Our actions to respond to Covid-19 will have public health winners and losers today and in the future. We each have a responsibility to examine all the risks and have a difficult but necessary public conversation to get the balance right.
By Rajiv Bhatia MD, MPH
If I told one of my patients that quitting her job would save lives, I suspect she’d have some questions. She’d want a lot more facts.
Covid-19 didn’t given us time for much of a public conversation. The restrictions on travel, gathering, and business came swiftly. What was once unimaginable quickly became quickly acceptable.
The first wave has now crested and hospitals have coped. Yet, people are still at risk and the costs of shutdown are in view. States and even counties are doing their own thing. We don’t need more division.
We do need to examine the facts and have an honest public conversation. How much Covid-19 risk will we accept and what are we willing to pay, not only economically, but also with our health?
Sometimes cancer drugs kill the tumor but end up damaging the heart. In medicine we always inform patients of risks and benefits and help them to make wise choices. There is always a discussion.
Decisions about Covid-19 are complicated by tremendous uncertainties. We should be skeptical about anyone who claims that they have the solution.
We don’t know whether we are preventing deaths or just pushing the pain down the road.
The virus kills but still we don’t know how deadly it really is or who is at risk. It might flare up again or simply smolder along. Maybe, we’ll develop some kind of immunity, but that could be short lived, meaning that Covid-19 might be back next year.
Public health solutions are imperfect and costly. People without symptoms spread infection, so testing and contact tracing is much less useful. People are getting sick even with social distancing. We don’t know whether we are preventing deaths or just pushing the pain down the road.
With all the uncertainty, naturally, people don’t agree on the goals. Do we keep the virus in check just enough to preserve hospital capacity or do we go further to suppress transmission? Well-meaning people disagree.
I have elderly patients who are just fine staying at home; their children shop for their groceries. I have others out hustling for the next job, asking me what to do to stay safe.
Yes, the decisions are complicated. That’s why we need some critical reflection.
Unemployment, anxiety, and hunger are not consequences of well designed public health interventions.
Covid-19 has unleashed a cascade of secondary health threats. Unemployment, topped 33 million last week, and jobs aren’t coming back soon. We see lines at food banks. Children aren’t getting vaccinations. Our patients are avoiding doctors and hospitals. Nearly half the county reports their mental health is worse. Domestic violence has already surged. These are not the characteristics of well thought through public health interventions.
Our actions are creating having winners and losers. When schools close, children without means are not learning and, sometimes, are not eating. Public colleges may not open while private ones might. The workers in the technology economy are losing less than those whose income requires an on-site work presence. There are many, many moral questions that we are just simply not asking.
It’s clear that the newly unemployed are going to bear a large share of this pain. Unemployment following the Great Recession of 2008 saw declines in birth weight, more medication use, and increased hospital visits. And an extra 4,750 suicides occurred. The death rate for unemployed people is 63% higher than for those who are working; and the toll falls on those in the early and middle of their careers. If unemployment hits 20 percent, 25 million people in the US may lose health insurance.
I worry that we will tire out and lack the will to protect those hurt. Our country has shut down with the hope that our actions will save lives in the long run. And we have spent trillions to minimize hardship and resuscitate the economy. Recovery is unlikely to be swift. We may need to spend more. Will our politics allow for things like long term income support and public health care? Or will budget cuts be coming next, along with cuts to social programs and a weakened safety net?
And what about our global community? Migrant workers are stranded on their roads home. Lockdowns are being enforced with violence. Deaths from hunger could well outpace those from Covid-19.
I fear that we are losing perspective. Covid-19 has never been our only health threat. We need a better public conversation to find the balance, but, honestly, that conversation is hard to imagine. There are few solid facts. Decisions keep being made for us. People are rightly uncertain. Public conversations are not open to alternative views.
Our polarized environment is working against us. The country is divided. We feel “better” if we oppose. The media just reinforces our biases. Health is pitted against the economy even though, as decades of science tell us, for many, economic costs ultimately become health costs.
Finding a balance isn’t just about influencing policy. It’s about restoring our own peace of mind. Before “stay-at-home” orders, most people were already distancing themselves. And they will continue to do so unless they themselves feel confident about their safety. Government actions will follow the public sentiment. They almost always do.
As the Chilean economist Manfed Max-Neef astutely pointed out, society sometimes takes an action to satisfy one human need but, tragically, in doing so, undermines others.
We really need a different conversation. It doesn’t weaken the fight against Covid-19 to count all of our health risks. We are not giving up or opposing public health if we investigate and question the assumptions and facts.
These are conversations that should be happening with our doctors, in living room, and on the zoom calls.
Human health has many needs. It does today and it will tomorrow. Our choices must be informed and forward-looking. We must not lose sight of where the balance lies. Wise public health should do no harm.