The Curve Is Not Flat Enough

Hospitals are poised to face the kind of life-and-death decisions that industrialized countries typically encounter only in times of war and natural disaster.

JAMES HAMBLIN MARCH 28, 2020 THE ATLANTIC

An intensive-care unit for COVID-19 patients at an Italian 

hospital ANTONIO MASIELLO / GETTY

Editor's Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here.

Two weeks ago, a man came to an emergency room in New York with pain in the lower-right quadrant of his abdomen. A CT scan showed inflammation around a fingerlike projection at the base of his colon. Combined with a fever, this was a classic case of appendicitis. Surgeons took the man to the operating room and removed his appendix.

The next day, recovering upstairs, the man still had a fever. Doctors ordered a test for the coronavirus. A day later, his results came back positive.

Under usual circumstances, a person with a dangerous, infectious respiratory disease such as COVID-19 requires special precautions in a hospital. Everyone who enters the patient’s room—even to ask how they’re doing or to pick up a lunch tray—is required to don a fresh gown, gloves, and a mask. If the worker must get in close contact with the patient, the mask has to be an N95 respirator, and a face shield is required to guard the eyes. Without exception, every piece of this gear must be discarded in a biohazard dispenser upon leaving the room. An errant mask or glove or gown, coated in virus, can become lethal.

After the man with appendicitis (a patient of one of the doctors I spoke with for this story) tested positive, the hospital implemented such precautions. And staff members who’d cared for him went into two weeks of isolation.

Today, if every hospital employee who had a close encounter with a COVID-19 patient disappeared for two weeks, the medical workforce would quickly become depleted. A safe alternative would be to minimize potential exposures by testing everyone who stepped foot in the hospital: The virus has an average incubation period of five days, which means people can spread it in the absence of symptoms. The U.S. does not have that testing capacity. The next best thing might be to require some form of mask and other personal protective equipment (PPE) for all staff, and possibly even patients, presuming that anyone could be a disease transmitter. The U.S. does not have enough medical supplies to do this either.

Last week, the Illinois Department of Public Health sent a notice to clinics that only those people “hospitalized with severe acute lower respiratory illness” could be tested for the coronavirus. California and New York, similarly, have restricted testing to health-care workers and patients who plainly seem to have the disease. The lack of widespread screening means the coronavirus may well be present in countless hospital wards without anyone realizing it. Accordingly, many emergency-room workers are now behaving as if they’re already infected and separating from their families. One ER physician told me he has been sleeping in the guest bedroom for weeks. Other doctors have sent their families off to stay at second homes.

The majority of workers who keep America’s hospitals running don’t have the salary to afford extra bedrooms, much less extra properties. For technicians, respiratory therapists, first responders, cleaning staff, and many others, doing their job is an act of moral complexity. Without adequate PPE, they’re putting their own health at risk every time they report for duty, as well as that of their families. They also may have other urgent reasons for staying home: being sick themselves, for one, or caring for children who are out of school or for family members who have fallen ill. Not working, for the minority who could financially manage this, isn’t an easy choice either, given that it means increasing the burden on colleagues and putting them at greater risk of getting infected. And this isn’t even to mention the obligation workers at all levels of the hospital hierarchy feel to their patients.

With the United States now leading the world in COVID-19 diagnoses, the demands on the medical system are increasing with each passing day. Nowhere is that more evident than in New York City, the current epicenter of the crisis, where major academic hospitals are being forced to radically restructure how they deliver care. In talking with dozens of hospital workers over the past few weeks (most of whom asked not to be named for fear of professional repercussions), I heard that dermatologists are staffing emergency departments and cardiologists are taking ICU shifts. Medical students at NYU are being invited to graduate early so they can enlist as interns and begin practicing medicine immediately. Governor Andrew Cuomo has asked retired doctors to return to service as the city’s convention center is turned into a field hospital. On Thursday, Avril Benoit, the executive director of Doctors Without Borders—the group known for deploying teams to war zones and other medical deserts—told me she was working on plans to deploy resources to New York City.

Fred Milgrim: A New York doctor’s warning

During World War II, Ford and General Motors rallied to the cause by building tanks and manufacturing ammunition instead of cars. These companies have now begun making ventilators, the devices that push air into the lungs of people who can’t breathe on their own. But without more widespread testing and basic protective equipment, the problem will be less the number of ventilators, and more the number of health-care workers available to operate them. The United States has entered its coronavirus rationing era, and the kind of medical care many people are used to isn’t going to be available all the time. The ubiquitous curve is being flattened by shutdowns and social distancing, but it is not flat enough. Those who might end up in a hospital, which is to say all of us, can do at least one thing to help relieve pressure on the medical system and its overtaxed, dwindling workforce.

On a gray monday in October 2018, a group of biomedical scientists convened in Saranac Lake, New York, to conduct a war game. The enemy was “Disease X,” a hypothetical doomsday pathogen. The scientists weren’t working for the government, but, like that of many experts who have gathered to offer guidance to bureaucrats and politicians, their goal was to take an inventory of existing U.S. capabilities, assess “gaps,” and suggest measures to “improve our position,” according to meeting records shared by Stephen Thomas, the chief of the infectious-disease division at SUNY Upstate Medical University.

One team was told to be risk-averse, modeling the steps the U.S. would take to be optimally prepared to save as many lives as possible. The other was risk-tolerant, modeling what the country would do if it chose to save money and roll the dice, hoping that things wouldn’t get too bad. A risk-averse approach would involve roughly doubling the country’s 170,000 mechanical ventilators, bulking up its strategic national stockpile of masks and medications, and expanding the ability to immediately scale up testing and vaccine development. It would also shore up supply chains of all sorts and create protocols to boost personnel in times of emergency.

America rolled the dice. For just one example, the federal government has invested only about $500 million annually in the strategic stockpile, maintaining about 12 million N95 masks and 16,600 ventilators. This is enough to equip an area hit by a localized disease outbreak, natural disaster, or terrorist attack. But it is nowhere near what could be necessary in a Disease X pandemic.

Read: We were warned

In January of this year, some Chinese scientists warned that a Disease X had arrived, based on genetic sequencing they’d performed. This novel coronavirus, SARS-CoV-2, was almost identical to others that had been found in bats and was capable of hijacking an enzyme in human cells to cause acute respiratory failure.

When I first spoke with Thomas in February, before New York had a single confirmed case, he told me his chief concern: “ICU beds will be limited, and that will mean rationing of expertise in the intensive-care setting. That’s a whole different type of medicine than most of us are used to practicing.” Thomas had spent 20 years in the Army developing “medical countermeasures” against infectious diseases, and, like other military experts who plan for disaster scenarios, he sounded coolheaded in talking about the looming catastrophe. He remained so when he told me on March 16 that his hospital had gotten its first case. At 10 p.m. that day, he emailed and said it had gotten its second. By March 20 he had seven. On Tuesday afternoon he wrote, “We are doing ok. Running out of PPE and trying to build a reliable supply chain

When we spoke by phone late Tuesday night, as he was driving home from the hospital, he sounded tired. I asked him to think back to the Disease X war game. The coronavirus “is much worse than what I had envisioned,” he said. “You never think the planets are going to align. You get used to the near misses. I’m taken aback by the scope, the speed, and how relentless it is. It’s amazing.”

Many doctors are nonetheless being asked to operate as usual. Last week an internal-medicine physician with whom I trained in residency told me she’d been chastised by the head of her department for wearing a surgical mask at work. She feels unsafe without one, given the lack of certainty about who has the virus—not to mention the worry that she herself could be an asymptomatic carrier.

Wajahat Ali: Where are the masks?

Across the world, people are implored to avoid contact with anyone outside a small circle of family members or cohabitants. In clinics and hospitals, doctors aren’t doing their job if they are unwilling to get within inches of people, many of whom are in high-risk groups, and often do so without any protection. “This week we got an order that no masks are allowed for routine care and just walking around inside the hospital,” John Mandrola, a cardiologist in Kentucky, told me. He said his initial reaction was opposition, but he has now accepted that shortages demand rationing.

In fact, taking the standard precautions—using fresh masks and gowns—has become impossible in hospitals in the hardest-hit areas, even when treating people with florid cases of COVID-19. One New York doctor told me she keeps her mask in a brown paper bag until it is time to put it on again, though other doctors at her hospital leave theirs lying out on a countertop. Another physician has been taking his mask home and “sterilizing” it in his oven at night.

This reuse of equipment is a form of rationing, though it may not usually be considered as such. It began weeks ago, when the U.S. surgeon general urged people not to buy face masks. It continued last week when the New York Department of Health implored residents to “only seek health care if you are very sick.” It continues in New York with the cancellation of “elective surgeries,” which now include even cancer treatments that can reasonably be postponed. Many if not most sick people are not getting tested, and not everyone will be treated by the doctor they might expect. Deciding who gets to see the chief of infectious diseases and who is relegated to the retired ophthalmologist will involve rationing via triage.

At a small hospital in Sleepy Hollow, New York, James Lindsey works overnight as the sole doctor in the ER, a setup that is standard in all but the biggest medical centers. Lindsey told me that though he hasn’t yet felt unable to manage on his own, he has had to intubate more patients than usual. That involves inserting a tube into a person’s trachea, in order to force air into their lungs (via a ventilator). When a person can’t breathe on their own, intubation is the default action taken by all doctors and paramedics in the U.S., as is attempting to restart the heart with electric shocks, in between rounds of chest compression that often break ribs. In a typical ER, this process involves a team of people. The question on the minds of Lindsey and others is: What happens if or when there are more patients who need to be kept alive than there are equipment or personnel to help them?

Read: America’s hospitals have never experienced anything like this

Already, ventilators in New York City are in short supply. “Everything is chaotic, and the staff is stretched really thin,” one physician wrote to me yesterday. She has had to pronounce two people dead who have been utterly alone, owing to the rule against visitors that hospitals have established for COVID-19 patients. “It’s really eerie and sad to have no family or visitors around to grieve their deaths,” she told me.

New York’s major medical centers are poised to face the kind of life-and-death decision making that industrialized countries typically experience only in times of war and natural disaster. And unlike with a hurricane, when the sudden force of nature makes obvious that not everyone can be saved, the drawn-out advance of the coronavirus will make these decisions more difficult to accept. We have failed to shore up protections for health-care workers. We have set ourselves up to experience the same shortages of vital care that have already happened in Italy. The rationing is already here.

“The assumptions in a pandemic scenario are that personal and community good can be expected to fall out of alignment,” Thomas told me in one of his emails.“Difficult decisions will need to be made.” Deciding how to allocate limited resources is a nightmare scenario for any physician, a violation of the oath to do no harm. As Thomas put it, “Doctors should not be put in the position of dispensing of justice.”

In an attempt to lift some of the burden from individual providers, Thomas’s hospital and others around the country are convening emergency meetings to develop guidelines for rationing, according to who is least likely to benefit from treatment. The goal is to make the guidelines objective, accurate, and easy to use, as well as to minimize the waste of resources. The instructions could be as strict as age limits for intensive care, or withholding care from people who have the lowest chance of survival, such as those suffering from heart failure or emphysema. On Thursday, The Washington Post reported that Northwestern University’s medical center, in Chicago, was considering putting every patient with COVID-19 on “do not resuscitate” (DNR) status. This would mean that if their heart stops, no “code blue” would be called; instead, a time of death would be noted.

As of Friday afternoon, Thomas’s county was up to 110 confirmed cases. “Winter is coming,” as he put it. But Thomas maintains hope that a blanket DNR policy will not be necessary. “Assess, make decisions, reassess, make another decision. Repeat” is how he described the coronavirus-treatment playbook to me. “We can do this … as long as we have PPE and vents.”

Kerry Kennedy Meltzer: I’m treating too many young people for the coronavirus

Although explicit, widespread rationing by health-care providers is unprecedented in the modern history of the United States, it is constantly happening around the world. “Our doctors face moral dilemmas and impossible choices every day,” said Doctors Without Borders’ Avril Benoit. “Even while COVID-19 is requiring reallocation of resources, we still have women who need emergency C-sections and children with malnutrition. We are converting trauma and burn clinics to care for the disease. You do the best you can with what you have. And many of our locations will not be able to do more than isolate people and provide palliative care.”

Patients, too, make rationing decisions. Every time we weigh whether or not to go to the doctor or to take medication, we’re balancing costs and benefits. Many people—an estimated third of U.S. adults—also make decisions about what they want should they become very ill. In the form of advance directives, they give instructions about when medical professionals should extend their lives with so-called extraordinary measures, and when they shouldn’t.

The directives can be elaborate or spare, but generally land on a spectrum between prioritizing comfort and prolonging life, should the two become mutually exclusive. The most common designations are “full code” and “DNR,” but directives can also get very specific. The options are not binary, care or none. A person who voluntarily designates as “DNR” wouldn’t be abandoned—he or she would still get IV fluids, oxygen, and medication, especially for pain.

Read: How the coronavirus became an American catastrophe

After determining advance directives, you should share them with family members or friends who might be communicating with medical professionals on your behalf. Have nuanced conversations with people close to you about what you do or don’t want in various dire scenarios. This eases the burden on them.

It eases the burden on medical providers as well. Too often, Lindsey said, a person is found unconscious by paramedics, then shocked back to life and brought to the hospital, or put on a ventilator, and only hours later a family member shows up with an advance directive that indicates that this was not what the patient wanted. “This was a tragic and challenging scenario pre-COVID, particularly if an individual’s directives weren’t followed during that period of resuscitation,” he said. But in the midst of this pandemic, the delay puts “all the providers in the chain of care” at unnecessary risk of exposure. And it takes a ventilator out of use for someone who might have wanted it.

As straightforward as it is to establish an advance directive and talk through what kind of care you want with your family, many of us avoid doing precisely that. Who wants to talk about the possibility of getting sick and dying? Thomas does. “I’m still a relatively young person, and my wife and I have that discussion relatively often,” he told me. “It should be had frequently, but especially now.”

JAMES HAMBLIN, M.D., is a staff writer at The Atlantic. He is also a lecturer at Yale School of Public Health and author of the forthcoming book Clean.
Related Podcast

Listen to James Hamblin talk with bioethicist Arthur Caplan on an episode of Social Distance, The Atlantic’s podcast about living through a pandemic:

The Social-Distancing Culture War Has Begun

Across the country, social distancing is morphing from a public-health to political act. The consequences could be disastrous.

MCKAY COPPINS 3/30/2020

INA JANG

Editor's Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here.

For Geoff Frost, the first sign of the coronavirus culture war came last weekend on the golf course. His country club, located in an affluent suburb of Atlanta, had recently introduced a slew of new policies to encourage social distancing. The communal water jugs were gone, the restaurant was closed, and golfers had been asked to limit themselves to one person per cart. Frost, a 43-year-old Democrat, told me the club’s mix of younger liberals and older conservatives had always gotten along just fine—but the guidelines were proving divisive.

At the driving range, while Frost and his like-minded friends slathered on hand sanitizer and kept six feet apart, the white-haired Republicans seemed to delight in breaking the new rules. They made a show of shaking hands, and complained loudly about the “stupid hoax” being propagated by virus alarmists. When their tee times were up, they piled defiantly into golf carts, shoulder to shoulder, and sped off toward the first hole.

Frost felt conflicted. He wanted to encourage the men, some of whom he’d known for years, to be more careful. “I care about their well-being,” he told me. “But it’s a tough call, just personally, because it’s become a political thing.”

For a brief moment earlier this month, it seemed as if social distancing might be the one new part of American life that wasn’t polarized along party lines. Schools were closed in red states and blue; people across the political spectrum retreated into their home. Though President Donald Trump had played down the pandemic at first, he was starting to take the threat more seriously—and his media allies followed suit. Reminders to wash your hands and avoid crowds became commonplace on both Fox News and MSNBC. Those who chose to ignore this guidance—the spring-breakers clogging beaches, the revelers on Bourbon Street—appeared to do so for apolitical reasons. For the most part, it seemed, everyone was on the same page.


The consensus didn’t last long. Trump, having apparently grown impatient with all the quarantines and lockdowns, began last week to call for a quick return to business as usual. “we cannot let the cure be worse than the problem itself,” he tweeted, in characteristic caps lock. Speaking to Fox News, he added that he would “love” to see businesses and churches reopened by Easter. Though Trump would later walk them back, the comments set off a familiar sequence—a Democratic backlash, a pile-on in the press, and a rush in MAGA-world to defend the president. As the coronavirus now emerges as another front in the culture war, social distancing has come to be viewed in some quarters as a political act—a way to signal which side you’re on.

Some of the more brazen departures from public-health consensus have carried a whiff of right-wing performance art. Jerry Falwell Jr., an outspoken Trump ally and president of the evangelical Liberty University, made headlines this week for inviting students back to campus over objections from local officials. The conservative website The Federalist published a trollish piece proposing “chicken-pox parties” as a model for strategically spreading the coronavirus. Throughout the conservative media, calls to reopen the economy—even if it means sacrificing the sick and elderly—are gaining traction.

FRIDAY, MARCH 27,2020 

WHITE HOUSE PRACTICES SOCIAL DISTANCING REPUBLICAN STYLE,

 ALL WHITE MEN SHOULDER TO SHOULDER

CONGRATULATING  THEMSELVES ON A $2 TRILLION DOLLAR 

BUDGET NANCY PELOSI, CHUCK SCHUMER AND THE DEMOCRATS

IN BOTH HOUSES WERE RESPONSIBLE FOR.


“I would rather die than kill the country,” Glenn Beck declared on his radio show.

“Those of us who are 70-plus, we’ll take care of ourselves,” Texas Lieutenant Governor Dan Patrick said on Fox News.

Dennis Prager, a conservative commentator, even compared outbreak-mitigation efforts to Nazi appeasement: “That attitude, that the only value is saving a life … it leads to cowardice. It has to. No one can die? Then it’s not a war.”

This dynamic is playing out in small ways across the country. Bret, a sales representative from Plano, Texas, who asked that I not use his last name, proudly told me how unfazed he and his conservative neighbors were by the threat of an outbreak. In his view, the recent wave of government-mandated lockdowns was a product of panic-mongering in the mainstream media, and he welcomed Trump’s call for businesses to reopen by Easter.

When I asked whether the virus had interfered with his lifestyle, Bret laughed. “Oh, I’m going to the shooting range tomorrow,” he replied.

Was he worried that his friends might disapprove if they found out?

“No,” he told me, “around here, I get much more of people saying, ‘Why don’t you go Saturday so I can go, too?’”

Terry Trahan, a manager at a cutlery store in Lubbock, Texas, acknowledged that a certain “toxic tribalism” was informing people’s attitudes toward the pandemic. “If someone’s a Democrat, they’re gonna say it’s worse,” he told me, “and if someone’s a Republican, they’re gonna say it’s bad, but it’s getting better.”

As an immunocompromised cancer survivor, Trahan said he’s familiar with commonsense social-distancing practices. But as a conservative, he’s become convinced that many Democrats are so invested in the idea that the virus will be disastrous that they’re pushing for prolonged, unnecessary shutdowns in pursuit of vindication.

Among experts, there is a firm consensus that social distancing is essential to containing the spread of the virus—and they warn that politicizing the practice could have dangerous ramifications. “This is a pandemic, and shouldn’t be played out as a skirmish on a neighborhood playground,” Dina Borzekowski, a professor at the University of Maryland School of Public Health, recently told Stat. (For the moment, at least, the scientists seem to have brought the president around: Yesterday, Trump announced he was extending social-distancing guidance until the end of April.)

Of course, not everyone who flouts social distancing is making a political statement. Many have to work because they can’t afford not to; others are acting out of ignorance or wishful thinking. Beyond personal behavior, there is a legitimate debate to be had about how to balance economic demands while combatting a global pandemic.

Still, the polarization around public health seems to be accelerating: In recent days, Republican governors in Alabama and Mississippi have resisted calls to enact more forceful mitigation policies. Polling data suggest that Republicans throughout the U.S. are much less concerned about the coronavirus than Democrats are. According to a recent analysis by The New York Times, Trump won 23 of the 25 states where people have reduced personal travel the least.

Some of this is likely shaped by the fact that the most serious outbreaks so far in the U.S. have been concentrated in urban centers on the coasts (a pattern that may not hold for long). But there are real ideological forces at work as well.

Katherine Vincent-Crowson, a 35-year-old self-defense instructor from Slidell, Louisiana, has watched in horror this month as businesses around her city were forced to close by state decree. A devotee of Ayn Rand, Vincent-Crowson told me Louisiana’s shelter-in-place order was a frightening example of government overreach.

“It feels very militaristic,” she said. “I’m just like, ‘What the hell, is this 1940s Germany?’”

But when we spoke, she seemed even more aggravated by the “self-righteous” people on social media who spend their time publicly shaming anyone who isn’t staying locked in their house. “It really reminds me of my kids who tattle on their siblings when they do something bad,” she said. “I’m a libertarian … I don’t really like being told what to do.”




MCKAY COPPINS is a staff writer at The Atlantic and the author of The Wilderness, a book about the battle over the future of the Republican Party.

TRUMP SCREWS POCAHONTAS'S PEOPLE, AGAIN

Trump moves to take away land from Mashpee tribe — whose casino plans irked president’s ‘special interest friends’

[Trump] was asked to do so by Matthew Schlapp, the chair of the American Conservative Union, the folks who put on CPAC. and a longtime Trump ally. He’s also a lobbyist—hey, we all have to make a living—and among his clients is Twin River Management Group, a company that manages two casinos just over the Massachusetts state line in Rhode Island. The casinos are about 26 miles fromTaunton, and Twin River obviously sees the prospect of a Mashpee-run casino as a threat to their market share.

 

March 30, 2020By Common Dreams


The tribal chairman said the announcement came “on the very day that the United States has reached a record 100,000 confirmed cases of the coronavirus.”

The Mashpee Wampanoag Tribe vowed Friday to fight for its land after the Trump administration announced its reservation would be “disestablished” and its land trust status removed.

This is unconscionable. And making this move in the middle of a pandemic seems to be a clear attempt to steal land while people are otherwise occupied. We all need to speak up. https://t.co/XBG4alCYWo
— katemessner (@KateMessner) March 28, 2020

The announcement came “on the very day that the United States has reached a record 100,000 confirmed cases of the coronavirus,” tribal Chairman Cedric Cromwell said in a Friday statement, calling the move “cruel” and “unnecessary.”

Cromwell said the Bureau of Indian Affairs informed him of the order from Interior Secretary David Bernhardt.

“The secretary is under no court order to take our land out of trust,” Cromwell said in his statement. “He is fully aware that litigation to uphold our status as a tribe eligible for the benefits of the Indian Reorganization Act is ongoing.”

“It begs the question, what is driving our federal trustee’s crusade against our reservation?” he added.

Rep. Bill Keating (D-Mass.), who last year introduced legislation to protect the tribe’s reservation as trust land in Massachusetts, called the order “one of the most cruel and nonsensical acts I have seen since coming to Congress.”

The legislation has stalled in the Senate, the congressman said, since “President Donald Trump tweeted his opposition in an attempt to assist his lobbyist and special interest friends.”

This is one of the most cruel and nonsensical acts I have seen since coming to Congress. The Secretary should be ashamed.https://t.co/rluvccxwKL
— Congressman Bill Keating (@USRepKeating) March 28, 2020


Among the projects put into limbo with the order, as the Cape Cod Times reported Saturday, are “the tribe’s plans to build a $1 billion casino in Taunton, which was part of a yearslong litigation that led to the questioning of whether the tribe qualified for land-in-trust status.”

“The planned gaming operation,” as HuffPost noted Sunday, “would have competed for business with nearby Rhode Island casinos with strong ties to Trump, who once owned, then bankrupted, casinos in Atlantic City, New Jersey.”

As David Dayen outlined at The American Prospect last year, Trump intervened to shore up opposition to Keating’s reservation reaffirmation bill because of the tribe’s plans for the casino on the land.


[Trump] was asked to do so by Matthew Schlapp, the chair of the American Conservative Union, the folks who put on CPAC. Schlapp is the husband of White House strategic communications director Mercedes Schlapp and a longtime Trump ally. 

He’s also a lobbyist—hey, we all have to make a living—and among his clients is Twin River Management Group, a company that manages two casinos just over the Massachusetts state line in Rhode Island. The casinos are about 26 miles from Taunton, and Twin River obviously sees the prospect of a Mashpee-run casino as a threat to their market share.


Author and Intercept co-founder Jeremy Scahill suggested the disestablishment move would have cronies of the president “waiting in the wings to cash in.”

As a casino “businessman,” Trump often tried to destroy and deride Native American casinos. Now he’s using the power of the presidency to steal land from the Mashpee Wampanoag Tribe. #StandWithMashpee https://t.co/BHL5aHMN9c
— jeremy scahill (@jeremyscahill) March 28, 2020


Cromwell said whatever the motivation for the order may be, he remains undeterred in his fight for his tribe to continue having the special legal status afforded by having the land “held in trust.”

“We the People of the First Light have lived here since before there was a Secretary of the Interior, since before there was a State of Massachusetts, since before the Pilgrims arrived 400 years ago. We have survived, we will continue to survive. These are our lands, these are the lands of our ancestors, and these will be the lands of our grandchildren,” he said.

“This administration has come and it will go. But we will be here, always,” Cromwell continued. “And we will not rest until we are treated equally with other federally recognized tribes and the status of our reservation is confirmed.”

---30---

Cuban doctors have been called in to help the Italian healthcare system i

Sunday 22 March 2020 

Cuban doctors have been called in to provide backup for the Italian healthcare system in its battle against the Covid-19 pandemic. Last month it was Jair Bolsonaro who invited them to practice in some regions of Brazil, having previously having chased the doctors off Brazilian soil, accusing them of being ‘guerrilla cells’. Back in 2006, Hernando Calvo Ospina told the story of Cuba’s cooperation with the disadvantaged populations of the Global South. The first international medical brigade was formed in 1963, in a newly independent Algeria.

BERNIE KEPT FALLING BACK ON LITERACY WHEN CHALLENGED ABOUT CUBA AND THE CASTRO'S. 

HE SHOULD HAVE REALLY HIT THEM WITH CUBA'S MEDICARE FOR ALL INCLUDING FOR THE REST OF THE WORLD.

FROM THE ARCHIVES AUGUST 2006

Some 14,000 Cuban doctors now give free treatment to Venezuela’s poor and 3,000 Cuban medical staff worked in the aftermath of last year’s Kashmir earthquake. Cuba has plans to heal those poorer than itself.

by Hernando Calvo Ospina

When Hurricane Katrina ripped through the southern United States in August 2005, the authorities were overwhelmed and the governor of Louisiana, Kathleen Babineaux Blanco, appealed to the international community for emergency medical aid. The Cuban government immediately offered assistance to New Orleans and to the states of Mississippi and Alabama, also affected by the storm, and promised that within 48 hours 1,600 doctors, trained to deal with such catastrophes, would arrive with all the necessary equipment plus 36 tonnes of medical supplies. This offer, and another made directly to President George Bush, went unanswered. In the catastrophe at least 1,800 people, most of them poor, died for lack of aid and treatment.

In October 2005, the Kashmir region of Pakistan experienced one of the most violent earthquakes in its history, with terrible consequences in the poorest and most isolated areas to the north. On 15 October an advance party of 200 emergency doctors arrived from Cuba with several tonnes of equipment. A few days later, Havana sent the necessary materials to erect and equip 30 field hospitals in mountain areas, most of which had never been previously visited by a doctor. Local people learned of Cuba’s existence for the first time.

To avoid causing offence in this predominantly Muslim country, the women on the Cuban team, who represented 44% of some 3,000 medical staff sent to Pakistan in the next six months, dressed appropriately and wore headscarves. Good will was quickly established; many Pakistanis even allowed their wives and daughters to be treated by male doctors.

By the end of April 2006, shortly before their departure, the Cubans had treated 1.5 million patients, mostly women, and performed 13,000 surgical operations. Only a few severely injured patients had to be flown to Havana. Pakistan’s President Pervez Musharraf, an important ally of the US and friend of Bush, officially thanked the Cuban authorities and acknowledged that this small nation in the Caribbean had sent more disaster aid than any other country.

First medical brigade

Cuba set up its first international medical brigade in 1963 and dispatched its 58 doctors and health workers to newly independent Algeria. In 1998 the Cuban government began to create the machinery to send large-scale medical assistance to poor populations affected by natural disasters. After hurricanes George and Mitch blew through Central America and the Caribbean, it offered its medical personnel as part of an integrated health programme. The Dominican Republic, Honduras, Guatemala, Nicaragua, Haiti and Belize all accepted this aid.

Cuba offered massive medical assistance to Haiti, where healthcare was chronically inadequate. In 1998 Cuba even approached France, Haiti’s former colonial power, with a proposal to establish a humanitarian association to help the people of Haiti. The French government did not respond (although, finally, in 2004, it sent troops). Since 1998 Cuba has sent 2,500 doctors and as much medicine as its fragile economy permits.

This free aid - the Cuban government funds the personnel - has been effective. The willingness of the new barefoot doctors (1) to intervene in areas where their local equivalents refuse to go, because of the poverty of the clientele or the danger or difficulty of access, has persuaded other countries, especially in Africa, to apply for assistance.

Between 1963 and 2005 more than 100,000 doctors and health workers intervened in 97 countries, mostly in Africa and Latin America (2) By March 2006, 25,000 Cuban professionals were working in 68 nations. This is more than even the World Health Organisation can deploy, while Médecins Sans Frontières sent only 2,040 doctors and nurses abroad in 2003, and 2,290 in 2004 (3).

The most seriously ill patients are often brought to Cuba for treatment. Over the decades these have included Vietnamese Kim Phuc, the little girl shown in the famous war photograph running naked along a road, her skin burned by US napalm. Cuba also took in some 19,000 adults and children from the three Soviet republics most affected by the Chernobyl nuclear accident of 1986.

In June 2001 the United Nations General Assembly met in special session to discuss Aids. Cuba, with an HIV infection rate of 0.09% compared with 0.6% in the US, made an offer of “doctors, teachers, psychologists, and other specialists needed to assess and collaborate with the campaigns to prevent Aids and other illnesses; diagnostic equipment and kits necessary for the basic prevention programmes and retrovirus treatment for 30,000 patients”.

If this offer had been accepted, “all it would take is for the international community to provide the raw materials for the medicines, the equipment and material resources for these products and services. Cuba will not charge and will pay the salaries in its national currency” (4).

The offer was rejected. But eight African and six Latin American countries did benefit from an educational HIV/Aids intervention project which broadcast radio and television programmes, treated more than 200,000 patients and trained more than half a million health workers.

There are currently some 14,000 Cuban doctors working in poor areas of Venezuela. The two governments have also set up Operation Milagro (miracle) which, during the first 10 months of 2005, gave free treatment to restore the eyesight of almost 80,000 Venezuelans, transferring those suffering from cataracts and glaucoma to Cuba for operations (5). More widely, the project offers help to anyone in Latin America or the Caribbean affected by blindness or other eye problems. Venezuela provides the funding; Cuba supplies the specialists, the surgical equipment and the infrastructure to care for patients during their treatment in Cuba.

So far no other government, private body or international organisation has managed to put together a global medical programme on such a scale or to offer such a level of assistance to those in need of care. Operation Milagro’s goal is to operate on the eyes of a million people every year.

A few hours before he took up office as president of Bolivia in December 2005, Evo Morales signed his first international treaty, which was with Cuba, setting up a joint unit to offer free ophthalmological treatment. As well as the national institute of ophthalmology in La Paz, recently equipped by Cuba, there will be medical centres in the cities of Cochabamba and Santa Cruz. Young Bolivian graduates from the Latin American School of Medicine (ELAM) will take part in the programme.

ELAM was founded in 1998, just as Cuba began to send doctors to the Caribbean and Central America. It operates from a former naval base in a suburb of Havana and trains young people of poor families from throughout the Americas, including the US. There are also hundreds of African, Arab, Asian and European students. Cuba’s 21 medical faculties all participate in training. In July 2005 the first 1,610 Latin American students graduated. Each year some 2,000 young people enroll at the school, where they receive free training, food, accommodation and equipment in return for a commitment to go back home and treat their compatriots (6).

Really doctors?

Ideological considerations have inspired the medical and ophthalmologic associations of some countries to launch a campaign against this initiative. The review of the Argentine council of ophthalmology, for example, questioned whether the Cuban ophthalmologists really were doctors and announced that it was taking steps, along with humanitarian NGOs, to fund a similar programme (7).

There was the same reaction in 1998 in Nicaragua, where, despite the severity of the catastrophe caused by hurricane Mitch, President Arnoldo Alemán refused to admit Cuban doctors. Similar reactions have been seen in Venezuela since 2002 and now in Bolivia. Conservative doctors, who prefer to specialise in diseases of the credit-worthy and refuse to enter shantytowns, accuse Cuba’s barefoot doctors of incompetence, illegal medical practice and unfair competition.

In April 2005 the legal authorities in the Brazilian state of Tocantins ordered out 96 Cuban doctors who had been treating the poor. The state governor disagreed, but could do no more than “recognise the professional bravery of the doctors who were welcome here and whom we wish to thank”.

The medical associations are afraid that if the Cuban medics bring down prices or even offer some services free, medical treatment will cease to be a profitable, elitist service. As each new doctor graduates in Cuba, they intensify their protests and political pressure.

There is also a threat that diplomas obtained in Cuba will not be recognised elsewhere. Excessive charges in Chile have prevented many Cuban-trained doctors from validating their medical qualifications there. But, as the BBC has pointed out, if Latin America’s medical associations persist in their opposition they risk losing the support of populations deprived of access to health services, for whom the project is a glimmer of light in the darkness (8). In the US, where 45 million people have no health cover and medical studies cost about $300,000, a blockade forbids students to study in Cuba, threatening up to 10 years’ imprisonment and fines of up to $200,000.

Sceptics see the humanitarian aid offered by Cuba as a publicity stunt, an investment to secure diplomatic support in the face of continuing US hostility. They point out that when the UN Human Rights Council was established in March 2006, Cuba was elected with the support of 96 of the 191 UN member states, whereas Nicaragua, Peru and Venezuela, where political opposition is legal, as it is not in Cuba, were rejected.

But a western diplomat was prepared to recognise that Cuba’s policy of exporting doctors was an initiative which benefited so many people that it should be applauded even by its political enemies (9).

Hernando Calvo Ospina is a journalist and the author of ‘Bacardi: the Hidden War’ (Pluto Press, London, 2002)
Translated by Donald Hounam

(1) This term originated in China around the time of the Cultural Revolution and described farmers with basic medical training who worked in rural areas.


(2) During 2005 the programme helped the most deprived areas of six countries in Latin America and 20 in Africa. The staff delivered more than half a million babies, carried out 1,657,867 operations and did almost 9 million vaccinations.


(3) Financial report for 2004.


(4) Speech by the Cuban vice-president, Carlos Lage Davila, http://www.iacenter.org/Cuba/cuba_a...


(5) In the region, a cataract operation costs a minimum $600.


(6) The joint projects between the governments of Venezuela and Cuba include one to offer free medical training to 10,000 Latin Americans annually, not only in Cuban universities but also in an infrastructure being set up in Venezuela.


(7) Periódico Informativo Oftalmológico, 37, Buenos Aires, 26 December 2005.


(8) BBC, 5 April 2001.


(9) Ibid.

Unconditional Freedom 2049


Jorge Pinto and Eduardo Viana’s comic on European basic income and what it meant for one family among millions.

https://www.greeneuropeanjournal.eu/unconditional-freedom-2049/

Rebooting Humanity: Blueprints for 2049

The fourth industrial revolution is upon us, and it is here to stay. How can progressives take back control from tech giants so that the benefits are reaped by all, not just a privileged few? Green European Journal editor-in-chief Laurent Standaert spoke to philosopher Rosi Braidotti about how, to make an increasingly robotised world both fair and inclusive, we must interrogate what it means to be human.

Laurent Standaert:  You’re someone who already studies the future in the present.

Rosi Braidotti: Well, I look at the present in the way that my philosophical mentors and teachers did, which is to look at its genealogy and ask “How did we get to this point?” Take Foucault’s genealogy of psychoanalysis, in which he analysed its evolution and its institutions, all the way from prisons in medieval times to asylums, madhouses, and psychiatry. He and others were asking how you can detect in the present the seeds of the future. How are the new figures and discursive categories that then rule our lives emerging? Look at how the new discursive category of the ‘terrorist’ has evolved to affect our daily lives, our institutions, our ideas and policies, modelling society and influencing technological developments.

In the end, what is really important and interesting is what we are in the process of becoming. And to those who criticise this way of working as being ‘marketing’ or doing what research and development people in Google and corporate labs are doing, I say, “So what?” This is what I call the accelerationist argument for the Left and progressives. Are we going to leave the blueprints for the future to the corporations, or are progressives going to influence dominant ideas and counter neoliberal trends? Where the marketing department of Google pushes in one direction – and that is mainly profit-making and a certain view of what is human – we must push the future in the other direction: democratic participation, solidarity, distribution of wealth, and so on.

What are the biggest challenges for progressive forces in apprehending technology, which is today either sold to workers as a threat or to citizens as the panacea for democracy and society?

One of the first things the Left and progressives need to do is to get rid of the social constructivist, dualistic methodology that has become our mode of thinking. It’s binary. It’s us and them. It’s nature and culture. It’s machines and humans. In particular, the idea that technology and humanity are opposed is ridiculous. Ask your readers who are against technology to shut down all their devices. In fact, throw them away. Oh? Now most of us are not so against technologies anymore because we can’t live without them, because they are not devices, they are us, they are extensions of ourselves. This shift is massive and there is both anxiety and contradiction in the Left’s relationship to technology, mostly for lack of better ideas. This confusion comes down to thinking that the smartphone with which you are recording this interview is external to the human.

Are we going to leave the blueprints for the future to the corporations, or are progressives going to influence dominant ideas and counter neoliberal trends?

The fourth industrial revolution is here and it is extraordinary, in both positive and negative ways. Artificial intelligence will replace millions of jobs and the economic order is mutating. The task of the Left and progressives should be to manage that transition because there is a polarisation of resources and those at the bottom are missing out badly. This means repairing the situation of those people who have been left behind due to the speed and violence of the transformations, but also due to outdated forms of resistance. A basic, 20th-century model of solidarity is necessary, but this alone is not enough because the technological revolution is continuing, as are its social consequences. The computational networks will continue to generate enormous wealth and enormous disparity in access to this wealth. The idea that our lives – both social and economic – are technologically mediated and that we consume and generate data day and night for free has acquired not a left-wing label but a right-wing one with the tag ‘pay as you consume’. The profit motive guides technological development. We need to take a different direction and make this technology a universal and free human right.

What worries me is that progressives and the Left don’t even agree on the diagnosis of the technologically driven and mediated social sphere. These developments are here to stay. For all its problems, the fourth industrial revolution is an exciting prospect and I don’t see why we can’t have a future-oriented economy with present-day solidarity and redistribution mechanisms.

What governance structure and institutions do we need to create that effect?

More Europe! Fiscal power and unity is absolutely crucial to have regulation and redistribution programmes. And yes, the EU can be about redistribution of income, solidarity, and blocking the monopolies of Facebook, Uber, AirBnB, and others who are basically running fiscally illegal operations. When the EU clamped down on Facebook through the GDPR, founder and CEO Mark Zuckerberg lifted a couple of billion accounts from Ireland to Florida overnight. These are the Rockefellers and Guggenheims of our times and we need to tackle them. When the OECD predicts that millions of jobs are going to robots by 2030, we need to act now and at the European level because the transition is already here. People are not stupid and they are going to be angry when their jobs disappear. For lack of response, they’ll turn to the far right in desperation for some strongman to solve their problems. We can avoid that if we’re absolutely clear on the need to redistribute what we have and to train people for the new economy.

Having the European governance here is the only model. It is tragic that Eurosceptics on the Left base their scepticism on a 19th-century model of the economy (while those on the Right revert to virulent nationalism). It is up to progressives and the Left to produce a credible alternative that is anchored in the present and the future, not the past.

In your words, the Left seems to have missed out badly on the tectonic shifts taking place in economy and technology.

The Left missed the early warnings about capitalism’s transformations in the 1970s when Gilles Deleuze, Félix Guattari, and other post-structuralist thinkers explained, on the aftermath of the political fallout of May 1968 that capitalism does not break – it bends and adapts. The dialectical paradigm was inadequate: we could not and cannot continue with ‘us and them’. The post-structuralist thinkers were saying that we ourselves are part of the problem: we love our television, our cinema, the technology of the day. These technologies are so seductive that they just take off, and we produce more and more information. Capitalism does not need the industrial base, it can invent new products; a financial economy disconnected from the real economy. Back in 1990, in Three Ecologies,Guattari commented on the rise of information capitalism and talked about personas such as Donald Trump as emblematic of this economy. The Left did not listen!

But today tech goes much further than information technologies. It pertains sometimes to the very fabric of life.

Indeed, advanced capitalism runs on algorithms and on biogenetic codes. It capitalises on life and life systems. In this respect, it does not need an industrial base to flourish – (under) paid labour is not the only source of its surplus value. Today the meeting of biology and technology means that bioeconomy is invading our corporeal system, from what we eat to how we heal ourselves. Artificial meat is already old news – we can make enough synthetic meat in laboratories to supply China.

A progressive position would consist in debating, for instance, whether it’s right or not to have a new bio-technologised food industry, with moderate prices and open access, or whether it’s better to have agroecology, but the point is that we cannot leave these developments to the Right and to the unregulated profit-seeking companies. Why not a bio-socialism for the future? At the moment, if one of my colleagues in the life sciences department patents a new type of carrot, it is their private property. How this is even allowed?

Who’s going to break with that system and offer a new paradigm? Hackers? Digital commoners and pirates?

Hackers, pirates, and digitals commons people are all facilitating the change but it cannot happen without the involvement of citizens in their own right, plus some serious institutional support – a much more mainstream change like the EU taking on tech giants or South Africa taking on pharmaceutical companies on HIV medicines. Universities have a very big role in this. The neoliberal takeover of universities is an unredeemed catastrophe because it has gone too uncriticised. Universities are becoming money-making machines. Since when did universities have to make profit and compete in a financial market? They used to have charity status and now they participate in the monetisation of knowledge. The university is a centuries-old institution whose model has survived massive revolutions and changes throughout history, from the Guttenberg press to the computer. And now they should model themselves on banks and corporations?

To come back to technology, you’re saying that it allows a more profound discussion about humanity?

Yes, and much of what I’m describing in my books is actually the current economy. The way Amazon or hospitals are increasingly being managed is with AI and robots: from logistics and decision-making to surgery and robots taking care of old people and rocking babies’ cradles! And here comes my big disagreement with transhumanists, all the way from Oxford to Silicon Valley. They are putting the post-human in the future so as to extract themselves from the reality of the present. Oxford scholars are transposing the dominant formula of the Silicon Valley into the world of research. Their thesis is that machines are faster and better than the human brain and body today and therefore we need to enhance the human to make it competitive and surpass the machine. But who decides what machines can or should do? Who decides who is enhanced to become the superintelligent human?

Oxford transhumanists are attaching their thesis to the notion of the liberal individual agent who is epistemologically the humanistic, Eurocentric, masculine, heteronormative, sovereign image of the subject. What I am saying is exactly the opposite: relinquish the liberal individual, bring in nomadic subjectivity, transversal connections and think of ourselves always as an assembly, a complex multiplicity, a plurality. Going beyond ‘human-versus-nature-versus-machine’ is already a way of starting to recompose a different democratic order.

The unit of assemblage is indeed an individual, but completely enhanced, transversal, connected, and mediated. This philosophical and political vision and attitude allows us to ‘relax into’ technology and repurpose it for the benefit of society and the planet.

So the ‘post-human’ goes way beyond just technology and transhumanism?

The post-human is a way of marking where we are at in evolution. But it’s not ‘one day we will be post-human’, it’s something that is in the process of happening. The post-human is about the displacement of the centrality of the anthropomorphic brain as the producer of knowledge, and it’s about convergences. The fourth industrial revolution is defined by the convergence of technologies: info, geo, bio, and nano technologies. Artificial meat is a combination of stem cells, neurological stuff, and, of course, computers, computers, computers. The digital grid is the starting point and everything converges.

We have a lot to learn from all that which has long been excluded from ‘humanism’, from women to indigenous people.

But we cannot escape the fact that all this happens within what is commonly called ‘the sixth extinction’. The connection between the fourth industrial revolution and the sixth extinction is the missing link. We cannot move into the post-human fully if we stick to an old conception of humanism that excludes women, feminists, the indigenous, the post-colonial, the foreigners, the refugees, nature, and animals.

We can’t even start to think who exactly is ceasing to be. And if the fourth industrial age is what we are in the process of becoming, what is ceasing to be then? Unfortunately the fourth industrial revolution and the sixth extinction are ever more disconnected. My favourite example is bitcoins and crypto-currency. Wonderful technology, but one calculation finds that blockchain uses as much electricity as the whole of Iceland. So should it exist? From the perspective of sixth extinction, the fourth industrial age looks like suicide, unless we seriously start looking at redistribution along non-human lines as well as human lines.

Today, telling citizens that climate is changing, that everything is connected, and to get them involved without causing mass hysteria seems utopian. Instead, we have the radical mediocrity of a political system that doesn’t want to break the news that we can’t afford the fourth industrial age. Nobody is bringing radical ecology into it, there is no calculation of cost and risks that takes in the earth as a primary mover. A few countries make small steps giving legal personhood to nature and defending indigenous people, and to that we can add international law and conventions, but this does not take us very far. We have a lot to learn from all that which has long been excluded from ‘humanism’, from women to indigenous people. Indigenous people sustained land for thousands of years and Western humanism destroyed it in 150 years, if not less. But do Silicon Valley and Western governments listen to any of this? It’s the disembodied and disembedded nature of the worst European, Western science at work.

For me, the solution has been all along with feminism. Feminism says we have to learn to live differently. But asking people to change the way we live appears to be asking a lot. Capitalism does this, 100 times over, eliminating jobs, destroying family structures, profoundly changing the ways we lived and live, but that’s OK because that is ‘progress’. If we ask people to change in a different direction, it’s utopia! The basic lesson of feminism is interrogating the way we live and speaking from experience grounded in realities, not from a black box that we call the human consciousness. To be grounded and responsible for the planet is also a contribution of post-colonial theory. It is a critique of globalisation as it is sold – a disembodied and abstract process, capital flowing through the air and on the internet. I’m not opposed to market economy; capitalism is a simply a very bad, unsustainable market economy.

What would your Europe of 2049 look like?

My Europe would have retained its democratic achievements and would not be at war in 2049. It would have full, free internet for all, border to border. It would have a population that sees technology as part of what they do and how they live. Robots would be included as friends and co-workers because we will have made it possible for people to see this way by distributing the income that we will have made through the fourth industrial revolution. I see new forms of literacy, and people working less because there will be less need for it but being involved at a very local level. A rebirth of the local, making communities work, making sure that city centres don’t die, and making sure that none are left behind.

I dream that we make the sixth extinction avoidable by 2030. And if it sounds like a utopia, it is because we don’t yet have this space of democracy and solidarity that allows and nurtures critical intelligence. This will be a Europe where the political economic system does not keep citizens in the dark. Institutions will help citizens understand the conditions of their freedom and their un-freedom. There’s a lot we can do to further improve our collective intelligence, to have an empowered, energised citizenry and a system that does not create generations and classes of dispossessed. Collective intelligence gives hope and certainly can help to address the real problems our planet and our societies are facing.

https://www.greeneuropeanjournal.eu/rebooting-humanity-blueprints-for-2049/