October 2, 2021

700,000 – that’s the number of American deaths from Covid since the beginning of the pandemic. That’s roughly equivalent to the population of Boston or Washington DC. It’s also about the same number as American deaths from HIV (just a bit over 714,000). HIV took forty years to hit that number. Covid has done it in just over 18 months. The death toll has been pretty steady over the last week or so as those sickened by the Delta wave in August are in the midst of their inevitable die off. There are still plenty of critically ill in the hospital. Even though the admission numbers on a whole are trending downwards (fortunately), the ICU numbers remain shockingly high, and mainly previously young and health people. A number of states – Alaska, Idaho, the Dakotas – continue to have maxed out their ability to care for the seriously ill and are working under various sorts of triage and rationing of care. It’s just not possible to be all things to all comers in the situation we currently find ourselves.

Someone much more intelligent than I once said of health care that it can be inexpensive, it can be universal and it can be of high quality – but it can only be two of those things at any one time. No one has yet invented a system that can deliver all three simultaneously. At the moment, given the stresses of the coronavirus, a lot of our health care is having difficulties even delivering one of these things at a time and I don’t foresee that getting a whole lot better in the near future. Eighteen months of societal stress, toxic work environments, emphasis on payment over people, bad behavior by the general public, and a host of other factors, large and small, has ground down the human capital of our system. Nurses are leaving their jobs in droves, some to do other things, some to take advantage of the enormous salaries being offered by temp staffing agencies in providing qualified bodies to desperate hospital systems. I’ve heard of travel nurses making roughly double what I make with assignments to Covid wards – and I don’t begrudge them a penny. I had my annual review this week with UAB (relax, I have a job for another year, my twenty-fourth with them) but my big comment was what is UAB going to do to help me not to choose early retirement as my best option in life. Something for both me and my powers that be to think upon.

I did a couple of Zoom book club meetings this week about The Accidental Plague Diaries, one with a civic group and one with a UAB audience. The most interesting question I got was where do I stand with the idea that the willfully unvaccinated be refused treatment for complications of Covid infection. That got me thinking about medical ethics and what I truly believe. Everyone knows about physicians and the Hippocratic oath. Most US medical schools no longer use it, as it’s something over 2500 years old and has a lot of odd things in it that probably made sense to the Ancient Greeks but which don’t really apply these days such as not having sex with the maids when making a house call and prohibiting surgery. At my graduation ceremony from medical school, we used something called The Physician’s Oath which is similar in spirit, even if it doesn’t have quite the same storied tradition. Med schools these days make a lot more pomp and circumstance about such things than they did back when I was in training. There is now a ‘White Coat Ceremony’ for entering medical students where they are given their white coats and swear to uphold medical ethics. My white coat ceremony was going to the bookstore, grabbing the right size off the rack, and being told ‘That’ll be $17.95’ by a bored cashier.

There is significant symbolism in the white coat. It’s the ceremonial robe that reminds everyone that we are descended from the priesthood, interceding with the gods for a favorable outcome in the eternal battle between health and disease. And, just like with priests, there is a sacred bond between the intercessor and he or she who seeks help. We are told things that people do not share with anyone else. We’re regarded as a safe space for unburdening of feelings, emotions, unanswerable questions. In the ideal world, the healer and patient become a dyad that together can find a path forward. The healer becomes the advocate for the patient on the journey and is answerable to no one and nothing but the needs of the patient. But we don’t live in an ideal world. In the American system, there are multiple layers of entities inserting their tentacles into that bubble. Financial, quality assurance, legal, clerical – the list goes on. It’s easy to lose one’s way. It still boils down to the fact that the physician is responsible to the patient – the one sitting in front of him/her at any given time and ethically the healer is bound to put the needs of that patient above all other considerations. Therefore, the willfully unvaccinated are as deserving of treatment as the smoker with lung cancer, the overweight with diabetes, the rock climber with a broken arm. We cannot make judgement calls on the circumstances that bring patients to us, we only look forward, not back.

The argument then becomes, what about the costs to society of these choices? Society has every right to impose whatever rules they see fit on people over these costs and that’s happening. Surcharges on insurance, requirements for vaccination to continue employment etc. But those are not rules for a physician to employ within the dyad of care. If you’re my patient, I will do whatever I think is necessary to get you the treatment I think you need to restore health and function. I may run into brick walls imposed by the system or by society at large, but then it becomes my job to try to find a way over or under or around if I can. Sometimes I win, sometimes I don’t but I have to try. I suppose this particular tilting at windmills is what gives me my love for Don Quixote. My gift to myself from my recent vacation is a hand painted tile of him and Sancho Panza.

The costs to society run up by the willfully unvaccinated are now in the billions of dollars. Money spent on acute care hospitalization, money needed to care for orphaned children, money to help support those who have survived but who are not healthy enough to return to their previous lives. Society will continue to react to that. Some of that will be through the legal system with new laws and rules but most of it, I think, will come through the economic system as corporate interests of various stripes will seek to shield themselves from losses and liabilities. Where and how will it end and what will things look like six months or a year for now? I don’t know but I imagine it’s going to be harder and harder for the willfully unvaccinated to access public transportation or venues of public accommodation. I read somewhere that a significant portion of these individuals would like to secede from the country. I wonder how their utopia would fare in a globalized world and economy without continued support from urban and coastal America? I imagine it would devolve into something akin to one of the poorer countries of sub-Saharan Africa within a decade.

It’s Saturday night. I should be out pitching the quick fantastic somewhere, but I’d rather stay curled up with the cats (one of whom leapt up on the dinner table and started lapping up my ranch dressing and had to be whacked on the butt) and a nice bottle of red wine. Be safe, be well, wash your hands, get your vaccines.