Here comes “the spike…”
2020-06-19 · Guest: — · 52:10
Bob Zadek and Dr. Jeff Singer evaluate the government’s performance during the COVID-19 pandemic, focusing on the failure of executive decision-makers to weigh economic and social trade-offs against narrow public health advice. They discuss the regulatory hurdles that delayed testing and treatment, the “unseen” health consequences of lockdowns and elective surgery bans, and the politicization of medical treatments.
Topics: COVID-19, Public Health Policy, FDA Regulation, Certificate of Need Laws, Medical Trade-offs, Executive Decision Making, Lockdown Consequences
Speakers: Bob Zadek, Jeff Singer
Introduction [00:18]
Bob Zadek: Hello everyone, welcome to the Bob Zadek Show, the longest-running live libertarian talk radio show in all of radio. Every Sunday we are the show of ideas, never once the show of attitude. Thank you so much for listening.
Last Sunday we discussed the future of cities as impacted by the after-effects of the coronavirus. And those of you who recall the show will recall that it was my conclusion and the conclusion of my guest that the country, we believe, will enjoy in the intermediate future of five to seven years from now, a long-range, very positive economic and social benefit from the after-effects of the virus. Sounds counter-intuitive. Listen to last Sunday’s show and you will see the points we made and why we reached that conclusion.
This show, as it turns out, I think will be a continuation of that, in the sense that the lessons you will learn this morning will help us evaluate the behavior of our government, the performance of our government, when they are, when it is put to the test. And we can learn from the effects of the virus how well our government performed when, if you will, in a somewhat dramatic way, the chips were a bit down, the playbook wasn’t all that clear, and elected officials, whether they are in the executive or the legislative branch, and perhaps even the judicial branch, the elected or appointed officials were asked to, if you will, do their job.
For the most part, elected officials, those in government, have a pretty easy, fill-in-the-blanks, play-by-number painting kind of job. Once in a while, you are actually required to earn your keep. And this morning we will examine, using the coronavirus as the test, how well our elected officials did during the time they were asked to, to put it bluntly, do their job and do what they are elected to do.
Evaluating Government Performance [01:01]
Bob Zadek: To help us understand how our elected officials performed, to help us build up our report card on how well our elected officials did what they were supposed to do, I’m delighted to welcome back to the show my dear friend, frequent guest on the show, Jeff Singer. Jeff is a practicing general surgeon in Phoenix, Arizona. He is also a senior fellow at the Cato Institute, studying matters among others of health policy studies. Jeff has studied the government’s performance in health policy areas for as long as I have known him. His information is as clear as clear can be. It is database. It is not driven by any motivation other than the truth. So when Jeff speaks, everybody ought to listen. Jeff, welcome to the show this morning.
Jeff Singer: Thank you. It’s such a kind introduction. I really appreciate that. Happy Father’s Day.
Bob Zadek: Thank you, and well-deserved, Jeff. Thank you for being on the show. Now Jeff, here’s my question. Here’s where we start this morning. All of us, whether we are participating in running a family, in running a small business, in running a big business, in running a city, when we have executive responsibilities—and Jeff, you and I simply as family members have, if you will, executive responsibilities even at that level—when we have to make decisions, we cannot be expected and we acknowledge we do not “know” everything. Therefore, when I have to make a decision about my health, about my loved one’s health, what do I do? I seek out professionals and then I do my best to get opinions. Some opinions will be different than others. I sort them out using whatever skills I have to sort out the best opinion, and I process the opinion of others, and then I—scary though it may seem—make a decision. And the decision that I make will affect my own life and the life of those people who are near and dear to me. If I’m in business, I affect the life of my employees, my customers, my creditors, and the people who own the business. If you’re a mayor, you affect the life of the people who elected you.
Now, with that examination of the function of executive decision-making, the executive branch of our government, whether they’re at the city, the state, or the federal level, was required to process information concerning the virus, but more than just health information. They were required to make decisions, decisions that affected large numbers of people. Therefore, given the importance of the decision, one would expect the decision-making process would be sound and thoughtful and follow the outlines that I have explained.
I now ask you to comment on, looking back, whether it’s at the city, the state, or the federal level, what was right and what was wrong with the decision-making by the executive branch—because mostly it was the executive branch operating. The legislative branch basically ceded all power through executive power to the executive branch, so the legislatures were kind of passive in this process. We look mostly at the executive branch. Critique, if you will, on the big level first, and then we can drill down. How did the executive branch—state, federal, local—perform? What did they do right in the process of making decisions and what did they do wrong?
Regulatory Failures and Testing [03:56]
Jeff Singer: Well, first I think it’s important to stipulate that as libertarians, we believe there is a legitimate function for government in certain situations. And when dealing with a public health emergency, that’s a legitimate function of the government to deal with the emergency and prosecute the crisis. So that being said, the government in my opinion has failed us on virtually every level of government function, from federal all the way down to the local.
So let’s start with the beginning. One of the things that the government should do when there’s an emergency like this facing the population is to give the people safe, good, solid, reliable information, understanding that we’re learning as we’re going, so the information needs to be constantly updated. Well, they didn’t do that. So in the early goings of this thing, first we were being told this is nothing to worry about. As recently as late February, we were being told this is mild, it shouldn’t affect anybody, go about your business. And we had that on every level from the federal level, even down for example, the mayor of New York City in March was telling people to go to Chinese New Year, get on the subway, go out to eat. So then they switched, turned around and said, “Wait a minute, this is really serious, everybody go inside.” So they failed on just on the information level.
Also, in the early goings, they were telling people don’t wear a mask, it does no good. And then all of a sudden in March, they say, “Actually, wear a mask.” And then we just recently learned that we were told that was a so-called “noble lie.” Dr. Fauci said, “Well, we didn’t want people to be using up the limited number of masks that are necessary by the healthcare workers, so we told them not to wear a mask.” Well, first of all, you didn’t have to lie to us because all you had to do was say, “We have a limited number of masks for the healthcare workers, and until we get more, use something like a cloth covering or a kerchief, and then eventually everybody can get those other masks.” And most people would have totally understood and cooperated with that. But when you lie, and especially when you admit it, now it makes you wonder, well, what else are you lying to me about? How could I believe anything you’re saying? So they weren’t truthful on that.
On the regulatory scheme, most of the regulations have made the government so rigid and sclerotic that it can’t respond quickly to a crisis, which is one of the most important reasons to have a government, is to respond to a crisis like this. So for example, our FDA regulations resulted in—I don’t want to get too into the weeds—but basically resulted in the fact that while all the other countries in the world were developing tests, which is very important to be able to sort out who needs to be isolated, who doesn’t, and help you get in touch with contacts, etc., in the United States, the FDA basically granted a monopoly status to the CDC, which then produced a test that turned out to be ineffective and flawed. And then by the end of February, suddenly had to play catch-up. So while other countries were already rapidly testing and getting the situation at least under better control, getting to know more about the situation they were dealing with, we were just getting started.
And then finally, the end of February, beginning of March, the FDA eventually relaxed enough of the regulations where they basically said to states, “You go ahead and any test that your state decides wants to be allowed within its borders, you can go ahead, you don’t need our approval anymore.” And they also fast-tracked a lot of development tests. Same thing with drugs. Because of the rigid FDA drug approval process, it takes on average about 12 years to bring a drug to market through the long, staged clinical trials process. All of a sudden they fast-tracked Remdesivir, which showed promise in reducing length of stay in the hospital, so that within about six weeks it went all the way up to approval process, which also tells us they can do this if they want to. But those things were standing way down.
On the state level, we had state licensed medical healthcare licensing laws, actually all occupational licensing laws, which made it difficult for healthcare personnel to be able to move to other states to provide their services when they were needed. So many governors basically gave temporary recognition to licenses held by healthcare practitioners in other states because they needed help. So they said, “If you’re a nurse, you’re a doctor, and you’re licensed in Texas, we need you here in Massachusetts, so your license is okay, come here.” But of course that’s temporary. But so licensing laws obstructed the movement of people to areas where they were needed. Over 35 states have Certificate of Need laws where you basically, if you wanted to add beds to your hospital or build a hospital or a surgery center or whatever, you have to get permission from a government committee that’s usually made up mostly of your competitors to decide if the state needs this. Could you imagine if we had that for restaurants? So you wanted to open up, you have a great idea for a new kind of restaurant, but it has to go through the Certificate of Need board that is staffed by all the other restaurants, and they say, “Well, Bob, that’s a really interesting idea for a restaurant, but we have plenty of that type, so we don’t need it.” Of course they’re going to say that. So those things made it difficult in some states for hospitals to make adjustments to the anticipated surge in patients. And in some states, the governors temporarily suspended it, and some they still haven’t. But for example, in my state of Arizona, we don’t have a Certificate of Need law for that, so hospitals immediately began saying, “Why don’t we convert this section of the hospital which we usually use for cafeteria, or why don’t we take the recovery room that we use for post-op patients and make it bigger and convert it into additional ICU beds because we have that.” Well, they could do that. They could add beds. They could put beds in parts of the hospital where there were no beds to be able to handle a larger load of patients. But in states with Certificate of Need laws, the hospitals can’t necessarily do that. They have to get permission.
So, you know, these are kinds of things. And then you have scope of practice laws on the state level where the states not only determine licensed healthcare practitioners, but they decide the scope of practice of each profession. So for example, in some states they allow nurse practitioners to basically practice without supervision from a physician to the extent to which they’re trained. So a lot of excellent primary care is given by nurse practitioners, also physician’s assistants. But in other states they’re not. In some states, nurse anesthetists, which are people who are trained in providing anesthesia, can’t provide anesthesia without an anesthesiologist present. Other states they can go ahead and do that and just, if they need someone with more training than them, it’s up to them to decide if they want to have one on standby. But those kind of things have all stood in the way. And we learned that as we’re going along, we say every time we were encountering these problems on the state level, governors were waiving all of these restrictions. And of course there are lessons in this, which is, do you want to go back to putting those restrictions in place as soon as this crisis occurs and have the same flat-footed response, or do you want to say, “Hmm, do we really need these restrictions?” So there are opportunities as well as sad lessons.
The Narrow Lens of Public Health [07:41]
Bob Zadek: Now Jeff, just one question if I may. I notice when I have conversations with colleagues, with friends, when I listen to pundits and experts speak, I find that I am far less interested in the opinion of the speaker, in the conclusion of the speaker—that’s just a statement—I am deeply interested in how they got there. So when governors and mayors made the lockdown decisions, they shared with us, with the public, their voters, they shared with us why they made the decision. So, and they made the decision not because they were doctors or they were epidemiologists or they were anything. They were at the top, and as I said at my opening, their job, what they are hired to do, is to receive information, to process it using their intellect and the people who assist them, and having processed the information from all of the experts they enlisted, reach a conclusion. That’s what their deliverable is. Their deliverable to us, the voters, is their decision. Now, tell us if you will, on the issue of the lockdowns, what was as best you can tell the decision-making process? What was the process by which Cuomo and others in the Northeast decided on the lockdowns, and what was wrong with their decision-making process?
Jeff Singer: Well, first of all, let me say that one of the advantages of our federal system is that one size does not fit all. So the situations on the ground should determine the actions. And the situations on the ground in the New York metropolitan area were not the same as, let’s say, in South Dakota or California. So I don’t want to give a sort of a blanket opinion on decision-making process because rigid restrictions on the movement of people might make sense in one region of the country depending on what’s going on there. There’s also population density concerns, demographics, age of the population, etc. So all those things should play into the decision.
In my opinion, what I saw happening all too frequently was that the executives basically deferred all the decision-making to public health officials. So they basically said to the public health official, “Tell me what needs to be done to eradicate this virus.” And whatever the public health official said needs to be done to eradicate the virus, they pretty much implemented. But what I have a problem with is that when you’re an executive, you have to consider all the trade-offs involved with any decision you make about anything. So the public health officials—and this is not criticizing them—they basically, they’re looking at through one narrow lens. This is all about getting rid of the virus. They’re not, they don’t pretend to be experts on economics, on sociology. So they’re not considering the economic consequences or the social consequences of the interventions that they say you need to get rid of the virus. They’re not considering the long-term consequences, unintended, of some of those things.
So it’s the job of an executive to not just consult the public health experts, but in my opinion what you should be doing is after you hear what the public health experts tell you needs to be done to, let’s say, get rid of the virus or get the virus under control—because you really, by the way, you can’t get rid of the virus. This virus is part of our ecosystem, so to speak. It’s here to stay. There’s only one virus that affects humans that has ever been eradicated, and that’s the smallpox virus. So even now when people are stopping getting immunizations because they’re afraid of vaccines, we’re seeing measles re-emerge 20 years after we thought we’d never see a case again. And same thing with polio, things like that. So viruses never go away. We reach a point in our population where we have what epidemiologists call herd immunity, where enough people have immunity to it that the virus can’t find enough hosts and vectors to spread around the population to any significant degree, so it is no longer a menace to the public. There’ll always be a case here or there, but not enough to be a huge social problem. And whether you get there through vaccinating the entire population or just enough of the population has gotten it that they’ve developed immunity, and usually it’s a combination of the two. In some cases we never get a vaccine. We’ve been trying 20 years to get one for HIV. We don’t have one for hepatitis C, for example.
But anyway, so you’re not going to get rid of the virus. But getting back to what I was saying originally is I think after the executive consults the public health people, he should then consult people who are experts on economics, on the sort of the unseen economic consequences of those decisions and say, “If we were to implement these decisions, how do you think that would affect things?” And also discuss things with their political people too. How do you think the public would be, would the public be willing to go along with some of these measures? What do you think the reaction would be? And kind of mix this all together, and you also want like, you know, first best solution, second best solution, third best solution. And then you as the executive need to kind of weigh all these things into your ultimate decision.
And what I think has happened all too often on all levels of government is that the executives have basically just limited it completely to the decision-making process of public health officials. And they themselves have admitted—I remember Dr. Fauci was asked by Senator Rand Paul, “Have you considered the economic consequences of some of these things?” And he said, “I’m not an economist, I don’t pretend to be one. I’m a public health expert and I’m giving you my public health insights.” And so it’s almost like if you, you have a roach problem in your house and you hire a pest control guy and say, “I want you to get rid of these, I want these roaches eradicated. I don’t care what you have to do to eradicate them.” And then you go away for a couple hours, come back, your house has been burned down to the ground, and you say, “Well, where’s my house?” He said, “I got rid of your roaches. Isn’t that what you told me you wanted to do?” So it’s the same thing. You need to kind of balance the different trade-offs because every decision made in life involves trade-offs between pluses and minuses and there’s relative risks. And unfortunately, a lot of that was left out, in my opinion.
The Unseen Consequences of Lockdowns [10:46]
Jeff Singer: So there has been a tremendous amount of suffering that was created that could have been avoided, particularly in certain regions of the country. And like I say, in certain areas, like in the New York metropolitan area, largely because of the population density, and as you know, there have been some studies showing that they’ve been actually able to trace a lot of the spread of the virus to the subway system where people were actually encouraged by Mayor de Blasio not to wear a mask, where the subway workers were told not to wear a mask because it may frighten the passengers. So at least in the early goings of this thing. So there it became a much more critical situation than in other parts of the country.
So I like the decentralization aspect. I also like there’s another thing we all, your listeners I’m sure completely understand, that the more decision-making authority you place in the hands of the fewer number of people, the more you’re creating incentives that actually, it doesn’t matter who the people are, there’s a set of incentives that are not in our best interest. So for example, if the governor decides he wants to lift the lockdown, what is seen when the lockdown is lifted is of course, as more people are able to come out of quarantine—because basically our policy has consisted of quarantining the healthy, which I don’t think has ever been done before, we usually quarantine the sick—but if they come out of quarantine, more and more people of course are going to get exposed to this virus because as I’ve said, the virus isn’t going away. So there’s going to be more cases. So the case number is going to go up and the press is going to say, “Another thousand cases today, another thousand cases tomorrow.” And of course the governor is going to come under a lot of criticism and it may affect his election prospects. So whoever the governor is, I don’t care what his ideology, the incentives in place are for the governor to err on the side of over-caution.
Meanwhile, what is not seen by the extended over-caution are how many jobs are lost permanently, how many life savings have evaporated, how many people didn’t see the doctors or get checkups or treatment for non-emergency but serious problems that then become advanced enough that when they finally get a chance to get treatment, it’s too late to have a good outcome. All those kind of things. How many, for example, we’ve learned according to the CDC that immunizations are down in the United States 40% over the last two months. Parents are afraid to take their children to the pediatrician to get immunized, even though pediatricians are making all sorts of efforts to social distance, where they’re isolating, in some places actually come down to you in your car and immunize your child in your car so you don’t even have to be near other people. But parents are afraid that their children are going to catch the COVID-19 virus or that they will, even though the data shows that the young children, it’s almost immeasurable how many of them can get seriously ill from COVID-19. And young adults of parenting age are very low risk for getting any serious infection from COVID-19. So what they’re doing by not getting their children immunized is actually they’re subjecting them to risks of much more deadly viral illnesses like measles or polio, whooping cough, which is of course that’s not a virus, but that could be very deadly and they’re not getting immunized against these things. Whereas so we’re going to get into how many people didn’t get immunized were it not for the extended lockdown. We do see how many cases go up. So the incentive is locked in place where the executive is going to err on the side of keeping things locked down longer than necessary, no matter who that person is.
The Politics of “Following the Science” [13:29]
Bob Zadek: We are reading a lot about number of cases, new cases, and there’s always an exclamation point when the media reports that. So we’ll get into that in a moment, that that’s an example I think, but Jeff, I’d like your opinion, of the kind of information you sort of mentioned it earlier, that’s exactly the kind of information that creates excitement and anxiety in the public but it’s kind of irrelevant to the discussion. And you mentioned a very important concept that I want to explore in a moment, which is the trade-offs. That when an executive, a mayor or a governor, makes a decision based solely upon health considerations, it’s turning over executive power to a subordinate official, some official in the health department. Well, the government or the executive is—and this is really important to me—is one notch above the health department. He is at the top of the pyramid with a series of departments and advisors reporting to him. And his job is the decision, to take health department input, economist input, political input, sociological input, and do that last step is to process all of it and make a decision that may be adverse to the economics but advantageous to the health, or vice versa. But that’s the hard stuff. That’s a decision. It’s an abdication, Jeff, in my opinion, when a governor simply says, “Well, it’s the health department’s call, don’t yell at me. I’m doing what my health advisor says.” Well, in doing that, the government is saying, “I’m going by the science.” That’s what they say. “I’m going by the science.” It sounds of course very enlightened to say that. But what they’re really saying is, “I’m basically abdicating all executive decisions to one aspect of the dealing with the issue, which is the public health people.”
And so in this regard, to paraphrase there’s an old saying, “Patriotism is the last refuge of scoundrels.” Well, hiding behind “science” is the last refuge of elected officials. They get to get a pass. They get to abdicate the decision-making and saying, “Fauci or Birx or some scientist told me what to do and I’m simply doing it.” Well, the governor or the mayor is being obedient but not making a decision. And the point is that this is the one chance when an executive was required to gulp, make a decision, and process information, and make a decision where there was political danger, but make a decision that’s good for all.
The Impact of Elective Surgery Bans [15:16]
Bob Zadek: Now Jeff, I want to explore something which you have been so helpful in having me understand, which is you mentioned earlier the issue of trade-off. That when one makes a decision to eliminate elective surgery—and we’re going to discuss elective surgery specifically because of course you’re a general surgeon and you know that stuff, but also as a scholar you are aware of the trade-offs—when we make a decision to eliminate all elective surgery, basically saying you cannot use any healthcare facility—I’m exaggerating a little bit—unless it’s virus, COVID related, there were profound long-term health as well as economic damage. So you have done a lot of studies into this. Help us understand, Jeff, in some summary fashion, what were the unseen adverse health consequences of basically denying healthcare to the entire country other than COVID related?
Jeff Singer: Okay, first I want to point out that this goes back to the idea of putting all the decisions in one-size-fits-all decisions in the hands of a few people. Prior to this pandemic, every few years we get warnings, the CDC warns local regions that it’s going to be a worse than usual flu season and the hospitals need to be prepared in case they have an overload of patients. So normally what happens is on a hospital-by-hospital basis, the hospitals are in touch with us on the medical staff and they say things like, “For the next two months we’re going to ask you to be much more frugal in the patients you bring in because we need the beds.” Or sometimes I would schedule a surgery and get a phone call from the hospital chief medical officer and say, “How important is it that this man have this surgery on Wednesday? Because we’re down to two beds. Is there a way you could postpone it a couple of weeks till we have more beds?” And of course we handle these things. That’s what we do.
But the entire plan from the beginning was to “flatten the curve,” which means since this is a brand new virus and there was no immunity to it, we didn’t want the hospital system to get overwhelmed and be unable to take care of anybody. So the whole idea originally, which is very reasonable and things we deal with all the time, is to take steps to make sure the hospitals have enough capacity to handle everybody. Well, so in many states, virtually every state, the governors decided in this case, instead of the hospitals working it out with their medical staff on a local basis, they put in place blanket bans on all elective surgery.
Now, “elective” doesn’t mean like getting a facelift. Elective means not emergency. It means it doesn’t have to be done this minute. If you have a perforated ulcer, that’s not elective. You have to go to surgery right now. But you could have something that could be very serious, very immobilizing, but it could be scheduled in a more convenient way, like over the next few weeks or even a couple of months, and that’s considered elective. You elect when to have it. And even among electives, there are more urgent electives and less urgent electives. So for example, if you’re an elderly person living alone and you have really bad cataract and you’re really having trouble seeing, cataract surgery is elective, but it might be more urgent for that person who could fall and break a hip and that could be their final event that does them in, than it could be for a person who has milder cataracts and doesn’t live alone and has more mobility.
So when the governors banned elective surgery, all of these people were no longer able to get anything done. Elective also includes things like cardiac catheterizations. There are emergency cardiac catheterizations when you show up with a suspected heart attack going on and they diagnose it and maybe treat it with a stent. But there are other situations where doctors don’t like what they’re seeing and you need to have a catheterization because you might have basically a ticking time bomb going on in there, and that’s elective. That gets scheduled. Well, those things were not happening. There’s colonoscopies for screening for colon cancer. There’s a whole lot of people who are on numerous medications for chronic illnesses like heart disease or COPD who really need to do regular check-ins with their doctor to see if they need adjustments in their medications because they’re very fragile. And they were told during this spell to not go to the doctor because you can catch COVID.
So what we found is, well, first of all, in my state of Arizona, we had hospitals were about 40% of capacity as a result of this because nothing was allowed into the hospital that wasn’t emergency. So there were emergency surgeries going on, but only emergency surgery. The hospitals were actually furloughing or laying off doctors and nurses. But what’s not seen is how many people will end up presenting with advanced stage three or stage four cancers that could have been avoided had they gotten taken care of sooner. How many people are suffering immobilized in pain from they’re waiting for their now-cancelled hip operation who end up developing a blood clot and then a pulmonary embolism and die? I mean, these are all things we will never know actually because there’s no way to be able to get that information. But this is the unseen.
And gradually in my state, elective surgery was permitted once again starting May 1st. And one of the reasons why the hospitals are now at about 80 to 85% capacity statewide is all those patients are getting back into the hospital again. But even there, now the hospitals are in touch with us daily. I get messages from the medical directors of the hospitals that I go to, and they tell us, “If our hospital gets much busier, we may be contacting you and asking you to back off on your admissions for a while.” But notice how when it’s done on the local level with local knowledge, the back-off may only be for a week or two, and it may only affect one or two of the hospitals in the hospital system as opposed to all of them in the state. In my state, we had hospitals in parts of the state where there were almost no cases of COVID, very rural areas of the state, and they were, there’s no elective surgery allowed in the state. So people in those areas were also going without care.
So that’s just the elective surgery angle. But there’s a whole lot of other unseen things that like I talked about a little bit earlier regarding immunizations. And people to this day, even as states are opening up, are still afraid because of the daily drumbeat in the news about more cases, more cases, we got another thousand cases today, another thousand. So that’s keeping people afraid to go to the doctors, to go to hospitals. Recent reports are showing that emergency room visits are way down compared to this time at the previous years for people who would be normally coming in with things like chest pain or shortness of breath or exacerbations of COPD, things like that. In other words, non-COVID medical emergency visits are dramatically down. Is that because people are afraid to go to the emergency room and maybe they’re dying at home from other things because it didn’t get treated? So these are things that need to be taken into consideration, which is why I argue that we should, sometimes you need to do one-size-fits-all policies that affect the whole state or the whole county or whatever. But that should be kept down to the absolute minimum, only when absolutely necessary. And the decision-making should be as much as possible left to local actors based upon local knowledge who have the flexibility to more rapidly adjust to changes that develop in local areas. So, you know, if you have an area of the state which is not having any COVID-19 problem, it’s normally with a statewide policy to try to get the statewide policy lifted is like turning around a battleship. Whereas if these kind of decisions are devolved as much as possible to local actors, and the role of the government here is to give those local actors the most accurate and up-to-the-minute information as possible so they can make the best decision. That’s very important. It’s more important than telling them what to do.
Politicized Medicine: Hydroxychloroquine vs. Dexamethasone [18:01]
Bob Zadek: And Jeff, the examples you have indicated where governors, mostly governors, who forbid elective surgery—and elective was misunderstood perhaps by the governors—that’s the ultimate scary case of a phrase, Jeff, you have heard and you have spoken very often, where the government, elected officials, interject themselves into one of the most intimate of relationships between patient and healthcare provider. The governor steps in and says even though the patient needs the procedure, and even though the doctor’s best medical judgment is this patient must have the procedure, the government, for the wrong reason, simply because of the one-size-fits-all, the government invites themselves into the consulting room and says, “No, the greater good in the country dictates that that decision by the physician will be overruled.” It’s inviting itself, the government, into one of the most intimate and fiduciary relationships that exists in the world, healthcare provider and patient. And that is of course, that first came about with the discussion, maybe our first show, Jeff, we did maybe 10 years ago on Obamacare, when the fear was it was the government inviting itself into the decision-making process. This is a real-life example of what that looks like when the government, for the wrong reasons, interferes with the delivery of appropriate healthcare services.
Jeff Singer: Yeah, it’s not just unique to the COVID-19 pandemic. How about the opioid situation? We had the government, states around the country, passing these one-size-fits-all prescription guidelines and dosage guidelines to doctors prescribing opioids to patients in pain. And then they all, the states, set up these prescription drug monitoring programs, which are surveillance boards. And if they find doctors deviating from what the state thinks is the right dosage or number of pills that they’re prescribing to patients, they get a visit from law enforcement. And a lot of this was based upon, again, CDC guidelines, which the CDC has subsequently said, “You know, those were just guidelines and you’re taking them to be gospel and they’re not.” And of course they’ve also come under a lot of criticism from experts who are experts on pain management and addiction management. But that doesn’t matter. The government has decided, you know, you can only prescribe this many pain pills for this patient in this circumstance. And you have to get basically permission from people who are government officials if you want to maybe give your patient a larger dose or a greater number. So it’s not unique to the pandemic. It’s just been a pernicious trend that’s been going on for quite some time with the government intruding itself into the practice of medicine.
Here’s another example. We learned the other day this good news that it looks like the steroid Dexamethasone might be very effective in rescuing seriously, critically ill people who are having what’s called a cytokine storm. It’s we believe in many cases the people who die from COVID-19, they’re not dying from the virus per se, they’re dying from a hyper-active immune response to the virus that is so huge and aggressive that it actually starts destroying your own body. And that’s what you end up dying from, the complications of that. You have multi-organ system failure from the immune response. So we’ve known for years, and I know a lot of my colleagues who are treating these patients, when a patient gets to that point, just intuitively they’ve said, “Why don’t we just give them some steroids and see if that helps?” Because steroids are known of course to suppress the immune response. So whether it’s Dexamethasone or Methylprednisolone or Hydrocortisone, you can pick your steroid that you want, but they’re basically all acting the same way. Dexamethasone is very powerful and inexpensive and been around for decades. So, but using it in that situation is considered an off-label use. Off-label meaning the FDA approved it, but not to that particular thing. Under current regulations, once the FDA approves it, you could use it for anything your clinical judgment tells you to use it for. But if you use it for something it was not initially approved for, then that’s called off-label use because that wasn’t allowed to be a usage put on the label.
So we just recently learned from researchers in the UK that it may reduce deaths by up to a third of people who are in this kind of critical condition, which validates what a lot of doctors kind of intuitively have been thinking. Well, meanwhile, we all are familiar with this. In mid-March, there were a lot of doctors who intuitively had been prescribing Hydroxychloroquine or Chloroquine, both of which are used as anti-malarials, but they’re more commonly used to treat people with collagen vascular diseases like connective tissue diseases like rheumatoid arthritis or lupus for decades. Okay, so and I’m not passing judgment on whether that works. Initially there was a lot of good reason for clinicians to think it might help. In vitro studies suggested it might help and there were anecdotal reports. Unfortunately, President Trump decides to trumpet that this is the game changer. When that happened, that started a whole firestorm in the press. A lot of it I’m sure was politically motivated and partisan motivated because if Trump is for it, it can’t be good. And then in reaction to that, the FDA first said, “We want to point out that we don’t have convincing evidence on this and it is an off-label use,” which first was misinterpreted by the press as meaning it’s not approved, because they didn’t understand the difference between off-label and label use. And then many governors reacted by, same thing as with opioids, they said, “You cannot use Hydroxychloroquine to treat COVID-19 patients except under certain special circumstances that we define.”
In the meantime, probably under pressure from the executive branch, the FDA suddenly said, “We’re giving emergency use authorization for Hydroxychloroquine,” and ended up purchasing 63 million doses of Hydroxychloroquine for a national stockpile, emergency stockpile. And this took place on several state levels too, particularly states that were sympathetic to Trump. So Governor DeSantis in Florida bought a million doses of Hydroxychloroquine, none of which have been used. So meanwhile, data starts coming in on that one, and so far at this point there’s no convincing evidence from bigger studies. There’s not been any randomized controlled studies, but I think that I have to be honest and say I’m not convinced that it helps. I haven’t seen anything that convinces me. I’m aware of the anecdotal reports. So if a patient asked me what do you think, I would say I have no, I’m not convinced that it does any good. But that’s not the point. The point is that so now the FDA about a week ago, realizing that there’s no convincing evidence, terminated its emergency use authorization. And now we’re stuck with 63 million doses of unused Hydroxychloroquine that we paid for in a national stockpile, and millions of doses in different state stockpiles. And this is the difference between Dexamethasone, which the government had nothing to do with—this was just doctors using their judgment, sharing information, engaging in clinical trials and then sharing the information with each other, devoid of any government interference—and in the case of Hydroxychloroquine, government immediately injecting itself into it, not giving doctors and patients a chance to kind of find out if this is good or not good. And so now we have a situation where we’ve got all this waste, which was totally avoidable.
The Necessity of Trade-offs [21:01]
Bob Zadek: It’s all political and there was very little medical input from all of that. That’s the scary part. Now Jeff, we’re running out of time and you had mentioned an important word, and even though we don’t have much time left, you had mentioned the trade-off between the economic and the health considerations. And I’d like to frame up the issue, we only have a few minutes, with an everyday example that our audience will understand. We are told—I’ll start with Governor Cuomo saying even one life is invaluable, saying that we will sacrifice any degree of economic loss to save even one life. An utterly absurd concept because government every minute of every day, government at every level makes a decision to sacrifice an American life for a greater good. Think for example of sending troops into combat. We have decided to kill off a certain number of young men and female Americans because it’s good for the country. That’s not a heartless decision, hopefully that’s a rational decision. We make a decision to allow, to permit driving in this country, even though driving kills 55,000 Americans every year. So we make a decision, the loss of 55,000 lives, while regrettable, we will still permit driving because the economic benefit outweighs the loss of 55,000 lives.
So Jeff, comment on these, and we have only a few minutes, on how one ought to make a decision about lost lives and use the COVID virus. We have only a minute or two left. How the decision that government can make might cost us several, a few, maybe many American lives, but how the economic considerations, if they were given, would mitigate in favor of less lockdown and less closing of the economy. We have about a minute left, Jeff, minute and a half.
Jeff Singer: Okay, well first of all, you know, decisions like this as much as possible need to be made on the individual level because different people are willing to accept different risks. For example, the tobacco smokers know that they’re risking their life smoking tobacco, but they made a decision that the pleasure they’re getting from tobacco outweighs the health considerations, they’re willing to take their chances. Now, in certain situations, for example, if I’m contagious and I could affect a lot of other people around me, then it’s not just my decision because I’m obviously jeopardizing the life and rights of my neighbors. So that’s why I’m saying there is a legitimate role for the government to play here because these are externalities, and to prevent me from hurting my neighbor. So it’s not like everything has to be just up to me as long as I’m okay with it, it doesn’t matter to me if you catch it. So there’s a role there.
But still, that role has to be as narrowly defined as possible, and decisions made outside of the individual realm have to be, there has to be a compelling reason for that to be made, and there has to be a time limit set on it. And it should really only deal with your ability to affect the life and safety of others outside of you. Because otherwise, everything we make every day involves these kind of trade-offs. Some people scuba dive, some people ski, some people skydive. Some people, you know, drive, you could argue that raising the speed limit from 55 to 70, as was done in California, or 75 in Arizona, well, that caused an increase in deaths from automobile accidents. But it was, and you don’t have to drive up to the speed limit, that’s just the limit. You could drive below it if you want. These are all decisions we make. And as many decisions—
Bob Zadek: Jeff, I’m going to have to interrupt you. I do want to allow time to give you my heartfelt thanks for sharing your wisdom for the past hour. Everybody, please follow Jeff’s writing at Cato. He is a scholar, he is a brilliant surgeon, and he knows this stuff cold. He is really the truth and the source of all information on what government is doing with the virus. So Jeff, thanks for sharing what you know with us and with our friends out there who are listeners to the show. Bob Zadek saying thanks to Jeff, and so long for now.
Jeff Singer: Thank you. Thanks, Bob.