Post by Beth on Mar 26, 2020 8:22:33 GMT
I've been reading with deep aversion, but not surprise, about the current framing and guidelines many U.S. healthcare institutions are employing or reviewing to prepare for incredibly hard decisions about triage -- the process of determining what's needed for an emergency patient, and deciding how to initially proceed. In the present crisis, as many of you know, triage will determine who will get access to a ventilator in order to continue to breathe (and live), and who will not.
A few things to understand first about the numbers:
If you would rather just read about triage -- scroll down past this section.
Some folks are minimizing media exposure entirely, and others following avidly. I read and watch new stories fairly sparingly right now, but spend a little time each day going directly into data sources (statistics, new studies). The tab which is always open in my web browser is the Worldometer, a statistics site focused on global populations, which has a special section created for the Coronavirus. If you want to view it, you can click here. Its daily totals for country data (specifically new cases reported, and new deaths) are re-set to zero sometime after midnight, Greenwich Mean Time (GMT), and then are updated throughout the next day as reports become available.
What I've been watching in the last week is the status of the U.S., moving from one of the countries in the top 20 (for total reported cases), to pass Spain, Iran, Germany, France, Switzerland, the UK and South Korea, so that we are now listed third, only behind Italy and China. China however, has almost completely stopped the spread of the virus through very rigorous quarantine and testing, so their new cases are only trickling in (generally less than 100 per day), where as the U.S. had 13,000+ new confirmed cases this past day. We are now having more than twice as many new cases diagnosed daily as Italy. Given the current rate of increase, I expect that we will pass Italy, becoming the country with the second highest total number of diagnosed cases -- sometime tomorrow, and will pass China, before the weekend. All of that is true, despite the fact that we lag significantly, dramatically, behind many countries in testing. So if we factored in all the cases we would have diagnosed by now if we were rigorously testing, rather than denying most people in the U.S. access to tests, the numbers would almost certainly show that the U.S. now significantly out-distances every nation in the world, having the highest number of persons who have been infected.
I won't belabor why, and have acknowledged some reasons prior messages -- the U.S. essentially has poor, profit-driven healthcare infrastructure, and our federal government refused to prepare for too long, and refused help from the World Health Organization.
Pandemic vs. "Endemic":
The term pandemic is one we've all come to be familiar with if we weren't before. Some may not be familiar with the term "endemic", which in this context means that we don't just have an epidemic spread of a virus -- we remain in that state, as the virus contains to reinfect the survivors, gradually culling more and more people, and cycling back from currently infected persons to previously infected persons. Right now -- the question of whether we will be dealing with an Endemic, not just a Pandemic, is among the many things that are uncertain. But as the nation with the most rapid rates of current infection, the potential for an Endemic is most likely to manifest in the continental U.S.
A Little Data About Scarcity in U.S. Emergency Care:
Right now there are ~1 million staffed beds in U.S. hospitals, and there are somewhere around 100, 000 ventilators -- the expensive machines that can sometimes keep someone breathing when they are unable to do so independently (a vital resource in COVID-19 severe cases). Normally, about 75% of those 100,000 ventilators are actively in use in the U.S. at any time, treating other conditions which require respiratory support. Generally, the average time a patient spends on a ventilator (before COVID-19) is 3-4 days. But the current average time for COVID-19 cases is ranging between 11-21 days.
There are about 331 million people in the United States, and of course not all will ever become symptomatic even if infected, and not all will be infected at the same time, and of those who are symptomatic, many will not need emergency care. However, public health estimates indicate that between 90-100 million people in the U.S. may contract the virus over the duration of the virus' existence. So you can imagine that the need for emergency care, even if less than 10% of those infected at any time seek help, will outstrip current capacity to an extreme extent.
The Common Logic of Triage:
During emergencies when supply is overwhelmed by demand, the most universal norm expressed in healthcare institutions tends to be "save the most lives", which few of us would dispute. A second common ethic is "prioritize saving children", which many of us would also energetically support. A third and more controversial (and often dangerous) norm expresses itself as "save the people who likely have the most remaining years to live" or "save the most years of life". This norm is currently in play in Italy, as some hospitals have established emergency policy within the past two weeks to refuse to intubate (no access to ventilators) anyone over 60. Click here for more background.
I've confirmed through triage document review and consultation with colleagues that U.S. hospitals are looking at similar emergency policy measures based on age.
Years of life expectancy also factors in the presence of life-threatening conditions (even among those who are younger), so that people with heart conditions, people in cancer treatment, and people with chronic lung disease -- as examples, may be denied access to a ventilator, depending on the severity of the condition, based on the assumption that if their life were successfully saved, they would have less remaining years to live. In other words, people with chronic and more severe illnesses and disabilities, are at more extreme risk of being denied emergency care.
Disability, Illness and the Intersections of Race, Class, Childhood Trauma and Gender Violence in Triage:
Aside from the fact that elders and people with chronic illnesses and disabilities are in jeopardy en masse, the implications of attaching life-saving care to life expectancy fosters tremendous inequity across intersecting categories of identity and experience (like race, class, gender, but not limited to these). Life expectancy measured across populations is already reduced in the U.S. specifically for African-Americans and Native peoples. And more specifically, the kinds of conditions which may be flagged by health care institutions as reducing life-expectancy are in several instances disproportionately present among people exposed to poverty (manifesting as food and housing insecurity, chronic stress and overwork), survivors of environmental racism, and people who have histories of severe traumatic stress due to abuse -- survivors of child abuse, gender violence, and police or carceral violence (violence while incarcerated). People with severe mental illnesses generally have a reduced life expectancy as high as 20 years, due to higher rates of incarceration and food and housing insecurity, and due to the development of "co-morbid" physical conditions associated with chronic stress.
Having a greater life expectancy, having fewer experiences of severe trauma and deprivation reducing one's chance to live -- is attached to social privilege. So attaching emergency care access to increased life expectancy essentially helps ensure that the people who have the most privilege will similarly be privileged in triage, over those who have already had their health harmed before the current pandemic.
Practically, What Happens If You or a Loved One Needs Emergency Care?:
In the context of shortages -- it might seem counter-intuitive, but depending on how the healthcare institution is implementing policy on the ground, sharing information about health vulnerabilities other than the immediate issue (COVID-19 infection) can be counted against you. Triage staff will generally have a score sheet, and will be ranking patient priority according to responses to a set of questions posed to you or your family. The more you indicate that you were in poor health prior to the current infection -- in the worst case scenarios I've set up above -- the more likely it would be that you or your loved one would be considered lower priority for access to a ventilator, or bed. We should also assume that in some instances, explicit (conscious) and implicit (unconscious) biases (based on race, class, sexuality, gender identity, age, disability, physical appearance, and language) among triage staff will shape how they make sense of you and your needs (or your loved one's needs).
I am not going to try to give any specific advice here about what to say -- I think this is a complicated set of questions, and bears on your own ethics, and will be shaped by individual factors in the context, and by variations among different healthcare institutions. So my advice is limited to -- if you are not already contemplating how you would navigate triage if you need to, start to think about what you would want to share (or not share), and how you would want to advocate for your loved ones.
What Can We Do Now To Address the Problem?:
This is an opportunity, especially as many of us are already staying home -- to learn, dialogue, and organize (as rapidly as possible) -- and begin addressing the question of discrimination and inequity in triage directly to local healthcare institutions (through letters, calls, petitions, campaigns), and to municipal and state stakeholders -- especially those responsible for addressing either health policy, or civil rights. We can also try to reach local representatives to Congress.
To do this effectively, you need to decide what your own positions are. One we can likely all agree on (to address to policymakers) is: Pour available resources into expanding healthcare capacity -- get ventilators, N-95 masks, and beds created, and do everything we can to support healthcare and emergency workers who have higher infection risks. As municipalities and states scramble to increase capacity, and as the spread of COVID-19 outpaces those efforts, the second question to address is: what is your position on triage, and the basis for denying scarce resources?
To have a likely impact in shifting local institutional policies, community members need to develop some common beliefs and push for them together -- so dialogue right now is vital, and beginning to learn a little about medical ethics.
What I will say as an example is that I am against attaching access to emergency care to presumptions or scoring symptoms based on pre-existing predictions of life expectancy (though I would not personally contest policies prioritizing healthcare for children before adults of any age). I would also strongly push institutions to take active steps to minimize the practical impact of bias, when communicating with and instructing triage staff, and when developing internal policy. And I would urge state and municipal entities to echo the importance of eliminating bias back to healthcare institutions. Without external and official oversight and pressure, particularly in a crisis, it's very easy for an individual hospital administrator or board to make discriminatory policies.
A Last Note About Interpreting Social Distancing (or "Spacious Solidarity"):
A number of people I've spoken with lately have shared their behaviors or asked my opinion about how strenuous to be about the imperative of staying home (if that is a possibility for you). I witness, with empathy, that some people are trying to maintain as much normalcy as possible under these profoundly dislocating circumstances -- and normalcy is attached to still getting out of the house, to the grocery store, to get takeout, and whatever else is still allowable (depending on where you live).
What I would say is -- the circumstances are not normal and we have to make that adjustment. The imperative to #flattenthecurve is one of the most vital things we can do to minimize the severity of the horrible dynamics I've addressed in the prior discussions. The question is not "am I personally willing to take this risk?", but rather "in this instance, do I need to risk doing the harm of exposing myself and others I interact with, in the world or at home?". When you are out of food or medicine, or fulfilling a vital social function like providing essential healthcare directly to patients, or making food deliveries, or keeping utilities working -- then you can certainly answer -- 'yes, this risk to me, and to anyone in my household, and to anyone I encounter, still makes the most sense'.
Here's the crux: None of us are making truly individual choices now -- they are individual in the sense that they are mostly ours to make -- but they are collective in their repercussions. That will remain powerfully true as long as the COVID-19 crisis continues (and in some respects is always true!). So my response to those who've asked is: If you normally go to the grocery store once or twice a week: buy and refrigerate some under-ripe produce that doesn't spoil as quickly, and get used to going to the store every 3 or 4 weeks. Running out to the store because you can -- and you're missing a few things that you could wait for -- should be something you stop doing until the COVID-19 crisis passes. Where you can mail-order non-perishables, do that. Don't pick up take-out, just because you are allowed to. If you feel sure that you want to support a local restaurant or need food prepared for you (despite uncertainty about transmission of the virus through bags and containers) -- then stick to no-contact delivery services.
Many of us have no idea if we have already been exposed, and test access remains very restricted, so if you are asymptomatic, make decisions that factor in that you might be a COVID-19 carrier and not be aware of it. Keep thinking in this way even if you are fortunate to never have symptoms.
If you've read to the end, *thank you* for taking this in, and for the gift of your time.
A few things to understand first about the numbers:
If you would rather just read about triage -- scroll down past this section.
Some folks are minimizing media exposure entirely, and others following avidly. I read and watch new stories fairly sparingly right now, but spend a little time each day going directly into data sources (statistics, new studies). The tab which is always open in my web browser is the Worldometer, a statistics site focused on global populations, which has a special section created for the Coronavirus. If you want to view it, you can click here. Its daily totals for country data (specifically new cases reported, and new deaths) are re-set to zero sometime after midnight, Greenwich Mean Time (GMT), and then are updated throughout the next day as reports become available.
What I've been watching in the last week is the status of the U.S., moving from one of the countries in the top 20 (for total reported cases), to pass Spain, Iran, Germany, France, Switzerland, the UK and South Korea, so that we are now listed third, only behind Italy and China. China however, has almost completely stopped the spread of the virus through very rigorous quarantine and testing, so their new cases are only trickling in (generally less than 100 per day), where as the U.S. had 13,000+ new confirmed cases this past day. We are now having more than twice as many new cases diagnosed daily as Italy. Given the current rate of increase, I expect that we will pass Italy, becoming the country with the second highest total number of diagnosed cases -- sometime tomorrow, and will pass China, before the weekend. All of that is true, despite the fact that we lag significantly, dramatically, behind many countries in testing. So if we factored in all the cases we would have diagnosed by now if we were rigorously testing, rather than denying most people in the U.S. access to tests, the numbers would almost certainly show that the U.S. now significantly out-distances every nation in the world, having the highest number of persons who have been infected.
I won't belabor why, and have acknowledged some reasons prior messages -- the U.S. essentially has poor, profit-driven healthcare infrastructure, and our federal government refused to prepare for too long, and refused help from the World Health Organization.
Pandemic vs. "Endemic":
The term pandemic is one we've all come to be familiar with if we weren't before. Some may not be familiar with the term "endemic", which in this context means that we don't just have an epidemic spread of a virus -- we remain in that state, as the virus contains to reinfect the survivors, gradually culling more and more people, and cycling back from currently infected persons to previously infected persons. Right now -- the question of whether we will be dealing with an Endemic, not just a Pandemic, is among the many things that are uncertain. But as the nation with the most rapid rates of current infection, the potential for an Endemic is most likely to manifest in the continental U.S.
A Little Data About Scarcity in U.S. Emergency Care:
Right now there are ~1 million staffed beds in U.S. hospitals, and there are somewhere around 100, 000 ventilators -- the expensive machines that can sometimes keep someone breathing when they are unable to do so independently (a vital resource in COVID-19 severe cases). Normally, about 75% of those 100,000 ventilators are actively in use in the U.S. at any time, treating other conditions which require respiratory support. Generally, the average time a patient spends on a ventilator (before COVID-19) is 3-4 days. But the current average time for COVID-19 cases is ranging between 11-21 days.
There are about 331 million people in the United States, and of course not all will ever become symptomatic even if infected, and not all will be infected at the same time, and of those who are symptomatic, many will not need emergency care. However, public health estimates indicate that between 90-100 million people in the U.S. may contract the virus over the duration of the virus' existence. So you can imagine that the need for emergency care, even if less than 10% of those infected at any time seek help, will outstrip current capacity to an extreme extent.
The Common Logic of Triage:
During emergencies when supply is overwhelmed by demand, the most universal norm expressed in healthcare institutions tends to be "save the most lives", which few of us would dispute. A second common ethic is "prioritize saving children", which many of us would also energetically support. A third and more controversial (and often dangerous) norm expresses itself as "save the people who likely have the most remaining years to live" or "save the most years of life". This norm is currently in play in Italy, as some hospitals have established emergency policy within the past two weeks to refuse to intubate (no access to ventilators) anyone over 60. Click here for more background.
I've confirmed through triage document review and consultation with colleagues that U.S. hospitals are looking at similar emergency policy measures based on age.
Years of life expectancy also factors in the presence of life-threatening conditions (even among those who are younger), so that people with heart conditions, people in cancer treatment, and people with chronic lung disease -- as examples, may be denied access to a ventilator, depending on the severity of the condition, based on the assumption that if their life were successfully saved, they would have less remaining years to live. In other words, people with chronic and more severe illnesses and disabilities, are at more extreme risk of being denied emergency care.
Disability, Illness and the Intersections of Race, Class, Childhood Trauma and Gender Violence in Triage:
Aside from the fact that elders and people with chronic illnesses and disabilities are in jeopardy en masse, the implications of attaching life-saving care to life expectancy fosters tremendous inequity across intersecting categories of identity and experience (like race, class, gender, but not limited to these). Life expectancy measured across populations is already reduced in the U.S. specifically for African-Americans and Native peoples. And more specifically, the kinds of conditions which may be flagged by health care institutions as reducing life-expectancy are in several instances disproportionately present among people exposed to poverty (manifesting as food and housing insecurity, chronic stress and overwork), survivors of environmental racism, and people who have histories of severe traumatic stress due to abuse -- survivors of child abuse, gender violence, and police or carceral violence (violence while incarcerated). People with severe mental illnesses generally have a reduced life expectancy as high as 20 years, due to higher rates of incarceration and food and housing insecurity, and due to the development of "co-morbid" physical conditions associated with chronic stress.
Having a greater life expectancy, having fewer experiences of severe trauma and deprivation reducing one's chance to live -- is attached to social privilege. So attaching emergency care access to increased life expectancy essentially helps ensure that the people who have the most privilege will similarly be privileged in triage, over those who have already had their health harmed before the current pandemic.
Practically, What Happens If You or a Loved One Needs Emergency Care?:
In the context of shortages -- it might seem counter-intuitive, but depending on how the healthcare institution is implementing policy on the ground, sharing information about health vulnerabilities other than the immediate issue (COVID-19 infection) can be counted against you. Triage staff will generally have a score sheet, and will be ranking patient priority according to responses to a set of questions posed to you or your family. The more you indicate that you were in poor health prior to the current infection -- in the worst case scenarios I've set up above -- the more likely it would be that you or your loved one would be considered lower priority for access to a ventilator, or bed. We should also assume that in some instances, explicit (conscious) and implicit (unconscious) biases (based on race, class, sexuality, gender identity, age, disability, physical appearance, and language) among triage staff will shape how they make sense of you and your needs (or your loved one's needs).
I am not going to try to give any specific advice here about what to say -- I think this is a complicated set of questions, and bears on your own ethics, and will be shaped by individual factors in the context, and by variations among different healthcare institutions. So my advice is limited to -- if you are not already contemplating how you would navigate triage if you need to, start to think about what you would want to share (or not share), and how you would want to advocate for your loved ones.
What Can We Do Now To Address the Problem?:
This is an opportunity, especially as many of us are already staying home -- to learn, dialogue, and organize (as rapidly as possible) -- and begin addressing the question of discrimination and inequity in triage directly to local healthcare institutions (through letters, calls, petitions, campaigns), and to municipal and state stakeholders -- especially those responsible for addressing either health policy, or civil rights. We can also try to reach local representatives to Congress.
To do this effectively, you need to decide what your own positions are. One we can likely all agree on (to address to policymakers) is: Pour available resources into expanding healthcare capacity -- get ventilators, N-95 masks, and beds created, and do everything we can to support healthcare and emergency workers who have higher infection risks. As municipalities and states scramble to increase capacity, and as the spread of COVID-19 outpaces those efforts, the second question to address is: what is your position on triage, and the basis for denying scarce resources?
To have a likely impact in shifting local institutional policies, community members need to develop some common beliefs and push for them together -- so dialogue right now is vital, and beginning to learn a little about medical ethics.
What I will say as an example is that I am against attaching access to emergency care to presumptions or scoring symptoms based on pre-existing predictions of life expectancy (though I would not personally contest policies prioritizing healthcare for children before adults of any age). I would also strongly push institutions to take active steps to minimize the practical impact of bias, when communicating with and instructing triage staff, and when developing internal policy. And I would urge state and municipal entities to echo the importance of eliminating bias back to healthcare institutions. Without external and official oversight and pressure, particularly in a crisis, it's very easy for an individual hospital administrator or board to make discriminatory policies.
A Last Note About Interpreting Social Distancing (or "Spacious Solidarity"):
A number of people I've spoken with lately have shared their behaviors or asked my opinion about how strenuous to be about the imperative of staying home (if that is a possibility for you). I witness, with empathy, that some people are trying to maintain as much normalcy as possible under these profoundly dislocating circumstances -- and normalcy is attached to still getting out of the house, to the grocery store, to get takeout, and whatever else is still allowable (depending on where you live).
What I would say is -- the circumstances are not normal and we have to make that adjustment. The imperative to #flattenthecurve is one of the most vital things we can do to minimize the severity of the horrible dynamics I've addressed in the prior discussions. The question is not "am I personally willing to take this risk?", but rather "in this instance, do I need to risk doing the harm of exposing myself and others I interact with, in the world or at home?". When you are out of food or medicine, or fulfilling a vital social function like providing essential healthcare directly to patients, or making food deliveries, or keeping utilities working -- then you can certainly answer -- 'yes, this risk to me, and to anyone in my household, and to anyone I encounter, still makes the most sense'.
Here's the crux: None of us are making truly individual choices now -- they are individual in the sense that they are mostly ours to make -- but they are collective in their repercussions. That will remain powerfully true as long as the COVID-19 crisis continues (and in some respects is always true!). So my response to those who've asked is: If you normally go to the grocery store once or twice a week: buy and refrigerate some under-ripe produce that doesn't spoil as quickly, and get used to going to the store every 3 or 4 weeks. Running out to the store because you can -- and you're missing a few things that you could wait for -- should be something you stop doing until the COVID-19 crisis passes. Where you can mail-order non-perishables, do that. Don't pick up take-out, just because you are allowed to. If you feel sure that you want to support a local restaurant or need food prepared for you (despite uncertainty about transmission of the virus through bags and containers) -- then stick to no-contact delivery services.
Many of us have no idea if we have already been exposed, and test access remains very restricted, so if you are asymptomatic, make decisions that factor in that you might be a COVID-19 carrier and not be aware of it. Keep thinking in this way even if you are fortunate to never have symptoms.
If you've read to the end, *thank you* for taking this in, and for the gift of your time.