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Here comes “the spike”

Jeff Singer, The “Doctor 4 Liberty,” on trade-offs during the COVID-19 lockdowns.

Like clockwork, we are now seeing a modest spike in COVID-19 cases in states like Arizona, which mostly avoided the first wave of infections that hit big cities like NYC. The lockdown pre-empted many people from getting sick early only, flattened the curve, and delayed the inevitable. Now the spike in cases, and accompanying blip in fatalities, is being hyped by the media to stoke fear and continue lockdowns indefinitely.

Dr. Jeffrey Singer is one of the handful of “voices of reason” I turn to during times like these. The founder of Valley Surgical Clinics in Arizona has joined my show many times to discuss the “seen versus the unseen” in areas like the opioid epidemic. The news tells us all about the overdoses, but never talks about those living with chronic pain who are denied necessary prescription painkillers from their doctors because of draconian regulations.

Likewise, with COVID, we are seeing “Bastiat’s Law” writ large across the entire economy.

Jeff was recently interviewed by Reason’s Nick Gillespie, in which he presented a case study in that which is seen vs. that which is unseen (COVID edition #1,427):

“At first, [Singer] says, the idea was “flattening the curve,” or slowing the rate of infection so medical providers were not overwhelmed by the number of cases. Now, he says, the discussion is about making sure no one gets infected, an unrealistic goal for a viral infection in the absence of a vaccine.”

Jeff and I pick up where they he and Nick left off — talking about the recent spike in Singer’s home state of Arizona — and whether it’s something to worry about relative to other causes of death, such as suicides caused by economic desperation, cancers gone undiagnosed or treated, or preventable diseases from children who are falling behind on their vaccination schedule. The last thing we need is a measles epidemic on top of COVID.

We also discuss Jeff’s recent article in the Washington Examiner and the unseen costs of one-size-fits-all government policy.

Don’t miss any of the live shows — Sundays, at 8am PACIFIC TIME — streaming live online and broadcasting on AM stations across the West Coast. Or subscribe to get the podcast/read the transcript next week — newsletter subscribers get my free PDF guide to the administrative state, The Shallow State.

TRANSCRIPT

Bob Zadek: Last week, we discussed the future of cities as impacted by the after-effects of the coronavirus.

It was my conclusion that the country will enjoy long-range positive economic and social benefit from the after-effects of the virus. It sounds counterintuitive but you will see the points we made and why we reached that conclusion.

This show, as it turns out will be a continuation of that in the sense that we can evaluate the behavior of our government when it is put to the test. We can learn from the effects of the virus how well our government performed when they actually had to do their job.

To help us understand how our elected officials performed, I’m delighted to welcome back to the show my dear friend — a frequent guest on the show, Jeff Singer.

Assessing the Government’s Decision-making

Bob Zadek: Now Jeff, all of us, whether we are participating in running a family or running a small business, a big business, or a city — when we have executive responsibilities we acknowledge that 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 sought them out using whatever skills I have to sort out the best opinion and I process the opinion of others.

Then I, scary though it may seem, make a decision. 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. The executive branches of our government, whether they’re the city, the state, or the federal level, were required to process more than just health information concerning the virus. They were required to make decisions that affected large numbers. 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.

The legislatures were kind of passive in this process. We look mostly at the executive branch. How did the executive branches of state, federal, and local government perform? What did they do right in the process of making decisions and what did they do wrong?

Jeff Singer: I think it is important to stipulate that as libertarians, we believe there is a legitimate function for government in certain situations. When we are dealing with a public health emergency it is a legitimate function of the government to deal with the emergency and prosecute the crisis. That being said, the government has failed us on virtually every level – from federal all the way down to the local.

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 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.

First, we were told this was nothing to worry about. As recently as late February, we were told that this was mild and shouldn’t affect anybody, and to go about our business. We have that on every level from the federal level, even down, for example, to the mayor of New York City telling people to go to Chinese New Year in March — to get on the subway, and go out to eat. Then they turned around and said, “Wait a minute, this is really serious. Everybody go inside.”

Also in the early goings, they were telling people, “Don’t wear a mask. It does no good.”

Then, all of a sudden in March they say to wear a mask. We just recently learned that we were told that was a so-called noble lie. Dr. Fauci didn’t want people to be using up the masks for healthcare workers so he lied. 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 or covering kerchief, and then eventually everybody can get those other masks.”

Most people would have totally understood and cooperated with that. But when you lie, and especially when you admit it, 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 couldn’t have respond quickly to a crisis, which is one of the most important reasons to have a government – to respond to a crisis like this.

For example, FDA regulations made it so 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 and who doesn’t, the FDA basically granted a monopoly status to the CDC, which then produced the test that turned out to be ineffective and flawed. By the end of February, you suddenly had to play catch up. So while other countries were already rapidly testing and getting control of the situation we were just getting started.

Then, finally, at the end of February and beginning of March, the FDA eventually relaxed the regulations. It said to states, “You go ahead — you don’t need our approval anymore.”

They also fast tracked drug development, because the rigid FDA approval process 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 hospitals. In six weeks it went all the way up to approval process, which tells us they can [approve drugs much faster] if they want to.

Those things are standing in the way. Licensing laws also obstructed the movement of people to areas where they were needed.

On a state level, we had state-based medical healthcare licensing laws that made it difficult for healthcare personnel to move to other states to provide their services when they would need it. Many governors basically gave temporary recognition to licenses held by healthcare practitioners in other states because they needed help. They said if you’re a nurse or a doctor and you’re licensed in Texas, we need you here in Massachusetts.

Over 35 States have certificate of need laws where basically, if you want to add beds to your hospital or build a new hospital or surgery center, you have to get permission from a government committee. The committee to decide if a state needs this is usually made up mostly of your competitors.

Could you imagine if we had that for restaurants? Imagine 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. They say, “Well, you know, 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! This made it difficult in some states for hospitals to make adjustments to the anticipated surgeon patients. In some states the governors temporarily suspended it. In my state of Arizona, we don’t have a certificate of need law for that. The hospitals immediately began saying, “Why don’t we convert this section of the hospital – which we usually use for a cafeteria or a recovery room that we use for post-op patients — into additional beds?”

In states with certificates of need laws hospitals can’t necessarily do that –they have to get permission.

Then you have scope of practice laws. States not only license healthcare practitioners, but they decide the scope of practice of each profession. 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. A lot of excellent primary care is given by nurse practitioners. In some states nurse anesthetists, who are trained in providing anesthesia, can’t provide it without an anesthesiologist present in other states.

In other states this is not the case. We learned that as we were encountering these problems on a state level, governors were waiving all of these restrictions.

The One-Size-Fits-All Lockdown Plan

Bob Zadek: I am far less interested in the opinion of the speaker than I am interested in how they got there. So when governors and mayors made the lockdown decisions, they shared with us why they made the decision. They made the decision not because they were doctors or they were epidemiologists. Their job is to process information and reach a conclusion.

On the issue of the lockdowns, what was the decision-making process by which Cuomo and others in the Northeast decided on the lockdowns and what was wrong with their decision making process?

Jeff Singer: One of the advantages of our federal system is that one-size-doe-not-fit-all, so the situations on the ground determine the actions. The situations on the ground in the New York metropolitan area were not the same as in South Dakota, or California.

I don’t want to give a blanket opinion on the decision-making process because rigid restrictions on the movement of people might make sense in one area but not others. In my opinion, the executives basically deferred all decision-making to public health officials.

They basically said to the public health official, “Tell me what needs to be done to eradicate this virus,” and whatever the public health officials said needs to be done to eradicate the virus they pretty much implemented.

But when you’re an executive, you have to consider the trade-offs involved with any decision you make about anything. The health officials are looking at it from one narrow lens — getting rid of the virus. They cannot even pretend to be experts on economics or on sociology. So they’re not considering the economic consequences or social consequences or the long term consequences of some of those things. The job of the executive is to not just consult the public health experts.

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. The only virus that affects humans that has ever been eradicated is Smallpox. Even now when people are stopping immunizations, we are seeing the measles re-emerge 20 years after we thought we never see a case again. Same with polio and things like that. The virus never goes away. We reach a point in our population called “herd immunity,” where if enough people have immunity to it, the virus can’t find enough hosts and vectors to spread around the population to any significant degree.

After the executive consults the public health people, he should consult experts on economics on the unseen consequences of those decisions, “If we were to implement these decisions, how do you think that would affect things? Do you think the public would be willing to go along with some of these measures? What do you think the reaction would be?”

You want the first best solution, second best solution, third best solution. Then the executive needs to weigh all these things before their ultimate decision.

On all levels of government, the executives have basically just limited the decision-making process to public health officials. They admitted it themselves. 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.”

So it’s almost like if 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 eradicated. I don’t care what you have to do, eradicate them.”

Then you go away for a couple hours, come back and your house has been burned down to the ground and you ask, “Where’s my house.”

He says, “I got rid of the roaches. Isn’t that what you told me you wanted to do?”

Every decision made in life involves trade-offs. A tremendous amount of suffering was created that could have been avoided, particularly in certain regions of the country. There have been some studies showing that the spread of the virus in New York is due to the subway system, where people were actually encouraged by mayor De Blasio not to wear masks. There it became a much more critical situation than in other parts of the country.

The more decision-making authority you place in the hands of the fewer number of people, the more you create incentives that are not in our best interest.

For example, let’s say the Governor decides to lift the lockdown, allowing people to come out of quarantine. 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 once they come out of quarantine, more and more people, of course, are going to get exposed to this virus. The case number is going to go up and the press is going to say, “Another thousand cases today, another thousand cases tomorrow.”

Of course, the governor is going to come into a lot of criticism and it may affect his electoral election prospects. The incentives are for the governor to err on the side of precaution. Meanwhile, what is not seen by the extended over-precaution is how many jobs are lost permanently? How many life savings have evaporated? How many people didn’t see 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?

For example, we’ve learned according to the CDC that immunizations are down in the United States by 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 will immunize your children in the car.

Even though the data shows that the young children it’s almost immeasurable how many children can get seriously ill from COVID-19, and adults of parenting age are at a very low risk of getting seriously infected as well. So it is a trade-off of one risk for another.

“Science”: The Last Refuge of Scoundrels and Public Officials

Bob Zadek: 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, someone in 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, economists input, political input, sociological input, and do that last step, to process all of it and make a decision that may be adverse to the economics, but advantageous to the health or vice versa. It’s an abdication when a governor simply says, “Don’t yell at me. I’m doing what my health advisor says.”

Jeff Singer: They say, “I’m going by the science.” It sounds very enlightened, but what they’re really saying is, “I’m basically abdicating all executive decisions to one aspect of dealing with the issue, which is the public health people.”

Bob Zadek: To paraphrase, there’s an old saying that patriotism is the last refuge of scoundrels. Well, hiding behind “science” is the last refuge of elected officials. They get a pass. They get to abdicate the decision-making and say, “Fauci or some scientist told me what to do.”

In this case the governor or the president is being obedient, but not making a decision. The point is that this is the one chance when an executive was required to make a decision and process information when there was a political danger.

On the issue of trade-offs, when one makes a decision to eliminate all elective surgery (unless it’s COVID-related), there are profound long-term health and economic consequences to that decision. Help us understand the unseen, the trade-offs involved here. What were the unseen adverse health consequences of basically denying healthcare to the entire country other than COVID related?

Jeff Singer: First I want to point out that this goes back to the idea of putting all the decisions, a one-size-fits-all, in the hands of a few people. Prior to this pandemic, every few years we would get warnings that there is going to be a worse than usual flu season, and the hospitals need to be prepared in case they have an overload of patients. Normally what happens is that on a hospital by hospital basis, there is more frugality in terms of using beds. Sometimes elective surgeries are postponed until there are more beds.

The plan from the beginning was to “flatten the curve,” which means that 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.

In many states the governors put blanket bans on all elected surgeries rather than allowing local hospitals to make these decisions.

Now being “elective” doesn’t mean getting a facelift. Elective means not done this minute. If you have a perforated ulcer, that’s not elected –you have to go to surgery right now. But if you have something that could be very immobilizing, but which could be scheduled in a more convenient way, like over the next few weeks or even a couple of months, that’s considered elective.

Even among the 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 cataracts and you are really having trouble seeing, that’s cataract surgery is elective, but it might be more urgent for that person who could fall and break a hip — that could be their final event that does them in — then 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. There are catheterizations, colonoscopies for colon cancer, etc. There are people on medications to control chronic illnesses who need to see their doctors regularly to make changes to their medications.

In my state of Arizona, hospitals were about 40% of capacity as a result of this because nothing was allowed to the hospital and it wasn’t an emergency. There were emergency surgeries going on, but only emergency surgery, and the hospitals were actually furloughing or laying off doctors and nurses.

What’s not seen is how many people end up presenting with advanced stage III or stage IV cancers that could have been avoided had they gotten taken care of sooner. How many people are suffering immobilized in pain and who end up dying from pulmonary embolism? This is the unseen.

In my state elective surgery was permitted once again starting May 1st. And one of the reasons why the hospitals are now at about 80–85% capacity statewide is because 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 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 awhile.”

But you notice how when it is done on the local level with local knowledge the backoff may only be for a week or two and only affect one or two hospitals rather than every hospital in the state.

“What’s not seen is how many people end up presenting with advanced stage III or stage IV cancers that could have been avoided had they gotten taken care of sooner. How many people are suffering immobilized in pain and who end up dying from pulmonary embolism? This is the unseen.”

There are almost no cases of COVID in very rural areas of the state yet there was no elective surgery in the state. So people in those areas were also going without care.

Recent reports are showing that emergency room visits are way down compared to this time in previous years for people who would be 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 because people are afraid to go to the emergency room and may be dying at home from other things because it didn’t get treated.

Decision-making should be as much as possible based upon local knowledge and left to local actors, who have the flexibility to rapidly adjust to changes that develop in local areas.

Other Areas of Governmental Interference in Healthcare

Bob Zadek: The examples you have indicated where governors forbade elective surgery is the ultimate scary case where the government officials interject themselves into one of the most intimate of relationships between patient and healthcare provider. The governor steps in and says that 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 — 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.”

That first came about with our discussion on Obamacare – the fear being that it was the government inviting itself into the decision-making process. This is a real life example of what that looks like.

Jeff Singer: It’s not just unique to the COVID-19 pandemic. How about the opioid situation? We had the government passing these prescription guidelines and dosage guidelines. Then the states set up these surveillance monitoring boards, where if they found doctors deviating they’d get a visit from law enforcement.

This was all based on CDC guidelines, which were just guidelines. The government has decided you can only prescribe this many pain pills for this patient in this circumstance. You have to get basically permission from people who are government officials if you want to give your patient a larger dose or a greater number. So it’s not unique to the pandemic. This has been a pernicious trend that’s been going on for quite some time with the government and shooting itself into the practice of medicine.

In COVID-19 you end up dying from the complications — you have multi-organ system failure from the immune response. We’ve known for years, when patients are at this level why don’t we just give them some steroids and see if that helps? This suppresses the immune response. So whether it’s dexamethasone or methylprednisolone or hydrocortisone, they act the same way. Dexamethasone is very powerful and inexpensive and has been around for decades. But using it in that situation is considered an off-label use. The FDA approved it, but not for that particular thing. Once the FDA approved it, you could use it for anything your clinical judgment tells you to use it for, but if you use it for something that was not initially approved for it, then that’s called off-label use.

That wasn’t allowed to be a usage put on the label. We just recently learned from researchers in the UK that it may reduce deaths by up to a third, which validates what a lot of doctors kind of intuitively have been thinking. Mid-March there were a lot of doctors who intuitively had been prescribing chloroquine, which is used to treat malaria and also collagen and vascular diseases like rheumatoid arthritis or lupus for decades. I’m not passing judgment on whether that works. Initially, there was a lot of good reason for clinicians to think that might help.

Unfortunately, President Trump decides to trumpet that this is the game changer. That started a whole firestorm in the press, much of which was politically motivated and partisan motivated. In reaction to that, the FDA first said, “We want to point out that we don’t have convincing evidence on this. It is not approved for use in this,” which first was misinterpreted by the press as meaning it’s not approved, and then governors reacted by actually preventing doctors from using hydroxychloroquine from treating COVID-19 patients.

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 from the national emergency stockpile. Meanwhile data starts coming in, and at this point there is no convincing evidence that it helps.

The point is that the FDA, a week ago, terminated its emergency use authorization. Now we’re stuck with 63 million doses of unused hydroxychloroquine that we paid for in the national stockpile and millions of doses in different states stockpiles. This is a 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.

Devoid of any government interference and coming to the conclusion that in certain situations could be very helpful. In the case of hydroxychloroquine, the government immediately injected itself into it, causing so much waste.

Considering the Reality of Trade-Offs

Bob Zadek: Governor Cuomo said “even one life is invaluable,” that we will sacrifice any degree of economic loss to save even one life. This is an absurd concept because every minute government at every level makes a decision to sacrifice an American life for our greater good. For example, sending troops into combat. We have decided to kill off a certain number of young male 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 permit driving in this country, even though driving kills 55,000 Americans every year. Comment on how one ought to make a decision about lost lives might cost us lives, but how the economic considerations would mitigate against lockdown or closing the economy.

Jeff Singer: Decisions like these should be made much as possible on the individual level because different people are willing to accept this at different risks. For example, tobacco smokers know that they’re risking their lives smoking tobacco, but they made a decision that smoking outweighs the health considerations. They are willing to take their chances. Now in certain situations, for example, if I’m contagious and I could affect the level of the people around me, then it’s not just my decision. So in some cases there are legitimate interventions by the government.

The government’s role must be as narrowly defined as possible. Decisions made outside of the individual realm have to have a compelling reason and there must be a time-limit on it. It should only deal with your ability to affect the life and safety of others outside of you. Because otherwise every day requires these trade-offs. Scuba-diving, skiing, etc. entail risks.

These are decisions we have to make.

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