We are getting past the peak of the COVID deaths and we have used the strategy of social distancing and shutdown to try to prevent our hospitals from being overwhelmed. We all understand the tragedy of death by virus but the figure of merit that drove decisions by the government was ultimately ventilator supply and ICU occupancy. It really was an exercise in statistics.
Before you get mad at me, this discussion is about how our society makes decisions in the face of crisis. If you are a patient, or someone who may die some day, the way the system works is important so stick with me here. The way these processes work, in the back rooms and basements where real policy is made, matter to your life and you should understand it.
It is a fair analogy to think of this pandemic as a war. It is an invasion by a force which is hazardous and for which we have no defense. You might think of New York City as similar to the sinking of the Arizona at Pearl Harbor. We respond to the emergency with a host of defenses as we try to understand what we face. Some things work, some don't, but that is the nature of crisis.
As we get past that initial emergency response, we are faced with how to prosecute the long term battle with the virus and our systems begin to engage the "what do we do now" question. For everyone in the high risk pool, it is important to realize that we quickly become statistics. Individual death is important to the one doing it, and to those that care about them, but to the larger system the question is whether the process works or not.
Given the pathology we are coming to understand, we know how this will play out over time. In battle there is the concept of acceptable losses. Think about the invasion of Normandy. The military knew that many would die in that effort. The question had nothing to do with the individual. At issue was whether the losses would be acceptable. As we try to regain a functioning economy it isn't based upon whether people will die as a result of what we do. No one will likely say it officially, but in the end the strategy will be to keep the death rate acceptable and that is a matter of public perception.
As part of our response, we will certainly have our modern Manhattan Project seeking to create the weapon that will ultimately end this war. It will be in the shape of a vaccine but in the meantime we have to operate as a society in crisis. When we get beyond the political fog of blame and counter blame it is useful to know how healthcare actually operates at a system level.
There is a concept called "Quality Adjusted Life Years" (QALY) which lives at the base of the decisions about healthcare funding in this country. It is a way to value healthcare and is conceptually simple. If you are in perfect health your QALY is worth one. If you are dead your QALY is zero. So each year that you probably have left to live has a value and is defined by how far from perfect health you happen to be. If you are bedridden your QALY might be a half or 0.5. If society is going to buy another year of life for you, it might want to only spend half as much for you as it would for someone who is healthy.
The COVID virus creates the worst case scenario for us because it is so hazardous for those who are older and have other medical conditions. There is ongoing debate over what a QALY is worth in dollars but typically it is a range of $50,000 to $150,000 per year. As a simple example at the low end, the system would be willing to spend $25,000 to keep someone alive who is aged and infirm for another year versus $50,000 for someone who is healthy. Healthcare dollars and resources are limited and political posturing aside, there is the inevitable calculation of acceptable losses and estimates of QALY that will define the period between now and when a vaccine does become available.
The people who are part of the medical profession will do their best not to treat you in any way that is unfair. At a personal level the commitment to care is quite real and the existence of QALY isn't directly a part of that intimate journey of fighting for life, but to the systems that support the effort we are all just another GI storming Omaha Beach.
The message here is to never forget that you are your own advocate. The system exists to serve society but not really you as an individual. As society works to return to some more normal situation it falls to you to protect yourself. Remember the lessons learned during the crisis. Don't assume that just because many efforts are being made to return to normal that you can. The system is ultimately impersonal and as we go forward the financial costs of this pandemic will inevitably take their toll on resources and I predict that financial support for chronic illnesses will decline. As surely as gravity always works, QALY will affect your life and as part of our collective foundation family we don't want you to be among the acceptable losses.