On the menu today: a non-coronavirus medical problem facing America that probably can’t be put off any longer; enormous excitement about that study of the coronavirus in Santa Clara, Calif., and some evidence of why that study’s suggested ratio of unknown infections to known infections can’t fit the worst-hit places, laying out all the possible factors that made New York City the epicenter of the outbreak in America; and one large U.S. company does the unthinkable: It decides it doesn’t need aid money that badly and gives it back to the government.
Make America Care for Non-Coronavirus Patients Again
As the United States begins its first tentative steps out of a widespread and unprecedented lockdown, allow me to recommend that the one of the first changes we make is lifting the restrictions on “elective” medical procedures. Alaska, Oklahoma, and Texas have already done so.
“Elective” procedures sound like they’re optional; when some people hear that phrase, they may envision plastic or cosmetic surgery. What they mean, in most states, is non-emergency, a procedure that is not a matter of life and death. But there are a lot of procedures that are important, even if they’re not life-and-death.
I offered this thought as a quick tweet Friday and was deluged with heartbreaking responses about people living with delays in cancer surgery, hip surgery, knee surgery, in-vitro fertilization, ear tubes, chemotherapy, cardiac rehabilitation, physical therapy, CT scans, cardiology, endocrinology, neurology, cataract surgeries, colonoscopies, and more. And then there are the more minor procedures that are still annoying — people who can’t see the dentist, teens with braces who can’t get them removed by the orthodontists. Some dermatologists are soldiering on as best they can, trying to diagnose rashes through telemedicine. All kinds of non-life-threatening aches and pains that usually would get resolved with a doctor’s visit have been put off until hospitals give the all-clear sign.
(In some cases, oncologists may worry that regular cancer treatments like chemotherapy will weaken the immune system of the patient, making them more vulnerable to a coronavirus infection.)
The states, institutions, and doctors that delayed those procedures were not callous or “Chicken Littles.” They needed to ensure that hospital beds and personal protective equipment were available in quantities sufficient to handle an influx of coronavirus cases. Thankfully, most hospitals have not been overwhelmed and right now — knocking on wood — it looks like they aren’t likely to get overwhelmed anytime soon. Those hospitals had — and probably continue to have — legitimate worries about having non-coronavirus patients in the same hospital as coronavirus patients, particularly if those non-coronavirus patients’ immune systems aren’t 100 percent. Hospitals will have to think through whether they can set up separate and appropriately divided coronavirus and non-coronavirus emergency rooms, coronavirus and non-coronavirus halls and wings, etc. This is likely to be the sort of decision that has to be made on a hospital-by-hospital basis.
But don’t tell me that Americans are greedy and selfish in the face of this crisis. Americans who were expecting to have surgeries and treatments to relieve chronic pain and serious health problems accepted delays — in some cases, delays of five weeks or more — just so we could collectively increase the odds that everyone else would have a better shot at surviving coronavirus. We have a lot of heroic doctors, nurses, technicians, support staff, janitors, emergency medical technicians, and other people who work in those hospitals. But we probably ought to reserve a round of applause for everybody out there who accepted a delay in treatment — even if they didn’t have much of a choice.
On Friday, four big medical associations — the American College of Surgeons, the American Society of Anesthesiologists, the Association of perioperative Registered Nurses, and the American Hospital Association — laid out their general principles and a “game plan” for the resumption of regular medical procedures. They want the hospital and surrounding area to see a steady decline in coronavirus cases over two weeks before reopening for regular business. They need to ensure they have sufficient protective equipment and staff. This all sounds like common sense, and the sort of thing that bright, responsible leaders and staff should be able to work through, day by day.
One side effect of all this is that because these procedures are how these hospitals make most of their money, a lot of hospitals, particularly in rural areas, are struggling to keep their doors open. (Please hold off on the debate of whether this is how hospitals should make their money. Right now, we need to live in the here and now and discuss how things are, whether or not this is how you think things should be.)
One of the crazier side effects of this pandemic is hospitals being forced to lay off workers because they don’t have enough cash coming in and because care for coronavirus patients uses up so many resources. This is not a small problem; as of April 17, at least 140 U.S. hospitals have announced furloughs and layoffs; last month’s catastrophic jobs report indicated 43,000 jobs in the health-care industry were lost. On Friday, health-care giant Tenet announced a temporary furlough of 3,400 workers.
To the extent we can, as safely as we can, let’s reopen the doctor’s offices and all the non-coronavirus health care that’s been forced onto hiatus for more than a month.
The Rosetta Stone of Santa Clara and the Mystery of New York City’s Disaster
On Friday afternoon, a lot of people started touting the Stanford study of infection rates in Santa Clara as if it was the Rosetta Stone of this pandemic. It’s easy to understand why. That study suggested that for every test that detects the coronavirus, between 50 and 85 people are walking around with it, either asymptomatically or with such minor symptoms that they don’t think it’s the coronavirus and aren’t concerned.
People want hope right now, and that study argued, “we’re a lot closer to herd immunity than most experts think we are, because massive amounts of our people have already caught it and fought it off.” It would be wonderful if what this study is suggesting is true.
But there are some reasons to think the conclusions are far too optimistic. You can find scientists and statisticians who are a lot smarter than me picking apart that study. But allow me to lay out just one way that the study’s conclusion doesn’t fit with what we know.
If we really are detecting only one out of 50 cases because we are doing so little testing, as that study suggests, applying that ratio to other places gives you some really odd results. As of Sunday, New York City has 134,000 cases. If you multiply that by 50, you get 6.7 million cases. If you multiply the number of cases by 85, you get 11.39 million cases.
New York City only has 8.5 million people in the five boroughs, about 20 million in the wider metropolitan area. If your estimated number of cases in an area is more than the number of human beings living in that area, you’re probably overestimating somewhere along the line.
Even if we take that low end of that estimate, that fifty infected people are walking around for every detected case . . . do we think almost 80 percent of New York City residents are walking around with the coronavirus? (I doubt this is the case, but if it were, this percentage would be knocking on the door of herd immunity, and we would expect the number of new cases to drop like a stone.) The “fifty people have it for every diagnosed person” theory would mean 12.1 million New Yorkers have it out of 19.4 million; 4.2 million New Jersey residents out of 8.8 million, and 1.8 million Massachusetts residents out of 6.8 million.
Then again . . . Massachusetts is experiencing a surge of patients right now.
Mind you, we know that some people are walking around asymptomatic. Maybe it’s ten for every diagnosed case? Twenty? I was already a fan of Robert VerBruggen’s data-driven reporting and analysis before this virus came along, and he seems to be in that not-too-optimistic, not-too-pessimistic sweet spot.
One of the great mysteries of this epidemic is why New York City is getting so relentlessly hammered compared to the rest of the country. We can point to a slew of possible reasons — the city is an international air-travel hub, it has high population density, it has about a million people over age 65, it has heavily used enclosed mass transit like subways, commuter rail, and buses, it had Mayor Bill de Blasio telling people to go about their lives until the epidemic was obvious . . .
But a lot of big cities in the United States have these factors to varying degrees: a lot of international travelers, somewhat comparable population density, significant numbers of seniors, heavily used mass transit, and at least comparably idiotic mayors. But no city in the United States is even close to the number of cases in New York.
As of Sunday afternoon, New York City had 134,000 cases.
Cook County, Ill., which includes Chicago, has 20,395 cases.
Wayne County, Mich., which includes Detroit, has 13,471 cases.
Los Angeles County, Calif., has 12,021 cases.
Philadelphia County, Pa., has 9,214 cases.
Miami-Dade County, Fla., has 9,165 cases.
Suffolk County, Mass., which includes Boston, has 7,696 cases.
Orleans Parish, which includes New Orleans, has 6,000 cases.
Harris County, Texas, which includes Houston, has 4,653 cases.
Dallas County, has 2,428 cases.
San Francisco County has 1,160 cases.
The fear is that New York, while having all of these factors, shows what happens when this virus hits a place that just isn’t prepared or taking precautions. Probably no place else in America will get hit quite so badly — but that doesn’t mean that cases won’t increase in other places. We’re probably past the first peak. But sending people back to work means the number of cases and deaths will increase, and we will get at least another peak . . . perhaps a series of peaks and troughs.
I realize lots of people want to find any shred of evidence suggesting this won’t be that bad. But right now, it’s already pretty darn bad. It may well be less bad sometime soon. But we need to be prepared psychologically, medically, socially — for this to get really, really bad.
ADDENDUM: Something you don’t see every day: a business giving back taxpayer-funded aid:
Shake Shack, one of several large restaurant chains that got federal loans through the coronavirus stimulus law meant to help small businesses, said Sunday night that it is giving all $10 million back.
“We now know that the first phase of the PPP was underfunded, and many who need it most, haven’t gotten any assistance,” [Danny Meyer, Shake Shack’s founder and CEO of its parent company, Union Square Hospitality Group, and Randy Garutti, Shake Shack’s CEO] wrote, urging Congress to ensure that “all restaurants no matter their size have equal ability to get back on their feet and hire back their teams.”
“Our people would benefit from a $10 million PPP loan, but we’re fortunate to now have access to capital that others do not,” they wrote. “Until every restaurant that needs it has had the same opportunity to receive assistance, we’re returning ours.