Father Christmas hands out toys and games to evacuee children in Henley-on-Thames, Oxfordshire in December 1941.
Photo by Richard Stone, courtesy the Imperial War Museums.
Kriss Kringle, in his many magical guises, will need to put in some serious overtime tonight to spread cheer across a globe that has not seen such widespread desperation in generations.
From kindergartners whose schooling has been disrupted to elders who have spent months in prison-like isolation, nobody is likely to forget this holiday season. Oldsters might compare this Christmas Eve to the ones they experienced during World War II, and especially the singularly nightmarish December of 1941. The rest of us, from graying baby boomers to their grandchildren, may come to know this as the Crisis Christmas.
“Crisis” is the most appropriate word. It applies from the United Kingdom, where food shortages loomed and thousands of truck drivers were stranded behind closed borders this week, to Antarctica, where the new coronavirus finally appeared and forced the evacuation of dozens of Chilean military and civilian staffers.
Ten American medical organizations issued a joint call last Friday for nationwide implementation of “crisis standards of care” to “save lives and fairly allocate limited resources.” It is not hard to see how these organizations concluded that “crisis” measures are appropriate. Available space in Southern California intensive care units has dropped to approximately zero. By Tuesday of this week, according to The Wall Street Journal, nationwide hospitalizations for COVID-19 stood at 117,777, with 22,213 in intensive care. Both were high water marks thus far in the pandemic. The virus is expected to be the third leading cause of death for Americans in 2020, behind only heart disease and cancer, and will likely lower American life expectancy figures by two to three years.
“We have reached a point in the crisis at which critical decisions must be made in order to do the most good possible for the largest number of people with limited resources.,” according to the coalition of organizations that included the American Medical Association and the National Academy of Medicine. “These decisions effectively signal a shift from conventional to crisis standards of care (CSC). This means making unprecedented and agonizing decisions about how resources are used, stretching many resources well beyond conventional limits. Every action possible should be taken now to mitigate the need to operate under crisis conditions. Failure to act will inevitably mean more lives lost, lasting damage to our fragile health care system, and deepened scars of health inequity.”
Specific recommendations included having hospital systems implement plans to avoid “unlawful stereotyping” and making “resource allocation decisions based on individualized assessments of each patient, using the best available objective medical evidence concerning likelihood of death prior to or imminently after hospital discharge.” These determinations can include relevant clinical factors and, in some limited cases, age.
“However, such assessments should NOT use categorical exclusion criteria on the basis of disability or age; judgments as to long-term life expectancy; evaluations of the relative worth of life, including through quality of life judgments, and should NOT deprioritize persons on the basis of disability or age because they may consume more treatment resources or require auxiliary aids or supports,” the groups added.
This guidance may be somewhat controversial if it gets the attention it warrants. Nobody will quarrel with the broad goal of giving doctors and other health care providers ethical and legal guidance about who to try to save if they can’t save everyone. We are losing more lives on a daily basis right now than we lost on 9/11. The physical and emotional toll on front-line personnel is horrific.
But the emphasis on saving lives only over the short term, without regard to long-term trade-offs, appears to be driven more by social and political imperatives than by the impartial logic of science, economics and math – or even the ancient, common-sense wisdom that puts “women and children first” because it is better for the species as a whole.
If there is one ICU bed available, and a doctor must choose between giving it to a 93-year-old patient in generally good health apart from COVID-19 or a 52-year-old hypertensive bus driver, I see no logic in offering it to the 93-year-old. That is not the patient who is apt to still be around to benefit from treatment five years from now. The 93-year-old almost certainly will be gone in 10 years.
What about the choice between a patient who has a milder case of COVID-19 but an aggressive form of melanoma and a more severely sick COVID-19 patient who is otherwise uncompromised? The proposed guidelines would, at least from some viewpoints, disregard the cancer diagnosis and that patient’s resulting shorter life expectancy. On an individual level, that defies logic.
These organizations know this. They are making a socially conscious choice to acknowledge that disadvantaged populations have a higher incidence of comorbidities than more affluent groups, and that members of these disadvantaged populations are more likely in this country to be people of color. Practitioners treat patients one at a time. But these guidelines give more weight to addressing the aggregate effect on disproportionately disadvantaged social and racial groups.
Not everyone is going to agree this is appropriate, yet these are the choices a crisis presents. Someone has to make them, or at least give them serious thought.
Hard choices are being made, and debated, all over the world. The United Kingdom is implementing severe lockdowns more widely across the country this Christmas Eve to slow the spread of a new virus variant that is believed to be even more contagious than what we have seen until now. The BBC reported that more than 50 countries closed their borders to travel from the U.K. The most notable was France, which created the commercial traffic nightmare this week on both sides of the English Channel. Yesterday, France eased its ban to allow French citizens, British nationals living in France and truck drivers across the border if they test negative for the virus within 72 hours of the crossing. Trucks may be moving by the time you read this, as authorities administer rapid tests to their drivers. But many of those drivers are already doomed to spend Christmas far from their families.
I don’t believe a Christmas Eve has been so bleak for so many people in so many places during my lifetime. Naturally, anyone who has had a loved one away in a war zone has experienced something like this sadness before. But we baby boomers have known only comparatively limited war, with comparably limited sadness.
The best I can come up with is to try to imagine a Christmas Eve during World War II. They must have all been difficult, but December 1941 stands out. America was reeling from the Japanese attack on Pearl Harbor scarcely two weeks earlier. Families knew their husbands and sons would soon be in uniform and that many would never return. Hard as that Christmas must have been here in the States, it was far worse elsewhere.
The city of Leningrad (now Russia’s St. Petersburg) had been under siege by the German Army since September. In early November, access to the last reachable rail head had been cut, and the city was desperate for food. Some 4,000 people are thought to have died of starvation on Christmas Day alone. Things were not much better on the other side of the front line. The Nazis expected a rapid victory over the Soviet Union, and neglected to equip their troops with gear and clothing suitable for the brutal Russian winter. Things were so dire that even the bombastic propaganda minister, Joseph Goebbels, chastised citizens for enjoying comfort at home and urged them to send clothing and supplies to soldiers at the front.
In the Far East, imperial Japanese troops were advancing toward the British bastion of Singapore, the “Gibraltar of the East.” Singapore would fall after a one-week battle in February 1942, leading to the capture of some 80,000 British and allied service members. It must have been a terribly anxious Christmas in the threatened city that year. And also as far away as Australia, where citizens could see a serious risk of a Japanese invasion. That invasion never came, but the fall of Singapore roughly coincided with the start of Japanese air raids in Australia’s north.
I expect the hardest part of this Christmas for most people is the prospect of separation from loved ones. Some are taking a just-say-no-distancing approach. Air travel in this country last weekend reached its highest point since the pandemic set in. Some 85 million Americans are expected to travel from Dec. 23 through Jan. 3, according to estimates from AAA. But many more will heed the advice to stay away, especially if getting close might mean exposure to an older or frail relative who is more vulnerable to the current plague.
The World War II generation knew all about separation. Besides the millions under arms, there were internments, displacements and evacuations that sometimes lasted for years. Many involved parting children from parents, which must be the hardest separation of all.
The British had, rather remarkably, begun planning to evacuate children and certain other civilians from London and other vulnerable areas more than a year before war broke out in September 1939. Within days, parents handed over huge numbers of children to volunteers, who escorted them from the cities likely to be bombing targets to presumably safer rural locales. Many families retrieved their children when the bombing failed to materialize in the first months of the war, however. By Christmas 1939, a larger number of them were back home.
But then came the fall of western continental Europe to the Wehrmacht in 1940, followed by the aerial Battle of Britain. By that Christmas, the evacuations were back in full force. In December of 1941, many parents had not seen their children in more than a year, and some for more than two.
It surely took a terrible toll on everyone, but they did what they could to keep their spirits up. We can draw inspiration from that as we cope with our own crisis Christmas. This is true, I think, whether we personally observe Christmas or not.
Goodnight children everywhere,
Your mummy thinks of you tonight.
Lay your head upon your pillow,
Don’t be a kid or a weeping willow.
Close your eyes and say a prayer,
And surely you can find a kiss to spare.
Though you are far away, she’s with you night and day,
Goodnight children everywhere.
They got through their crisis; we will get through ours. Please be careful, think of others and know that you are not alone, even if you must be apart. All of us at Palisades Hudson wish you a happy holiday and a healthy, safe New Year.