Triage: If You Thought I was Over-reacting with the Food Storage Stuff…

Sharon May 7th, 2008

The idea that we might for an extended crisis be effectively on our own is something that gets you one of two reactions.  1. “OMG!  I’d better do something about this” or 2. “Yeah, it’ll never happen”.  Now not everyone has the same reaction time.  I completely ignored Y2K, never bought any plastic sheeting or duct tape after 9/11, and was too young for the duck and cover drills.  

 Now for a long time the “It’ll never happen” folks had the majority - but that may be coming to an end.  After all, there’s something about seeing your own military blocking people trying to walk out of New Orleans and folks screaming for help in the superdome while the government serenely ignores them that does point up the “maybe we should have a plan” idea. 

I’ve seen this myself, as people move from thinking “Sharon’s that whack-job apocalyptic nut” to “Well, she may be a whack-job apocalyptic nut, but she’s kinda right about some stuff…” ;-) .

Here’s a new bit of news on this subject.  From the Medical Journal _Chest_ comes a study that tries to deal with the hard questions of how to allocate scarce resources in a time of epidemic or other large scale medical crisis.  There’s an AP summary here as well.  And let’s just say that it didn’t precisely make my day to know that when there are difficulties with allocation of scarce resources, those with “severe mental impairment” (which is not clearly defined in the study or the article) will be on the list of people to be denied treatment, since my eldest son pretty clearly fits that definition.

There rest of the list includes:

_People older than 85.

_Those with severe trauma, which could include critical injuries from car crashes and shootings.

_Severely burned patients older than 60.

_Those with severe mental impairment, which could include advanced Alzheimer’s disease.

_Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.

 Now first off, I’d like say that I think that the project of triage is necessary, and unpleasant, and it is probably good that guidelines are being established.   I’m not demonizing this one report, or the doctors that made it.  I’m also aware that Eli would have to be very sick and have a high likelihood of death before this protocol was even relevant…probably.  

Let’s be clear  - this report does not say they would deny treatment to anyone with the above conditions, but that a combination of these conditions and a high likelihood of death already would cause triaging.  The reason I am concerned here, besides my personal investment, is that triage sometimes has to move down the chain - that is, a plan that carefully limits rationing works only when there still remain substantial supplies.  If supply chains tighten further, then you have to ration more stringently - and a set of guidelines for rationing that starts the process are likely to continue being part of the reasoning as rationing gets tighter.  So, for example, if mid-way through a crisis supplies begin to be limited, the above parameters are implemented.  But when supplies get really tight there has to be a mechanism for deciding how what remains gets allocated - and if we’ve already downgraded the elderly, mentally disabled and chronically ill, that does point out the next move.

The unfortunate truth is that you end up triaging one way or another - that is, if you have a limited supply of medical resources and no certainty that you will be resupplied, you can use them all up on early arrivals, and thus triage by when you show up, or you can find some other way to ration.  Just because I’m fairly horrified by the idea that in a pandemic or other widespread medical crisis my kid might not be treated doesn’t mean that I think that the doctors doing this aren’t trying to address a difficult concern. 

All of us may be doing some ugly triage at some point or another, as we sort out what resources in our communities are salvageable.  There is no way not to sort things out when there are limits on resources - one way or another, when needed items are scarce, you make choices about how to use them.  We often imagine that unconsciously going forward and using things up until they run out isn’t a form of triage, but, of course it is - and usually an inequitable one.  The reality is that rationing of some sort is almost always a better solution than not rationing, when you run into absolute scarcity.  And sometimes, the choices will be bad - there will be no way to make one without hurting someone. 

So I don’t think that this report is fundamentally a bad thing.  We do need a triage plan.  But we also need to fill in some steps before triage, and make sure those who have to implement strategies know when to go to triage, and when not to.

 You see,  the problem with applications like this is that they do get complicated.  And in the heat of things, complexity tends to fall by the wayside.  Medical studies have suggested that this is quite common, for example, that thousands of medical deaths are caused each year simply because in the heat of things, it is difficult for doctors and nurses to remember to do every single necessary step to minimize risk.  Doctors and nurses are human beings, and make ordinary human errors.

So a fairly complex way of sorting people out (evaluating both their likelihood of death and their quality of life/lifespan, giving each a score and then having a designated person make a decision) has a solid chance of going wrong when the crisis occurs when the designated person is not there, the chart is buried in the wrong office and no one has the key and the person who went through the training once six years ago has to make the decisions.  And it would be pretty easy for those decisions to translate, in a crisis to: we don’t have any resources for the elderly, sick, disabled or mentally impaired, or for triage protocols to be implemented before they are necessary. 

 And, of course, because the poor are more likely to fall into many of  these categories, they are likely to be disproportionately allowed to die in  such a crisis.  This is largely because of our present system of health care rationing, which sorts us out by ability to pay.  That is, people who are already being rationed out of care will then be penalized for this. I think it is worth noting that those who are most likely to be victims don’t look just like my middle class, white kid.  Heck, I could probably fake it if he were sick enough, and lie about his situation.  But it is harder to lie to doctors about your diabetes, your cancer, your skin color or to conceal your or your child’s obvious severe disability. 

This protocol may or may not become part of the SOP at hospitals around the nation.  But there’s a good chance that at some point, some kind of triage protocol will be implemented, and some sad, horrible choices will be made. It is even possible that such a protocol will never be misused - that good choices always will be made honorably.  But it is also possible that they will not.  The truth is that we ration right now by ability to pay - and that the people we ration to tend not to be very politically powerful.  So maybe, just maybe we have to be very, very careful about the assumptions we are nurturing under the auspices of preparedness.

 This is also a reminder (in case we needed one) that rather than prepare and adapt for oncoming crises, our society tends to choose the easiest ways to mitigate potential harm, rather than the most comprehensive ones.  Despite years of awareness of the possibility of epidemics or widespread disaster, it is always easier to claim that no one could have forseen this, and to under-prepare.  It is always easier to let the most vulnerable people in a society slide - they don’t protest very loudly in many cases.  It is easier to let the levees crumble than to allocate money to protect mostly very poor and very black people.  It is easier to talk about rationing for the disabled and elderly in a crisis than to come up with a plan for ensuring their needs are met.

Thus Hurricane Katrina became the ultimate expression of who we value: “Own a private car, or die…oh, and it is just a coincidence that you aren’t white…”  In a sense, I give this report credit - it at least opens up discussion and analysis of who we value, rather than leaving it unspoken, but just as deadly.  But I also recognize the risk of sending messages about who we value that get twisted into much more explicit, even more troubling messages.  The triage protocol may be necessary - but it is also necessary to ask “are we doing everything we can to ensure that this protocol’s use will be minimized?”  In this case, we are not.  US preparedness for medical disaster is woefully inadequate.

I think this document represents another expression of who we value in a society.  For those of us who value lives differently, who do our own calculations in different ways, it is a reminder that again, we may be on our own.  There may be no point in rushing Grandma to a hospital in a crisis, if she will be refused treatment.  Those of us with vulnerable family and friends may need to do more to ensure that they don’t become sick in the first place, or that plans exist for their support.  We may need to create community structures for the care of those who would be turned away who don’t have family to care for them. 

More important, for all that it is necessary to have triage strategies, it is worth noting that the scale of the disaster depends on our prior expressions of what and who we value.  That is, it is far less likely that this kind of ugly triage will have to ever occur if we actually allocate adequate resources both to preventatives and to responses.  It is true, as the report notes, that the idea of unlimited resupply is impossible.  It is not true that hospitals couldn’t have a greater degree of preparedness, larger stockpiles and, perhaps, plans for hospice care and community based care of those they cannot serve. 

There is often a tendency in a crisis to jump far too rapidly to the idea of triaging.  And it certainly is a balancing act, a difficult set of choices, and waiting too long is potentially disastrous too.  But too often, I see people who understand the crisis we face assuming that we must give up on the hope of addressing injustices, or for caring for certain people.  The idea is that crisis comes and we’re immediately reduced to a world in which every choice is life or death - that is, we are immediately thrust into the world in which a bite of food shared condemns me to death, we are immediately transformed into a world where we are sered of such lofty goals as justice or the protection of the weak, and we enter into a blind struggle for survival. 

The problem is that even in great exigency, the world is more complicated than that.  And the problem of seeing a coming scarcity in a world of great abundance is that you sometimes miss the fact that there’s still enough abundance to allow for a less urgent, less scarce view of the world.  That is, we are, in the rich world, still a long way away from the struggle for survival.  To give up on our struggle to  protect the weak along with the strong would be premature - easier, yes, but wrong.  And it is still within our powers to create a low energy society that never requires much of that sort of ugly triage - if we choose to prioritize the resources.

But this is also an important reminder - the priorities of institutions and governments are not my priorities. If I want to be sure that my family and those I care about are cared for, I must rely on *my* priorities, allocating what resources I can as I see fit.  This is true on a personal level - that is, I should prepare specifically to care for my son at home in a crisis (actually, the point may be kind of moot, since  my local hospital would be completely overwhelmed  and I should prepare to care for all my family at home), and that I should be looking about my community for those who are likely to fall through the cracks.


29 Responses to “Triage: If You Thought I was Over-reacting with the Food Storage Stuff…”

  1. Tara says:

    I appreciate that you brought up Katrina. This is a sore subject for me and my husband, and one that we were just discussing again the other night. I was explaining to him that Katrina was the point at which I experienced a paradigm shift. I had already begun to live in a more self sufficient way simply for the sake of doing so, but it was in the days immediately following Katrina that I realized that No Help Is Coming. I also had to face the rather ugly realization that because we’re white and have cars and decent jobs, there is a slightly greater possibility that some help might come for US, but probably not for the MANY people in our neighborhood who are poor, unemployed, non-white, elderly, non-English-speaking, disabled, etc. This gives us NO COMFORT.

    There’s just no way we could sit comfortably in our house and watch as our neighbors get sick, go hungry or whatever without doing what we could to help them. It does give me some comfort to think that in a time of crises, it will largely be the citizens who step up to help one another, not the government. At least that’s what I like to think will happen.

  2. MEA says:

    I was glad to see some public thought going into the question of who gets resources. I have to admit I read (mostly likely misread) it to mean that if you have someone who is very, very likely to die, you don’t use resources on them that will most likely save someone else’s life, and so took the bit about mental capacity to mean 1) someone who comes in with TBI and who might survive after a 12 hours op. and weeks in the ICU, while those recourses might save the life of 10 other people and 2) people with serve dementia who needed one-on-one care on top of whatever medical treatment, tying up nurses.

    I’ll admit, it’s not a very pretty picture however you look at it. But I hate to think of rationing by who turns up first and who has money, esp. in terms of injuries that could have been handled outside the ED setting.


  3. dewey says:

    The general point is a good one, but I think you can worry less about Eli in particular. These criteria are not really novel; they fit within the usual understanding of triage, and the “severely mentally impaired” language is not intended to refer to autistic children. If your son is capable of talking and otherwise functioning at all, he ought not to be refused treatment because he is “abnormal.” This refers primarily to people who are really, and permanently, vegetative through advanced senility or profound mental retardation. (Note that early- to mid-stage Alzheimer’s is specifically excluded as a criterion for lower prioritization, even though it causes obvious mental deficits compared to a “normal” person.) Even if resources were endless, I would question the ethics of going to great lengths to preserve the lives of people who are being saved for nothing but more years of near-mindless existence parked in a bed or wheelchair in a custodial institution. In a resource-limited catastrophe, it would not be acceptable to pursue such goals at the expense of letting people die who might have been saved for years of functional life. From what I have read on your blog, your son is capable of enjoying his life pretty well - no doubt having you for a mom helps him there!

  4. Tammy and Parker says:

    As a mother of a medically fragile child with Down syndrome, I read this article with more than the average concern. And then I realized that for the very first time I was kind of glad that my (crappy) insurance insisted that we purchase our own oxygen concentrator, vent (for night time use) and other durable medical supplies.

    My husband and I made the decision to purchase a generator in case the power goes since Parker is on oxygen 24/7.

    What I need to do now is to figure out how to get a supply of his most necessary medications. I have no doubt that his Cardiologist would write the scripts, but my insurance wouldn’t cover that far out and so I would need to be able to purchase these meds out of pocket. This would be exceptionally expensive on a couple of his meds.

    Even with the extra chromosome and the medical issues Parker is simply a joy and lives a happy and productive live. His potential is great. His life has no less value than my other children’s lives have. But there are those that would only see the extra chromosome and insist he leave the line of the treatable.

    This is an issue that can easily keep me up at night.

  5. Rosa says:

    Thank you for the Katrina mention, and the continual reminders that “ability to pay” is a form of rationing.

    One of the supporting arguments for community-based, government-funded health care (aside from the basic ones, which are justice and public health) is preparedness - because of the for-profit health care model, most cities do not have the beds to deal with emergencies, because empty beds cost money.

    A network of community clinics, not-for-profit hospitals, and hospices can have the elasticity to absorb sudden shocks, as well as simple redundance - multiple sites, multiple generators, multiple small stocks of supplies - to cope with floods, earthquakes, electrical blackouts, transportation issues, etc.

  6. Heather Gray says:

    I paid attention to Y2K, but that was because L and I were both in the computer software business (he still is). Not by buying emergency rations or whatever, of course.

    My job was calming down panicking people (friends, family, etc.), and his was making sure there was no reason to panic. No one seems to remember the testing that went on beforehand that found most of the things that failed — like the factory where the fire alarm being set off locked everyone _into_ the building. Good thing they tested that…

    One of L’s jobs was helping a power company when the software they’d checked didn’t activate in the new year. Fortunately it was a simple fix (it worked but hadn’t been moved out of the test environment onto the live system — think about what _could_ have happened). If people paid as much attention to what’s going on in the world today, in an active, useful and participatory way, as they did to Y2K, we’d all be better off. Of course, what’s going on these days is even more complex than the Y2K prep and planning was, and that took a few years…

    As for 9/11 - eh. I buy duct tape, but not because of 9/11.

    Thanks for posting about the triage plan — I’d read about it elsewhere too, so it’s getting a little coverage. I did a little research on flu last week, because the CDC recognizes the chance of a pandemic flu happening is a valid possible reality, especially given air travel these days. In their own document on preparing for a pandemic flu they admit the U.S. gov’t doesn’t have the resources to handle the fallout, and that people need to participate in containment and treatment.

    I’ve just started on the next step to not using (or using less of) allergy and asthma medications this week. Self-acupressure definitely helps, but sometimes it isn’t quite enough. So now I’m trying out nettles (allergies) and sassafras (asthma, respiratory stuff). Cautiously with the sassafras of course…too much can do damage to the liver however (or why they banned it from drinks). Nettles are quite safe, happily.

    They do seem to be helping, and what I like best is that they’re both local plants and are quite plentiful, so I can harvest and store with no worries about depleting the area.

    One of my favorites, which I have to grow some of indoors in the winter, is ginger. Awesome for stomach ills, heat exhaustion, and promoting circulatory health. In a few weeks I’ll be able to move them outdoors where they can happily multiply, then I’ll harvest some in the fall, and save some plants over the winter again.

    Us and a small group of friends are working on learning more about how to grow/harvest/prepare herbal medicinals. There’s also a great little herbal apothecary nearby that we’re trying to promote and support, because they have a local herbal CSA and are a great local resource both for the supplies and the knowledge they provide.

    I also (gently) try to encourage exercise for those who are able, and getting enough rest — the healthier one is, the better able to fend off illness.

    We’re working on being able to provide not only for the two of us (in general, not just meds) but also for the possibility of short-term hosting in an emergency. That’s a tough one though, and we know that in a long-term situation of several weeks, without outside support, that we wouldn’t be able to help people indefinitely, except maybe with clean water supplies.

    One thing I seem to have a lot of is stuff to keep people warm (or insulate a house year-round) — blankets, comforter-like things. And fabric that could become more of the same or clothing. And yarn (hats, mittens, socks, etc.). I like those as part of preparedness because as long as they’re stored properly, they don’t go bad. I know, not medicines, but avoiding hypothermia’s important too. Also, in case of contagion, it would be bad to have to burn blankets and bedding and have no replacements for them.

    I don’t know if everyone should store lots of things the way we’re doing, but we’re the designated emergency destination for a number of folks we know, so it makes sense to stock up on certain things (also, I use some of the fabric for insulating in the meantime). We also have some storage space that some of our friends have put extra food in to help provide for themselves.

    Are you going to write up suggestions for things people should think of for this kind of thing? I know there’s stuff out there, but I thought I’d ask. One thing I’d suggest is that people should be aware of the different ways to get wherever they might need to go — back roads, not just highways. If there’s major flooding or forest fires in your area and you need to evacuate, the usual routes may not not be available.

  7. Sharon says:

    Dewey, thanks for the reassurance. I’m not that terrifically worried about Eli, although he really can’t talk much, and he tests out as severely retarded, because he refuses to take the tests. So within your criteria, he might still fit - but regardless, it is the larger problem of application that I’m concerned with - not opposed to, just concerned with. I do agree that these are legitimate points for discussion - and that’s part of why I want us discussing them.


  8. catskillmamala says:

    I did prepare for Y2K and haven’t regretted a single part of that preparation. DH and I were living in Boston working in the corporate world. I was following the financial markets quite closesly, the dot com thing was clearly unsustainable on the fundamentals, people were living beyond their means, the credit availability was rediculous, health care rationed by pay, JIT food distribution, etc.

    Only now, those things are all SO much worse. I remember thinking that $1T in derivatives was unsustainable and the sign of a giant ponzi scheme, now we’re at $6T.

    Anyway, we moved “home” bought an old farm house with orchard and acreage, began storing food, raising chickens, taking a slower path. Traded for a treadle sewing machine, learned how to bake, started gardening.

    The other day I found a bottle of molasses dated 9/99 and you know what, it’s probably still good. But all of the other food we stored, we used and it helped us move to a single income family. At the time I begged family members to get out of tech stocks, to stock up, all to no avail. Fewer and fewer of them are rolling their eyes now.

    The feelings that Y2K elicited were based in reality, things were already severely unsustainable. Only now we’ve had Katrina, the dot com bust, Inconvenient Truth and food shortages to prove it. So I don’t mind when people point to Y2K prep and imply that it was a mistake. It wasn’t a mistake for my family and neither is the prep we’re doing today. When you’re talking about collapse being off by a decade isn’t a big deal.

  9. Sharon says:

    MEA, I think you are right, which is why I’m not out there with the people who are demonizing this report (I’ve seen several bloggers do that) and the people who do it as eugenicists. Yes, we need a rational strategy. My concern is that we’re rushing towards a scenario where, if such a crisis occurs, we need to implement this, perhaps badly, when we might otherwise have avoided getting the point of these choices.

    I think the odds are that Eli would pass muster - and the thing is, I have a serious trust in my ability as a well educated, middle class person with lawyer relatives to persuade a hospital to put my kid back in the care line even if they didn’t. But unfortunately, all parents aren’t as fortunate as I am. I know a woman who has a severely mentally disabled adult daughter who has twice caught doctors performing medical procedures on their daughter without the pain relief that you’d give anyone else - and this isn’t in the 19th century.


  10. Sharon says:

    Catskillmamala, I mentioned Y2K and 9/11 mostly just as an observation that everyone has their “click” moment at a different time. I’m not making fun of anyone.


  11. Sharon says:

    Heather, some of my suggestions for preparing to be the refuge are in an older post of mine - do a search for “Brother in Law on the Couch Apocalypse”. But I will do another post or even series of posts about “home as community refuge” - that is, given that public resources are being stripped so badly, not only may a lot of us end up as all purpose refuges for family and friends, but some of us may want to set up home based community structures - a family that includes in LPN, RN or etc… might stock up for a small clinic run out of the house that handles routine medical issue - blood pressure checks for elderly neighbors, first aid training, etc… and charges a small fee. Someone else might want to offer their library of garden and herb books to the community as a resource, either for a small income or as a public service.

    So yes, I’ll write about that.


  12. Amelia says:

    Not much to add to the topic in question — I live every day with the knowledge that four of my friends have MS and their odds for survival during a prolonged disruption of medical supplies aren’t good — but I did wonder, Sharon, if you’d seen this article on urban farming in the New York Times today.

  13. Cathy says:

    It does seem to me that our inability to prepare for or cope with a disaster like Katrina boils down to two faults: (1) the fear of being seen as “overreacting” when the disaster fails to occur, and (2) a general laziness to do what needs to be done before the disaster strikes. There’s no doubt in my mind that the New Orleans government could have organized school buses and city buses to evacuate the low-lying areas of the city prior to the storm but they were either too fearful of looking foolish - or they were too lazy to do so (as you say it’s easier to say “no one could have foreseen this disaster happening…).

    My 86-year-old fairly healthy mom just called last evening to see if I had read the triage artile in the local paper. She is very concerned and wants to start stockpiling her meds and medical equipment - although on her limited income I do not see how that will be possible. But it is certainly something that I will be looking into pronto.


  14. Heather Gray says:

    Thanks Sharon! Yes, I thought the Brother in law on the Couch post was excellent, but I’m glad you’ll be writing about other aspects of what is a truly complex subject.

    And of course it’s complex, since after all we’re talking about covering, on a smaller scale, all the needs that need to be covered in order to live. So glad you and other folks are writing about these things, and looking at the organizational and larger picture aspects of things. Me, I tend to stick to the smaller, how-to stuff :)


  15. lydia says:

    here is a link to a list of 100 items to Disappear First—-

    In the event of some disaster, war, epidemic, etc.

    It’s by no means comprehensive, but it’s a great start. Also specific medications for individuals would be good.

    Real time observation: Tacoma, Washington -May 6, 2008 at 7:00 in the evening-Just last night, I went to the neighborhood Costco for a couple things. There was NO RICE. AND I MEAN NONE-ZERO, NOT ONE SINGLE BAG. The clerk said they get it now every couple of days and they never know when it will be there. and there are lines outside the store of about a thousand people. People come an hour early to wait in line…. As soon as the store opens, the people rush in and head straight for the aisle, get their one bag limit and it is gone in no time! If this is not an indicator of things to come I don’t know what is! This is like the 1929 depression bread lines, only not as bad. However I am not holding my breath that it will improve. Better safe than sorry.


  16. Tara says:

    I was just in my Costco over the weekend (Dallas area) - no rice there either. None. I did go to the regular chain grocery store later though and found that there was PLENTY. so I don’t get it. It’s like the lottery - the jackpot isn’t “big enough” so people don’t play.-??

  17. Lisa Z says:

    Thanks for this post, and to everyone for commenting. It’s a good discussion.

    My 11yo son’s best friend has juvenile diabetes. I have been so afraid for him if we do end up in a crisis situation, but so far I’ve been too afraid to talk to his parents about it. His mom, a friend of mine, already thinks I’m a bit overboard on the economic disaster thing, and I’ve just barely hinted at what I think are the problems coming. Only hinted! And she, like most people, thinks I’m too worried. So how do I bring up the medical issues?

    Can anyone tell me what a family with a kid with diabetes could even do to prepare? He has an insulin pump. I know my friend, his mom, would know, but since I’m not ready to talk to her about it, I’d just like to know myself. Is there any hope in a low energy world for someone whose pancreas doesn’t function?

    He’s a great kid. His diabetes is very well-managed by his homeschooling mom, but I’m afraid for him! And I hope it never comes to the worst…

  18. Karen says:

    My husband, who is Haitian, lived with his aunt in Miami when he was a teenager. One day his aunt arrived home from work blowing her horn and he ran outside to watch her have a stroke right in the driver’s seat. He put her in the back seat and drove to Jackson Memorial emergency room where she was not treated, nor given any food for over 16 hours as she had no insurance. Fifteen years later, she is somewhat recovered but still in a wheel chair and my husband still can’t believe no one would help her. All this to say, it won’t take collapse for these things to occur. They already happen everyday.

  19. dewey says:

    I did “prepare” for Y2K and felt rather stupid afterward. Not everything I bought went to waste in the long run, but long before my 50 cans of tuna fish were eaten, I had gotten tired of my husband ragging me about it. I also learned that some of the online “experts” scaring me about Y2K had previously made their living convincing people that other causes, financial collapse, AIDS, what have you, would cause a fast crash in which everyone but rural residents well stocked with gold, guns, and food storage would be part of the starving cannibal hordes within a mere few years. Not to say that everyone who wallows in doomer porn has a profit motive, quite the contrary, but as Greer has pointed out, some people have an emotional attachment to the instant-apocalypse idea that ignores history. I’ve been trying not to be one of those people. It seems like every time the price of oil goes up $1, people on the peak oil sites start announcing “Time to Prepare,” by which they always seem to mean stockpiling the rural bunker - well, I won’t use the whole wheat, am not short of ammo, and also want to be “Prepared” for the contingency in which I lose my job but the mortgage company is still in existence and ready to throw me and my blankets and lentils out on the street if I spent my savings on, well, blankets and lentils instead of saving it for the mortgage payments. Because short of a total thermonuclear holocaust, the ****ing bankers are sure to be around longer than I am.

  20. dewey says:

    I meant to comment to Lisa Z - Under any realistic scenario, we would have the tech to treat relatively uncomplicated diseases for generations. Low energy isn’t no energy; pharmaceuticals are manufactured in Africa now. Society should, and hopefully would, choose to allocate severely limited resources first to essential uses, including reasonable healthcare (probably to be defined by a measure of quality-adjusted life years (QALYs) per cost). There will be no problem keeping an insulin factory running, as some important people need insulin too. But I know that injected insulin requires refrigeration; do the supplies for this boy’s pump? If so, a larger challenge might be ensuring that he or his family has some form of refrigeration, or at least a good icebox, if the time comes when average Americans can’t afford such. A state subsidy would be entirely justifiable on the grounds that what is for you a convenience is for him a necessity. But how many Americans will be willing to pay taxes to keep other people’s fridges running when they themselves can’t afford to keep theirs running? Many Americans who now enjoy many luxuries already object on philosophical grounds, or from simple greed, to their tax dollars being used to provide basic necessities to others. Like many others, I have some hope that when we can no longer afford all the luxuries that corporate media have convinced us we must have, we will become less greedy, less selfish, and more willing to make sacrifices for the needy in our communities. But it is also possible that we will adopt an “every man for himself” approach, as the survivalist crowd envisions.

  21. Lisa Z says:

    Thanks, Dewey, for your reply to my comment. It is reassuring.

    I agree with you that we will probably become less greedy, less selfish, and more willing to make sacrifices. America (as well as other countries) has a history of this, and I don’t see why this “crisis” will be much different. Yes, perhaps more long-term, perhaps more dismal, but in the end I think things will/are happening slowly enough that we have time to adapt and this will mean we’ll find ways to cope and help each other out. I already see this happening, as more people pick up gardening and bicycling and other means of coping.

    Still, I worry about those “on the edge”, who have chronic diseases or are already poor, etc. I hope you’re right that some medicines will remain available long-term. I know at least one “normal”, good kid whose life depends on it.

    Lisa in MN

  22. MEA says:

    I’d like to see the criteria for treament in an emergency situtation not depend on a person’s ability to contribute to society (no doubt becuase I have one child who probably won’t) but on their ability to make a meaning full recovery given what is available at the time measured against what it would cost in terms of other lives. To use a very simple example, would be better to keep pouring packed cells, then whole blood, then ringers and finally saline (until there was nothing left) into a anotherwise completely healthy, fit young person with lots of skills, etc. but who had a reptured aortic artery in a situtation where you are using all the resources trying to keep her alive until surgery can be performed or to use the liquids one or 3 bags at a time on lot of other people even if as individuals they didn’t meet the usefullness of person 1?

  23. Rebecca says:

    I too think there has to be a rational way to allocate triage. It will happen, like it or not, so it’s better to have the protocol in place ahead of time. I don’t have any real problems with this proposed protocol -in such a situation, hard choices have to be made. I don’t like it, but that’s the way it is. I also think the triage should go by age and recovery -I’m sorry, but if you’re resources are limited, you should treat a kid before an elderly or middle age person, and so on. At least when both have the same chance at making it.

  24. MEA says:

    Rebecca, in susbstance, I agree with you, and I have a tendency to spin a situtaion out to the wildest bounds — which is what I’m doing — not disagreeing with you — but could there be a situtation in which we were saving lots of children, but not enough adults to care for them? I guess part of the question is what to you consider middle aged? I think it’s 35+.


  25. Rebecca says:

    There’s always that possibility MEA, though I think it’s more than likely the result of these thought games. And even if it did happen, how many adults would say no, save me instead of the 12 year old dying next to me? Even if I didn’t make the choice myself, I’d be consumed with guilt for the rest of my life for being one saved in that situation.

  26. MEA says:

    Actually, I don’t know if the choice would be upto the patient.

    However, I do know west African refugees who chose to let a child in the family die rather than an adult on the theory that a family of young children without any adults would end up dead in the long run.

  27. Sharon says:

    Just for the record, I think middle-aged is at least 37 (says Sharon who will be 36 in three months ;-) ).

    I agree that it is dangerous to spin all this stuff out too far - and I absolutely agree with Dewey that it is perfectly possible to keep manufacturing insulin. What seems far more likely than “no insulin ever again” is the situation we have among the third world poor - “no insulin unless you are rich enough to pay for it.” That is, we *have got* to stop the absolute price rationing system for basics like food and medicine - we HAVE TO. Because it isn’t really a matter of what there’s energy enough to keep going, but the larger system.


  28. dewey says:

    MEA is correct that triage deals with who can be saved and at what cost. Except in the extreme and obvious cases, “contribution to society” questions are not ethical. In the midst of crisis, there is simply no way that a medic surrounded by wounded or sick people can make such decisions. The person with mild to moderate Down’s may work at the recycling plant and be beloved by his family and friends, while the guy in the expensive suit may be a drug dealer. The medic would have to rely on proxies like grooming, indicators of social status, and very possibly race, religion, and sexuality, as many will subconsciously place more value on people who are more like themselves; obviously this is to be discouraged. So in a mass-casualty disaster, the derelict with easily treatable injuries will go ahead of the housewife with full-body burns. (However, where transplant lists are concerned, the derelict will be downgraded severely.)

    Western medicine is unaffordable for most in the Third World, but it used to be affordable here and I think it could be more affordable again. Doctors have managed to get themselves a protected monopoly and limit their numbers so that members of their “guild” will always be assured a high income, but if too many of us can’t afford to go to the doctor, at some point their incomes will start to drop and, like the builders of McMansions, they’ll have to either reduce their prices or suffer from the lack of business.

  29. Linda Buzzell says:

    Some of the best analysis of our situation that I’ve ever read, Sharon! Thank you, thank you…

    My only quibble is with #5, the “sheer cowardice of us” bit. Human psychology is a little more complicated than that and most of those who write scientifically and rationally about what we’re facing aren’t very psychologically savvy and have resorted to fear and guilt which research has proven to be poor motivators (and cause trauma to boot).

    Your readers might want to check out “The Waking Up Syndrome,” an article I co-wrote with Sarah Anne Edwards which analyzes the psychological stages people go through in waking up to and dealing with our predicament. Eco-anxiety, eco-grief etc. all have to be processed so we can get active and respond appropriately to our challenging circumstances, not hide in denial, freeze in panic or succumb to depression or despair.

    The link to the article is It also appeared on

    I’m really looking forward to reading your books. We too are involved in “subsistence farming” - in our case a small urban backyard permaculture food forest.

    Linda Buzzell, M.A., M.F.T.
    International Association for Ecotherapy

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