The Choice

by Barry P Chaiken, MD

The inherent nature of patient care requires making a choice. What therapy will help the patient get better? What is the probability the drug will cure the disease? What are the risks? Can the chemotherapy lead to injury or death?

Both clinicians and their patients are faced with these options daily. Oncology patients regularly choose among paths where their decision has very serious and sometimes tragic consequences.

My dad, suffering from advanced prostate cancer, received a chemotherapy dose that compromised his immune system. He quickly caught pneumonia and died just a few days later. He was 63 years old. It was a necessary and logical choice, but it produced an undesirable outcome.

In addition to our clinicians having to make these life and death choices, we now have governors such as Cuomo (NY), Hogan (MD), Kemp (GA), and DeSantis (FL) in this position. Both NY and MD have decided to keep a tight grip on the activities their citizens can participate in during this pandemic. Schools are closed, businesses shuttered, and beaches are currently off limits. Both Cuomo and Hogan are following the science and saying there will be no opening up of activities until the data shows it is safe.

As Governor Cuomo often says during his daily briefings, “We will loosen the activity valve and monitor the data. When we slowly loosen the restrictions on activities the data will determine how much the valve is loosened or tightened to control the spread of the virus. “

The basic reproduction rate (R0) shows how many people an infected individual will transmit the disease to before they recover. To break the back of a pandemic, the R0 must be less than 1. This means that for every infected person, less than one other individual is infected by them. This forces the pandemic to burn itself out as the number of new cases declines. An R0 greater than 1 means the virus is spreading exponentially leading to an increasing number of new cases.

All reputable epidemiologists believe that relaxing activity restrictions will increase the R0 value leading to an exponential acceleration of the spread of the SARS-CoV-2 virus and its related morbidity and mortality.

Governor Cuomo uses measures such as number of new cases and hospitalizations to estimate the R0 and decides how to calibrate the loosening or tightening of mitigation measures (e.g., business closings).

Governors Kemp and DeSantis take a different approach. Rather than following the epidemiologic data, they focus on economic data. With businesses closed across their states, they heard from citizens about economic hardships. In addition, they looked at their tax receipts. With retail sales and payrolls smaller, so were the related state tax revenues. These governors of GA and FL believe that relaxing restrictions on activities will facilitate economic activity. And their states, like their citizens, could use some economic relief.

Faced with two different choices with essentially the same epidemiological and economic data, these governors have chosen completely different paths. Cuomo and Hogan believe preventing deaths from COVID-19, despite the economic hardships associated with restricting business activity and personal movement, is worth the economic cost.

In contrast, Kemp and DeSantis believe expansion of economic activity by relaxing restrictions on public activity is more valuable than preventing an increase in COVID-19 related deaths.

While data provides us with insight, it does not make decisions for us. Data informs our decision making, hopefully leading us to better choices. But in the end, it is us humans who choose. And in our choices, we reveal who we really are.

Comments 2
  • Barry, fabulous piece, thank-you for explaining the R value in way we can all understand. I have never believed that analytics should make decisions particularly in healthcare where effective patient engagement & behavior is highly personal, nuanced and a far greater influencer on outcomes than science Plus the science is always expanding. Providers teamed with patients and their families informed by data and insights insights should make these decisions and then better compliance and outcomes can follow. Jack, I totally agree that “one size” does not fit all. But the data belies more and more of the decisions being made less populated areas, https://time.com/5831319/coronavirus-rural-america/

  • Chaiken’s argument demonstrates how a “one size fits all” approach to healthcare, whether dealing with a pandemic or not, is simply unfeasible. The human factors are just too multi-various and complex. DiSantis has been roundly criticized for opening Florida too soon, but there is some evidence that the state has high-population pockets where stricter measures are appropriate but also wide swaths where population density is extremely low and people are relatively more safe. Cuomo should think about that: there’s a lot more rural New York than there is New York City.

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