Physicians’ recommendations regarding who gets ventilators

In “Fair Allocation of Scarce Medical Resources in the Time of Covid-19” (NEJM) a group of physicians ponders the big question that we were predicted to have to deal with right around now: who lives (with a ventilator) and who dies (because there aren’t enough ventilators; though actually most COVID-19 patients who do get a ventilator will die nonetheless).

They’re silent on the question of whether taxpayers should have priority over convicted felons and undocumented migrants on welfare. They have not considered whether a beloved film actor such as Tom Hanks should be preserved ahead of a merely well-liked tire salesman. Should Eric Yuan, a founding engineer of Webex and the founder of Zoom, tech companies that have enabled Americans to learn and work through the plague times, get priority over a strip mall “massage” parlor manager? The docs can’t say.

But there is one thing that they do know: “Critical Covid-19 interventions — testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to front-line health care workers and others who care for ill patients…”

In other words, the doctors think that doctors should be #1 for the ventilators!

[Coincidentally, I looked at all of the same issues and came to the conclusion that golden retriever owners should be #1 for the ventilators. After all, a golden who loses her master/mistress/zistress/theiress is more bereft than most other dogs would be.]


51 thoughts on “Physicians’ recommendations regarding who gets ventilators

  1. Shocking. I really thought they were going to go with Boomers first. Never give medical care to anyone over 30…

  2. I think healthcare workers being first priority makes sense in this case, because, first the usual reason that they can care for others later, and also because they are putting themselves at higher risk by being around most sick patients all day instead of sitting at home, which they may not do if they have no chance of being treated if needed.

    I trust that other priorities can be worked out by a great wise leader (as long as he/she(preferable?)/ze is democratic)?

  3. From the paper: “These workers should be given priority not because they are somehow more worthy, but because of their instrumental value: they are essential to pandemic response. If physicians and nurses are incapacitated, all patients — not just those with Covid-19 — will suffer greater mortality and years of life lost.”

  4. It’s not a long-term supply problem, so the arguments you’ve raised are irrelevant. It’s a short-term supply problem: if a lot of doctors and nurses get sick, it increases the risk of the health care system being overwhelmed. The biggest factors here are the preventive measures: testing (so they don’t infect everyone else!) and personal protective equipment (PPE).

    Did Jared Kushner seriously just say that the federal stockpile of medical equipment is not for the states?

    The main reason to provide priority access to ICU beds and ventilators for medical staff is so that fear of death doesn’t keep them away – they’re on the front lines, with a very high risk of being infected compared to the general population. In Italy, 10,000 hospital workers have been infected, and 74 have died. Dr. Bill Fisher (74 years old):

    I’m a full-time ER doc getting ready to work a 24 hour shift in the emergency department. I am genuinely more concerned about going to work tomorrow morning than I was the day I launched on the space shuttle. 1.5% shuttle mortality vs 9-12% if I get COVID-19.

    • If the doctors are going to head down to safe-for-now-at-least Honduras or El Salvador in a caravan rather than going to work, I guess it makes sense to promise them the ventilator option (though since ventilators can save only a minority of COVID-19 patients who get them, the doctor who is truly interested in self-preservation would still go to Honduras).

      But once a doctor is sick, it doesn’t make sense to give the doctor priority for the ventilator in hopes of maintaining short-term health care system capacity. The doctor who goes on a ventilator today won’t be back to work until long after the forecast period of high demand is over.

    • “If the doctors are going to head down to safe-for-now-at-least Honduras or El Salvador in a caravan rather than going to work”


      Doctors and nurses are coming out of retirement to help fight COVID-19 (“the greatest public health crisis of our lifetimes”). They’re putting their lives at risk, especially since older people are at higher risk. They don’t need to do this. If a hospital worker is infected, gets sick enough to need a ventilator, and dies because they’re basically abandoned by the system, I’d suggest that this would have a major effect on recruitment and morale. The US isn’t China; people can quit.

      Honestly, I’m puzzled about what’s happening to the US. Is social solidarity really so terrible there? Does it not makes sense to you that hospital workers, who are putting their lives at risk every day during this crisis, should get priority treatment? You think the paper’s arguments are as transparently fallacious as arguing for special treatment for golden retriever owners?

      There’s something Joseph Heath says about climate skepticism that sticks with me:

      Most people know full well that climate change is happening. They just are not motivated to do anything about it. … In this respect, saying “I don’t believe in climate change” is just a socially acceptable way of saying “I don’t care about other people.” It should not be taken too seriously—and certainly should not be regarded as the root of the current global impasse.

      This is an example of the genetic fallacy, of course (someone being a misanthrope doesn’t constitute an argument that their beliefs are false). But it does make me wonder if this kind of misanthropy is higher in the US than elsewhere.

    • Russil: Why caravan it down to Honduras? According to today’s WHO report, Honduras has only 219 COVID-19 cases total (1/1000th the # in the U.S.). El Salvador is even better at 41! And the caravan route is apparently well-marked!

      What happened to U.S. social solidarity? Immigration! The U.S. is increasingly a random assortment of people who don’t share any common values (consider an observant Muslim immigrant family from Afghanistan or Somalia that is on welfare, a Venezuelan who didn’t get along with Hugo Chavez and is now working as an Uber driver, a parent-funded Victimhood Studies major who is passionate about promoting LGBTQIA+, and the owner/manager of a 25-employee plastic molding company that competes with Chinese vendors).

      Bill Gates is a classic example of “there is nothing special about my fellow American citizens.” He takes tens of billions of dollars in monopoly profits that were mostly extracted from American consumers and, without it ever being taxed, funnels it over to Africa because All Lives Have Equal Value. There is nothing that ties Bill Gates to his fellow U.S. citizens (and the undocumented waiting for their chain migration or asylum turn!) other than, perhaps, fear that they’ll vote to impose a wealth tax and/or a tax on foundation money that is spent overseas.

      Add to this population growth (also primarily due to immigration). In a country of 330 million, the centers of both state and federal power are so remote from the average voter that he/she/ze/they is more properly considered an “inhabitant” rather than a “citizen”.

      Circling back to your question… should doctors get #1 priority? That goes against current American zeitgeist, in which active duty members of the military, former members of the military (veterans), and “first responders” must be elevated above all other residents. To judge by airline boarding policies, active duty military have to be #1 (even when they’ve run away from their aircraft carrier in fear of coronavirus!). Then maybe veterans and first responders (including those who work a desk/telephone). After that, why not grocery store and Costco clerks? They are at higher risk of contracting COVID-19 than a hospital worker (since the hospital worker has full-scale PPE). They take this risk because their services are essential. They do it for 1/10th the pay of a physician and 1/3rd the pay of a Massachusetts child support plaintiff who once had sex with a physician (see ).

    • “What happened to U.S. social solidarity? Immigration!”

      Given the demonstrated ability of the United States throughout its history to absorb and assimilate people from everywhere, I’m dubious. If you can find a second-generation American teenager with parents from anywhere in the world who doesn’t speak unaccented English and who hasn’t spent thousands of hours immersed in American pop culture, I’d be very surprised. More.

      As a Canadian, the most striking difference between Canadian and US society is the extreme precariousness of American life, which Americans take for granted. If you get sick, or you can’t find work, you’re in serious trouble. This both reflects and reinforces lack of social solidarity: if you’re constantly scrambling to survive, how much energy and resources do you have to try to help other people, or to build up new institutions?

    • > If … you can’t find work, you’re in serious trouble.

      Sadly, tens of millions will be in that trouble soon. They’re losing out so that people near the ends of their lives can die of cancer next year instead of pneumonia this year.

    • Russil: Some second-generation Americans who don’t seem to have been impressed with our culture (the most debauched in the history of humanity?)… (Tashfeen Malik was an immigrant from Pakistan/Saudi Arabia, but Farook was born in Chicago) was born in New York to immigrants from Afghanistan (back in the 1980s). was born in Virginia to Palestinian immigrants.

      Those are just some who made the news!

    • American society is precarious? “If you get sick, or you can’t find work, you’re in serious trouble.”

      If you’re seriously ill in the U.S., you have an absolute right to hospital care regardless of your inability or unwillingness to pay. That’s been Federal law since 1986.

      The undocumented who come to Boston to deliver anchor babies (after 18 years the children will have the right to bring in two parents under our “chain migration” policy) just show up to a hospital ED, say “I’m undocumented and have no address.” They get the same labor and delivery service as anyone else, but without a mailbox stuffed with annoying $25-100 co-pay bills trickling in for the next 2-3 months.

      The U.S. spends more, as a percentage of GDP, on welfare than any other country other than France (see ). Sometimes people need to be thoughtful about the best way to plug into this, depending on the state, but getting hold of a minor child will almost always open the door to free housing, free health care, free food, and a free smartphone. Chapter Jackson explains:

      There is a “chump class” in the U.S. that works full time and yet has a lower spending power and material standard of living than what welfare provides. In some states, including Massachusetts, you have to be an above-median earner to do better than someone who is relaxing in public housing on welfare (see ).

      If the U.S. is stingy, Europe is far worse. Welfare in Europe pays only about as well as working full time at minimum wage or up to 150% of minimum wage. See

      The U.S. has some ugly-looking inequality statistics, but these are mostly created by our policy of unlimited low-skill immigration (documented and undocumented). People who can’t speak English and who lack even a high school education are not going to be high earners. Their children and grandchildren also tend to be below-median earners. Canada rejects these folks, which is why Canada puts up more equal aggregate scores. But if we set aside roughly 75 million low-skill immigrants and their children (see ), our socialist politicians wouldn’t have a compelling statistical case to make. And the 75 million low-skill immigrants and their children are, in fact, living a better material lifestyle (if not spiritual) than they would have had in their original homeland.

    • Russil: Circling back to your point What about the social solidarity in the U.S.? In a society packed with immigrants, I do think that Bill Gates is right. Why do people from Afghanistan, Somalia, and El Salvador who showed up in the U.S. last month and raised their hands for asylum status have a greater claim on working Americans’ wages than people who, perhaps due to old age or poor health, stayed in Afghanistan, Somalia, and El Salvador? In a global economy we are supposed to care enough about a Somali who arrived last week in Minnesota and want to work extra hours week to ensure that person has access to everything we do, but not care at all about Somalians in Somalia and therefore send nothing to them?

      Why aren’t the Somalians who stayed in Somalia equally deserving recipients of our welfare system?

    • “Some second-generation Americans who don’t seem to have been impressed with our culture”

      Fair point. We’ve had a handful of Canadians going to fight for ISIS. To me it seems overwhelmingly obvious that a functioning liberal democracy is better than Islamic theocracy in pretty much every respect, but evidently we don’t have 100% agreement.

      We’ve talked before about how the US social safety net is both expensive and ineffective (like the US health care system). Looking at your arguments here about how generous the US social safety net is, I think the fundamental tension may be epistemological. That is, the Internet (providing a flood of opinions covering the entire spectrum of possible beliefs) plus confirmation bias (making people latch onto whatever agrees with their existing beliefs) makes it impossible for people to agree on basic facts – even in the face of a crisis like COVID-19, people end up believing whatever they want to believe. Since I’ve spent my entire career trying to help make the Internet faster and more reliable, that’s pretty sad.

      I’m not sure why the US would be more prone to this than Canada. I haven’t seen anything in Canada analogous to Trump and Fox News downplaying COVID-19. It’s ironic that older people are most vulnerable, and simultaneously (because of the Fox News effect) the most likely to think that it’s not a real problem. It’s not that easy to switch from thinking “we’re at war with Eurasia” to “we’re at war with Eastasia” (or in this case, from “it’s a Democratic hoax” to “we’re at war with the coronavirus”).

      I’ve commented a lot here recently, often quite critically, but I have to say that I find your thinking useful as a window into what’s going on in the US.

      Are you taking precautions yourself to avoid getting infected (if you’re not already) and to avoid infecting other people (if you are infected)?

    • Russil: I don’t think it is irrational for an older person to be skeptical that shutting down the U.S. economy to fight COVID-19 is the correct course of action. An 85-year-old does not expect to live as many additional years as a 40-year-old, first of all. The 85-year-old has seen more grand government-directed plans fail than has the 40-year-old (too young to have seen the Vietnam War failure; not alive when the failed War on Cancer began in 1971; not alive when the failed War on Poverty began in the mid-1960s).

    • Russil: I think you’re arguing with a straw man. You assume that people who watch Fox News are stupid. Then you further assume that many of these stupid people believe that “COVID-19 isn’t a real problem”. What does that even mean? COVID-19 will kill fewer Americans than Medicaid-purchased opioids. It will kill fewer Americans in 2020, even under the more dire forecasts, than medical errors. If someone says “I think the U.S. has a lot worse problems than X” does that mean they don’t think X is a “real problem”? Or that it is a real problem, but we have additional realer problems?

      (And it is not “mistrust of government” to think that the government cannot cure cancer or protect a densely packed human population of 8 billion from being attacked by a virus, just as it is not “mistrust of a frying pan” if you believe that a frying pan cannot be used to access the Internet. People can “trust” government to run a police department, a fire department, and a court system even if they don’t think the government is the right tool for confronting a virus. The Swedish epidemiologist quoted in thinks government lockdowns have an insignificant effect on coronavirus prevalence and spreading velocity. He is the “state epidemiologist” for Sweden. Do we say that he “mistrusts government” but still enjoys working for the government? Or do we say that he disagrees with you about the appropriate role for government?)

    • “What does that even mean?”

      Survey 160 and Gradient Metrics ran a poll from March 13 to 16, asking registered Republican voters if they were personally staying home from work, and if they thought the media was exaggerating the threat. People who had watched Fox News in the last 24 hours were much less likely to be staying home (less than 10%) compared to those who had not watched Fox News (30%).

      I wouldn’t say that Fox News viewers are stupid. Lots of intelligent people believe things that aren’t true. Confirmation bias means that they can’t tell their beliefs are wrong.

    • “[Anders Tegnell] thinks government lockdowns have an insignificant effect on coronavirus prevalence and spreading velocity.”

      Were you thinking of a different article? He doesn’t say this in the Guardian article that you’ve linked. He says that lockdown measures are difficult to sustain, he doesn’t think they’re required at this stage in Sweden, and that when the lockdown is lifted there’ll be a new surge of cases.

    • From the Guardian piece… While Tegnell understands that he will be blamed if Sweden ends up in a similar situation to that of Italy, he refuses to be panicked. “I wouldn’t be too surprised if it ended up about the same way for all of us, irrespective of what we’re doing,” he says. “I’m not so sure that what we’re doing is affecting the spread very much. But we will see.”

      On the Fox News/idiot correlation… the survey was about whether the media was exaggerating the threat. You are confident that this is “untrue”, i.e., that the media correctly prophesied the number of Americans who would be killed by COVID-19. is now predicting fewer than 100,000 deaths, i.e., two years of Medicaid-funded opioid deaths. Without “social distancing” maybe this could be 130,000 if we take a more generous view of what ventilators can accomplish than the physician who wrote

      What was the NYT saying on March 16? Maybe 480,000, but also maybe 1.7 million.

      I certainly hope that the media was exaggerating back in mid-March because I don’t want to see 1.7 million Americans die or even the slightly smaller number that would die as a result of the same lethality, but slightly better medical care availability due to social distancing.

    • Thanks. Here he’s not exactly making definitive statements: he says he “wouldn’t be surprised” if all countries ended up with the same result, and that he’s “not sure” if measures are affecting the spread of the virus. Earlier in the article he appears to acknowledge that lockdown would slow the virus:

      Stopping it might even be negative, because you would have a pent-up possible spread of the disease, and then once you open the gates, there is a possibility that there would be an even worse outcome.

      I found another article by the same author, presumably based on the same interview. Tegnell appears to be hoping for herd immunity.

      He said that the big unknown was the extent to which populations are building immunity to the virus, and what would happen in areas of China, South Korea, or Hong Kong, where lockdowns had successfully contained the virus’ spread.

      “We don’t even know the level of immunity in China. And of course, that would be very, very good to know, for all of us. If we know that China has sort of reached, quote, ‘immunity level’, that tells the Swedish something about how we should move forward.”

      “If the level of immunity in China is only a few percent, then we have a completely different scenario in front of us.”

      … “This is not a disease that you get rid of. And if you don’t get rid of it, what are you waiting for?” Tegnell said. “You can either wait for some kind of immunity to develop in your population, or you can wait for a vaccine. And the vaccine is, most likely, at least a year away.”

    • “You are confident that this is ‘untrue’, i.e., that the media correctly prophesied the number of Americans who would be killed by COVID-19.”

      I would describe it differently: the non-Fox News media was correct in saying that COVID-19 was much more serious than the flu. The Fox News audience, being told that it was comparable than the flu, didn’t take it seriously, and didn’t protect themselves.

      The Imperial College model (which is what caused the UK to reverse course and order people to stay at home) projected an alarming number of deaths without effective social distancing measures (which are of course extremely disruptive and thus expensive). The University of Washington’s projection of 80,000 deaths is assuming effective social distancing measures are in place nationwide. It doesn’t make sense to point to the University of Washington projection and say, look, it’s only going to kill 80,000 people, why don’t we lift these measures and get the economy going again?

      My confidence in saying that Fox News was wrong is based on a couple things. First and most obviously, what happened in Italy. Second, the number of deaths in the US has been increasing exponentially to this point, with a doubling time of about three days: March 25, about 1000; March 28, about 2000; March 31, 4000; today (four days later), 8400. Third, Fox News has now reversed itself.

    • Russil: I think mostly you’ve shown that big media outlets, including Fox, have multiple contributors. This makes it possible for people to pick out the least successful prophets among those contributors and ridicule them after the fact. If you do a Google search into the domain, though, you find (March 3, suggesting that COVID-19 can lead to kidney and respiratory failure) (March 9, notes that “Other strains of the virus — such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) — can cause pneumonia and possible death.”) (January 29, quoting Federal and academic experts who say not to worry; flu is more risky)

      What if we do the same search into It is actually tough to do! Google shows you a page and says it is from February, but then you visit the site and find that the New York Times has rewritten the article and given it a new date. quotes a public health student as saying this won’t be any worse than the flu. And then a professor: “While the metrics of public health might put the flu alongside or even ahead of the new coronavirus for sheer deadliness, she said, the mind has its own ways of measuring danger. And the new coronavirus disease, named COVID-19 hits nearly every cognitive trigger we have. That explains the global wave of anxiety.”

      In other words, chill out! You’re overreacting.

      From late January, the smartest folks in the world:

      “We don’t have evidence yet to suggest this is any more virulent than the flu you see in the U.S. each year,” said Michael Mina, assistant professor of epidemiology at Harvard T.H. Chan School of Public Health, in a January 26, 2020 Los Angeles Times article. “Most people, with proper medical attention, will do just fine.”

    • Did you get turned around? Aren’t you looking for reasons to believe that the Fox News position before mid-March (i.e. that it wasn’t a serious threat) was correct, and that their position after mid-March (when Trump shifted his position and announced social distancing nationwide) was incorrect? Not sure why you’re looking for instances of Fox News saying the problem was serious.

    • The search was just for articles where coronavirus and flu were both mentioned. I think what the search shows is that Fox “News” like other American “news” media contains a huge amount of speculation. I did find that there was a “Fox News position”. As with the NYT and the “news” outlets that quoted the Harvard School of Public Health faculty, Fox News seems to have featured a range of speculation from a range of people. That’s what makes it easy for people who are passionate about Fox News to go back and pick out some of the speculation that currently appears to have failed to pan out.

    • I’m still puzzled about your line of argument here. Are you trying to defend the claim that the coronavirus threat is exaggerated and that people are over-reacting, or are you trying to defend Fox News and its coverage of the coronavirus? It’s not exactly an extraordinary claim requiring extraordinary evidence to say that Fox News is supportive of Trump, and that they’ve taken the same line as Trump: downplaying the coronavirus prior to mid-March, taking it more seriously after mid-March. To me the most interesting aspect of the Washington Post video clips is the “we’ve always been at war with Eurasia” effect of the same person saying very different things a week apart.

      If you want to focus on what one person has been saying, here’s a set of clips of Trump himself up to March 17, put together by the Guardian.

    • The argument that you’re trying to have about which media outlet, all of which contained a broad range of speculation, was, on average, closest to conveying the correct level of coronapanic cannot be settled right now. We have to see if everyone in open-for-business Sweden dies. We have to see how many Americans ultimately end up needing hospital care and how many test positive for antibodies (i.e., what the total infection rate was).

      Here’s an NBC affiliate, for example, from February 24: “Speaker of the House Nancy Pelosi toured San Francisco’s Chinatown Monday to send a message. She said there’s no reason tourists or locals should be staying away from the area because of coronavirus concerns.” Can we infer from this that NBC failed as a source of true prophecy? You’d have to look at everything else that NBC ran and all of the other people they quoted.

    • Are you still hoping that things won’t be that bad? It seems pretty clear already: by March 31, COVID-19 had killed more Americans than 9/11. A few days later, the death count has risen threefold. The US is basically at war with COVID-19. This isn’t traffic accidents, and it isn’t the flu. The daily count of new deaths is still rising.

      As far as I can see, the only grounds for optimism about the US outbreak are the Kinsa data. Everything else looks pretty bleak, from frontline reports by doctors and nurses to the White House response.

    • “killed more Americans than 9/11” regarding a disease is not an argument for panic and societal/economic shutdown. Regular flu also kills more Americans than 9/11 each and every year, sometimes 20X more (see ; the worst recent year killed an estimated 61,000 and possibly as many as 95,000 (there are huge error bars because, apparently, nobody cares enough about flu to try to get a more precise estimate).

      Diabetes due to obesity kills far more Americans every year than died on 9/11. We don’t put in a simple rule that anyone with a BMI over 25 cannot be served dessert or a large portion by any restaurant.

      Medicaid-purchased opioids kill far more Americans every year than died on 9/11. Nobody says “opioids should not be available via Medicaid except to the hospitalized”.

      We’re trying to have a free lunch. We will save rich people in rich countries with a shutdown and there will be no adverse effects on anyone else.

      Just today: from the Secretary General of the United Nations. He says “Peace is not just the absence of war. Many women under lockdown for #COVID19 face violence where they should be safest: in their own homes. Today I appeal for peace in homes around the world. I urge all governments to put women’s safety first as they respond to the pandemic.”

      Do you want to make sure that every COVID-19 patient comes into an uncrowded ICU (challenging since Americans are completely incompetent at load balancing; a hospital 5 miles away might be empty but there is no mechanism for transferring ambulatory patients there before they start to code out)? Or do you want to make sure that women are safe? Pick one because you apparently can’t have both as a practical matter. The UN guy now says “put women’s safety first.” Okay, so every country has to end its lockdown and try to deal with COVID-19 as best it can.

    • A more accurate analogy from what we are doing to 9/11 would be the following: “Because thousands of Americans died on 9/11 from an Islamic Jihad against office buildings, we will demolish all of our office buildings and ensure that Americans never gather in any building that is more than 2 stories high or larger than 20,000 square feet. This will deny Jihadis the targets that they seek.”

      Or we might have said “Because thousands of Americans died on 9/11 from an Islamic Jihad, we will stop accepting Muslims immigrants or visitors, thus flattening the curve on domestic Islamic Jihad. We can get all of the high-skill immigrants that we need from among the world’s Buddhist, Hindu, Shinto, and Christian populations so why take the risk of an immigrant or child of an immigrant waging Jihad?”

    • “‘killed more Americans than 9/11’ regarding a disease is not an argument for panic and societal/economic shutdown.”

      I’m thinking more of the fact that the Trump administration had plenty of warning that COVID-19 was coming, and failed to act: failed to get testing and contact tracing in place, failed to get enough personal protective equipment for health workers, and failed to act quickly to limit movement once containment failed.

      Problem is, once the epidemic has spread, you need far tighter and more disruptive measures than if you’d acted earlier. It’s a “pay now or pay more later” situation.

    • It makes sense that people who didn’t vote for Trump blame him for the coronavirus “going viral”. And they can also stretch this to explain why none of the 50 independent state public health agencies or myriad city public health agencies took any action (no buying of masks, writing down a plan to load balance among hospitals, etc.). The theory can be that every state public health agency looks to Professor Epidemiology Donald Trump for guidance and will do nothing without his say-so.

      But how do people who didn’t vote for Trump explain the failure to prepare in Canada and in seemingly every European country? Why didn’t Spain, for example, have testing and contact tracing in place and then seal their borders back in February? Spanish government officials and academic experts were glued to Professor Trump’s lectures on epidemiology and accepted no other authority?

    • Spain had less warning; other than that, I don’t know enough to comment. I’m glad to see that the daily death rate in both Italy and Spain has levelled off. Comparing Canada and the US, so far the US has 30X as many deaths as Canada.

      “The theory can be that every state public health agency looks to Professor Epidemiology Donald Trump for guidance and will do nothing without his say-so.”

      Why wasn’t Trump making it a priority for the CDC to get testing underway? At the end of February, BC – a province of 4 million people – had conducted twice as many tests as the entire US. Without testing, you’re blind to outbreaks. On March 1 the Washington Post reported that the virus had been spreading undetected in Washington state for six weeks.

      Why is Trump leaving it to the states to bid against each other for protective equipment, and then outbidding them or seizing their shipments? California is trying to set up a consortium for buying protective equipment.

      The states don’t have the power to invoke the Defense Production Act to order manufacturers to make more protective equipment. Only Trump has that power.

      Truman’s known for saying, “The buck stops here.” As President, he bore the ultimate responsibility. Trump’s view is completely reversed: he accepts no responsibility.

      The Narcissist’s Prayer:

      That didn’t happen.

      And if it did, it wasn’t that bad.

      And if it was, that’s not a big deal.

      And if it is, that’s not my fault.

      And if it was, I didn’t mean it.

      And if I did…

      You deserved it.

    • Why would it be any president’s job to tell the CDC to get testing ready? says “Our Strategic Framework and Priorities are a bold promise to the Nation (and the world). We will use our scientific expertise to bring a new level of preparedness in the US and global health security against current and growing threats, finally eliminate certain diseases, and bring an end to the devastation of epidemics. CDC has a broad mandate and specific directives from Congress for our work…”

      Congress already told the CDC what to do and supplied them with funding (steadily growing, in constant dollars, since the 1970s: ). The COVID-19 outbreak is exactly the problem for which the CDC gets funding. shows that the top managers at the CDC have a technical credentials and 10+ years of experience in public health. Why would you want a non-technical president stepping in and telling them to stop executing on their core mission?

      Your statement is essentially equivalent to “President Trump should have told the FAA to build radars and buy radios and hire air traffic controllers to separate aircraft. He should have reminded them that there were going to be a lot of airliners and also some personal and business airplanes wanting to use the biggest airports and busiest airspace. Without Trump to hold their hands, how was the FAA supposed to know that there would be congestion during thunderstorms at JFK or a surge in private jet traffic to Miami for the Super Bowl?”

      If the CDC is incompetent, that’s perhaps an argument for privatizing this function and contracting out their responsibilities to a few competing companies (instead of relying on a single bureaucracy to give you the tests that you want). But a non-technical president can’t fix an incompetent agency (i.e., one that has failed at its funded core mission) by going in and telling them “be less incompetent”.

      The Defense Production Act? We just need $30 billion and 16 years and we’ll get half of what we ordered.

      Most of the world’s mask-production capability is in China. No U.S. president can order the Chinese around. explains why there isn’t much U.S. capacity. Prestige Ameritech ramped up production in 2009 for the H1N1 panic. As soon as the panic was over, the hospitals switched their orders to cheaper Chinese suppliers (2 cents/mask instead of 10 cents) and the company had to fire everyone.

    • Also, why is Canada’s achievement impressive? Mexico has more than triple the population of Canada. Mexico has 1/4 the number of new cases today, according to the WHO. Despite Canada’s wealth and better-equipped hospitals, Mexico has had only 79 deaths from COVID-19, compared to 231 in Canada. Does that mean that Andrés Manuel López Obrador is vastly better at his job than Justin Trudeau (in or out of blackface) and Donald Trump?

    • “Why would it be any president’s job to tell the CDC to get testing ready?”

      Because he’s the President, responsible for the executive branch of the government? (An Internet wit: “Trump supporters treat him like a god but hold him to the expectations of a special needs golden retriever.”) His job isn’t to tell them how to do it, but he needs to make sure that they’re doing it. With any large organization, whether it’s a business division or a government agency, you need to make sure that their internal focus (what people are actually working on) reflects what the external needs are. That’s true whether you’re a private-sector CEO or the President.

      Here’s what Ron Klain, Obama’s Ebola czar, had to say, in an interview published March 12.

      So if Trump had called you when reports of the disease first came out of Wuhan late last year, what would you have advised him to do?

      A couple things. Once it became clear how bad this was in China, in late December you had to know it was coming here. It’s just, that’s a fact. So you would need to do a couple of things. One, even if he had previously abolished the White House office of pandemic preparedness, he should have then put someone in charge in the White House. That’s the first thing. So we had no one in charge in the White House until essentially last week, when he put Pence in charge. So that’s a lot of lost time in January and February, early March.

      Second thing is, he should have really upped the pressure on China at the highest levels to get U.S. experts on the ground in China, to get a really accurate read on what’s happening and what we know. So he finally did call President Xi several weeks into this thing, but you remember the very first White House briefing on this thing, when Azar chaired the task force, he said, basically, We’re trying to get into China, we called their health minister, they said no, blah. As opposed to, you know, this is a White House problem. The president of the United States calls the president of China and says we’ve got to know what’s going on there. That was the second lost opportunity in January.

      And then, you know, some of this is basic blocking and tackling and good government. Which is, someone running a task force at the White House should have made a list of what the urgent priorities are, like testing, like capacity, and started to execute against that list, early. And, if anything, over-prepared. Like, if we had ordered the capacity to test 30 million people in January and we didn’t need it, that’s just life. Instead, we’re waiting until we know we need it, and that’s just too late.

    • Russil: It may be time for you to edit and add “micromanaging the CDC” to the President’s responsibilities! (right now the CDC, not being at the Cabinet level and presumptively competent to do its technical job, is not mentioned at all) Then I will step in and add “micromanaging the FAA” and demand a White House office to second-guess every Air Traffic Control decision in real-time.

      On the Ebola czar… the guy you cite as an authority says “We learned a lot of things in the Ebola response that color how the administration will look at what it’s doing with Zika. The administration got behind the eight ball and we were playing catch-up all along on Ebola. … In the case of Ebola, we submitted our emergency funding request to Congress the first week of November, six or seven weeks into the peak of the Ebola fear.” So the Federal government was at least seven weeks behind?

      How important is the White House czar? “I didn’t feel very czar-like. Nor should someone. I’m just saying that one thing we have to understand about all these epidemic outbreak responses is we live in a society in America with a very diffuse and pluralistic health care system, right? So even the senior federal official working on one of these things doesn’t control what the governors do.”

      With Obama and this guy in charge, we were prepared at the time for something like coronaplague? He says “I still think as a country and as a world, we’re not prepared for [a pandemic flu].” says that the White House czar was appointed on 10/17/2014. says that the outbreak was reported to WHO on 3/23/2014 (seven months earlier).

      He says it should have been obvious to order 30 million test kits back in January. Did he order 30 million test kits for Ebola? I searched with Google and did not find anything to suggest that he ever ordered 1 kit. And, circling back to my point about what the president’s job is, why wouldn’t the CDC just order the kits itself if the need was obvious to someone with an epidemiology background?

      Regarding Klain, though, he does seem to have learned a huge amount between that February 2016 interview and today!

    • Philip: what we’re talking about falls under the “Executive powers” section of the Wikipedia article:

      Within the executive branch itself, the president has broad powers to manage national affairs and the priorities of the government.

      Thanks for posting the 2016 Ron Klain interview! He talks about the US not being prepared for a truly dangerous pandemic:

      I was brought in to serve what was largely a bureaucratic function.

      But in the course of doing it, it piqued my interest in how we as a country prepare for what’s coming. To me, Zika is front and center. But what America should really be concerned about is how prepared — or not — we are for a truly dangerous pandemic, which will come, sooner or later.

      The Ebola experience was a bit of a test run for that. It was a relatively easy test run in the sense that Ebola is relatively hard to transmit, it broke out in three very small countries. And they were countries that were happy to accept outside help, well-aligned with the West, where we could send a few thousand troops to Liberia, and they’d be greeted as a welcome addition.

      The world faces a pandemic threat that’s very different than that. Some kind of pandemic flu that is airborne and transmits very easily and very rapidly. It could break out in a global megacity, in a densely populated area, it could break out in a country where lots of travelers every day come to the United States. … And I still think as a country and as a world, we’re not prepared for that.

      What could the US do to respond more quickly to a pandemic?

      Should there be a Zika czar?

      I don’t think there needs to be a Zika czar.

      I do think that it would make sense for perhaps the next president to set up a pandemic response directorate inside the National Security Council. We have a permanent directorate to manage threats from [weapons of mass destruction]. We have a permanent directorate to manage threats from climate change. We have a permanent directorate to manage threats from terrorism. We need one to manage threats from pandemics.

      Obama did set up a pandemic response directorate inside the NSC. Trump downgraded it, and its leader (Timothy Ziemer) was pushed out. From May 2018:

      What else could have been done to prepare? Maybe some kind of briefing exercise for the incoming administration?

  5. What has changed? I thought a few posts ago there was no shortage of ventilators and that they were useless? These posts are like presidential briefings.

    • Updated to link to that older posting! The article cited in this post assumes that ventilators have a significant survival value and that they will be in short supply. That older post also answers the question of how we can run out of ventilators even though the number of COVID-19-positive patients who might benefit from a ventilator is small compared to the number of ventilators that the U.S. health care system had in closets (e.g., last year’s model).

  6. Out in the fog there is a story about the number of respiratory therapists in the country, gist of it was doesn’t matter how many ventilators we have there are only so many people that know how to use them. Claimed it took years to make new RTs, no idea if that is ‘licensing standard’ based on job protection and longer $chooling or how long it actually takes to train someone to do the job.

    • He is just finishing! I didn’t want to keep releasing in case he got in trouble with the school bureaucrats for highlighting (at my urging, of course!) their passion for identifying and celebrating victimhood. More to be released starting in May!

  7. You’re a Massachusetts man, and presumably a Patriots fan. Yet you would deny life-saving help to a strip mall “massage” parlor manager? After losing Brady, can Pats fans really risk potentially depriving Kraft of what he needs to ensure a “happy ending” for the team’s season?

  8. I much prefer helicopter aviation, but…you seem to confuse ventilators with respirators. Primacy :).

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