COVID-19, Stigma, Obesity, and Rationing Care

A pandemic such as COVID-19 has a way of raising difficult issues to confront. Questions about who’s at risk also raise issues about stigma and bias. On top of that, when the pandemic overruns our capacity for healthcare, triage becomes a reality. In Italy, physicians on the frontlines of this pandemic are facing difficult decisions about who will get care. Caring humans have to do the very best they can to make impossible decisions for rationing care.

Health Stigma in a Pandemic

Especially in an infectious disease pandemic, stigma can easily become an issue. Remember HIV and AIDS. We do. We remember healthcare providers who refused to provide care. Now we see stigma already arising. In the New York Times, a Chinese-American teen describes the racism she and her friends encounter in the early days of this pandemic.

CDC tells us that stigma may attach to people of Asian descent, travelers, and healthcare workers in this pandemic. Social stigma gets in the way of caring for the people affected. It undermines efforts to control the disease. But there’s a long history of epidemics used to rationalize bigotry. In various flu pandemics, the blame went to Germans, Russians, or Spanish people. In the 14th century, people blamed Jewish people for the bubonic plague. Racism toward Chinese Americans became an issue with SARS in 2003.

It’s an ugly legacy.

Risks, Caution, and Rationing Care

When we wrote yesterday to describe risks that COVID-19 might raise for people with obesity, it was interesting to note how the very thought made some people uncomfortable. “Can we just not talk about this?” was a reaction we heard from a few people.

But there’s a good reason to talk about it. Because some people are vulnerable and they can take extra care to avoid infection. That’s just simple good sense. People over 80 have very high risks if they become infected. Risks are high even for people over 60. Recognizing this fact is not an expression of age discrimination. It’s a necessity to protect loved ones. Likewise people with severe obesity are clearly more likely to have diabetes, heart disease, and pulmonary conditions that bring higher risks with a coronavirus infection. So extra care only makes good sense.

Regardless of all of that, every one of us must prevent the spread of this new coronavirus, because having it spread too far, too fast can have devastating consequences. Healthcare providers are learning this in Italy as rationing care and triage has become a reality. Some patients need a ventilator to survive severe lung problems. But hospitals don’t have enough of them.

Difficult Decisions and Implicit Bias

With rationing and triage comes a risk of implicit bias. What shall the criteria be for favoring one patient over another? Age? Pre-existing conditions? Would implicit bias about obesity creep into these decisions? Such questions are difficult, says George Anesi, a critical care expert at the University of Pennsylvania:

These are really hard decisions. In a public health emergency, you shift from a focus on individual patients to how society as a whole benefits and that’s a big change from usual care.

That leaves us with with an imperative that’s unmistakeable. We have two battles to fight. One is against the coronavirus. The other is with ourselves and our biases. We cannot afford to lose in either case.

Click here for more on the ugly legacy of bigotry and epidemics. For more on implicit bias and medical triage, click here. Finally, for more on the how the coronavirus pandemic can overwhelm our healthcare system, click here and here.

Old Bourke Hospital Bed, photograph © Matthew Perkins / flickr

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March 17, 2020