April 10, 2020
Dear Interested Readers,
COVID-19 Is A Stress Test For Our Country
For over forty years I used stress tests to help me solve clinical problems and judge the capacity of my patient to respond to a physical stress. Over the years, I performed thousands of those tests, but the most interesting observation I ever made occurred in 1974 when I first began to do stress tests as a fellow in cardiology. In 1974 there were no angioplasties or stents. We had two ways of treating coronary disease, bypass surgery with vein grafts, and medical management. I learned to use stress tests three ways. Stress testing helped me decide if a complaint of chest pain or some other symptom was an indication of coronary artery disease. The tests were also an objective measurement of a patient’s response to treatment or a measurement of fitness before treatment that was much more reliable than asking, “How are you feeling.” Finally, the tests were a good way to discover if a patient was vulnerable to an unexpected event.
I was a fellow in cardiology at the Peter Bent Brigham Hospital in 1974. One of my mentors was Dr. Peter F. Cohn. At the time patients who were to undergo diagnostic cardiac catheterizations were admitted for five days. There was a lot of wasted time. On the first day nothing much happened. The house staff took their histories and did their physical exams. On the second day there was non invasive testing. Echocardiography was nothing like it is now. The images were essentially blips on a screen that were not yet organized into anything that looked like a heart. We were still doing Master’s Two Step exercise tests as well as using some early treadmill testing. We did tests that are rarely done now like phonocardiograms. Almost all of the patients were involved in some sort of research protocol. On the third day the patient had their catheterization, which was usually associated with extensive hemodynamics before the angiography was done. The day after the catherization the patient was observed before discharge on the fifth day. Rarely based on the outcome of the cath, surgery was done as an emergency before discharge, but the routine was to return for elective surgery if surgery was indicated.
Dr. Cohn and I began to talk about the fact that a certain percentage of patients would have a “positive” stress test as judged by the ischemic changes on their EKG and the subsequent angiographic study, but they had no associated angina. We discovered in the literature that a certain number of pilots who had to have stress tests to maintain their flight status had also been found to have “positive stress tests” without symptoms. To regain flight status they had angiographic studies to prove that they were fit to fly. Some of them were found to have coronary disease even though they had no symptoms.
We presented our findings at the annual meeting of the American Heart Association and published the findings in the American Journal of Cardiology. “Silent Ischemia” remained a research interest for Dr. Cohn Cohn for the rest of his academic career. I went on to a career in practice, and always valued the objective results of a stress test without reference to whether or not the patient had angina. It made sense given the fact that the first symptom many heart patients have is their heart attack. For some it was their first and last symptom. Our analogy was that these patients had a “defective” anginal warning system and were at risk of a heart attack or death because they had no warning that they had a problem. They were like a car with no gas gauge, like an old Volkswagen beetle, but without an auxiliary tank.
It occurred to me recently that the coronavirus has been a stress test for us as a nation. Like many of the patients we tested at the Brigham so many years ago, this test has demonstrated that we had problems we had not appreciated, or if we appreciated them, we had not adequately dealt with them. We see denial in patients. Why not imagine denial at the national level? The coronavirus has stressed us individually and collectively. It has revealed vulnerabilities in personal relationships. It has demonstrated the vulnerability of many businesses. It has uncovered how close to physical and financial distress many people are who appear to be healthy and secure. These individual and collective vulnerabilities existed before we were stressed by the virus, but now as we struggle to conform to harsh demands of our collective “treatment” we can no longer deny or hide our vulnerabilities.
I was not in practice long before I stopped asking patients whether or not they had chest pain. What was the point since some had intense denial and others just honestly had no symptoms? What I did as an alternative was to talk to them about what they could do. I tried to use questions to get a picture of their functional capacity. I always expected a little inflation to the answer of that question. If the answer was, “I take a long walk almost every day,” I would ask about the terrain and pace. The best question was to ask for a comparison to what they were doing last year. It became clear that many patients had no symptoms because they were living in a “collapsing world” where they did less and less. Sometimes the discovery was pretty mundane. I would learn that my patient had decided to get a lawn service rather than mow his yard as he had done for the last thirty years. “Why?” The answer was “Doc, I don’t know; maybe I just did not want to waste my energy.” The follow up to that question was often a strongly positive stress test and a cath that revealed significant coronary disease. I felt it was my professional responsibility to prove that there really was not a problem. To just ask, “How are you doing” when there was reason to suspect a potential problem, and not pursue the issue to see if there was objective proof that all was really well seemed like an abrogation or neglect of my responsibility.
As a nation we have not been always been asking the right questions, and when the right questions have been asked, or an event has revealed a vulnerability, we have denied or ignored its existence. Like many of the patients I first met in the coronary ICU after their first heart attack, we have been denying some significant problems for a long time, and we have been getting by. We have told ourselves that everything was fine because the stock market was higher than ever and unemployment was lower than ever. It was a “faux prosperity” that allowed us to ignore, or delay acting on, the fact that significant numbers of our citizens were living very difficult existences where the edge of disaster was always just around the next corner.
I don’t need to review all the facts and clues, and it would be unlikely to be beneficial because Bernie Sanders has been doing it for over thirty years and look at what that has gotten him. Bernie long ago pointed out our need for universal healthcare at a cost that ordinary people could afford. For over thirty years he consistently pointed out that if we want a glorious future it needs to be built on the competencies that come from educating everyone to their full potential without smothering them in debts that preclude future opportunities. He has always believed that people who worked hard deserved a living wage. He advocated protecting the environment because we only have one home, and it behoves all of us to share in its protection. Perhaps he sealed his own fate by attacking a status quo that supports the fact that less than 1% or the population has more resources and comfort than the lower 80% of all Americans. Almost all of Bernie’s complaints could be reduced to the accusation that inequality was the shaky operating principle that enabled our “success” and that “security” was a delusion limited to a minority of the population.
It was easy for Bernie to be discounted as a nut or as a socialist. It is not so easy to look at what the coronavirus has revealed and say that he was all wrong. Over the last forty years we have taken many stress tests that we have failed. One of the most recent wake up calls was Katrina. We have just shrugged our shoulders at the data that reveals gun violence is a public health problem. We have noted that our life expectancy is a function of where we live and have said, “That’s interesting,” but nothing has changed. We have documented that we have an opioid problem, but we don’t commit the resources necessary to ameliorate or even fully understand the problem. We have documented that minorities have worse outcomes even when they have comparable coverage, and say that’s interesting but don’t search for the solution to the inherent biases and cultural issues that explain the observation. We complain that healthcare is too expensive, and we know that the outcomes are mediocre compared to other developed nations, but we prefer to celebrate our science and remarkable innovations even though it is obvious that we are inept in effectively and equitably distributing the benefits of our accomplishments.
What galls me most is that many of our leaders are elected because they run for office on the myth that the government is incapable of improving our lives. I have never understood the reverence with which Ronald Reagan is treated. He succeeded by marginalizing the poor as “welfare queens,” and is famous and adored by some for saying,
Reagan made that statement in 1986 at about the same time we learned about his Iran-Contra misuse of power. I find it in stark contrast to a more appropriate expression of shared values and the role of government offered by Hubert Humphrey.
“The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped.”
President Trump has always operated under the Reagan philosophy, and since we first were warned of the devastating potential of the coronavirus he has taken that philosophy to a new level. Fortunately, as he has failed us in the midst of our current struggle with the pandemic, others, mostly governors, have operated under the Humphrey philosophy. Bernie always modeled the Humphrey ideal of government, as did Barack Obama, and as I hope Joe Biden will do. No matter what we do the coronavirus will eventually come under control. The question is the depth of suffering and the size of the losses that will occur as it either runs its natural course like a tornado we can’t control, or as we mitigate its impact as the result of an approach that overrides the natural inclinations of an incompetent leader. What we can be sure of is that our incompetent leader will spend the next seven months trying to deny he ever made a mistake. His denials will contradict the objective evidence of the “test.” Like a devastated landscape on the morning after the storm suggests the need for better construction in the future, the loss of thousands of our most vulnerable lives, and the economic state of the nation once the pandemic has passed will argue that he and the political philosophy that produced him are anachronisms that we should have discarded 75 years ago in favor of a more just and equitable philosophy.
This week the editors of the New York Times have published a manifesto, “The America We Need,” that deserves your attention, The article begins with two bold headings
- The coronavirus pandemic may have reminded Americans that they are all in it together. But it has also has shown them how dangerously far apart they are.
- It may not feel like it now, but out of this crisis there’s a chance to build a better America.
The editors describe a shameful reality of a world that made us vulnerable to failing “the test” of the coronavirus without substantial loss of life and collective wealth.
Over the past half century, the fabric of American democracy has been stretched thin. The nation has countenanced debilitating decay in its public institutions and a concentration of economic power not seen since the 1920s. While many Americans live without financial security or opportunity, a relative handful of families holds much of the nation’s wealth. Over the past decade, the wealth of the top 1 percent of households has surpassed the combined wealth of the bottom 80 percent.
The present crisis has revealed the United States as a nation in which professional basketball players could be rapidly tested for the coronavirus but health care workers were turned away; in which the affluent could retreat to the safety of second homes, relying on workers who can’t take paid sick leave to deliver food; in which children in lower-income households struggle to connect to the digital classrooms where their school lessons are now supposed to be delivered.
Our coronavirus stress test has revealed that we are led by a self interested narcissist who is maintained in power by a political minority that has been willing for years to sacrifice a better future for everyone to the short term satisfaction of the privileged. There is a governing coalition of religious zealots and promoters of white dominance working with a greedy minority composed of the excessively wealthy. This unholy cabal is joined and protected by the unctuous behavior of the wannabe powerful sycophants in Congress that have been the president’s enablers. The virus has revealed that we are living in an unhealthy democracy that is teetering on the brink of becoming an authoritarian kleptocracy.
The article makes a series of statements that describe the “current state”
- [We are] a nation in which local officials issuing stay-at-home orders must reckon with the cruel irony that hundreds of thousands of Americans do not have homes.
- [ We are] a nation in which enduring racial inequalities, in wealth and in health, are reflected in the pandemic’s death toll.
- …already some politicians are asserting that the extraordinary nature of the crisis does not warrant permanent changes in the social contract.
- Our society was especially vulnerable to this pandemic because so many Americans lack the essential liberty to protect their own lives and the lives of their families.
- This nation was ailing long before the coronavirus reached its shores.
In essence, the editors take objection to a the common conservative explanation that the poor are poor because they lack personal responsibility and integrity as the explanation for their plight. A lack of “character” in the poor is not an acceptable explanation for the variation we see in opportunity and outcomes of the American experience.
The erosion of the American dream is not a result of laziness or a talent drought. Rather, opportunity has slipped away. The economic ladder is harder to climb; real incomes have stagnated for decades even as the costs of housing, education and health care have increased. Many lower-income Americans are born into polluted, impoverished neighborhoods, with no decent jobs to be found.
The virus has been the “stress test” that has revealed how vulnerable we are to our ability to deny reality, and the fact that our problems have progressed since we exchanged the war on poverty for the war in Vietnam, the war on drugs, and a leaders who told us that most of us were great, but some of us were having more babies to enable greater income from a misdirected government that was vulnerable to social programs that might be “gateway” policies to socialism. Many of us have become sick as the pendulum of concern has swung from creating equitable and thriving communities built on investments in people and infrastructure to gated communities where we can withdraw to protect our self interests while others do the dirty work of life.
The inequalities of wealth have become inequalities of health. A middle-aged American in the top fifth of the income distribution can expect to live about 13 years longer than a person of the same age in the bottom fifth — an advantage that has more than doubled since 1980.
The editors are eloquent in their disdain:
Advocates of a minimalist conception of government claim they too are defenders of liberty. But theirs is a narrow and negative definition of freedom: the freedom from civic duty, from mutual obligation, from taxation. This impoverished view of freedom has in practice protected wealth and privilege. It has perpetuated the nation’s defining racial inequalities and kept the poor trapped in poverty, and their children, and their children’s children.
The editors sum up our collective vulnerability to our preexisting condition that has made us so vulnerable to flunking the test of the pandemic:
The idealization of individual action in an open marketplace has had its mirror image in the denigration of collective action through government…The nation’s hierarchies are starkly visible during periods of crisis. The coronavirus pandemic has necessitated extraordinary sacrifices, but the distribution is profoundly unequal.
It’s a long article. The editors provide many examples to embellish their points, as if they need further explanation. Their objective seems to be similar to Rahm Emanuel’s admonition that “We should not waste a good crisis.”
A critical part of America’s post-crisis rebuilding project is to restore the effectiveness of the government and to rebuild public confidence in it.
That suggests to me that we begin the process by holding the current leadership accountable for its failures and vote it out in November. My biggest concerns are not that we will never get past the virus, or that the economy won’t recover. I am more concerned that we may not be able to have elections, and that even if we do, there is no guarantee that the outcome will be different because of a collective desire to deny we had set ourselves up for the extent of the damage we endured. My great fear is that after the storm is over nothing will change. We did not create the virus, but we must accept that some of what we have endured was evidence that we did not pass the test of preparation. We forgot that if we leave anyone vulnerable, we are all vulnerable. It is hard to admit at this time when we would rather celebrate the heroism and sacrifices of our brave healthcare professionals, that the extent of their jeopardy is in fact the result of our collective inattention to obvious symptoms. It is hard to admit that in various ways we have all contributed to the horror of this moment, and it will happen again if we fail to admit that the test has revealed continuing deficiencies that we must find the will to correct.
Seeking Renewal From Spring, Passover, and Easter
Today’s header is the view looking south down Clark Pond toward Mount Kearsarge. It was lifted from a video, Emerging~Spring 2019 Chapter 2, created by Peter Bloch about a year ago. If the scene looks familiar to you, it should, because I used the same scene in the letter for March 6. The obvious difference between the two pictures is that today’s picture is an early spring view. There is no snow, and the pond is not frozen. In that letter a month ago I said that I was looking forward to exploring the trails leading to the pond after the snow had melted. In the interim, I have made good on the promise to myself. The round trip trail loop is a short mile and a half through a peaceful forest and along some stone walls that reveal that the land was once cleared. Part of the loop is “upland,” but for my money the best part of the trail runs along the marsh that borders Clark Creek. The trail is wide with just a few small ups and downs. Several streams cross the trails, but there are new bridges from which to view the fast flowing feeder streams that bound over granite boulders and weave through some large erratics deposited by the glacier that melted over 12,000 years ago. The Conservation Commision has peppered the trail with labels revealing seventy different species of trees and plants that can be identified along the trail. The trail should be a great experience for families. It is not too hard or long for kindergarten aged children, and would not be too painful for parents, even if the children demand being carried for some parts of the trip, as my kids always did. I hope that this summer, after travel is possible again, my grandsons, aged 2 and 5, will be able visit and do this lovely walk with me.
Last week end we were warned that this would be a horrendous week, and it is true that there has been a huge spike in reported deaths, but there have also been signs that social distancing is working and that the sacrifices we have made in personal convenience and economic loss will result in many lives being saved. We are “cutting” our losses, and that reality is good news. It is not unrealistic that we can look forward to someday looking back and cataloging all that our sacrifices taught us about what is important. This is also “Holy Week” in the Christian tradition, and Wednesday was the first night of Passover in the Jewish tradition. My family has become a religiously blended family. My two youngest sons married Jewish women which means that my grandsons, and our whole family, will be able to draw meaningful experiences from both traditions.
My youngest son and his wife escaped Brooklyn three weeks ago and after two weeks of confinement, we can enjoy each other’s company. My daughter-in-law was determined to enjoy a seder with her sisters in Washington, DC. Thanks to Zoom the seder blossomed into an event that brought family and friends together from New Hampshire, Japan, California, two sites in Massachusetts, Rhode Island, Washington, and Connecticut.
Together, we read a wonderful version of the Passover Haggadah. It was my third Passover experience, but never before had the story felt more current or its messages more pertinent as a guide for life. The themes include, but are not limited to a remembrance of bondage, the joy of the freedom from bondage, the appreciation of the fragility of life, the importance of community, the fact that the stranger should be welcomed, the possibilities of rebirth and renewal, and the assertion that the wisdom that what has been learned must be passed to the next generation.
This letter comes to you on Good Friday with Easter soon to follow on Sunday. I am sure that across the country congregations will gather by Zoom to hear their clergy seek to relate this two thousand year old story to our current challenges. An early spring walk in the woods, Passover, and Easter all converge to remind us that our common challenge from COVID-19 will pass and life will continue with its reliable cycles of events and stories. I have had many springs and many Easters to go along with my three Passovers. The springs and the Easters all blur, and I am sure that as Passover becomes an annual event for me, the Passovers will blur together also. I am sure that this year will be the exception to all of the blended springs, Passovers, and Easters. We will remember this week because of the new ways the virus has forced us to adapt our traditions to reality. Perhaps we will also remember it as the week when we began to get evidence that our isolation was bearing fruit and we were “flattening the curve.” Like rainbows, early spring, Passover, and Easter are a reminder of the fullness of life and the importance of sharing the experience. I wish you a wonderful spring, and a memorable Passover and Easter.
Be well! Practice social distancing. Wash your hands frequently. Don’t touch your face. Cover your cough. Stay home unless you are an essential provider. Follow the advice of our experts. Assist your neighbor when there is a need you can meet. Demand leadership that is thoughtful, truthful, capable, and inclusive. Let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
