We must not ‘tolerate’ the deaths of the nation’s most vulnerable

Today, as mask mandates are dropping in many American cities, counties and states, the 7-day average is more than twice as high, at 1,268. Far from a rational response to changing epidemiological metrics, the relaxation of COVID regulations appears to reflect a broad acceptance of mass mortality. 

 

Exactly which deaths we find acceptable should trouble us all.

 

The death toll associated with COVID-19 has been staggering. Deaths directly attributed to COVID-19 in the United States are nearing 1 million. That number is likely quite low, as it includes only those where the death certificate lists COVID-19 as a cause of death, and the politicization of the pandemic has led many coroners and death investigators to refuse to attribute deaths to the disease. “Excess deaths,” a measurement that includes not only those directly linked to the virus but also other deaths that are higher than expected, are now well over 1 million. The director of the CDC’s mortality statistics branch, Robert Anderson, told the Washington Post last month, “We’ve never seen anything like it.”

 

These are sobering figures. Yet numbers like these may well become a basic fact of American life for the foreseeable future with the rollback of basic public health measures. New CDC recommendations for masking place the burden of responsibility on individuals, and effectively raise the threshold for masking to a caseload that will mean more than a thousand deaths per day. A number of pundits have come to accept this on the grounds that most people are only mildly affected by the disease. The New York Times’ David Leonhardt implied in late January that Americans should come to accept the hospitalization and deaths of certain populations, arguing that because COVID is primarily dangerous for older and immunocompromised people, it is not “rational” for the population at large to continue “to disrupt our lives.”

 

More surprising, the principal official charged with managing the COVID-19 crisis in the United States has made remarkably similar claims. When asked to predict the future of the pandemic in a discussion with physicians at Washington University in St. Louis earlier this month, CDC director Rochelle Walensky said “we will have a coronavirus that will lead to death in some people every season that we will then tolerate in some way.” The critical question is who those “some people” are.

 

Walensky began the conversation in St. Louis by noting, correctly, that “where infectious diseases go” is not “places of wealth but places of poverty and places of lack of access.” She added that we would see this in long COVID as well, “where those who have been more commonly afflicted with the disease, who had less access to care and more comorbidities and therefore high risk are going to bear the burden of that disease as well.”

Inequity is of course a central fact in the unequal burden of disease. But in noting that we will come to “tolerate” COVID-19 deaths, Walensky is suggesting that deaths among the poor and among those with comorbidities are somehow acceptable.

 

Still, the statement shows a deep and increasingly common disregard for the deaths of those with underlying health problems. The implication is that vaccinated Americans should celebrate the knowledge that those with no comorbidities are extremely unlikely to die from COVID. But children under five cannot yet be vaccinated, and for the 3 percent of Americans who take immunosuppressant drugs, vaccines have not proven effective. 

Moreover, according to the CDC’s own data, many if not most Americans suffer from underlying health problems that put them at risk for COVID hospitalization and death. As I have noted elsewhere, two-thirds of Americans are overweight or obese, nearly 15 percent are diabetic, and roughly half of Americans have hypertension. Seven percent have coronary artery disease, 40 percent will be diagnosed with cancer in their lifetimes, and 15 percent have chronic kidney disease. According to the American Lung Association, more than 10 percent have chronic lung disease. And many Americans suffer from several of these conditions at once. For the past 20 years, two-thirds to four-fifths of all deaths here have had multiple causes. Comorbidity is a basic fact of American life. Rather than find solace in the idea that only those with underlying health conditions are vulnerable, we should be troubled by the prevalence of comorbidity.

 

Considering these deaths to be inevitable amounts to trivializing them. It accepts the development of what Scientific American Columnist Steven K. Thrasher has called “a viral underclass.” The return to normalcy implied by a dropping of mask mandates and other measures makes life more convenient for the healthy, but it ignores the risks and burdens of morbidity and mortality that such a move creates for people all around us with disabilities and comorbidities. As Ed Yong has noted in a recent essay in The Atlantic, it amounts to a tacit form of eugenics, by clearly valuing certain lives and devaluing others.

 

Public health is dedicated to the protection of populations rather than individuals. This often entails utilitarian calculations about how limited resources can do the most good. The normalizing of COVID-19 deaths involves a cruel calculation that privileges resilient Americans over vulnerable ones, exacerbating their risk where it should be working to minimize it. 

 

If those charged with managing our public health have come to accept deaths among the poor, the immunocompromised, older Americans, and those with underlying health conditions as those we should “tolerate,” they are actively devaluing the lives of those in greatest need of their support. As we march toward a future of endemic COVID-19, we must struggle to defend the most vulnerable rather than sacrifice them.