By George Duncan, MD
March 24, 2020
This week I joined the first multi-specialty team in our hospital specifically dedicated to patients with COVID-19 infection. The “tidal wave” analogy has now many echoes in the mainstream media. I was saying this too. It will be a “tidal wave.” We can see the “tidal wave” coming in from the horizon. We can feel the undertow. Indeed the last couple of weeks in the hospital were probably the most surreal, oddly poignant moments of a lifetime. And now we have our first patients at death’s door.
Before saying a few words about the hospital and the delivery system in general, some observations:
The poor have gotten so much poorer.
I love the indictment of income inequality in the Wilkinson and Pickett analysis. But poverty itself – and so many more are poor than wealthy – is killing us. The matter of the plutocracy almost seems separate, although obviously their wealth comes at the expense of the poor. Life expectancy is falling, not rising, in the United States.
Racism remains the axis of American culture and bourgeois politics.
The American Civil War marked a revolutionary step when it formally ended slavery, but the American Thermidor – the undoing of that revolutionary step – just won’t quit. The father of the President of the United States was Ku Klux Klan and vilified as a racist landlord in folk song lyrics by Woody Guthrie. His son has carried this into our present century – with an avid “base” of support. Meanwhile we feel the consequences of mass incarceration, police killings, racist zoning, job discrimination, myriad systematic racist policies, unrelenting daily injustice, harassment overt and covert, and simple humiliation – to name some of the evils that wend their way into my own daily life in a safety net hospital.
American society has become more anti-woman.
The “#MeToo” movement, with its exposure of private criminality of powerful public men, marks how far backward and debased our society has become. The organized counter-response to the 1960s and 70s feminist movement, from state policy to personal behavior, empowered an anti-woman era that I could never have imagined in my youth. Trump could be cited again as an emblem of hate and assault. In everyday life my young adult daughters expect that, if there is a certain type of gathering of people their age, rape will predictably occur. Jenny Brown, who wrote the best book of 2019, “Birth Strike,” explicates the class, race, and anti-woman connections of all of this, across countries and over time.
Once upon a time the health care delivery system could ameliorate these things to some degree – but the opposite is the case now. We might pause to remember that once people this country created not only great public hospitals but whole public healthcare delivery systems, including the Veteran’s Administration and the Indian Health Service. There was the mighty New York City Department of Health – well before, even, the days of Berton Roueche. I’m thinking for example of the 19th century inventions of the death certificate and the floating hospital. In the 20th century there was the desegregation of health care – and the great people who led it, many of whom I have had the privilege to know in the flesh.
But nowadays the health delivery system exacerbates inequalities of all kinds, from cash payments that discourage necessary care, an infrastructure that mirrors racist zoning laws – with health outcomes that reveal shocking racial “disparities,” – and blunt anti-woman work and health policies. Newsflash: Ohio, Texas, and Mississippi have just invoked the COVID-19 pandemic as an excuse to ban abortions.
On top of this, money interests organize every aspect of healthcare in the United States. Profit-seeking incentivizes myriad ways of withholding necessary care, with horrifying results, with outcomes that too-predictably manifest along the lines of the observations above. Speed-up and profitization within the delivery system introduces every type of rudeness, from sarcastic dismissal to callous shrug, making inhumanity and indignity routine in the act of care and care-giving – when kindness alone might have sufficed. And again, a lifetime in our country is getting shorter, not longer.
From these realities we now must turn to the fact that no one runs a hospital from the viewpoint of “surge capacity.” Administrators run the hospitals, non-profit as well as for-profit, like a just-in-time warehouse. They try to turn the beds over as quickly as possible, thanks to the perverse DRG system. Similarly, they turn the inventory of supplies over as quickly as possible (like toilet paper in the supermarket).
This is 21st century American health care. The main actors are the middlemen (inside and outside the hospital) who keep everything “just in time.” Shifting suddenly to another way of running the society and the hospital simply won’t happen. The doors of our health care delivery system will be blown off. Preventable deaths, foretold over recent weeks, will come.
All of the backward momentum wrought by the continuous health and social policy of a dying empire (Reagan-Bush-Clinton-Bush-Obama-Trump) set us up for this moment. The chickens are coming home to roost – remembering Malcolm X here – with terrible consequences for all of us, and even worse consequences for many, along the lines of the observations above.
The saving grace may be, simply, we caregivers ourselves – from the bedside to the public health community to those of genuine social consciousness of every walk of life.
Out of this crisis we need more than health justice for all, more than “everybody in, nobody out.” We need social solidarity in all of its forms, from person to person mutual aid to disaster socialism as state policy.
Raise your voices! Don’t mourn, organize!
George Duncan is the pen name of a physician in New York.
 The Spirit Level: Why More Equal Societies Almost Always Do Better, by Richard G. Wilkinson and Kate Pickett, 2009, Allen Lane.
 “Old Man Trump” by Woody Guthrie, 1954. Lyrics: woodyguthrie.org/Lyrics/Old_Man_Trump.htm
 Birth Strike: The Hidden Fight over Women’s Work, by Jenny Brown, PM Press, 2019.
 Berton Roueche was for 50 years the medical writer for the New Yorker, often describing the public service heroism of individuals in the New York City Department of Health and other public agencies.
 A DRG, or Diagnosis-Related Group, implemented under Reagan, is how Medicare and Medicaid and many health insurance companies categorize hospitalization costs to determine how much to pay for a patient’s hospital stay. Rather than paying the hospital for what it spent caring for a hospitalized patient, Medicare pays the hospital a fixed amount based on the patient’s DRG or diagnosis. If the hospital treats the patient while spending less than the DRG payment, it makes a profit. If the hospital spends more than the DRG payment treating the patient, it loses money. Critics of DRGs say this system of payments incentivizes skimping on quality of care while encouraging the discharge of patients too soon, while also incentivizing “upcoding” and fraud (billing for diagnoses the patient may not in fact have had).