Editor’s Note: This is a follow-up to Death By Procedure, which explored the adverse impact of our tortious culture on the pandemic response, and Incentives Matter, wherein we see that the pandemic was subordinate to political gamesmanship.
New York Governor Andrew Cuomo, facing blowback from his disastrous early actions during the pandemic, continues to defend his decision to return COVID patients to the nursing homes because he did not know that was happening. “Didn’t know,” however, is not only the most common excuse for government failure, it is the reason for most government failure. During the pandemic, I knew this decision was a mistake/ Indeed, everyone, down to the nurse’s aides, knew it. But the governor, who was making the decisions, “didn’t know” (and he didn’t call me to find out). He neutralized several clinicians who tried to tell him. We know (in retrospect) that we had surplus capability to manage incoming patients, but did not adapt that surplus to a quarantine of nursing home patients, though we had many options to do so. We know that the government’s power to act seized up the world economy to try to protect us from the virus, but ours failed to realize this blatantly obvious threat. Cuomo’s defense of his ignorance is indefensible. It’s indefensible because we know better. Really, what’s indefensible comes from not finding out.
And finding out is hard (it’s called the entire history of science). Knowing mainly comes through evolution. Knowing is evolutionary because finding out normally carries consequences: clinicians are not forgiven for failing to know the things they are responsible for knowing. An engineer has no protection from a manslaughter charge if he was unaware his bridge could fold up.
The Soviet Union’s economic system collapsed because there was no way any army of bureaucrats, despite being armed with limitless power to find out (summary executions, exile to Siberia), could ever really know true things about their economies. The USSR’s economy would have failed simply because there was no accurate price signal to tell them what was abundant versus what was scarce. This is because prices are not “decided,” they are evolutionary indicators of the balance between value and scarcity. The Soviet apparatchik could never explain why bread in a bodega is more expensive than bread in a supermarket, even though everyone in a market (even the children) knows, and can adapt to any changes almost instantaneously.
That’s for something simple, like knowing what a loaf should cost. Much less knowable is something complex, like which patients are at risk in a virus outbreak and which are not. These are many orders of magnitude more complex. Knowing-true, clinically, was what created the vaccine that is rescuing our way of life. It is not a coincidence that this creation came from a private company, in an evolution of risk and reward, and not by the hundreds of governmental health departments the world over.
Add that in the “knowing things” ecosystem of the USA, the main mechanism has been the press. Which has been politically compromised. Most of the media was as blind to the consequences of the governor’s decision as he was. They gave Cuomo an Emmy because they thought his daily briefings were important, but they didn’t bother to find out (or even ask) if the information he was briefing was accurate. They have an army of reporters at hand – or, they could have called me. Those reporters are useless if there is no incentive to find out something they don’t want to know because of political bias (remember when Cuomo was the one Democrat who could save us from President Orange?). What’s worse, is that in a checks-and-balances system, it’s the watchdog honoring the wolf.
Cuomo explains that his not being able to know was due to the complications of our legal processes (it is instructive to watch the whole press conference). The answer to that is: “YES! Of course; subpoenas make things MUCH harder.” Why would anyone expect efficiency, or clarity, if knowing the price of a loaf has to be done through lawyers? Putting a lawyer intermediary between clinicians is laughably ridiculous (but I wouldn’t put it past the lawyers). But that is the system they use to find out. Which is why he didn’t (couldn’t) know.
All of this is before we begin to consider how Cuomo’s arrogance towards his nursing home failure has been a feature of his political persona for decades. His personality makes him especially prone to not knowing, because he never needed to, because it’s rare that governmental ignorance is brought into such a clear view (and he still enjoys a great deal of political support). His whole career rewarded him for bullying to get what he wants rather than for his knowing (and learning). Politics is the only arena of American life where this can happen. No clinician can be so contemptuous of feedback loops and still rise to the top of their profession (Cuomo is not only Governor, he heads the Governors’ Association, in an irony too delicious for we government skeptics).
Trying hard is irrelevant. Bad instruments cannot yield good data. I have no doubt the Governor worked himself ragged, and tried his damndest to handle the crisis as well as he could. Lots of the intentions behind the decision were clearly honorable: the nursing home decision was partly motivated by keeping these patients from being left homeless. But the problem of knowing remains above motivation: he did not have an information loop agile enough to cope with the fact that if the decision was right-headed, it was wrong-resulting. Add that the political process tends to bend and distort everything (since it is serving politics). Even now, actual responsibility for the disaster remains murky, under all the political recriminations between Cuomo and Trump.
We have an adversarial system, and adversaries are crippled in cooperation. Cooperation is sharing knowledge dynamically, without compulsion. Clinicians do this as part of our job description.
Knowing IS the problem.
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