EDITORIAL |  Doctors and economists : the same view of risk?

EDITORIAL |  Doctors and economists : the same view of risk?

The Covid-19 crisis brutally confronts economic and health issues.

It also exposes astonishing analogies between these two worlds.

Among these, the relationship to risk – both in the immediacy of the crisis and, tomorrow, in dealing with a new pandemic.

At the height of the crisis, when the pandemic overwhelms the intensive care units, the time has come to assess and prioritize risks.

Faced with such sudden and disproportionate events, an epidemic or a stock market crash, we are struck by a similarity in reactions: the astounding return of empiricism.

It must be said that in both cases, the figures abound, but lose in their disorder the capacity to enlighten us: for the coronavirus epidemic, the obsession is with the number of deaths in intensive care, quickly confused with those occurring in nursing homes (certified Covid? by whom?), but carefully concealing the very many patients who died of other usually banal pathologies, « illegitimate » victims of a lack of care by time of Covid obnubilation…

Another analogy between crisis, the figures are given without any reference whatsoever, in particular to any relative order of magnitude: do we know, for example, in front of the 8 p.m. screen, that under normal circumstances, more than 400 people die every day in France from cardiovascular causes? An « incidental » figure that has increased by at least 30% since the beginning of confinement, according to an estimate by the French Society of Cardiology?

And in the face of the rapid progression of the virus – such as a stock market crash, for example – the known models are outdated: hospital management models, like economic models, are proving to be obsolete.

We must therefore resolve to act, largely blindly, to improvise solutions, far from « processes »: this is the return of empiricism, or even of the so-called System D. Data is no longer our Grail, its own finality, it no longer sits enthroned in majesty, but is modestly placed at the service of crisis management. Moreover, whether it is a health or economic crisis, any instantaneous accounting proves to be uninformative: the same biases, the exaggeration of trends by algorithms, or the blinding obsession with certain figures that are more fetishes than indicators – for example, the « number of new cases » donned every night: which « cases »? symptomatic? and what about the asymptomatic ones in the absence of systematic tests?

To escape empiricism, and to master the raging machine, it will take time, and as in an economic crisis, « new » tools, such as AI, will only become appropriate with the benefit of hindsight.

For year after year, the health crisis, like a stock market crash, will be experienced. But what does the future hold in store for us? At the end of the crisis, the relationship towards risk changes focus: the hazards of deconfinement, the return of the pandemic, future winters and their new mutant viruses?

We can ignore any future risk.

We can pretend to assess it: but this can only concern, as David Vallat writes, « the predictable unknown, the known unknown ».

But what should we do with a « black swan », whether in the health or economic domain? In this perspective, should we overplay caution and build a world with the dreaded « zero risk »?

Here again, doctors and economic actors are united around two convictions that radically distinguish them from politicians.

On the one hand, lucidity as to the inevitability of Uncertainty: neither economics nor medicine are exact sciences, the best assume their ignorance, such as Jean-François Delfraissy, an eminent virologist, repeating the formula « I don’t know » several times in response to disconcerted elected officials.

On the other hand, the audacity to raise the fundamental, taboo problem of our choice of society.

In this respect, a purely financial analysis, evaluating our health economy, brings together much more than doctors and economists think at first sight.

First of all, pragmatism is common to them. Thus the general public – and politicians concerned about their virtuous image – discover with horror that it is the same « logic » that leads a company to the dramatic abandonment of a large industrial site deemed unproductive, and incites a resuscitator to refuse to deploy expensive technical means for an old man presenting multiple risk factors… Medicine, thus exposed « hot », tending towards efficiency, is not to be confused with compassion, or solidarity.

Secondly, neither doctors nor economists can understand the multiple paradoxes of the media-political discourse.

The scandal of the remuneration of health professionals in our country, one of the lowest in the OECD (including doctors) seems so flagrant, in the light of a purely economic analysis of the level of qualification or productivity – in this respect, nurses and doctors are under no illusion, the applause at 8pm will quickly be forgotten…

As for the real trade-offs, they are regularly overlooked.

Is it really necessary to spend fortunes to support a very premature baby at high risk of neurological after-effects at all costs? Will it be necessary in the future to maintain a fleet of 10, 15, why not 20,000 respirators while waiting for the next virus?

And what should we think as a doctor – or as an economic analyst – of the huge gap in resources with the developing countries? The sole dialysis treatment for kidney failure patients over 75 years old in Europe could largely finance neglected research against malaria, a disease that in the rest of the world kills a child every two minutes… Here, ethics meets pragmatism.

Incidentally, it is interesting to note that the rich and over-medicalized West would be interested today in a rapid sharing of its resources with the rest of the world, so high is the probability of future pandemics with « exotic » starting points…

Our choice of society is of course also a « philosophical » one, and here again, economic actors and doctors seem to be thinking along the same lines, clearly opposing the dictatorship of the precautionary principle. Politicians have thus chosen as an acronym for one of the two committees in charge of Covid-19 the term C.A.R.E, the name of this cotton wool company which has their preference.

Concretely, we are trapped these days in the gears of confinement, the « government of bodies » feared by Michel Foucault, an experiment – in the full sense of the term! – completely new: the only indisputably effective confinement is indeed a lifetime confinement, and what a life, masked and hydro-alcoholized. The opposite of what Jan Patocka called « life in the amplitude ». Economic survival and medical common sense are thus, together in the same boat, severely abused.

Through their relationship to risk, economic actors and health actors prove to be close by their methodologies (and their limits), their pragmatism (sometimes brutal, but fruitful).

Some doctors, for example in major surgery, tame « black swans » almost every day: « Everything will happen to you, because everything has happened to me », used to say to his students Francis Fontan, one of the founding fathers of cardiac surgery. Could we imagine crossing experiences, between economics and medicine, to invent and assume a « new » empiricism for the 21st century, where technologies and data no longer claim to control the world, but are once again tools « adjusted to reality », in the service of common sense and of a full humanity, rich in risks and meaning.

Anaïs Nin wrote in the 1940s what could be, in medicine as in economics, the song of rallying to a « camp of risk »: « I push back death by living, suffering, making mistakes, risking, giving and losing. »

by Jean-Charles Vernhet, Cardiac Surgeon, Member of the ICR’s College of Experts and representative of civil society