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Sunday, April 26, 2020

Science, Standards, and Government

But now we’ve all heard social determinants of health. How are they implicated in the delivery of medical care? How are medical care delivery questions answered, by what standards, on what information?

A growing trend in recent years in the Worker’s Compensation market has been a retrospective self-evaluation on the manner in which decisions are made regarding the presence or treatment of comorbidities and pre-existing conditions. Those may result from prior injuries or from our personal medical status, body habitus, genetics, diet, and more. Though there remains room for discussion, there is evidence that our lifestyle, diet, and more can influence our health. And, there is evidence that those who are well tend overall to respond and recover better to injury or illness than those who are already ill.

The potential exists, armed with this statistical information, that some may strive not to hire those whose personal health portends risk of complication in the event of an injury. Certainly, one would hope that hiring decisions would not be made on such a basis, the potential exists. Could social determinants of health evolve into Social Determinants of Employability? Fear of potentials for negative employer engagement of our health or health propensities led in 2009 to the Genetic Information Non-Discrimination Act. Whether it would come to pass, there is some fear of it. Might discrimination occur elsewhere based on our health? 

Among the subjects upon which the news periodically espouses, there is periodically "indisputable science." Despite the word "indisputable," this is sometimes generally accepted and other times ridiculed. The fact is that "indisputable" is an editorial label. And, science is subject to the limitations we all have in regards to understanding it. In a more general sense, science is a subject that is seemingly persistently in dispute and disagreement, and thus rarely indisputable. 

No matter how smart the individuals, or how much consensus for a conclusion, science is not always right. The chances for science to be incorrect are likely greater when the challenges are new, the data is incomplete, and the demand for answers is acute. There is also a potential for "groupthink" to influence conclusions. The answer to "groupthink," according to Neuroleaderhsip.com is science. But if the "groupthink" is about science, then . . . well that is a conundrum

The subject of social determinants raises its head once again in the midst of the COVID-19 international pandemic. A study conducted in America‘s COVID/Wuhan epicenter, New York, concluded that a significant volume (90%) of individuals hospitalized because of this virus suffered pre-existing conditions. Data is supporting this in both the general population and the young. Remember, early reports from "experts" mistakenly assured us that the disease is not a threat to the young. We were also assured early on that there was no threat of human-to-human transmission of this disease. Authority no less than the World Health Organization made such assurances. Suffice it to say there have been a few examples of science and experts reaching mistaken COVIDclusions. 

The statistics in hand now, through the addition of volumes of information acquired at great human cost, are suggesting that pre-and coexisting morbidities can affect the body's reaction to this viral attack. I use "supporting" because there is undoubtedly more data yet to come; this ailment, our response, and the science that will affect it will be studied for years to come. As the British Broadcasting Corporation noted "history will judge which countries got it right" similarly, retrospect will judge which experts did as well. There is discussion of what is causing deaths; issues include pneumonia, respiratory failure, and more. How deaths are categorized is attracting scientific attention as well. 

Despite the involvement of these other conditions, there is a perception of a tendency in America to default to labeling deaths as COVID-related if there is a positive test, as reported by WUSA9 in Washington D.C. There are also some who believe that COVID death in the U.S. is being under-reported, according to CNN. This, despite Center for Disease Control ("CDC") advice in March "that Covid-19 should be reported on the death certificate for all decedents where the disease caused or is assumed to have caused or contributed to death." Science is thus encouraging the use of assumption. 

Belgium has been in the news because the COVID-19 death statistics there "include not only deaths that are confirmed to be virus-related, but even those suspected of being linked, whether the victim was tested or not" (emphasis added) according to National Public Radio. This is reminiscent perhaps of the debate that has raged regarding how to determine deaths from a hurricane. How direct must the causation be? 

Time, study, and reflection will bring reflective conclusions as to actual COVID-19 infection rates and death statistics. The point is that science, which depends on facts, definitions, and experimentation is scrambling at this time for all three. Despite that, the experts continue to hold forth on the nightly news and express their expert scientific conclusions. As Sherlock Holmes once famously noted "It is a capital mistake to theorize before you have all the evidence. It biases the judgment.” Some feel we are far from having all the evidence regarding COVID-19, and perhaps some other human ailments. 

The critical point with the comorbidities may be bodily reaction. There is no evidence that this virus is somehow sentient or intelligent. It does not choose which organisms to enter, or which cells to attack. This discussion is solely about the human body's reaction to the attack. It is notable that some studies have concluded large volumes of Americans have developed COVID-19 antibodies without symptoms or complaints. In short, some bodies are able to resist this attack. I find myself wondering if I have already had COVID-19/Wuhan, while I simultaneously worry that I may get COVID-19. Switching between these worries is just something else to provide mental exercise in this trying time. 

There is suggestion therefore that the infection rate may exceed the number of diagnosed cases by several orders of magnitude. A California study concluded that symptom–free individuals with the antibodies present may number between 50 and 85 times the number of diagnosed cases. The New York Times recently reported on an antibody test there that supports perhaps as many as 20% of New Yorkers (millions) having already had COVID/Wuhan. These projections, if borne out in future research, suggest a much higher infection rate than previously suspected. 

The known hospitalization and death rates (subject to the discussion above of accurate determination of cause of death) are compared to the infection rate. As overall infection rate increases, the comparative rate of hospitalization decreases. These infection rate numbers, which will be learned only through extensive testing for the presence of antibodies in the general population, are a critical consideration in various analyses regarding the pandemic, our response, and recovery. According to CBSN New York, the Governor there now says that antibody testing "is critical" in this regard to the efforts in reopening New York. However, the World Health Organization suggests that the data is not yet sufficient to conclude that suffering this viral attack will render a victim thereafter immune from future relapse or infection. 

Recently, a group of doctors made the national news complaining about the lack of governmental "advance" guidance on their decision making. The essence of the article is that government is not providing criteria or decision matrices regarding the administration of treatment for COVID/Wuhan. There have been similar discussions in the Wall Street Journal, Politico, and Pew. They question why government is not intervening to define their decisions. 

The expressed fear or anxiety is that doctors will be forced at some point to make life or death decisions regarding which COVID-19 patients receive care, and which are left to their own devices. Some doctors lament and criticize being put in that position by increasing volumes of patients and limited resources. They seemingly long for government intervention, guidelines, criteria, by which they could make decisions and not face the untoward outcomes. Some, in the press, discuss how such guidelines have been previously postulated and considered, but lament that government has not enacted them. 

In comparison, the New York Post recently reported that New York adopted guidelines for emergency medical personnel. They reportedly "directed emergency service workers not to attempt to revive anyone without a pulse." This is a resource allocation decision, perhaps similar to what the doctors seek regarding COVID. Essentially, if some New Yorker lacks a pulse then save your time, effort, and supplies. After about 6 days, and very little media coverage, the "controversial guidelines" were rescinded because "they don’t reflect New York’s standards." If they do not, one might wonder how they were ever published in the first instance. Remember Rhianna in Take a Bow? ("when I know you're only sorry you got caught").

It is possible they in fact mirror the standards, but don't stand up to scrutiny? The failed experiment for emergency technician guidelines reflects the potential that public opinion might influence government action. They are an example of government setting policy for care providers. In one instance, above, medicine seems to seek guidelines, but in this example there is a lack of public support for such guidelines. Is it possible that with or without published guidelines that uncomfortable decision making may be periodically required in some instances? 

There are generalized fears that medical providers will be increasingly forced to make resource allocation decisions. The Atlantic recently described issues of resource shortage. In the end, there may be instances in which there are not enough beds in intensive care, respirators, medications, or time/attention from care providers. Resources may be finite. Who will make those allocation decisions and how? Coincidentally, in March, the Daily News reported on a patient under Corona care, who was also battling cancer. He reportedly made the hard call himself, telling doctors to stop treating his COVID/Wuhan and “Save someone else.” Would I, could I, be so magnanimous? Should it be the patient who decides, the doctor (scientist), or the government (groupthink)? 

Left without a patient ready or willing to make such a call, without government guidelines or matrices, the physician must. Should those decision-makers be "risk averse" or "risk tolerant?" There is discussion of risk to the medical providers, risk to the patients, and risk to the capacity of the medical care process. At best, this is a difficult, emotional, and distressing process. 

The recognition is seemingly that people will suffer, and some will die. A portion of the untoward outcomes may be traceable in the decision tree back to some point in time in which a physician decides to intubate or not, administer medication or not, place the patient on her side or not, and similar. At least for now, those decisions are made based on scientific and medical training, experience, and belief. Such individual decisions may be later subject to second guessing or Monday-morning-quarterbacking by lawyers, judges, and juries. Some decisions may be wrong, for a variety of reasons, and without even a modicum of bad intention or negligence. 

Thus, doctors who make mistakes, even in the best of faith and worst of conditions, may find themselves questioned. Their decision processes, criteria, assumptions, and conclusions may all find scrutiny. Some published, scholarly, government guidelines might affect that retrospection, or might not. In the end, the very best doctor may be questioned for the very best decisions because an outcome disappoints. There are legislative and executive decisions already concerning shielding care providers from liability in the COVID setting, but questions remain. 

In all honesty, I am no scientist. However, as notably, a great many non-scientists are already opining on the Coronavirus situation. In addition, a great many scientists are espousing conclusions and conjectures regarding the virus on a daily basis in the news media. They have been for weeks. Their opinions have at times differed with each other, periodically changed, or been substantiated, or been wrong. The results and reporting have led some to determine that a fair few of these experts and scientists perhaps lack credibility, despite significant medical and scientific training and experience. Thus, though I am no scientist, perhaps I can ask some pertinent questions? 

We as an American society are prone to value human life. We rise incredibly, and persistently, in response to human suffering, and have as long as I can remember. A recent news interview regarding China and its response to the Wuhan/COVID noted "The difference between collectivism and common good is a huge disconnect with the U.S. because we regard . . . human life [as] sacred." That commentator seemingly suggested that the rights, freedoms, and intellect in our society are geared to personal liberty in a way that collective societies perhaps do not understand. 

In a way the medical guidelines debate hearkens back to the Obamacare debates. There was discussion then about a single-payer system in which the government covers all medical expense and makes all decisions regarding the administration of health resources. In the face of COVID, we have heard similar calls for socialization, free medical testing, treatment, and replacement wages for all who are ill or who must quarantine. 

There was Obamacare debate regarding the efficacy and morality of government making decisions regarding who merits treatment and who is left to their own devices. A great many libertarian and free Americans then lamented that potentiality of Independent Payment Advisory Boards ("death panels"), and argued against their facilitation or implementation. Those controversial Obamacare provisions were eventually removed from that bill (similarly to the withdrawal of New York's recent "do not resuscitate" order?). The imprint of that Obamacare discussion on socializing medical care will remain in some minds indefinitely however. To some, the Boards were the defining element of that legislative proposal's spirit and intent, control. 

If we cede to government the authority to make decisions regarding who is treated who is not, what freedom have we lost? Is the long-term effect the same as the short? If government would make those decisions, would pre-existing comorbidities become a part, as the scientific evidence perhaps portends, or would those be ignored? Could physicians be "guided" to not treating those with diabetes in the same manner New York strove to guide paramedics not to treat (revive) those who lack a pulse? Would our public opinion and ire rise in response to such a guideline, or would we acquiesce? 

Some would suggest that the decision tree (process) remains the same without the government. They would say that health insurers, hospital committees, and doctors already make such difficult analyses in the rationing of various care and treatment. They might argue that the "who" of such decisions is a red herring and urge instead a frank and open discussion of the "what," that these decisions are likely inevitable. Those perspectives likely deserve discussion as well, as do the perspectives that perhaps our medical science is not yet omniscient or omnipotent. 

Like characters in a classic dystopian novel, will Americans find themselves eschewing the cookie in favor of the carrot stick? Will obesity, diabetes, high blood pressure and more become excuses to exclude us from increasingly rationed care and treatment? If not in the day-to-day, perhaps only in the pandemic? Consciously or not, will our focus on personal health increase? Would our focus upon our own health and fitness change if we knew that our ability to obtain medical care might one day depend upon our weight, body mass index, blood pressure, or other pre-morbidity? As a free society, do we want it to?