The Pandemic-Economic-Epistemic Triple Whammy

The word “whammy” first appeared in print in 1940. It likely developed from the slang term for a paralyzing or lethal blow. Whammy does not sound like a respectable scientific term, nevertheless, it is. The National Library of Medicine’s PubMed database lists 171 scientific papers describing various double, triple, and quadruple-whammy syndromes.

There are whammy syndromes in many specialties, from neurology (orthostatic hypotension with Parkinson disease) to obstetrics (twin pregnancy with gestational diabetes). The most important triple whammy in primary care is the syndrome of acute kidney injury precipitated by concurrent use of a diuretic, an ACEI or ARB, and a nonsteroidal anti-inflammatory drug. Each drug alone may be well tolerated, but taking all three—especially by a patient with underlying renal insufficiency—can lead to disaster.

The essence of the whammy phenomenon is the failure of a vulnerable system resulting from simultaneous injuries. The model works well for describing the failure of biological systems. It also applies to higher-order systems, like nations. Right now, our nation is experiencing the mother of all triple whammies—pandemic, economic, and epistemic—and its vulnerabilities have never been more obvious.

We have a vulnerable healthcare system. Despite the gains in insurance coverage and protections for pre-existing conditions provided by the Affordable Care Act, our own government is preparing its case before the Supreme Court seeking to roll back these gains. Meanwhile, our state refuses to accept funds to expand Medicaid, leaving over 120,000 citizens with no realistic access to health insurance.

The primary care workforce is vulnerable. Nations with high-performing healthcare systems have built theirs on a strong foundation of primary care. The US healthcare system is upside down, placing its emphasis—and financial support—on specialty care and technology. The economic downturn has exposed the tragic neglect of primary care. Practices are struggling to survive as patient visits have declined. Face-to-face visits pay the bills. Unfortunately, there is no CPT code for doing what you can to preserve the continuity of care.

Our socioeconomic system is vulnerable. Despite its wealth and military might, the United States is a fractured society. The CIA World Fact Book describes our economy as a “two-tier labor market” where those at the bottom “fail to get comparable pay raises, health insurance coverage, and other benefits.” This two-tier system is the driving force behind the wealth inequality that threatens to unravel the social order.

Public trust in our institutions is vulnerable. “Post-truth” might be the best label for our current political climate. Senator Daniel Patrick Moynihan once said, “Everyone is entitled to his own opinion, but not his own facts.” This axiom, the foundation of a functioning democracy, has been turned on its head. Facts and logic have yielded to emotion and sophistry. There is growing distrust of science and expertise, manifested by the anti-quarantine movement and an endless barrage of conspiracy theories.

Like a weakened kidney whose perfusion is shut down by simultaneous volume depletion, afferent vasoconstriction, and efferent vasodilation, our vulnerable institutions are threatened by the triple whammy of a global pandemic, economic fragility, and epistemic crisis.

Thus far, our response to this triple whammy has been mixed. On the positive side, the initial shutdown orders may have prevented or delayed 60 million coronavirus cases in the United States. Congress moved quickly—initially—to provide economic relief. State health departments, healthcare systems, and hospitals valiantly rose to the challenge. Physicians rapidly re-engineered their practices and protocols to protect their patients and staff. Unfortunately, the initial wave of positive response seems to be receding.

While most of the world hunkers down to crush the pandemic, America seems to have tendered its unconditional surrender. The plan to “re-open” the economy based on achievable gating criteria, hobbled by its ambiguity, was ultimately ignored. We desperately need a consistent message and coordinated response from all levels of government. Instead, we hear happy talk about the worst being behind us, and open contempt for our most effective tools (social distancing and mask-wearing). A second wave whammy is looming.

Like the kidney triple whammy, which exposes the unrecognized fact of renal insufficiency, the pandemic-economic-epistemic triple whammy reveals the unresolved flaws in our national character. Perhaps there is no greater flaw than the legacy of racial injustice.

The COVID-19 pandemic has profoundly demonstrated the root cause of healthcare disparities. According to CDC data from New York City, the death rate for African-American patients was roughly twice as high as the rate for white patients. Death rates for Latinos and Indigenous Americans show similar disparities. Health disparities exist across the spectrum of care, from maternal mortality to cardiovascular disease outcomes. The AAFP recognizes that these disparities arise, not from biology, but from “the patterns, procedures, practices, and policies within organizations that consistently penalizes and exploits people because of their race, color, culture, or ethnic origin.” Institutional racism exists. It remains a threat to the social order and a menace to those who are forced to endure it.

Family physicians have a duty to be advocates for healthcare equity. We can chip away at the problem on the individual level, but to be truly effective requires collective action. Your active participation in the AAFP and the South Carolina chapter has never been more important. Together, we can root out implicit bias in healthcare. We can redouble our efforts to address the social determinants of health. We can promote a fact-based response to the pandemic. We can lobby for healthcare reform and insist that primary care take its rightful place as the foundation of a high-quality healthcare system—a system that serves the needs of everyone.

It is possible to avoid a triple whammy. The first step is to recognize your risks and vulnerabilities. If you are starting an NSAID be sure to review the medication list and check a creatinine level.

It is too late to prevent America’s pandemic-economic-epistemic triple whammy. It was probably unavoidable given the vulnerabilities we face. Nevertheless, the triple whammy has struck. Now we must figure out how to survive it, together.

This article was published in South Carolina Family Physician.