, all working on the front lines of this fight.) As I haven’t gotten the permission to quote the last one he sent me (and won’t get the chance to, until whenever he gets back), what follows is a paraphrase. As I’ve been at pains to stress in previous posts, anecdotal evidence can’t necessarily be generalized, but offers some evidence about what’s going on at a given place and time. The evidence can be generalized by those who find themselves relevantly circumstanced to do it.
Suleman tells me that the work so far has been exhausting but manageable. They’re very short on nursing and critical care staff (as are most hospitals in north Jersey). But they’re getting extra help from unemployed physicians who might otherwise have been doing elective procedures (in a very broad sense of “elective”). Without that help, I infer, things would be close to unmanageable.
The obvious upside of getting that help is that it is badly-needed extra help, but the downside is that it’s been difficult to bring physicians unused to emergency and critical care work up to speed in doing that sort of work. So it takes awhile to bring them up to speed. Once they are up to speed, they still can’t produce at the same rate as physicians trained to do the relevant work. And they require constant supervision. (The New York Times reported on a similar phenomenon in New York about a week ago.)
To use a frivolous example, the situation is a bit like hiring a bunch of first-year graduate students in philosophy to team teach a seminar in advanced modal logic, where the problem sets don’t end, and more students enter the class than pass it. Every few minutes, your TAs have a question about how to do a particular problem, and you have no choice to explain it to them on the fly, hoping that you’ve explained the material well enough to teach it. If someone had ever given me a job like that, I’d have quit within the first few minutes. But then, no one has ever suffered respiratory arrest for lack of the ability to do S5 modal logic. That might have changed my decision.
He lists a bunch of other adaptations his hospital has made. One of them is the elimination of what might (under different circumstances) be called salutary redundancies. If we weren’t in a pandemic, COVID patients might be assigned two different physicians, say, a critical care physician and a hospitalist, each physician’s efforts complementing the other. Now those two physicians have to be split between two patients. There’s a loss of salutary redundancy, but an approximate doubling of output.
The bottom line here is that we’re in good hands. Things will be bad. Mass death is certain. But we’ll make it in more or less the way New York has.
Before you celebrate, though, don’t forget that every one of these predictions was borne out, exactly as written:
The coronavirus is coming to you.
It’s coming at an exponential speed: gradually, and then suddenly.
It’s a matter of days. Maybe a week or two.
When it does, your healthcare system will be overwhelmed.
Your fellow citizens will be treated in the hallways.
Exhausted healthcare workers will break down. Some will die.
They will have to decide which patient gets the oxygen and which one dies.
The only way to prevent this is social distancing today. Not tomorrow. Today.
That means keeping as many people home as possible, starting now.
That’s the much derided Tomas Pueyo, avowed “storyteller,” as contrasted with, say, Phil Magness, avowed professional “scrutinizer of statistical takes.”
Pueyo again, from the article mentioned here:
Our healthcare system is already collapsing.
Countries have two options: either they fight it hard now, or they will suffer a massive epidemic.
If they choose the epidemic, hundreds of thousands will die. In some countries, millions.
And that might not even eliminate further waves of infections.
If we fight hard now, we will curb the deaths.
We will relieve our healthcare system.
We will prepare better.
We will learn.
The world has never learned as fast about anything, ever.
And we need it, because we know so little about this virus.
All of this will achieve something critical: Buy Us Time.
If we choose to fight hard, the fight will be sudden, then gradual.
We will be locked in for weeks, not months.
Then, we will get more and more freedoms back.
It might not be back to normal immediately.
But it will be close, and eventually back to normal.
And we can do all that while considering the rest of the economy too.
People who didn’t say that–who spent the last month deriding it, advising us to leave the universities open–lack the credibility to tell anyone else what to do. To repeat something I’ve said before, and am happy to say again: people like that should shut their mouths for awhile, and let the rest of us buy time for the people who are on the ground, working to save lives, working to get people off respirators, and doing their best to ensure that they themselves don’t end up on a respirator or six feet under.
It’s not over until it’s over. We’ll have plenty of graves to fill before we get there.
*I also didn’t sit here and insist, as some leftists did, that the pandemic proved once and for all that a single-payer system was our only salvation, or that the pandemic vindicated (or falsified) any particular ideological system (e.g., “capitalism,” “socialism,” “libertarianism,” etc). There’s no way to know such things. The dust has yet to clear. There’s something ridiculous about people whose first priority in an emergency is to vindicate their pet ideology rather than figure out what the hell to do.
**I’m saving the ones who didn’t for a separate post.
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What the surge looked like in New York:
I’m inclined to think that New Jersey will avoid this problem. Those of us who’ve worked in New York have long complained about its bureaucratic culture, but the complaints seldom get through to people in love with the idea that regulations produce “order”:
More from the surge as it happened in New York:
This sort of story is becoming par for the course:
As I put things in a Facebook discussion with a libertarian journalist:
In fairness to advocates of the free market, one reason for the asymmetric bargaining power is that physicians are prohibited on anti-trust grounds, from forming unions. (The issue is more complicated than that, but that’s the essence of it.) I was somewhat amused when a leftist Facebook friend posted an article about doctors’ being deprived of PPE, saying, “Let the doctors’ and nurses’ unions know!” For all intents and purposes, there are no doctors’ unions.
Though I haven’t done a study of it, in my experience libertarians focus less on doctors’ lack of a right to unionize, and more on the monopoly produced by institutions like licensure, and/or the cartelization effect produced by the AMA–occasionally on the anti-market implications of Certificates of Need for medical equipment.
Like higher education, health care is an anomalous market. In my view, the hard fact that libertarians won’t face is that there is a tension between the internal goods of education and health care on the one hand, and the profit-motive of the free market on the other. The hard fact that leftists won’t face is that an insistence on a right to education or health care confers the equivalent of a property right in the labor of those who produce it. Both implications are unpalatable, and both are hard to avoid. At the end of the day, I find both left-wing and libertarian analyses of the health care system unsatisfying.
Regardless, when we exit this pandemic, the asymmetric bargaining power enjoyed by hospitals (or health care institutions generally, including government agencies) has to be high up on the agenda of issues we face.
Already I’m seeing people on Facebook complain that journalists are over-doing the “horror stories.” But horror is a significant part of the story. Personally, I think they should keep the horror coming.
I find it interesting that many of the people who protest having to see so many “horror stories” seem to have quite an appetite for stories that, given their ideological predilections, explain why the horror is happening. One prominent theme among libertarians is that the pandemic was a case of governmental failure via regulation. I don’t dispute that. What’s odd is fixation on the explanans combined with reluctance to look directly at the explanandum. “We’ve already told you that the horror of our situation is explained by regulatory failure, so enough already with the horror stories! People are suffering, we get it!”
The testing situation in New Jersey as of right now. No question that there’s been government failure here, but loftily to criticize the testing on “methodological grounds”–as though we were running an experiment in a university laboratory–strikes me as both callous and clueless:
There are even more ramifications here than meets the eye:
A sign of the times:
EMTs with Holy Name Hospital, Teaneck, NJ:
Volunteer ambulance squad professionalized:
The tragic face of triage at point of entry into the medical system:
New York to send New Jersey 100 ventilators:
Out of state doctors coming to help: