On money: Health care, police officers, and social services.

On money: Health care, police officers, and social services.

Last week, my kids and I visited my father in Indianapolis. We went to a playground near his apartment.

Playgrounds had re-opened the day before, so my kids were super excited. They’d gone almost three months without climbing much. And the playground near my father’s apartment is excellent, with a variety of nets and terraces suspended from platforms near the canal.

When we arrived – at about eleven a.m. on an eighty-five degree day – we noticed a child sprawled face down in the shade at the other end of the playground, apparently asleep.

My own eldest child promptly started climbing toward the highest slide, which was going to be quite difficult for her. I followed her up, ready to provide encouragement whenever she felt too nervous, and to catch her if she slipped.

My four-year-old hopped onto a swing.

My father, temporarily free of supervisory duties, crossed the playground. In addition to us and the sleeping child, one other family was playing – a woman my age with a baby strapped to her chest and a four-year-old careening in front of her.

My father asked if the sleeping child had come with them. The woman shook her head. So my father asked a few more people, calling down to folks who were sitting on benches near the water.

Nobody knew who this child was.

My father knelt down and gently woke him, to ask if he was okay. My father is a medical doctor. Helping people is what he likes to do.

When roused, the child had a seizure. His body shook. His eyes went stark white, having rolled all the way to the side.

My father called 911.

But then, after about thirty seconds, the child’s seizure ended. And, unlike the fallout from a typical epileptic seizure, the child sat up immediately, alert and unconfused.

My father told the dispatcher that maybe things were fine – no need to send an ambulance – then hung up to talk to the child.

“Are you okay?” my father asked.

“Oh, that’s my sugar high,” the child said. “Some people get a sugar high from eating sugar, but I get that when I sleep. It happens a lot, just when I sleep.”

“I think you had a seizure.”

“Well, I just call that my sugar high.”

“Do you take any medications?” my father asked.

“Only a little, sometimes, for my ADHD.” And then the child started to climb up toward the high slide of the playground, near me.

A few moments later, a drone began to hover near us. I’m not fond of drones, mechanically whirring through the air. And I’ve never even had reason to feel traumatized! They must be so terrifying for people who’ve survived contemporary war zones, or who’ve been subject to drone-enhanced policing.

“What’s that noise?” my six-year-old asked.

“It’s a robot,” I said. “A flying robot. See, over there. Sometimes they put cameras in them.”

“It’s called a drone,” the formerly sleeping child clarified. “I used to work with drones. I’m an inventor. But that person should be careful. That drone is over the water, and when drones crash into the water they can short circuit and catch fire.”

“You like drones?” I asked.

“I like to build stuff. Some drones you can control with your mind, like telekinesis, with a strap …”

“Oh, like an electroencephalogram?” I asked. “We played a game at a museum once, you wear a headband and try to think a ping-pong ball across the table.”

“You can make a drone fly that way, too. But those are tricky because if you laugh they crash.”

“You wouldn’t want to laugh while it was over the water!” my six-year-old exclaimed, giggling.

“You wouldn’t,” the child agreed, sagely. And then he turned to me to ask, “Say, do you know where the nearest McDonalds is? My dad wants me to get him something.”

I shook my head, apologizing. “We’re visiting my father, I don’t know where anything is around here. But you could try asking him.”

When asked, my father shook his head, too. His apartment is in a rather fancy part of of Indianapolis, it seems. “I don’t know of one … I don’t think I’ve seen a McDonalds around here.”

“Well, that’s okay, I’ll get something at a gas station instead. Thanks!”

And with that, the child jogged away. I never even learned his name.

My father walked over to me. “I’m worried about him,” he said. “That was a tonic-clonic seizure! I don’t know how he came out of that feeling lucid. I mean, he’s obviously a bright kid, but …”

“It didn’t look like he had a phone with him,” I said. “I don’t know, suddenly needing food … I’d guess schizophrenia, but that’d be really strange for an eight-year-old.”

“I know,” my father said. “But something’s wrong.”

On that, we definitely agreed. A lot of somethings might be wrong if a third grader is napping at a city playground on his own.

And I didn’t help him.

In retrospect, I’m still not sure what I should have done.

When my father thought the child was experiencing an acute medical emergency, he called 911. But then he canceled the request when the problem seemed chronic, not urgent. The arrival of an ambulance probably would’ve caused more harm than good, because a trip to the ER is often followed by egregious bills.

A few weeks ago, my spouse woke up with blurry vision. This might be nothing serious, or it might be the sign of a detached retina, so we drove her to the ER. After two hours of waiting, a doctor spent three minutes with her, visually examining my spouse’s eye while shining a light on it.

Thankfully, nothing was wrong.

We received a bill for $1,600. After requesting an itemized bill, they split the charges into a $200 ER fee and $1,400 for “ED LEVEL 3 REGIONAL.”

To diagnose a child who’d just emerged from an atypical seizure, they might levy poverty-inducing charges, which is why my father canceled with the dispatcher. He volunteers at the free clinic because he knows how many people are priced out of access to health care in our country.

But, if not a hospital, who could we call for help?

Currently, there’s a big push to defund the police. In many cities, the budget for policing is so large, and the budget for other public services so small, that police officers are de facto social workers. Which doesn’t make anybody happy.

In a recent New York Times conversation, Vanita Gupta said, “When I did investigations for the Justice Department, I would hear police officers say: ‘I didn’t sign up to the police force to be a social worker. I don’t have that training.’

Police officers are tasked with responding to mental health crises, despite receiving little training in psychology, counseling, or even de-escalation. Police officers use their budget to combat the downstream effects of poverty – which often includes theft, vandalism, and domestic violence – without a commensurate amount being spent on addressing the poverty itself. Police budgets dwarf the amounts spent on jobs programs and public work projects.

Many police officers join the force because they want to help people. They’re motivated by the same altruism that inspired my father to practice medicine. But just as hospital billing, as a system, undermines the altruism of individual doctors (“In this seminar, we’re going to train you to optimize billing. If you perform diagnostics on a third organ system, we elevate patient care to the preferred reimbursement tier.”), American policing, as a system, exacerbates racial injustice and inequality.

Even a charming, well-spoken, eight-year-old Black child has good reason to fear the police. I don’t think any good would have come from us calling the cops.

And so I’m left wondering – what would it be like if we did have an agency to call? What if, instead of police officers with guns, we had social workers, counselors, and therapists patrolling our streets?

Maybe then it would have been easy to help this child.

As is, I did nothing.

. .

Feature image: photograph of sidewalk chalk by Ted Eytan, Washington D.C.

Responses to “On testing.”

Responses to “On testing.”

My spouse posted my previous essay on social media, and I’d like to address some of people’s comments.  There were some excellent points! 

My apologies if I failed to address everything that people said, but I tried my best.

Scroll to find my responses to:

  1. A shutdown could have prevented the Covid-19 epidemic.
  2. We know that the current shutdown is either delaying or preventing deaths due to Covid-19. 
  3. Ending this epidemic with a vaccine would be ideal. 
  4. Ending the shutdown while requesting that at-risk people continue to self-isolate would save lives.
  5. Why is it urgent to end the shutdown soon?
  6. Why might more people die of Covid-19 just because we are slowing the spread of the virus?
  7. How is the shutdown causing harm?
  8. What about the rate at which people get sick?  Isn’t the shutdown worthwhile, despite the risks described above, if it keeps our hospitals from being overwhelmed?
  9. Don’t the antibody tests have a lot of false positives?
  10. What about the political ramifications of ending the shutdown?


1: “A shutdown could have prevented the Covid-19 epidemic.”

If we’d acted early enough, we could have isolated all cases of Covid-19 and prevented this whole debacle.

But we didn’t.

Covid-19 is highly infectious, and we made no effort toward containment or quarantine until the virus was already widespread.  We took action in March, but we already had community transmission of Covid-19 by January.  Given where we are now, current models predict that the epidemic will continue until the level of immunity reaches somewhere near 70%.


2: “We know that the current shutdown is either delaying or preventing deaths due to Covid-19.”

To date, the data suggests that the virus has only reached saturation inside a few closed environments, such as prisons.  In Italy, both the timecourse of mortality and the results of antibody studies suggest that infections were still rising at the time of their lockdown. 

Among the passengers of the Diamond Princess cruise ship, deaths peaked 21 days after infections peaked – if the virus had already reached saturation in Italy, we’d expect to see deaths peak sooner than 21 days after the lockdown began.  They did not.

So, again, this much is clear: worldwide, there was a significant new cause of death.  When we look at mortality data, we see the curves suddenly rise in many locations.  Some researchers, such as John Ioannidis, have speculated that Covid-19 causes death primarily in people with low life expectancy, in which case we would expect to see these mortality curves drop to lower-than-average levels after the epidemic ends.  But even then, it’s unprecedented to see a number of deaths that would usually occur over the course of a year all within a matter of weeks.

Covid-19 is killing people, and the shutdown is either delaying or preventing people’s death from Covid-19.

For the shutdown to actually prevent death, one of the following needs to happen:

1.) We create a vaccine, allowing our population to reach 70% immunity without as many people contracting the illness.

2.) We take action to change which segment of the population is exposed to the virus, allowing us to reach 70% immunity without as many at-risk people being exposed.

See #3 and #4, below.


3: “Ending this epidemic with a vaccine would be ideal.”

Vaccination is great science.  Both my spouse and I love teaching about vaccines, in part because teaching the history of vaccine use is a good component of anti-racist science class.

Developing vaccines often takes a long time.  I’ve read predictions of a year or two; my father, an infectious disease doctor, epidemiologist, research physician who runs vaccine trials, and co-developer of Merck’s HPV vaccine, guesses that it will take about five years.

And then, for the vaccine to end this epidemic, enough people will need to choose to be vaccinated that we reach approximately 70% immunity.

The reason it’s worthwhile to compare Covid-19 to seasonal influenza is that a vaccine will only end the epidemic if enough people choose to get it.  Many people’s personal risk from Covid-19 is lower than their risk from seasonal influenza.  Will those people choose to be vaccinated?

Obviously, I would be thrilled if the answer were “yes.”  I’d love to live in a nation where people’s sense of altruism and civic duty compelled them to get vaccinated.  My family is up-to-date on all of ours.

But many privileged families in the United States have elected to be freeloaders, declining the (well tested, quite safe) measles vaccine with the expectation that other people’s immunity will keep them safe.  And, despite the well-documented dangers of influenza, only 40% of our population gets each year’s influenza vaccine.

Yes, the influenza vaccine tends to be less effective than many others – some years it gives as little as ten percent protection, other years about sixty percent protection.  By way of comparison, the HPV vaccine has over 90% efficacy.

A vaccine with low efficacy will still offer better protection when more people get it.  If a higher percentage of our population were vaccinated against influenza, then influenza transmission would drop, and so each person’s immunity, whether high or low, would be less likely to be challenged.

Also, the efficacy of influenza vaccines is measured in terms of the likelihood that vaccination prevents infection.  The influenza vaccine is not great at keeping people from getting sick.  But vaccination also tends to reduce the severity of your illness, even if you do catch influenza.  Because you got sick, it seems as though the vaccine “failed,” but your case might have been far more severe if you hadn’t been vaccinated.

The influenza vaccine saves lives.  In Italy, where fewer people choose to get vaccinated against influenza (about 15% compared to our 40% of the population), the death rate from influenza is higher.  Although it’s worth noting that this comparison is complicated by the fact that our health care system is so bad, with poor people especially having limited access to health care.  In the United States, people between the ages of 18 and 49 comprise a higher proportion of influenza deaths than anywhere in Europe.  Either our obesity epidemic or limited access to health care is probably to blame; possibly a combination of both.

In summary, for this plan to help us save lives, we will need to develop an effective vaccine, and then people will have to get it. 

I am quite confident that we can eventually develop a vaccine against Covid-19.  The virus includes a proofreading enzyme, so it should mutate more slowly than most RNA viruses.  We don’t know how long it will take, but we can do it.

I am unfortunately pessimistic that people will choose to get the vaccine.  And, unfortunately, when a low-risk person chooses to forgo vaccination, they’re not just putting themselves in harm’s way, they are endangering others.  Most vaccines elicit a weaker immune response in elderly or immunocompromised recipients – exactly the group most at risk from Covid-19 – which is why we spend so much time harping about herd immunity.


4: “Ending the shutdown while requesting that at-risk people continue to self-isolate would save lives.

This plan has major downsides, too.  Because we didn’t take action soon enough, every plan we have now is bad.

Low-risk people can still die of Covid-19.  Even if they don’t die, Covid-19 can cause permanent health effects.  Covid-19 reduces your ability to get oxygen to your body and brain.  Even a “mild” case can leave your breathing labored for weeks – you’re not getting enough oxygen.  Your muscles will ache.  Your thoughts will be sluggish.

With a more severe case, people can be looking at heart damage.  Renal failure.  It would be cruel to look at all these long-term consequences and blithely call them “recovery.”

If our health care system were better, we’d treat people sooner.  The earlier you intervene, helping to boost people’s oxygen levels, the better outcome you’ll have.  There’s a great editorial from medical doctor Richard Levitan recommending that people monitor their health with a pulse oximeter during this epidemic.

If you notice your oxygen levels declining, get help right away.  Early intervention can prevent organ damage.  And you’ll be helping everyone else, too – the sooner you intervene, the less medical care you will need.

Because medical debt can derail lives, many people in this country delay treatment as long as possible, hoping that their problems will go away naturally.  That’s why people are often so sick when they show up at the ER.  I imagine that this is yet another reason – alongside air pollution, food deserts, sleep loss, and persistent stress exacerbated by racism – that poor communities have had such a high proportion of people with severe cases of Covid-19.

And I imagine – although we don’t yet have enough data to know – that financial insecurity caused by the shutdown is making this worse.  It’s a rotten situation: you have a segment of population that has to continue working during the shutdown, which means they now have the highest likelihood to be exposed to the virus, and they’re now under more financial strain, which might increase the chance that they’ll delay treatment.

We know that early treatment saves lives, and not everyone is sufficiently privileged to access that.

All this sounds awful.  And it is.  But, if we took action to shift exposure away from high risk groups, the likelihood that any individual suffers severe consequences is lower.

And there is another caveat with this plan – some people may be at high risk of complications for Covid-19 and not even realize it.  In the United States, a lot of people either have type 2 diabetes or are pre-diabetic and don’t yet realize.  These people have elevated risk.  Both smoking and air pollution elevate risk, but people don’t always know which airborn pollutants they’ve been exposed to.  (Which, again, is why it’s particularly awful that our administration is weakening air quality standards during this epidemic.)

Even if we recommended continued self-isolation for only those people who know themselves to have high risk from Covid-19, though, we would be saving lives.  The more we can protect people in this group from being exposed to the virus – not just now, but ever – the more lives we will save.

We won’t be able to do this perfectly.  It’ll be a logistical nightmare trying to do it at all.  People at high risk from Covid-19 needs goods and services just like everybody else.  We might have to give daily Covid-19 PCR tests to anyone visiting their homes, like doctors, dentists, and even delivery workers. 

At that point, the false negative rate from Covid-19 PCR tests becomes a much bigger problem – currently, these false negatives reduce the quality of our data (but who cares?) and delay treatment (which can be deadly).  A false negative that causes inadvertent exposure could cost lives.

Stores will need to set aside morning hours for at-risk shoppers, and undertake rigorous cleaning at night.  We know that infectious viral particles can persist for days on a variety of surfaces.

Some people will be unable to work, either because they or a close relative has high risk of Covid-19.  Some children will be unable to go to school.  We will need a plan to help these people.

We will have to work very hard to keep people safe even after the shutdown ends for some. 

But, again, if everyone does the same thing, then the demographics of people infected with Covid-19 will reflect our population demographics.  We can save lives by skewing the demographics of the subset of our population that is exposed to Covid-19 to include more low-risk individuals, which will require that we stratify our recommendations by risk (at least as well as we can assess it).


5: “Why is it urgent to end the shutdown soon?

1.) By delaying Covid-19 deaths, we run to risk of causing more total people to die of Covid-19.

2.) The shutdown itself is causing harm.

See #6 and #7, below.


6: “Why might more people die of Covid-19 just because we are slowing the spread of the virus?

[EDIT: I wrote a more careful explanation of the takeaways of the Harvard study. That’s here if you would like to take a look!]

This is due to the interplay between duration of immunity and duration of the epidemic.  At one point in time, seasonal influenza was a novel zoogenic disease.  Human behavior allowed the influenza virus to become a perpetual burden on our species.  No one wants for humans to still be dying of Covid-19 in ten or twenty years.  (Luckily, because the virus that causes Covid-19 seems to mutate more slowly than influenza, it should be easier to design a single vaccine that protects people.)

In the Harvard model, we can see that there are many scenarios in which a single, finite shutdown leads to more deaths from Covid-19 than if we’d done nothing. Note the scenarios for which the colored cumulative incidence curves (shown on the right) exceed the black line representing how many critical cases we’d have if we had done nothing.

Furthermore, their model does not account for people’s immunity potentially waning over time.  Currently, we do not know how long people’s immunity to Covid-19 will last.  We won’t know whether people’s immunity will last at least a year until a year from now.  There’s no way to test this preemptively.

We’ve seen that immunity to other coronaviruses fades within a year.  If immunity to Covid-19 is similar, we really don’t want to prolong the epidemic past a year.

If we could all go into stasis and simply not move for about a month, there’d be no new cases of Covid-19, and this virus would be gone forever.  But people still need to eat during the shutdown.  Many people are still working.  So the virus is still spreading, and we have simply slowed the rate of transmission.

This seems good, because we’re slowing the rate at which people enter the hospital, but it’s actually bad if we’re increasing the number of people who will eventually enter the hospital.

Based on our research with other coronaviruses, we expect that re-infection will cause a person to experience symptoms less severe than their first case of Covid-19.  But a re-infected person can still spread the disease to others.  And we don’t know what will happen if a person’s risk factors – such as age, smoking status, diabetes status, etc. – have increased in the time since their last infection.


7: “How is the shutdown causing harm?

If you turn on Fox News, I imagine you’d hear people talking about the damage we’re doing to our economy.  They might discuss stock market numbers.

Who gives a shit?  In my opinion, you’d have to be pretty callous to think that maintaining the Nasdaq bubble is more important than saving lives.

At the same time, I think you’d have to be pretty callous to not feel extremely concerned by the United Nations’ policy brief, “The impact of Covid-19 on children.”

In this report, they estimate that the shutdown we’ve had so far will cause hundreds of thousands of children to die, many from malnutrition and the other health impacts of poverty.  The longer the shutdown continues, the more children will die.

That’s a worldwide number, and most of those children live outside the United States.  But I’d like to think that their lives matter, too.

The report also discusses the lifelong harm that will be inflicted on children from five months (or more!) of school closure.  Drop-outs, teen pregnancy, drug abuse, recruitment of child soldiers, and the myriad health consequences of low educational attainment.

I live in a wealthy college town, but even here there is a significant population of students who don’t have internet access.  Students with special needs aren’t getting the services they deserve.  Food insecurity is worse.

You’re lucky that privacy protections prevent me from sharing a story about what can happen to poor kids when all the dentists’ offices are closed.  I felt ashamed that this was the best my country had to offer.

As the shutdown continues, domestic violence is rising.  We can assume that child abuse is rising, also, but we won’t know until later, when we finally have a chance to save children from it.  In the past, levels of child abuse have been correlated with the amount of time that children spend in the presence of their abusers (usually close family), and reporting tends to happen during tense in-person conversations at school.

We know that online sex work has increased during the shutdown.  There is an increased supply of sex workers who are experiencing increasing financial insecurity.  We don’t yet have data on this, but I’d be shocked if the shutdown hasn’t led many to feel pressured into riskier acts for lower amounts of money, including meeting clients in isolated (and therefore unsafe) spaces.

The shutdown has probably made our drug epidemic worse (and this was already killing about 70,000 people per year in the U.S.).  When people are in recovery, one of the best strategies to stay sober is to spend a lot of time working, out of the house, and meeting with a supportive group in communal space.  Luckily, many of the people I know who are in recovery have been categorized as essential workers.

But any slip can kill someone recovering from addiction.  One of my friends froze to death last year.

A neighbor recently sent me a cartoon suggesting that the biggest harm caused by the shutdown is boredom.  (I’m going to include it, below, but don’t worry: I won’t spend too much time rattling sabers with a straw man.) And, for privileged families like mine, it is.  We’re safe, we’re healthy, we get to eat.  My kids are still learning – we live in a house full of computers and books.

But many of the 75 million children in the United States don’t live in homes like mine, with the privilege we have.  Many of our 50 million primary and secondary school students are not still learning academically during the shutdown.

Whether the shutdown is preventing or merely delaying the deaths of people at risk of serious complications from Covid-19, we have to remember that the benefit comes at a cost.  What we’ve done already will negatively impact children for the rest of their lives.  And the longer this goes on, the more we’re hurting them.


8: “What about the rate at which people get sick?  Isn’t the shutdown worthwhile, despite the risks described above, if it keeps our hospitals from being overwhelmed?

In writing this, I struggled with how best to organize the various responses.  I hope it doesn’t seem too ingenuous to address this near the end, because slowing the rate of infection so that our hospitals don’t get overwhelmed is the BEST motivation for the shutdown.  More than the hope that a delay will yield a new vaccine, or new therapies to treat severe cases, or even new diagnostics to catch people before they develop severe symptoms, we don’t want to overwhelm our hospitals.

If our physicians have to triage care, more people will die.

And I care a lot about what this epidemic will be like for our physicians.  My father is a 67-year-old infectious disease doctor who just finished another week of clinical service treating Covid-19 patients at the low-income hospital in Indianapolis.  My brother-in-law is an ER surgeon in Minneapolis.  These cities have not yet had anything like the influx of severe cases in New York City – for demographic and environmental reasons, it’s possible they never will.  But they might. 

Based on the case fatality rate measured elsewhere, I’d estimate that only 10% of the population in Minneapolis has already been infected with Covid-19, so the epidemic may have a long way yet to go.

If we ended the shutdown today for everyone, with no recommendation that at-risk groups continue to isolate and no new measures to protect them, we would see a spike in severe cases.

If we ended the shutdown for low-risk groups, and did a better job of monitoring people’s health to catch Covid-19 at early, more-easily-treatable stages (through either PCR testing or oxygen levels), we can avoid overwhelming hospitals.

And the shutdown itself is contributing toward chaos at hospitals.  Despite being on the front lines of this epidemic, ER doctors in Minneapolis have received a 30% pay cut.  I imagine my brother-in-law is not the only physician who could no longer afford day care for his children after the pay cut.  (Because so many people are delaying care out of fear of Covid-19, hospitals are running out of money.)  Precisely when we should be doing everything in our power to make physicians’ lives easier, we’re making things more stressful.

We could end the shutdown without even needing to evoke the horrible trolley-problem-esque calculations of triage.  Arguments could be made that even if it led to triage it might be worthwhile to end the shutdown – the increase in mortality would be the percentage of triaged cases that could have survived if they’d been treated, and we as a nation might decide that this number was acceptable to prevent the harms described above – but with a careful plan, we need not come to that.


9: “Don’t the antibody tests have a lot of false positives?

False positives are a big problem when a signal is small.  I happen to like a lot of John Ioannidis’s work – I think his paper “Why Most Published Research Findings Are False” is an important contribution to the literature – but I agree that the Santa Clara study isn’t particularly convincing. 

When I read the Santa Clara paper, I nodded and thought “That sounds about right,” but I knew my reaction was most likely confirmation bias at work.

Which is why, in the essay, I mostly discussed antibody studies that found high percentages of the population had been infected with Covid-19, like the study in Germany and the study in the Italian town of Robbio.  In these studies, the signal was sufficiently high that false positives aren’t as worrisome. 

In Santa Clara, when they reported a 2% infection rate, the real number might’ve been as low as zero.  When researchers in Germany reported a 15% infection rate, the real number might’ve been anywhere in the range of 13% to 17% – or perhaps double that, if the particular chips they used had a false negative rate similar to the chips manufactured by Premier Biotech in Minneapolis.

I’m aware that German response to Covid-19 has been far superior to our bungled effort in the United States, but an antibody tests is just a basic ELISA.  We’ve been doing these for years.

Luckily for us, we should soon have data from good antibody studies here in the United States.  And I think it’s perfectly reasonable to want to see the results of those.  I’m not a sociopath – I haven’t gone out and joined the gun-toting protesters.

But we’ll have this data in a matter of weeks, so that’s the time frame we should be talking about here.  Not months.  Not years.  And I’ll be shocked if these antibody studies don’t show widespread past infection and recovery from Covid-19.


10: “What about the political ramifications of ending the shutdown?

I am, by nature, an extremely cautious person.  And I have a really dire fear.

I’m inclined to believe that ending the shutdown is the right thing to do.  I’ve tried to explain why.  I’ve tried to explain what I think would be the best way to do it.

But also, I’m a scientist.  You’re not allowed to be a scientist unless you’re willing to be proven wrong.

So, yes.  I might be wrong.  New data might indicate that writing this essay was a horrible mistake.

Still, please bear with me for a moment.  If ending the shutdown soon turns out to be the correct thing to do, and if only horrible right-wing fanatics have been saying that we should end the shutdown soon, won’t that help our current president get re-elected?

There is a very high probability that his re-election would cause even more deaths than Covid-19.

Failing to address climate change could kill billions.  Immigration controls against migrants fleeing war zones could kill millions.  Weakened EPA protections could kill hundreds of thousands.  Reduced access to health care could kill tens of thousands.

And, yes, there are horrible developments that neither major political party in the United States has talked about, like the risk that our antibiotics stop working, but I think it’s difficult to argue that one political party isn’t more dangerous than the other, here.

I feel pretty confident about all the scientific data I’ve discussed above.  Not as confident as I’d like, which would require more data, but pretty confident.

I feel extremely confident that we need to avoid a situation in which the far right takes ownership of an idea that turns out to have been correct.  And it’ll be dumb luck, just a bad coincidence.  The only “data” they’re looking at are stock market numbers, or maybe the revenue at Trump-owned hotels.


EDIT: I also wrote a more careful explanation of the takeaways of the Harvard study. That’s here if you would like to take a look!


Header image by Goran Paunovic.

On testing.

On testing.

UPDATE: Wow, this got a lot of readers! Honestly, though, I wrote a response to common questions and comments about this essay and it is probably a better read.


My spouse recently sent me a link to the article “Concerns with that Stanford study of coronavirus prevalence” by Andrew Gelman, a statistician at Columbia University.  From reading this article, I got the impression that Gelman is a good mathematician.  And he raises some legitimate concerns. 

But I’ve noticed that many of the people criticizing the work coming out of the Ioannidis group – such as the study of how many people in Santa Clara county might have antibodies to Covid-19 – don’t seem to understand the biology underlying the numbers.


First, some background: in case you haven’t noticed, most of the United States is operating under a half-assed lockdown.  In theory, there are stay-at-home orders, but many people, such as grocery store clerks, janitors, health care workers, construction workers, restaurant chefs, delivery drivers, etc., are still going to work as normal.  However, schools have been closed, and most people are trying to stand at least six feet away from strangers.

We’re doing this out of fear that Covid-19 is an extremely dangerous new viral disease.  Our initial data suggested that as many as 10% of people infected with Covid-19 would die.

That’s terrifying!  We would be looking at tens of millions of deaths in the United States alone!  A virus like this will spread until a majority of people have immunity to it – a ballpark estimate is that 70% of the population needs immunity before the epidemic stops.  And our early data suggested that one in ten would die.

My family was scared.  We washed our hands compulsively.  We changed into clean clothes as soon as we came into the house.  The kids didn’t leave our home for a week.  My spouse went to the grocery store and bought hundreds of dollars of canned beans and cleaning supplies.

And, to make matters worse, our president was on the news saying that Covid-19 was no big deal.  His nonchalance made me freak out more.  Our ass-hat-in-chief has been wrong about basically everything, in my opinion.  His environmental policies are basically designed to make more people die.  If he claimed we had nothing to worry about, then Covid-19 was probably more deadly than I expected.


Five weeks have passed, and we now have much more data.  It seems that Covid-19 is much less dangerous than we initially feared.  For someone my age (37), Covid-19 is less dangerous than seasonal influenza.

Last year, seasonal influenza killed several thousand people between the ages of 18 and 49 in the United States – most likely 2,500 people, but perhaps as many as 5,800.  People in this age demographic account for about 10% of total flu deaths in the United States, year after year.

Seasonal influenza also killed several hundred children last year – perhaps over a thousand.

There’s a vaccine against influenza, but most people don’t bother. 

That’s shocking. 

Seasonal influenza is more dangerous than Covid-19 for people between the ages of 18 and 49, but only 35% of them chose to be vaccinated in the most recently reported year (2018).  And because the vaccination rate is so low, our society doesn’t have herd immunity.  By choosing not to get the influenza vaccine, these people are endangering themselves and others.

Some people hope that the Covid-19 epidemic will end once a vaccine is released.  I am extremely skeptical.  The biggest problem, to my mind, isn’t that years might pass before there’s a vaccine.  I just can’t imagine that a sufficient percentage of our population would choose to get a Covid-19 vaccine when most people’s personal risk is lower than their risk from influenza.

When I teach classes in jail, dudes often tell me about which vaccines they think are too dangerous for their kids to get.  I launch into a tirade about how safe most vaccines are, and how deadly the diseases they prevent. 

Seriously, get your kids vaccinated.  You don’t want to watch your child die of measles.

And, seriously, dear reader – get a flu vaccine each year.  Even if you’re too selfish to worry about the other people whom your mild case of influenza might kill, do it for yourself. 


We already know how dangerous seasonal influenza is.  But what about Covid-19?

To answer that, we need data.  And one set of data is unmistakable – many people have died.  Hospitals around the world have experienced an influx of patients with a common set of symptoms.  They struggle to breathe; their bodies weaken from oxygen deprivation; their lungs accumulate liquid; they die.

Many people have been put on ventilators, but that’s often the beginning of the end.  Most people put on ventilators will die.  Among patients over 70 years old, three quarters who are put on ventilators will die

For each of these patients saved, three others are consigned to an agonizing death in the hospital, intubated among the flashing lights, the ceaseless blips and bleeps.  At home, they’d die in a day; in the hospital, their deaths will take three weeks.

And the sheer quantity of deaths sounds scary – especially for people who don’t realize how many tens of thousands die from influenza in the United States each year.

Or, consider: cigarette smoking causes 480,000 deaths per year in the United States, including 41,000 people who die from second-hand smoke exposure.  Those 41,000 aren’t even choosing to smoke!  But cigarettes kill them anyway.

Indeed, when people die of Covid-19, it’s often because their lungs fail.  Smoking is obviously a major risk factor for dying of Covid-19 – a significant portion of reported Covid-19 deaths could be considered cigarette deaths instead.  Or as air pollution deaths – and yet, our current president is using this crisis as an opportunity to weaken EPA air quality regulations.

Air pollution is a huge problem for a lot of Black communities in the United States.  Our racist housing policies have placed a lot of minority neighborhoods near heavily polluting factories.  Now Covid-19 is turning what is already a lifelong struggle for breath into a death sentence.

I would enthusiastically support a shutdown motivated by the battle for clean air.


So, Covid-19.  We know how many people have died – already (CORRECTION AS OF APRIL 21) forty-two thousand in the United States

But if we want to know how scary this virus is, we need to know how many people were infected.  If that many people died after everyone in the country had it, then Covid-19 would be less dangerous than influenza.  If that many people died after only a hundred thousand had been infected, then this would be terrifying, and far more dangerous than influenza.


Initially, our data came from PCR testing.

These are good tests.  Polymerase chain reaction is highly specific.  If you want to amplify a certain genetic sequence, you can design short DNA primers that will bind only to that sequence.  Put the whole mess in a thermocycler and you get a bunch of your target, as long as the gene is present in the test tube in the first place.  If the gene isn’t there, you’ll get nothing.

PCR works great.  Even our lovely but amnesiac lab tech never once screwed it up.

So, do the PCR test and you’ll know whether a certain gene is present in your test tube.  Target a viral gene and you’ll know whether the virus is present in your test tube.  Scoop out some nose glop from somebody to put into the test tube and you’ll know whether the virus is present in that nose glop.

The PCR test is a great test that measures whether someone is actively shedding virus.  It answers, is there virus present in the nose glop?

This is not the same question as, has this person ever been infected with Covid-19? 

It’s a similar question – most people infected with a coronavirus will have at least a brief period of viral shedding – but it’s a much more specific question.  When a healthy person is infected with a coronavirus, the period of viral shedding can be as short as a single day.

A person can get infected with a coronavirus, and if you do the PCR test either before or after that single day, the PCR test will give a negative result.  Nope, no viral RNA is in this nose glop!

And so we know that the PCR test will undercount the true number of infections.


When we look at the age demographics for Covid-19 infections as measured by PCR test, the undercount becomes glaringly obvious.

Consider the PCR test data from the Diamond Princess cruise ship.  To date, this is our most complete set of PCR data – everyone on board was tested multiple times.  And from this data, it appears that very few children were exposed to the virus.

Friends, it is exceedingly unlikely that such a low percentage of children were exposed to this virus.  Children are disgusting.  I believe this is common knowledge.  Parents of small children are pretty much always sick because children are so disgusting. 

Seriously, my family has been doing the whole “social distancing” thing for over a month, and yet my nose is dripping while I type this.

Children are always touching everything, and then they rub their eyeballs or chew on their fingers.  If you take them someplace, they grubble around on the floor.  They pick up discarded tissues and ask, “What’s this?”

“That’s somebody’s gross kleenex, is what it is!  Just, just drop it.  I know it’s trash, I know we’re not supposed to leave trash on the ground, but just, just drop it, okay?  Somebody will come throw it away later.”

The next day: “Dad, you said somebody would throw that kleenex away, but it’s still there!”

Bloody hell.  Children are little monsters.

It seems fairly obvious that at least as high a percentage of children would be infected as any other age demographic.

But they’re not showing up from the PCR data.  On the Diamond Princess cruise ship, the lockdown began on February 5th, but PCR testing didn’t begin until February 11th.  Anyone who was infected but quickly recovered will be invisible to that PCR test.  And even people who are actively shedding viral particles can feel totally well.  People can get infected and recover without noticing a thing.

We see the same thing when we look at the PCR data from Italy.  If we mistakenly assumed that the PCR data was measuring the number of infections, and not measuring the number of people who were given a PCR test while shedding viral particles, we’d conclude that elderly people went out and socialized widely, getting each other sick, and only occasionally infected their great-grandchildren at home.

Here in the United States, children are disgusting little monsters.  I bet kids are disgusting in Italy, too.  They’re disgusting all over the world.

A much more likely scenario is that children spread this virus at school.  Many probably felt totally fine; some might’ve had a bad fever or the sniffles for a few days.  But then they recovered.

When they got their great-grandparents sick – which can happen easily since so many Italian families live in multigenerational homes – elderly people began to die.

So we know that the PCR test is undercounting the true number of infections.  Unless you’re testing every person, every day, regardless of whether or not they have symptoms, you’re going to undercount the number of infections.

In a moment, we can work through a way to get a more accurate count.  But perhaps it’s worth mentioning that, for someone my age, Covid-19 would seem to be about as dangerous as influenza even if we assumed that the PCR data matched the true number of infections.

If you’re a healthy middle-aged or young person, you should not feel personally afraid. 

That alone would not be an excuse to go out and start dancing in the street, though.  Your actions might cause other people to die. 

(NOTE & CORRECTION: After this post went up, my father recommended that I add something more about personal risk. No one has collected enough data on this yet, but he suspects that the next most important risk factor, after smoking and age, will be type 2 diabetes. And he reminded me that many people in their 30s & 40s in this country are diabetic or prediabetic and don’t even realize it yet. Everyone in this category probably has elevated risk of complications from Covid-19.)


After you’ve been infected with a virus, your body will start making antibodies.  These protect you from being infected again.

Have you read Shel Silverstein’s Missing Piece book?  Antibodies work kind of like that.  They have a particular shape, and so they’ll glom onto a virus only if that virus has outcroppings that match the antibody’s shape.  Then your body sees the antibodies hanging out on a virus like a GPS tracker and proceeds to destroy the virus.

So to make an antibody test, you take some stuff that looks like the outcroppings on the virus and you put it on a chip.  Wash somebody’s blood over it, and if that blood contains antibodies that have the right shape to glom onto the virus, they’ll stick to the chip.  All your other antibodies, the ones that recognize different viruses, will float away.

An antibody test is going to be worse than a PCR test.  It’s easier to get a false positive result – antibodies are made of proteins, and they can unfold if you treat them roughly, and then they’ll stick to anything.  Then you’ll think that somebody has the right antibodies, but they don’t.  That’s bad.

You have to be much more careful when you’re doing an antibody test. I wouldn’t have asked our lab tech to do them for me.

An antibody test is also going to have false negatives.  A viral particle is a big honking thing, and there are lots of places on its surface where an antibody might bind.  If your antibodies recognize some aspect of the virus that’s different from what the test manufacturers included on their chip, your antibodies will float away.  Even though they’d protect you from the actual virus if you happened to be exposed to it.

If you’re a cautious person, though – and I consider myself to be pretty cautious – you’d much rather have an antibody test with a bunch of false negatives than false positives.  If you’re actually immune to Covid-19 but keep being cautious, well, so what?  You’re safe either way.  But if you think you’re immune when you’re not, then you might get sick.  That’s bad.

Because antibody tests are designed to give more false negatives than false positives, you should know that it’d be really foolish to use them to track an infection.  Like, if you’re testing people to see who is safe to work as a delivery person today, use the PCR test!  The antibody test has a bunch of false negatives, and there’s a time lag between the onset of infection and when your body will start making antibodies.

It can be dangerous to use antibody tests to address the wrong questions.

If you use the antibody test on a bunch of people, though, you can tell how many were infected.  And that’s useful information, too.

In the town of Robbio in Italy (pop. 6,000), the PCR test showed that only 23 people had been infected with Covid-19.  But then the mayor implored everyone to get an antibody test, and 10% of people had actually been infected with – and had recovered from – Covid-19.  Most of them couldn’t even recall having been sick.

The PCR test measured 23 cases.  The antibody test suggested there’d been at least 600.  And antibody tests, by design, will generally have a bunch of false negatives.  When a team at Stanford assessed the antibody tests manufactured by Premier Biotech in Minneapolis, they found that for every 3 people who’d been infected with Covid-19, the tests registered only 2 positives.

I don’t know who made the tests used in Robbio – maybe they were a little better, maybe they were a little worse.  Based on my experience, I wouldn’t be so surprised if the true infection rate with Covid-19 in that town was really just 10% – nor would I be surprised to hear that the chips had a high false-negative rate and that the infection rate was 20% or more.

If you calculate the fatality rate of Covid-19 in Italy by assuming that the PCR tests caught every infection, you’d get a terrifying 10%.

If you instead assume that many other towns had a similar infection rate to Robbio, you’ll instead calculate that the fatality rate was well under one percent. 

Italy has higher risk than the United States due to age demographics, smoking rates, and multigenerational households – and even in Italy, the fatality rate was probably well under one percent.

When researchers in Germany randomly chose people to take a Covid-19 PCR test (many of whom had no symptoms), they found that 2% of the population was actively shedding virus – a much higher number of cases than they would have found if they tested only sick people.  And when they randomly chose people to take an antibody test, they found that 15% had already recovered from the infection (again, many of whom had never felt sick).  According to these numbers – which are expected to be an undercount, due to false negatives and the time lag before antibody production – they calculated a case fatality rate of 0.37%

That would be about three-fold more dangerous than seasonal influenza.

In the United States, our bungling president gutted the CDC, leaving us without the expertise needed to address Covid-19 (or myriad other problems that might arise).  During the first few months of this epidemic, very few people managed to get a PCR test.  That’s why our data from the PCR tests is likely to be a dramatic undercount – indeed, when we finally started producing accurate tests, the apparent growth in Covid-19 caseload superimposed with the growth in test availability.

In the absence of good PCR data, we have to rely on antibody data to track infections after the fact.  Which is why a town in Colorado with zero reported infections, as measured by PCR, had sufficiently widespread exposure that 2% of the population had already recovered from Covid-19.

And it’s why the data from the Stanford Santa Clara county study is so unsurprising. 

Yes, there were problems with the Stanford study’s data collection – they displayed advertisements to a random selection of people, but then a self-selected subset responded.  The pool of respondents were enriched for white women, but Santa Clara’s outbreak probably began among Asian-Americans.  And we all know that random sampling doesn’t always give you an accurate depiction of the population at large – after all, random polling predicted that a competent president would be elected in 2016.

Now look at us.

It’s also likely that people with a poor understanding of the biology could misinterpret the result of the Stanford study.  They found that PCR tests had undercounted the infection rate in Santa Clara county, at the time of this study, by 85-fold.

It would be absurd to assume that you could simply multiply all PCR results by 85 to determine the true infection rate, but some people did.  And then pointed out the absurdity of their own bad math.

In places where more people are being tested by PCR, and they’re being tested more often, the PCR results will be closer to the true infection rate.  If you gave everyone in the United States a PCR test, and did it every day, then the PCR data would be exactly equal to the true infection rate.

If we had data like that from the beginning, we wouldn’t have been scared.  We would’ve known the true case fatality rate early on, and, also, at-risk people could’ve been treated as soon as they got infected.  We’d be able to save many more lives.

If access to health care were considered a basic right in the United States, we might’ve done something like this. 


In Italy, it seems like Covid-19 is three- or four-fold more dangerous than seasonal influenza.  My guess is that Italy might have had about 50,000 deaths if they hadn’t enacted the lockdown.

In the United States, on a population level, Covid-19 is probably also more dangerous than seasonal influenza.  But there’s a big difference in terms of the distribution of risk.

The New York Times is running a series with short biographies of people who’ve died of Covid-19.  As of noon on April 17, about 10% of the people profiled were younger than 35.

10% is roughly the proportion of young people who die of seasonal influenza.  But only 1% of Covid-19 deaths are people younger than 35.  The news reports don’t always make clear how much the risk of Covid-19 is clustered in a small segment of the population.

This has serious implications for what we should do next.  If we were dealing with a virus that was about three-fold more dangerous than seasonal influenza for everyone, we might just return to life as normal.  (Indeed, we carried on as normal during the bad years when seasonal influenza killed 90,000 people instead of last year’s 30,000.)

Because the risk from Covid-19 is so concentrated, though, we can come up with a plan that will save a lot of lives. 

Healthy people under retirement age should resume most parts of their lives as normal.  Schools should re-open: for students, Covid-19 is much less dangerous than seasonal influenza.  I think that people should still try to work from home when possible, because it’s the right thing to do to fight climate change.

At-risk people should continue to isolate themselves as much as possible.

This sounds crummy, but at-risk people would just continue to do the thing that everyone is doing currently.  And the plan would save many lives because the epidemic would end in about 3 months, after the virus had spread to saturation among our nation’s low-risk cohort. 

Indeed, when a team of researchers from Harvard’s School of Public Health modeled the Covid-19 epidemic, they found that social distancing was generally unhelpful.  That’s what their data show, at least – but in their abstract, they instead recommend that we continue social distancing for the better part of two years.

Their data are easy enough to understand.  In each of these graphs, they show a blue box for how long social distancing would last, and then four colored lines to represent how many infections we’d see if we did no social distancing (black), medium quality social distancing (red), good social distancing (blue), or excellent social distancing (green).

So, from top to bottom, you’re looking at the graphs of what happens if we do a month of social distancing … or two months … or three, or four … or forever.

And you can see the outcomes in the panels on the right-hand side.  The black line shows what would happen if we did nothing.  Infections rise fast, then level off after the virus has reached saturation.  There are two important features of this graph – the final height that it reaches, which is the total number of severe cases (and so a good proxy for the number of deaths), and the slope of the line, which is how fast the severe cases appear.  A steeper hill means many people getting sick at the same time, which means hospitals might be overwhelmed.

So, okay.  Looking at their graphs, we see that social distancing saves lives … if we do it forever.  If you never leave your house again, you won’t die of Covid-19.

But if social distancing ends, it doesn’t help.  The slopes are nearly as steep as if we’d done nothing, and the final height – the total number of people who die – is higher.

(Often, one of their curves will have a gentler slope than the others — usually the good-but-not-excellent social distancing seems best. So you’d have to pray that you were doing a precisely mediocre job of not infecting strangers. Do it a little better or a little worse and you cause people to die. This isn’t an artifact — it’s based on the density of uninfected people when social distancing ends — but let’s just say “mathematical models are wonky” and leave it at that.)

In a subsequent figure, the Harvard team tried to model what might happen if we occasionally resumed our lives for a month or so at a time, but then had another shutdown.  This is the only scenario in which their model predicts that social distancing would be helpful.

But, unfortunately, there’s a problem.  Research done with other coronaviruses shows that immunity fades within a year.  Because the Harvard model would cause the epidemic to last longer than a year, people would have time to lose their immunity and get infected again.

Even in the extreme case that we mostly stayed in our homes for the better part of two years, social distancing would case more deaths from Covid-19 than if we had done nothing.

That’s not even accounting for all the people who would die from a greater risk of domestic violence, hunger, drug addiction, suicide, and sedentary behavior during the shutdown.  


When our data was limited, the shutdown seemed reasonable.  We wouldn’t be able to undo the damage we’d done by waiting.

Except, whoops, we waited anyway.  We didn’t quarantine travelers in January.  The shutdown didn’t begin March, when the epidemic was well underway in many places. 

Now that we have more data, we should re-open schools, though.  For most people, Covid-19 is no more dangerous than seasonal influenza.  We already have enough data from antibody testing to be pretty confident about this, and even if we want to be extremely cautious, we should continue the shutdown for a matter of weeks while we conduct a few more antibody studies.  Not months, and certainly not years.

At the same time, we need to do a better job of protecting at-risk people.  This means providing health care for everyone.  This means cleaning our air, staunching the pollution that plagues low-income neighborhoods.  This might mean daily medical checkups and PCR tests for people who work closely with at-risk populations.

Our country will have to be different in the future, but mostly because we, as a people, have done such a shitty job of creating justice and liberty for all.  We need to focus on addressing the inequities that we’ve let fester for generations.  That’ll help far more than using a bandanna to cover up your smile.



UPDATE: Wow, this got a lot of readers! Thanks if you made it this far. I’ve also written a response to common questions and comments about this essay.

On inequality and disease.

On inequality and disease.

I should preface these remarks by stating that my political views qualify as “extremely liberal” in the United States.

I’m a well-trained economist – I completed all but the residency requirement for a masters at Northwestern – but I don’t give two shits about the “damage we’re doing to our economy,” except insofar as financial insecurity causes psychological harm to people in poverty.  Our economy should be slower, to combat climate change and inequality.

One of my big fears during this epidemic is that our current president will accidentally do something correctly and bolster his chances of reelection.  The damage that his first term has already caused to our environment and our judiciary will take generations to undo – imagine the harm he could cause with two.

And yet, in arguing that our response to the Covid-19 epidemic is misguided, I seem to be in agreement with our nation’s far right. 

As far as I can tell, the far right opposes the shutdown because they’re motivated by philosophies that increase inequality.  Many of them adore Ayn Rand’s “Who will stop me?” breed of capitalism, as though they should be free to go outside and cough on whomever they want.  They dislike the shutdown because they think our lives are less important than the stock market.

By way of contrast, I care about fairness.  I care about the well-being of children.  I care about our species’ future on this planet.  It’s fine by me if the stock market tanks!  But I’ve written previously about the lack of scientific justification for this shutdown, and I’m worried that this shutdown is, in and of itself, an unfair response.


Quarantine could have prevented this epidemic from spreading.  If we had acted in December, this coronavirus could have been contained.  But we did nothing until several months after the Covid-19 epidemic began in the United States. 

Then schools were closed: first for two weeks, then a month, then the entire year.

Stay-at-home orders were issued: first for two weeks, then extended to a month.  No data supports the efficacy of these orders – haphazard, partial attempts at social distancing, from which certain people, like my buddy doing construction for a new Amazon facility, have been exempted.  And no metrics were announced that might trigger an end to the shutdown.

Currently, the stay-at-home orders last until the end of April.  But, as we approach that date, what do people expect will be different?  In the United States, we still can’t conduct enough PCR tests – and even these tests yield sketchy data, because they might have false negative rates as high as 30%, and they’re only effective during the brief window of time — perhaps as short as one week — before a healthy patient clears the virus and becomes invisible to testing.

Based on research with other coronaviruses, we expect that people will be immune to reinfection for about a year, but we don’t know how many will have detectable levels of antibody in their blood.  As of this writing, there’s still no serum test.


In the United States, New York City has the largest concentration of risk – densely populated elderly people with constant exposure to unclean air. But even the New York Times has begun to print articles describing the folly of our response to Covid-19.

The Italian government is considering the dystopian policy of drawing people’s blood to determine if they’ll be eligible for a permit to leave their homes.  If you were worried about the injustice that the virus itself imposed on people who are elderly or immunocompromised, this is worse!

We can’t evaluate our response without tests.  Missteps by the CDC (which was gutted by the Trump administration) have left us blind to the progression of the epidemic.  And we can’t evaluate our response if we have nothing to compare it to – we will have to end the shutdown to see what happens next (with the option of resuming these safety measures if our test shows they were necessary).

We know, clearly, that the shutdown has been causing grievous harm.  Domestic violence is on the rise.  This is particularly horrible for women and children in poverty, trapped in close quarters with abusers.  The shutdown is creating conditions that increase the risk of drug addiction, suicide, and the murder of intimate partners.

We don’t know whether the shutdown is even helping us stop the Covid-19 epidemic.  And we still don’t know whether Covid-19 is scary enough to merit this response.  As of this writing, our data suggest that it isn’t.

Covid-19 is a rare breed, though: a communicable disease where increased wealth correlates with increased risk.

And so we’re taking extreme measures to benefit the most privileged generation to ever walk the face of this Earth, at the cost of great harm to vulnerable populations.  This is why I feel dismayed.

Hopefully I can present some numbers simply enough to explain.


Many diseases are more likely to kill you if you’re poor.

Malaria kills between 400,000 and one million people every year.  The vast majority are extremely poor, and many are children – the World Health Organization estimates that a child dies of malaria every thirty seconds.

Wealth protects against malaria in two ways.  Wealthy people are less likely to live in parts of the world with a high prevalence of malaria (most of the deaths each year occur in Africa and India), and wealthy people can buy effective anti-malarial medications. 

I took prophylactic Malarone when I visited Ecuador and India.  Lo and behold, I did not get sick. 

I believe Malarone costs about a dollar per day.  I am very privileged.

HIV kills between 700,000 and one million people every year.  Again, the vast majority are poor.  HIV is primarily transmitted through intimate contact – exposure to blood, needle sharing, or sex – so this virus rarely spreads across social boundaries in stratified communities. 

In the United States, HIV risk is concentrated among people living in our dying small towns, people without homes in inner cities, and people trapped inside the criminal justice system. 

It seems that these people are all easy to ignore.

Wealth will protect you even if you do contract HIV.  We’ve developed effective anti-retroviral therapies.  If you (or your government) can pay for these pills, you can still have a long, full life while HIV positive.  About 60% of the people dying of HIV happen to have been born in Africa, though, and cannot afford anti-retrovirals.

Even the myriad respiratory infections that plague our species – of which Covid-19 is but one example – are more likely to kill you if you’re poor.  The World Health Organization lists the top causes of death for people living in low-income versus high-income countries.  The death rate from respiratory infections is twice as high for people living in low income countries.

The second-highest cause of death among people in low-income countries is diarrhea.  Diarrhea kills between one million and two million people each year, including about 500,000 children under five years old.

These deaths would be easy to treat and even easier to prevent. 

Seriously, you can save these people’s lives with Gatorade!  (Among medical doctors, this is known as “oral rehydration therapy.”)  Or you could prevent them from getting sick in the first place by providing clean water to drink.

We could provide clean water to everyone – worldwide, every single person – for somewhere between ten billion and one hundred billion dollars.  Which might sound like a lot of money, but that is only one percent of the amount we’re spending on the Covid-19 stimulus bill in the United States.

We could do it.  We could save those millions of lives.  But we’re choosing to let those people die.

Because, you see, wealthy people rarely die of diarrhea.  Clean water is piped straight into our homes.  And if we do get sick – I have, when I’ve traveled – we can afford a few bottles of Gatorade.

Instead, wealthy people die of heart disease.  Stroke.  Alzheimer’s.  Cancer.

If you’re lucky enough to live past retirement age, your body will undergo immunosenescence.  This is unfortunate but unavoidable.  In old age, our immune systems stop protecting us from disease.

Age-related immunosenescence explains the high prevalence of cancer among elderly people.  All of our bodies develop cancerous cells all the time.  Usually, our immune systems kill these mutants before they have the chance to grow into tumors.

Age-related immunosenescence also explains why elderly people die from the adenoviruses and coronaviruses that cause common colds in children and pre-retirement-age adults.  Somebody with a functional immune system will get the sniffles, but if these viruses are set loose in a nursing home, they can cause systemic organ failure and death.


I haven’t seen this data presented yet – due to HIPAA protections, it can’t easily be collected – but Covid-19, on average, seems to kill wealthier people than influenza.

On a personal level, wealth will protect you from Covid-19.  We know that early treatment saves lives, which is a reason why Germany’s death rate is so low, and wealthy people are less likely to postpone going to the hospital.  Wealthy people can afford the medications that might keep you out of the ICU. Wealthy people are less likely to experience the stresses, sleep loss, and discrimination that have caused disproportionate numbers of Black people in the United States to succumb to Covid-19.

But on a population level, wealth is correlated with increased risk.

Part of this wealth gap is due to age.  Currently we don’t have enough data to know exactly where the risk curves for seasonal influenza and Covid-19 intersect, but it seems to be around retirement age.  If you’re younger than retirement age, seasonal influenza is more deadly.  If you’re older than retirement age, Covid-19 is more deadly.

And in the United States, if you’re older than retirement age, you’re more likely to be wealthy.

Covid-19 is also more dangerous if you’re already sick.  A study of Covid-19 deaths found that 97% of the people killed were already sick with at least one serious medical condition.  The average person killed by Covid-19 had 2.7 other serious diseases.

Because these people were receiving expensive medical care, they were able to survive despite their other diseases.  Imagine what would have happened if these people had chanced to be born in low-income countries: they would already be dead. 

This is a tragedy: all over the world, millions of people die from preventable causes, just because they had the bad luck of being born in a low-income country rather than a rich one.

We don’t have data on this yet, but it’s likely that Covid-19 will have a much smaller impact in Africa than in Europe or the United States.

When my father was doing rounds in a hospital in Malawi, his students would sometimes say, “We admitted an elderly patient with …”  And then my father would go into the room.  The patient would be 50 years old.

Covid-19 is particularly dangerous for people in their 80s and 90s.  Great privilege has allowed so many people in Europe and the United States to live until they reached these high-risk ages.


Our efforts to “flatten the curve,” in addition to increasing many people’s risk of death (from domestic violence, suicide, and the lifelong health repercussions of even a few months of sedentary living), will save relatively few lives, even among our country’s at-risk population.

The benefit of this shutdown is simply the difference between how many people would die if we did nothing, compared to how many people will die if we “flatten the curve.” 

Assuming that our efforts to flatten the curve succeed – and neglecting all the other risks of this strategy – we’ll be able to provide ventilation to everyone.  But there will still be a lot of deaths.  The shutdown will not have helped those people.  The shutdown is only beneficial for the small number who would be treated in one scenario, would not be treated in another, and who actually benefit from the treatment.

The Lancet reported that in the initial wave of the Covid-19 epidemic, 97% of patients receiving invasive ventilation died.  Later on, the death rate among people receiving ventilation was still over 80%

Their lives matter, too.  Many of us have a friend or relative whose life was cut short by this. But something that we have to accept is that we all die.  Our world would be horrible if people could live forever.  Due to immunosenescence, it becomes increasingly difficult to keep people alive after they reach their late 70s and 80s.

And the priorities of elderly people are different from mine.  I care deeply about the well-being of children and our planet’s future.  That’s why I write a column for our local newspaper discussing ways to ameliorate our personal contribution to climate change.  That’s why my family lives the way we do.

These priorities may be quite different from what’s in the short-term best interests of an 80-year-old.

Schools are closed.  Children are suffering.  Domestic violence is on the rise.  All to protect people who have experienced such exceptional privilege that they are now at high risk of dying from Covid-19.

Our national response to Covid-19 is being directed by a 79-year-old doctor.  I haven’t gotten to vote in the presidential primary yet, but if I get to vote at all, I’ll be allowed to choose whomever I prefer from a selection of a 77-year-old white man or a 78-year-old white man.  Then comes the presidential election, where there’ll be an additional 73-year-old white man to choose from.

It makes me wonder, what would our national response be like if we were facing a crisis as risky as Covid-19, but where elderly people were safe and children were most at risk?

And then I stop wondering.  Because we are facing a crisis like that. 

It’s climate change.

And we have done nothing.

On the moon landing, and who benefits if you believe it was faked.

On the moon landing, and who benefits if you believe it was faked.

If you’re worried that you don’t feel enough stress and anxiety, there’s an easy chemical fix for that.  Habitual methamphetamine use will instill intense paranoia. 

In our poetry classes in jail, I’ve talked with a lot of guys who stayed up for days watching UFO shows on TV.  A few were also stockpiling military grade weaponry. One man used strings and pulleys to link his shotgun’s trigger to a doorknob, ensuring that anyone who tried to enter the house would be rudely greeted. 

They’ve dismantled dozens of computers and phones: sometimes out of suspicion, sometimes because there are valuable components. Although they were rarely organized enough to hawk the proceeds of their dissections.

Suffice it to say that, deprived of sleep and dosed with powerful stimulants, their brains became tumultuous places.

Which is why we spend so much time talking about conspiracy theories.

I’ve written several previous essays about conspiracy theories – that the Santa myth teaches people to doubt expertise (children learn that a cabal of adults really was conspiring to delude them); that oil company executives have been conspiring to destroy the world; that, for all the ways Thomas Pynchon’s Gravity’s Rainbow probes at the undercurrents of truth beneath government conspiracy, the text blithely incorporates metaphors from a Disney-promulgated nature conspiracy.

But, with the fiftieth anniversary coming up, the men in my class have been talking more about whether the moon landing was faked.

There’s only so much I can say.  After all, I, personally, have never been to the moon. 

One of my colleagues from Stanford recently conducted molecular biology experiments on the International Space Station, but that’s only zero point one percent of the way to the moon … and she and I were never close enough for me to feel absolutely certain that she wouldn’t lie to me.

Visiting the moon does seem much easier than faking it, though.  Our government has tried to keep a lot of secrets, over the years.  Eventually, they were leaked.

But that line of reasoning is never going to sway somebody. The big leak might be coming soon.

Instead, the strategy that’s worked for me is to get people worried about another layer of conspiracy.

“Let’s just say, hypothetically,” I say, “that we did send people to the moon.  Why would somebody want to convince you, now, that we didn’t?”

When NASA’s project was announced, a lot of people were upset.  Civil rights activist Whitney Young said, “It will cost $35 billion to put two men on the moon.  It would take $10 billion to lift every poor person in this country above the official poverty standard this year.  Something is wrong somewhere.”  (I learned about this and the following quote from Jill Lepore’s excellent review of several new books about the moon landing.)

During John F. Kennedy’s presidential campaign, he argued that we needed to do it anyway.  Despite the challenge, despite the costs.  “We set sail on this new sea because there is new knowledge to be gained, and new rights to be won, and they must be won and used for the progress of all people.

We did reach the moon. But, did we use that knowledge to benefit the rights and progress of all people?  Not so much.

A lot of the guys in jail went to crummy schools.  They grew up surrounded by violence and trauma.  They didn’t eat enough as kids. They’ve never had good medical care.  They’ve struggled to gain traction in their dealings with government bureaucracies … we’ve spent years underfunding post offices, schools, the IRS, the DMV, and, surprise, surprise!, find that it’s arduous interacting with these skeletal agencies.

To keep these men complacent, the people in power would rather have them believe that we didn’t visit the moon.  “Eh, our government has never accomplished much, we faked that shit to hoodwink the Russians, no wonder this is a horrible place to live.”

The fact that people in power are maliciously undermining our country’s basic infrastructure would seem way worse if you realized that, 50 years ago, with comically slapdash technologies and computers more rudimentary than we now put into children’s toys, this same government sent people to the moon. 

Ronald Reagan said, “Government is not the solution to our problem; government is the problem.”  And he was in a position to make his words true – he was the government, so all he had to do was be incompetent.  And then people would hate the government even more, and become even more distrustful of anyone who claimed that good governance could improve the world.

Needless to say, 45 has taken strategic incompetence to a whole new stratosphere.  Beyond the stories of corruption that pepper the news, there’s also the fact that many appointments were never made; there are agencies that, as of July 2019, still don’t have anybody running them.  These agencies will perform worse.

If people knew how good our government used to be, they might revolt.  Better they believe the moon landing was a sham, that the faked photographs are as good as anybody ever got.

Our one and only.

On the Tower of Babel and beneficial curses.

On the Tower of Babel and beneficial curses.

In Jack Vance’s The Eyes of the Overworld, a bumbling anti-hero named Cugel the Clever is beset by one misfortune after another.  He attempts to burglarize a wizard’s palace but is caught in the act.  The wizard Iucounu forces Cugel to retrieve an ancient artifact – a seemingly suicidal quest.  To ensure that Cugel does not shirk his duties, Iucounu subjects him to the torments of Firx, a subcutaneous parasite who entwines searingly with nerve endings in Cugel’s abdomen, and whose desire to reuinte with his mate in Iucounu’s palace will spur Cugel ever onward.

Early in his journey, Cugel is chased by a gang of bandits.  He escapes into a crumbling fortress – only to find that the fortress is haunted.

eyesofthe.jpgThe ghost spoke: “Demolish this fort.  While stone joins stone I must stay, even while Earth grows cold and swings through darkness.”

          “Willingly,” croaked Cugel, “if it were not for those outside who seek my life.”

          “To the back of the hall is a passage.  Use stealth and strength, then do my behest.”

          “The fort is as good as razed,” declared Cugel fervently.  “But what circumstances bound you to so unremitting a post?”

          “They are forgotten; I remain.  Perform my charge, or I curse you with an everlasting tedium like my own!”

“Everlasting tedium” sounds like a raw deal, so Cugel figures he’d better slay his assailants and get to wrecking this haunted edifice.  He kills three bandits and mortally wounds the fourth with a boulder to the head:

Cugel came cautiously forward.  “Since you face death, tell me what you know of hidden treasure.”

          “I know of none,” said the bandit.  “Were there such you would be the last to learn, for you have killed me.”

          “This is no fault of mine,” said Cugel.  “You pursued me, not I you.  Why did you do so?”

          “To eat, to survive, though life and death are equally barren and I despise both equally.”

          Cugel reflected.  “In this case you need not resent my part in the transition which you now face.  The question regarding hidden valuables again becomes relevant.  Perhaps you have a final word on this matter?”

          “I have a final word.  I display my single treasure.”  The creature groped in its pouch and withdrew a round white pebble.  “This is the skull-stone of a grue, and at this moment trembles with force.  I use this force to curse you, to bring upon you the immediate onset of cankerous death.”

“Immediate onset of cankerous death” sounds grim.  Dude’s day has gone from bad to worse.

          Cugel hastily killed the bandit, then heaved a dismal sigh.  The night had brought only difficulty.  “Iucounu, if I survive, there shall be a reckoning indeed!”

          Cugel turned to examine the fort.  Certain of the stones would fall at a touch; others would require much more effort.  He might well not survive to perform the task.  What were the terms of the bandit’s curse?  “ – immediate onset of cankerous death.”  Sheer viciousness.  The ghost-king’s curse was no less oppressive: how had it gone?  “ – everlasting tedium.”

          Cugel rubbed his chin and nodded gravely.  Raising his voice, he called, “Lord ghost, I may not stay to do your bidding: I have killed the bandits and now I depart.  Farewell and may the eons pass with dispatch.”

          From the depths of the fort came a moan, and Cugel felt the pressure of the unknown.  “I activate my curse!” came a whisper to Cugel’s brain.

          Cugel strode quickly away to the southeast.  “Excellent; all is well.  The ‘everlasting tedium’ exactly countervenes the ‘immediate onset of death’ and I am left only with the ‘canker’ which, in the person of Firx, already afflicts me.  One must use his wits in dealing with maledictions.”

At times, one curse can save us from another.



In the biblical story of the Tower of Babel, humans are cursed for building a bridge to heaven.  Implicit in this story is the idea that humans nearly succeeded: our edifice of bricks and stone was threatening God.


In part, this story was written to disparage other religious beliefs.  In the beginning, Yahweh was worshiped by a small tribe of relatively powerless people, and so the Old Testament seems to be riddled with rebuttals (some of which I’ve discussed previously, here).  In From Gods to God (translated by Valerie Zakovitch), Avigdor Shinan and Yair Zakovitch write that:

fromgodstogodThe derivation of “Babel” from b-l-l seems to have originated as a response to the widely accepted Babylonian explanation of that place’s name, Bab-ilu, “God’s Gate,” or Bab I-lani, “Gate of the Gods” – a meaning that, we’ll soon see, was known in Israel.  Indeed, the story of the Tower of Babel in its entirety polemicizes against a Babylonian tradition according to which the tower-temple in Babylon, which was dedicated to the god Marduk, was built as a tribute both to him and to the belief that Babylon was the earthly passageway between heaven and earth.  According to ancient Babylonian belief, the tower in Babylon – Babel – was Heaven’s Gate.

It seems that the biblical writer, unwilling to accept that Babylon – a pagan city – was the entryway to heaven, found various ways to counter this Babylonian tradition that was well known in Israel.  First, he converted the story of the building into one of ultimate failure and human conceit.  At the same time, though, he introduced an alternative story about the gate to heaven.  This time the gate’s location was in Israel, the Land of One God.  This replacement story is found in Genesis 28: the story of Jacob’s dream.


The Bible succeeded in its propaganda campaign: by now the standard interpretation of the Tower of Babel is that humans approached the world with insufficient humility, we began a technological campaign that ultimately ended in failure, and Yahweh cursed us such that we could not cooperate well enough to attempt a similar project in the future.  Babel – Babylon – was not a passageway to heaven.  The gateway was never finished.  Because we’ve lost the ability to communicate with each other, it never will be finished.


The story of the Tower of Babel implies that all humans shared a single language before our brash undertaking.  The world’s current multitude of tongues were spawned by Yahweh’s curse.  But… what if languages are good?  What if we need diversity?

In 1940, Benjamin Lee Whorf speculated that the language we speak shapes the way we think.  His idea was egregiously overstated – creatures with no spoken language seem to be perfectly capable of thought, so there’s no reason to assume that humans who speak a language that lacks a certain word or verb tense can’t understand the underlying concepts.


But Whorf’s basic idea is reasonable.  It is probably easier to have thoughts that can be expressed in your language.

For example, the best language we’ve developed to discuss quantum mechanics is linear algebra; because Werner Heisenberg had only passing familiarity with this language, he had some misconceptions about the Heisenberg Uncertainty Principle.

Or there’s the case of my first Ph.D. advisor, who told me that he spent time working construction in Germany after high school.  He said that he spoke extremely poor German… but still, after he’d been in the country long enough, this was the language he reflexively thought in.  He said that he could feel his impoverished language lulling him into impoverished thought.

His language was probably more like a headwind than a cage – we constantly invent words as we struggle to express ourselves, so it’s clear that the lack of a word can’t prevent a thought – but he felt his mind to be steered all the same.

19537_27p1pWhorf’s theory of language is also a major motif in Elif Batuman’s The Idiot, in which the characters’ English-language miscommunication is partly attributed to their different linguistic upbringings.  The narrator is perpetually tentative: did her years speaking Turkish instill this in her?

I wrote a research paper about the Turkish suffix –mis.  I learned from a book about comparative linguistics that it was called the inferential or evidential tense, and that similar structures existed in the languages of Estonia and Tibet.  The Turkish inferential tense, I read, was used in various forms associated with oral transmission and hearsay: fairy tales, epics, jokes, and gossip.

… [-mis] was a curse, condemning you to the awareness that everything you said was potentially encroaching on someone else’s experience, that your own subjectivity was booby-trapped and set you up to have conflicting stories with others.  … There was no way to go through life, in Turkish or any other language, making only factual statements about direct observations.  You were forced to use -mis, just by the human condition – just by existing in relation to other people.

She felt cursed by the need to constantly consider why she held her beliefs.  And yet.  Wouldn’t we all be better off if more people considered the provenance of their beliefs?


Most languages have good features and bad.  English has its flaws – I wish it had a subjunctive tense – but I like that it isn’t as gendered as most European languages – which treat every object as either masculine or feminine – or Thai – in which men and women are expected to use different words to say a simple “thank you.”  Although Thai culture is in many ways more accepting of those who were born with the wrong genitalia than we are in the U.S., I imagine every “thank you” would be fraught for a kid striving to establish his or her authentic identity.

And, Turkish?  I know nothing about the language except what I learned from Batuman’s novel.  So I’d never argue that speaking Turkish gives people a better view of the world.

But I think that our world as a whole is made better by hosting a diversity of perspectives.  Perhaps no language is better than any other … but, if different languages allow for different ways of thinking … then a world with several languages seems better than a world with only one.

tongueofadamThis is the central idea explored by Abdelfattah Kilito in his recent essay, The Tongue of Adam (translated by Robyn Creswell).  After an acquaintance was dismissive of the Moroccan Kilito after he composed an academic text in Arabic instead of French, he meditated on the value of different languages and the benefits of living in a world with many.

Here is Kilito’s description of the curse Yahweh used to stop humans from completing the Tower of Babel:

After Babel, men cannot seek to rival God as they seemed to do when they began building the tower.  They cannot, because they’ve lost the original language.  God’s confusion of tongues ensures his supremacy.  The idea may seem odd, but consider the story of Babel as we find it in Genesis: “And they said, Go to, let us build us a city and a tower, whose top may reach unto heaven; and let us make us a name, lest we be scattered abroad upon the face of the whole earth” [11:4].  A tower whose top would touch the heavens: taken literally, the expression suggests a desire to reach the sky, to become like gods.  A rather worrisome project: “And the Lord came down to see the city and the tower, which the children of men builded” [11:5].  Man’s attempt to rise up is answered by the Lord’s descent: “Go to, let us go down, and there confound their language, that they may not understand one another’s speech” [11:7].  God does not destroy the work.  He punishes men by confounding their language, the only language, the one that unites them.  For Yahweh, the root of the menace is this tongue, which gives men tremendous power in their striving toward a single goal, an assault on the heavens.  The confusion of tongues brings this work to a stop; it is a symbolic demolition, the end of mankind’s hopes and dreams.  Deprived of its original language, mankind breaks into groups and scatters across the surface of the earth.  With its route to the heavens cut off, mankind turns its eyes to the horizon.

And here is Kilito’s description of this same dispersal as a blessing:

The expression, “the diversity of your languages,” in [Genesis 30:22, which states that “Among His wonders is the creation of the heavens and the earth, and the diversity of your languages and colors.  In these are signs for mankind”], means not only the diversity of spoken tongues, but also, according to some commentators, the diversity of articulated sounds and pronunciation of words.  Voice, like the color of the skin, varies from one individual to the next.  This is a divine gift.  Otherwise, ambiguity, disorder, and misunderstanding would reign. … Plurality and heterogeneity are the conditions of knowledge.

Kilito endorses Whorf’s theory of language.  Here is his analysis of the birth of Arabic as told in the Quran:

According to Jumahi, “Ismael is the first to have forgotten the language of his father.” This rupture in language must have been brutal: in a blinding instant, one language is erased and cedes its place to another.  According to Jahiz, Ismael acquired Arabic without having to learn it.  And because the ancient language disappeared without a trace, he had no trouble expressing himself in the new one.  This alteration, due to divine intervention, also affected his character and his nature, in such a way that his whole personality changed.

His personality is changed because his language is changed: new words meant a new way of thinking, a new way of seeing the world.  If humans had not built the Tower of Babel – if we had never been cursed – we would share a single perspective… an ideological monoculture like a whole world paved over with strip mall after strip mall … the same four buildings, over and over … Starbucks, McDonalds, Walmart, CAFO … Starbucks, McDonalds …


The current occupancy of the White House … and congress … and the U.S. Supreme Court … seems a curse.  The health care proposals will allow outrageous medical debt to wreck a lot of people’s lives, and each of us has only a single life to live.  Those who complete their educations in the midst of the impending recession will have lifelong earnings far lower than those who chance to graduate during boom years.  Our vitriolic attorney general will devastate entire communities by demanding that children and parents and neighbors and friends be buried alive for low-level, non-violent criminal offenses.  Innocent kids whose parents are needlessly yanked away will suffer for the entirety of their lives.

I can’t blithely compare this plague to fantasy tales in the Bible.  Real people are going to suffer egregiously.

At the same time, I do think that kind-hearted citizens of the United States needed to be saved from our own complacency.  Two political parties dominate discourse in this country – since the Clinton years, these parties have espoused very similar economic and punitive policies.  I have real sympathy for voters who couldn’t bear to vote for another Clinton in the last election because they’d seen their families steadily decline in a nation helmed by smug elitists.

Worse, all through the Obama years, huge numbers of people deplored our world’s problems – widespread ignorance, mediocre public education, ever-more-precarious climate destabilization, an unfair mental toll exacted on marginalized communities – without doing anything about it.  Some gave money, but few people – or so it seemed to me – saw those flaws as a demand to change their lives.

Climate-Change-Top-PhotoAnyone who cares deeply about climate change can choose to eat plants, drive less, drive a smaller car, buy used, and simply buy less.  Anyone embarrassed by the quality of education available in this country… can teach.  We can find those who need care, and care for them.

After the 45th stepped into office – or so it has seemed to me – more people realized that change, and hope, and whatnot … falls to us.  Our choices, as individuals, make the world.  I’ve seen more people choosing to be better, and for that I am grateful.

Obviously, I wish it hadn’t come to this.  But complacency is a curse.  Sometimes we need new curses to countervene another.

On AIDS and drought in Malawi.

On AIDS and drought in Malawi.

Nobody wants to be bitten by a wild animal.  Even my former housemate, who is exceedingly likely to wrestle raccoons or be chased up a tree by a flock of angry turkeys each time she visits her ancestral home, would prefer not to be bitten.  But let’s say you slip up.  Make a wrong move and let some critter sink its teeth into your wrist.  In the United States, there are limited consequences to your mistake.raccoon.JPG

Maybe you’ve heard that the rabies vaccine is scary, but it’s not so bad.  A series of four; none hurt; none made me feel sore.  It did hurt when the nurse injected human-anti-rabies immune serum directly into my wound.  I began a long, loud diatribe – I know this is for the best, and I know that it hurting is not your fault, but I am decidedly unhappy right now – that went on for the entire twenty minutes it took for the nurse to inject ten milliliters.  All the children screaming in the ER at four a.m. sudden became very quiet; because the hospital was overcrowded that night, I was on a gurney just outside their ward.

Still, I didn’t suffer much.  By five thirty I was home, snoozing contentedly.

I’m not saying that health care in the United States is great.  I was a graduate student at Stanford.  We had fancy coverage.  I could drop by a fantastic hospital for free.  Others are less lucky.  People go broke from medical bills in this country.

I am saying that health care in the United States is pretty great compared to the standard fare on offer in Malawi.

malawiMalawi is a very poor country.  We – meaning not you & I personally, but rather the people who engendered the prosperity of the United States, from whom the contemporary beneficiaries inherited both wealth and blame – are responsible for the poverty of Malawi.  Throughout Africa, resources were plundered.  Europeans brought horrific violence to the continent.  And, because wealth begets wealth, the repercussions of these sins have grown more severe over time.  Unless there is a conscious effort to repair past economic wrongs, they won’t vanish on their own.

This same principle underpins lingering individual inequality in the United States.  Some wounds, time does not heal.  A rising tide only lifts those comfortably ensconced in boats.  The world’s plundered nations are still struggling, sinking farther and farther behind.

In addition to dire economic circumstances, Malawi has been ravaged by an HIV epidemic.  Ten percent of the population, approximately 1 million people, are living with HIV.  30,000 or more die of HIV-related illnesses each year.  This public health crisis is tragically self-perpetuating.  Poverty exacerbates epidemics by reducing access to medication and pushing people toward riskier lifestyles.  And then it’s hard to escape poverty since young people are dying daily and huge numbers of children are orphaned by disease.

In the United States, we often discuss the curtailed economic prospects for children raised in single-parent households.  Those children have it hard.  Now picture all the Malawian children in zero-parent households.

My father, who has worked with sick patients in HIV clinics in the United States for many years, is now practicing medicine in Malawi.  It’s grim.  For instance, the reason I began this piece with a description of rabies vaccination?  Those vaccines are not available in Malawi.  Instead of four relatively painless shots, those who get bit face death.

After four decades of practice as an infectious disease doctor, my father has obviously seen patients die.  But a sign like the one below is new for him.

image1 (1).JPG

“Dying from rabies is a terrifying experience for both the patient and their relatives,” it says, before admonishing, “Don’t forget to ask about spiritual needs!”  Nothing drives home privilege like the thought that someone else’s son would die from the sort of bite that simply sent your own to a hospital for a late night.

It feels even worse knowing that his doctoring – and my sister’s, who will be traveling to Malawi with her newborn child to practice pediatric medicine starting this fall – is a meager staunch against whelming calamity.  People are dying now.  They can’t make effective long-term plans when the short-term outlook is so bleak.

And yet.  Poverty there is so deep, and infrastructure so quickly deteriorating, that many people have been chopping down the country’s few remaining forests to produce charcoal.  For many, charcoal production is the only source of income.  For others, in circumstances only slightly less dire, it’s necessary to buy charcoal to weather the frequent blackouts.  Even those responsible for protecting the forests buy illegal charcoal.  There’s no winning.

Without the forests, there will be drought.  When the drought comes, people will starve.  Climate change – caused primarily by the nations responsible for plundering our world’s currently-impoverished nations, yet which will beleaguer those plundered nations first – will exacerbate this problem.  New tragedies are coming.

I’ve obviously benefited from the prosperity of the United States.  I have a computer.  I have access to the internet.  When I turn the tap, there is clean water.  When I flick a switch, the room is instantly (and always!) illuminated.

But this means that the blame for the current plight of our world’s plundered nations – which brought my prosperity – falls on me, too.  I’m glad that my family members are doing what they can to help.  I wish it were enough.

On medical spending.

On medical spending.

Trepanation_-_feldbuch-der_wundartzneyBack when doctors were curing headaches by drilling holes through people’s skulls, or slapping on a few leeches to drain out the bad blood when sick patients came stumbling through the door, medical spending wasn’t a big deal.  There weren’t any serious political considerations attached.  If you were wealthy, you might visit a doctor and get yourself killed.  If you were poor, you’d probably go without medical care.  You’d live or die according to the virulence of your disease and the quality of your diet.  Maybe you’d buy a small amulet representing one of the healing saints, or pay a witch to bury herbs in an auspicious location near your house.

I haven’t done an extensive review of the historical data, but to the best of my knowledge no ancient kingdoms were bankrupted trying to provide leeches to all their sick citizens.

Now, though, the situation is different.  Medical care is better.  Doctors know enough that patients receiving care fare significantly better than those left untreated.

There are dramatic economic consequences of improved medical care, though.  Leeches and bloodletting and trapanation were ineffectual, but they were cheap.  Modern medical care actually saves people’s lives, but it comes at a huge cost.  In the United States, health care spending is about a fifth of the total economy, and rising.


Albrecht_Dürer_-_Death_and_the_Lansquenet_(NGA_1943.3.3611)Death is scary.  For people who started learning philosophy with Camus (which is not something I’d recommend — this can result in an excessively bleak world view and is probably appropriate only for incurable depressives), inescapable death seems to be the major quandary in our attempt to ascribe meaning to life.

The fear of death fuels medical spending.  Also our spending on biomedical research.  Medical care is pretty great currently, especially if you’re comparing statins and anti-retrovirals and insulin to leeches.  But people still die.  We haven’t reached the singularity yet (thank goodness).

Leeching-largeBiomedical research spending makes the population as a whole sicker, though.  Most research innovations — and certainly the most lucrative ones — are for managing chronic conditions, not curing them.  People who would’ve died — how many leeches do we prescribe for atrial fibrillation? — survive instead, lowering our population’s average health.  And raises average age, since those first few maladies aren’t killing people as often.

It’s not so difficult to imagine that, if these biomedical research trends continue, people might survive until a hundred and fifty, maybe two hundred years old … and health care spending will rise until it’s a third of the U.S. economy, or fifty percent, or more.

That could doom the country.

But the real tragedy, to my mind, is the way that health care money is being spent.

9781250044631I think a passage from Damon Tweedy’s Black Man in a White Coat gives an elegant summary of the problem.  The whole book is great — I’d highly recommend it to anyone who cares about either racial inequality or the U.S. medical industry.  Tweedy’s writing is so compassionate, always looking to describe the best in people even when his narrative compels him to shown them at their worst.

The passage I want to quote appears just after Tweedy describes a preventable medical tragedy brought on by poor lifestyle choices.  Tweedy grabs a hasty meal with some of his colleagues and is still mulling over what more could’ve been done to help the patient.  Ironically, this leads to a conversation about counseling patients to eat better, but Tweedy and the other doctors are scarfing extremely unhealthful meals.

It really is a great book — big-hearted and earnest, with Tweedy always clear-eyed about his own failings.  His descriptions of his own struggles with poor lifestyle choices really dramatize his efforts to address other black men’s unhealthy lifestyles.

(Oh, and, I fixed a minor typographical error in the following quote without marking it — I always think  sic erat scriptum sounds snarky, and Tweedy’s book was good enough that I’d feel like a total jerk if I made him look bad for what was probably someone else’s mistake.)

Medical doctors should know better than to eat hospiteria (hospital cafeteria) pizza.

I asked them their thoughts on counseling patients about nutrition and exercise.

“That’s the responsibility of his outpatient primary care doctor,” he said.  “We’re here to deal with the life-and-death stuff.”

This focus on biomedical treatment over preventative care is not limited to Duke or similar schools.  Indeed, outpatient primary care physicians — the doctors that Mike felt bore the responsibility for counseling patients on diet and exercise — are often no more inclined than other doctors to have this discussion, even for diseases where these interventions are vital.  There are many barriers, among them money (dietary counseling is reimbursed poorly compared to medical procedures), time (physicians often see patients every ten or fifteen minutes), and the sense that nutrition talk is better left to dieticians, and that doctors should focus on their expertise (prescribing medications, interpreting tests, and performing procedures).  In addition, experience has made many doctors cynical about patient behavior and the likelihood for change.

The tragedy of U.S. health care spending isn’t just that we shovel too much money into it, which limits what we can spend on other, more important causes, but also that we pour huge sums of money into end-stage therapies that don’t increase quality of life nearly as much as cheaper, earlier interventions.

My father-in-law’s treatment is a great example.  By the end of his life, the federal government was spending hundreds of thousands on his care.  Medication for cholesterol and diabetes, high-tech surgery to replace arteries & restore nervous function in his hands after they’d been numbed by diabetic neuropathy, installing an internal defibrillator once his heart began to fail…

Those treatments helped.  Sure.  They kept him alive longer.  He was incredibly happy after the hand surgery — for months he’d been unable to play guitar because he couldn’t feel anything and could barely exert enough pressure to fret the strings, and after that surgery he could play again, invited everyone he knew for another potluck & jam session.

When K dropped her father off after that surgery, she realized our government’s medical spending on him was actually helping dozens of people — all his neighbors were outside waiting to greet him, and once he could use his hands well enough to cook again he resumed baking loaf after loaf of sourdough bread to give to them.

I couldn’t find an image of any breads that look quite as dense as the whole-wheat loaves Mike used to bake for everyone, but David Jackmanson‘s seems close.

At the same time, our government could’ve brought K’s father — and everyone he helped — more joy by helping him earlier.  They spent nothing on him until his untreated conditions left him too disabled to work.  Only then, and even more so after he reached sixty-five, could he get help.

It’s crummy knowing that he would’ve been happier, and would’ve been able to give more back to his community, if he’d been helped earlier.  His childhood was rotten, but nothing was spent to overcome the scars left from hostile parenting.  Our government didn’t help him get counseling after a traumatic event in his early adulthood, either, and that was the root of so many of his later problems.  A few thousand spent to help him then could’ve kept him from becoming indigent. A few thousand spent on psychiatric counseling then would’ve staved off the need for the hundreds of thousands in medical care that were provided later.

This bizarre state of spending priorities is reflected very clearly in our federal budget.  For instance, there’s no money set aside for universal pre-K education.  This would only cost on the order of $10 billion dollars, though, whereas we spend something like $500 billion on health care for the elderly.  But if our goal is to produce good health, childhood education accomplishes much more than surgery and pharmaceuticals for the elderly.

As Tweedy wrote, simply teaching people to eat better would obviate the need for a significant percentage of our medical spending.  Maybe we’d need to spend some money subsidizing real food so that a better diet was within more people’s reach, but, still… that’s much cheaper than the life-and-death medical care that Tweedy was trained to provide.

After an education worth some hundred thousand dollars, after two decades of hard work & studying on his part, Tweedy served as part of a care team working arduous thirty-hour shifts … all to save people who might’ve stayed away from the hospital entirely if they’d been eating vegetables.