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.

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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.

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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 produce a small benefit for 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.

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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 antiretroviral 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 antiretrovirals.

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.

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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 Albuterol inhaler 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.  I’ve made a rough sketch of the risk of death versus age for both Covid-19 and seasonal influenza.  Currently we don’t have enough data to know exactly where these risk curves 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.

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.

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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 hope is that we won’t exceed the capacity of our hospitals.  If someone’s condition deteriorates after a Covid-19 infection, they need invasive ventilation.

Please note that we can often prevent people’s condition from deteriorating by giving them Albuterol inhalers.  And these used to be so cheap!  In the early 2000s, you could buy an inhaler for about five dollars.  But pharmaceutical companies were allowed to re-patent these and the price has soared to nearly four hundred dollars.

Many news reports have included sensational numbers about how many people in their 30s and 40s have gone to the hospital for Covid-19.  These reports rarely mention that many of these hospitalizations could be prevented with a five dollar inhaler.

But we’re allowing drug companies to charge people four hundred dollars a pop for these now, which puts them out of reach for many people.

When I caught what I assume to be Covid-19, I took an inhaler.  I am very privileged.

Some young people can’t afford an inhaler, and many elderly people develop symptoms too severe to be treated with Albuterol, so they need care in an ICU.

But 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 now. 

In a recent essay, I gave an estimate for how many people would die if we’d done nothing.  New data suggests that my estimate was too low – the numbers out of Italy (where they did nothing until it was probably too late) suggest that around 80,000 people might have died in the United States.  Hospitals would have been overwhelmed, and some people whose condition required invasive ventilation would have been denied that treatment.

Even with the shutdown, though, we’re doing a crappy job.  Our numbers are pretty much guaranteed to be worse than Germany’s, which has a more equitable health care system overall and is testing enough people to track the spread of the disease and treat people early.  With this shutdown, all we’re hoping for is that the severe cases will be spread enough in time that everyone whose condition deteriorates to the point of needing invasive ventilation can have it.

Maybe.  The shutdown is so slapdash that hospitals in certain high-risk areas, like New York City, will still be overwhelmed.

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%

So we’d actually be saving only a fifth of the people who would have to be triaged if we’d exceeded our hospitals’ capacity to provide care.  This could be as few as 10,000 at-risk people.

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 70s or 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 a few thousand 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 Buddhism, suffering, and Deadpool.

On Buddhism, suffering, and Deadpool.

335px-The_Victory_of_Buddha.jpgSiddhartha was born into luxury.  Wealth wasn’t enough to banish a nagging sense of emptiness, but if Siddhartha hadn’t left the palace, he never would’ve known deprivation.

Instead, he walked.  He met people afflicted with worse ills than his own lack of purpose – bedraggled souls who were poor, and sick, and miserable.  He was horrified by the world we humans have been given.

Seeking a way to improve people’s lives, Siddhartha began to meditate.  He sat beneath a tree and cleared his mind until it effervesced with psychedelic hallucination.

The local gods feared that Siddhartha would gain enlightenment.  Like Yahweh in the Old Testament, these gods believed that knowledge should be the exclusive province of the divine; like white supremacists in the Jim Crow era, they believed that shared access to the fountain would tarnish their own privilege.  And so they sent a storm to disrupt Siddhartha’s concentration.

320px-Muchilinda_Buddha_from_Cambodia,_Angkor_kingdom,_Bayon_style,_12th_century,_sandstone,_HAALike Satan in the Old Testament, a snake came to help.  Mucalinda, a cobra-like naga king, believed in equality – humans too should have access to knowledge.  The cobra’s hood formed a protective bubble around Siddhartha, protecting him from the storm.

Siddhartha gained knowledge.  He now knew that non-attachment would free humans from suffering.  Everything in this world is impermanent – in the very end, each speck of matter will be so far from every other that the entire universe will be dark, empty, and cold – and so our attachments can only bring us pain.  We must recognize that our transitory world will always leave us unsatisfied.  Even our moments of joy will fade – those fleeting bursts of dopamine aren’t enough to sustain lasting happiness.

To be free of suffering, we have to let go.

But I’m an assistant coach for the local cross country team.  I run with the kids.  We suffer – that’s kind of the point.

Attachment brings suffering, but, again – that’s kind of the point.

My favorite superhero right now is Deadpool.  Most heroes have powers that keep them safe from harm – spider sense, super strength, telepathy.  Deadpool’s power is simply the willingness to endure harm.  As though tattooed with the word THOLE down his neck, Deadpool knows that life will hurt and sardonically accepts it.

He briefly considers non-attachment.  When he learns that he has a daughter, he plans to stay away from her.  Distance might keep her safe from Deadpool’s enemies – and would keep him safe from emotional turmoil.

Instead, he lets himself become attached.  He will suffer; so will she.  But he’s decided that the pain is part of life.

When Deadpool meets a young woman who’s so depressed that she’s contemplating suicide, he doesn’t advocate non-attachment.  It’s true that her torments will be temporary, but that’s a Buddhist consolation.  Instead, he tells a joke (he justifies his levity by claiming that his powers came when he was “bitten by a sad radioactive clown”) and takes her to experience more pain and suffering.

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Find the full story in Deadpool (2015) #21.

My own depression has seemed more manageable for similar reasons.  Since I’ve been working with people entrapped in the criminal justice system, I experience more pain.  More horrors are shared with me now.  But that very sharing connects me more clearly to the world.

Those connections – attachment – will bring suffering, but that’s the very stuff of life.  All you can do is endure.  As the chemist Primo Levi wrote in If This Is a Man, his account of time spent in a Holocaust concentration camp (translated by Stuart Woolf), as long as you can resist becoming too absorbed in your tiny experience of the present moment, there is always cause for hope:

It is lucky that it is not windy today.  Strange, how in some way one always has the impression of being fortunate, how some chance happening, perhaps infinitesimal, stops us crossing the threshold of despair and allows us to live.  It is raining, but it is not windy.  Or else, it is raining and is also windy: but you know that this evening it is your turn for the supplement of soup, so that even today you find the strength to reach the evening.  Or it is raining, windy, and you have the usual hunger, and then you think that if you really had to, if you really felt nothing in your heart but suffering and tedium – as sometimes happens, when you really seem to lie on the bottom – well, even in that case, at any moment you want you could always go and touch the electric wire-fence, or throw yourself under the shunting trains, and then it would stop raining.

You could always kill yourself later, Levi says, so why not see how much more you can bear?

And, yes, Deadpool takes the young woman to the hospital.  When one of my acquaintances needed to go, I took her in as well.  (I was on the phone with my father: “Just lie to her, tell her anything, but get her in.”  I keep the volume on my phone loud enough that she heard everything he said.  At least it was something to laugh about.)

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Hang in there.  The suffering won’t change.  But you might.

On citizenship.

On citizenship.

Syrian_refugees_having_rest_at_the_floor_of_Keleti_railway_station._Refugee_crisis._Budapest,_Hungary,_Central_Europe,_5_September_2015Without citizenship — without, as per Hannah Arendt, “the right to have rights” — people are buffeted by the political whims of whatever nation they might find themselves in.  Syrian refugees, for instance, might expect a certain treatment based on their status as humans, but they aren’t officially documented Europeans.  Even when they safely reach a supposed refuge, they’re excluded from finding their own employment or housing, they can’t travel freely, they might be deported at any moment.

Or the “Haitians” in the Dominican Republic who have never seen Haiti.  Or the “Mexican” children in the United States who have never consciously known Mexico.  Their fates seem to be totally out of their hands.

If they’re poor, that is.  A flush bank account would fix things.

Green_Card_nika_volekBefore reading Atossa Araxia Abrahamian’s The Cosmopolites, I already knew that citizenship was for sale.  The United States, for instance, will give green cards to people who make $500,000 investments in our country.  This seems a little unfair — we offer the very wealthy, who rarely need our help, protections that we deny refugees — but more egregious is how cheap this is.  Amidst burgeoning numbers of multimillionaires, $500,000 is not that much.  And this money doesn’t even change hands!  The United States just wants reassurance that somebody is well-off.  A $500,000 investment in real estate can bring high returns, meaning wealthy foreigners can be paid to take a green card.

3458184491_ca07847dab_oGiven that the mighty United States sells green cards, it wasn’t so surprising to learn from Abrahamian’s book that many poor nations are also selling “economic citizenship.”  Wealthy resource-plunderers from beleaguered developing nations can easily purchase a whole portfolio of other countries’ passports, which is very helpful to ease travel restrictions and facilitate money laundering.

Sounds great!

So the horrible abuses documented in The Cosmopolites often did not shock me.  But, given that I was born in the United States, a nation of vast privilege, I realized that I haven’t thought enough about the philosophical implications of citizenship.  As in, the very idea of citizenship.  The rights that (might) be granted to a new human by one nation or another at birth.

The basis for most modern nations is Rousseau’s idea of the social contract.  You, at birth, did not click a box asserting “I have read the terms and conditions and I agree.”  Instead, by remaining inside the borders of a nation, you are considered to be moment by moment assenting to those terms.  If you didn’t agree, you wouldn’t stay!

Once upon a time, this probably seemed sensible.  For those who felt unduly constrained by the laws and regulations of civilization, there were untamed wilds to slip away to.  And survive in.

Thoreaus_quote_near_his_cabin_site,_Walden_PondBy now, violent nations have staked claims everywhere.  Personally, I think Walden was suspect even when it was first written — there are a few quibbles you could make about Thoreau’s integrity  — but imagine how long you’d last if you decided today to waltz out to Walden Pond and build yourself a home.  You’d be forcibly escorted away by the police long before you’d chopped enough tall arrowy white pines (still in their youth) to build anything of merit.

Rousseau’s formulation of the social contract requires there be a viable way to leave.  Without that option, I think his philosophies break down.  Worse — and this is what I was most alarmed to learn from Abrahamian’s book — many people are not awarded citizenship to any nation at birth.  They are not allowed to live anywhere.

Large populations of citizenship-less people live in Kuwait and the U.A.E.  But it seems that these nations are attempting to solve their citizenship crisis, not by documenting all their ancestral inhabitants as Kuwati, for instance, but by purchasing other nations’ citizenship for these people.  Their hope is to staunch international criticism without actually conferring meaningful rights to their ancestral inhabitants.

This is yet another demonstration that the very act of being born is a ridiculously uneven lottery.  I don’t think human life begins at conception, but inequality begins then.  I thought this was well-stated in a passage from Robert Reich’s Saving Capitalism:

Reich_SavingCapitalism_Book_v3One of the most broadly held assumptions about the economy is that individuals are rewarded in direct proportion to their efforts and abilities — that our society is a meritocracy.  But a moment’s thought reveals many factors other than individual merit that play a role in determining earnings — financial inheritance, personal connections, discrimination in favor of or against someone because of how they look, luck, marriage, and, perhaps most significantly, the society one inhabits.  “If we are very generous with ourselves,” economist Herbert Simon once said, “I suppose we might claim that we ‘earned’ as much as one fifth of [our income].  The rest is the patrimony associated with being a member of an enormously productive social system.”

I owe a huge amount of my current comfort to the fact that I was conceived to American citizens.

In addition to those born without citizenship, Abrahamian got me thinking more about the plight of those whose citizenship evaporates.  It’s reasonable to include Syrian refugees here.  Climate change led to food & water insecurity, which led to horrific violence, which left these people effectively without a country.  They no longer had a safe place to live.

Others will soon see their home countries simply vanish off the map.  In Abrahamian’s words:

Largo,_FL_street_flooding_during_TS_Debby,_June_2012          Over the next few decades, entire nations will likely be submerged by rising seawater.  The need for binding international cooperation to curb climate change is critical, but on the ground, the question is existential.  Where will Maldivians be “from” if they lose the ground beneath their feet?  Will a new Nansen [ he was a politician who helped provide documents for displaced persons after WW2] step in and create passports for climate refuges?  Or will those displaced by the deluge end up bidding for a new nationality on the open market?

          These are the stakes of citizenship in the twenty-first century.

So I was quite pleased to read The Cosmopolites.  Which made me feel puzzled by Richard Bellamy’s negative review in the New York Times.  His complaints were based on rather illogical reasoning.  He wrote that:

Neither of these types of citizenship [the “unearned windfall of oil and gas revenues” that come with U.A. E. citizenship, and the multiple citizens purchases by ultra-rich robber barons] corresponds to the hard-won forms of citizenship found within democratic states.

          Herein lies the weakness of Abrahamian’s analysis.  The political and social rights of genuine, state-based citizenship derive from the contribution members make to sustaining the public life of the community, …

… which is why he found her idea of global citizenship unworkable.  The problem being that the social rights of genuine, state-based citizenship do not derive from any contribution whatsoever.  I am a citizen of the United States.  I earned this privilege by being born.  I mean, sure, I’m great, maybe angels should’ve flown down and trumpeted my coming, but, really?

I’m not convinced that the contribution I made to this nation by being born is more significant that the contributions of our many undocumented immigrants who pay social security taxes (with no hope of ever receiving benefits), do hard work, live peaceably, spend money here, remit huge portions of their earnings (which keeps neighboring countries more stable, lowering the amount that the federal government would need to spend on humanitarian aid or border control).  And yet, despite the magnitude of their contributions, all those people have “earned” in the eyes of the powers that be is deportation.

To my mind, Bellamy’s claim seems highly reminiscent of that barbecue t-shirt slogan “I didn’t claw my way to the top of the food chain to eat vegetables.”  Because, sure, once upon a time, people in your ancestry might’ve suffered.  Democratic governance was hard-won … many generations ago.  Most modern people didn’t do anything.  They were born.

Indeed, that misconception — mistaking for just deserts all the privileges heaped upon oneself for the significant accomplishment of being born in a particular place, or to particular parents, or with a particular skin color, or a particular set of genitalia — is precisely what both Robert Reich and Atossa Araxia Abrahamian are arguing against in their books.