Saturday, March 21, 2020

Imagining life after the coronavirus pandemic

Quote of the Day: “I can’t help thinking there is a Darwinian reset taking place, but it remains to be seen what evolutionary advantage is paramount …” Musician Roseanne Cash.

More and more of my mind-time is spent trying to imagine life after the coronavirus pandemic. Life on the planet will endure in some form but will be radically altered in at least some ways. One thing is certain, I think. There is no going back to “normal” - at least not to the comfort zone we experienced until December of 2019. The coronavirus pandemic exposes the fragile nature of our medical preparedness. Beyond the immediate need to ramp up quickly, consider two more possible changes.

  • Previously common practices, like face-to-face education and annual visits to our family physician, are on the block, likely to be replaced by other forms of communication such as on-line learning and telemedicine.
  • Modern transportation has enabled bringing us closer to other places, other peoples, other cultures. But because those means of transport are themselves sources of the infection, personal long distance travel has all but stopped. What kind of social structure, beyond small groups of immediate family, will be left? Will physical travel be replaced by virtual travel?

Short-term changes …

… result from attempts to control the spread of the virus and the drain on our hospitals and medical staff.

Coronavirus will radically alter the U.S.. Here’s what may lie ahead based on math models, hospital projections and past pandemics.

In the worst-case scenario, America is on a trajectory toward 1.1 million deaths. That model envisions the sick pouring into hospitals, overwhelming even makeshift beds in parking lot tents. Doctors would have to make agonizing decisions about who gets scarce resources. Shortages of front-line clinicians would worsen as they get infected, some dying alongside their patients. Trust in government, already tenuous, would erode further.

That grim scenario is by no means a foregone conclusion — as demonstrated by countries such as South Korea, which has reduced its new cases a day from many hundreds to a few score with aggressive steps to bolster its health system.

If Americans embrace drastic restrictions and school closures, for instance, we could see a death toll closer to the thousands and breathe a national sigh of relief as we prepare for a grueling but surmountable road ahead.

Doing that will require Americans to “flatten the curve” — slowing the spread of the contagion so it doesn’t overwhelm a health-care system with finite resources. That phrase has become ubiquitous in our national conversation. But what experts have not always made clear is that by applying all that downward pressure on the curve — by canceling public gatherings, closing schools, quarantining the sick and enforcing social distancing — you elongate the curve, stretching it out over a longer period of time.

Success means a longer — though less catastrophic — fight against the coronavirus. And it is unclear whether Americans — who built this country on ideals of independence and individual rights — would be willing to endure such harsh restrictions on their lives for months, let alone for a year or more.

Then we face a choice. We can cling to our American values - individual rights - at the expense of severe damage to our medical personnel. This is not a time for half-way measures (or hanging out with hundreds on a Florida beach). We must act collectively to lessen the impact of the coming catastrophy.

This month began with U.S. officials recommending actions such as hand-washing and social distancing. By Sunday, the Centers for Disease Control and Prevention was warning against gatherings of 50-plus people. By Monday, President Trump had made an abrupt turn from encouraging Americans to go on with their lives, to urging them to work from home and not meet in groups of more than 10, as well as calling on local officials to close schools, bars and restaurants. (Getting the public to comply has been alarmingly difficult. Young revelers from Bourbon Street to Miami have ignored those pleas, as have some elderly, who are at the highest risk.)

Trump’s sudden shift was driven by an alarming new scientific model, developed by British epidemiologists and shared with the White House. The scientists bluntly stated the coronavirus is the most serious respiratory virus threat since the 1918 flu pandemic. If no action to limit the viral spread were taken, as many as 2.2 million people in the United States could die over the course of the pandemic, according to epidemiologist Neil Ferguson and others at the Imperial College Covid–19 Response Team.

Adopting some mitigation strategies to slow the pandemic — such as isolating those suspected of being infected and social distancing of the elderly — only cuts the death toll in half to 1.1 million, although it would also reduce demand for health services by two-thirds.

Only by enacting an entire series of drastic, severe restrictions could America shrink its death toll further, the study found. That strategy would require, at a minimum, the nationwide practice of social distancing, home isolation, and school and university closures. And such restrictions would have to be maintained, at least intermittently, until a working vaccine is developed, which could take 12 to 18 months at best.

The report’s conclusion: This is “the only viable strategy.”

One reason [professionals] are alarmed: In China, the fatality rate in Wuhan, the raging epicenter, was 5.8 percent. But in all other areas of the country it was 0.7 percent — a signal that most deaths were driven by an overwhelmed health system.

We in America must adopt the recommended behavioral changes to reduce the load on our medical facilities and personnel.

Longer term changes

After the pandemic. How the coronavirus will change our lives forever — from music to politics to medicine.

FaceTime with your doctor

To reduce the risk of transmitting the coronavirus, health systems are hustling to switch to telemedicine. At our own institution, Johns Hopkins, and elsewhere, it’s happening almost overnight: Technological platforms have been launched, providers trained, patients educated and appointments converted to video visits. Patients get to speak to their physician in real time, securely, from their smartphone or home computer. You can’t accomplish everything through this method — patients who need testing must still go to a lab, and you’ll have to visit the doctor if she decides you need a physical exam. But it’s an extraordinarily useful tool: Long after the pandemic subsides, its adoption could mean good things for the delivery of health care.

Kimberly Gudzune @gudzune, an associate professor at the Johns Hopkins School of Medicine, is clinical director of the university’s preventive medicine residency. Heather Sateia @HSateiaMD, an assistant professor at the Johns Hopkins School of Medicine, is assistant clinical director of the general internal medicine practice at Green Spring Station.

Not-so-mass transit

Even before covid–19 hit, large urban centers like New York, Los Angeles and Chicago were losing population; more than 90 percent of all population growth since 2010 has taken place in the suburbs or exurbs. Millennials, as a new study from Heartland Forward demonstrates, based on an analysis of census numbers, increasingly head to cities and towns in the middle of the country and away from the supposed “magnets” of New York, Los Angeles and Chicago.

The current pestilence is likely to accelerate those shifts, which bear major ramifications for how Americans get to work. Transit ridership was doing poorly before the crisis, declining throughout the country, while telecommuting and driving alone continue to grow. With the specter of contagion, city-dwellers are told to avoid crowded subways, removing a critical element that makes ultradense cities work. In New York, subway traffic is down precipitously, as many commuters now work at home instead. Toronto is eliminating much of its downtown train service. The Washington Metro is also cutting back.

Just as progressives and environmentalists hoped the era of automotive dominance and suburban sprawl was coming to end, a globalized world that spreads pandemics quickly will push workers back into their cars and out to the hinterlands.

Joel Kotkin @joelkotkin, a presidential fellow in urban futures at Chapman University, is executive director of the Urban Reform Institute. His forthcoming book is “The Coming of Neo-Feudalism: A Warning to the Global Middle Class.”

After the handshake

Two weeks ago, I was on a cruise — I know, I know, but look, no one officially said, “Hey, maybe don’t go on a cruise” until the day after we left. But we all had a clear enough sense of what we were in for that one of the hot topics of discussion onboard was how the 2,000 of us were going to greet one another. Shaking hands was obviously not a great idea, much less hugging, …

Within a day, a winner emerged, one that was already under discussion on terra firma but that has rarely been attempted by any of the landlubbers I know: the elbow bump, in which two people thrust forward their elbows and touch them briefly together. It satisfied the convention of some physical contact, but with a body part that’s so isolated it’s unlikely to come into proximity to bacterial danger zones. (Go ahead, try to touch your face with your actual elbow, not just its crook. I’ll wait.)

Off the ship — and we all did get off the ship just fine, thank you — I don’t expect the elbow bump to gain much steam. I do think people will search for ways to greet each other if handshakes are considered bad form. Maybe it’s the science fiction novelist in me speaking, but we could do worse than the Vulcan salute. In the end, though, I suspect a simple wave “hello” will do the trick: an acknowledgment and a sign of potential friendship and an understanding that sometimes a little distance is kind, not rude.

John Scalzi @scalzi, is a novelist. His latest book, “The Last Emperox,” will be out April 14.

What (n0t) to wish for

Swear to never again fall for Trump’s self-aggrandizing assertions about how things are just great. Instead, let us commit to, and insist on, honesty and integrity from our national leaders.

Call Trump’s News Conferences What They Are: Propaganda writes Jennifer Senior in a Times Op-ed. Then contrast them with the leadership shown by Andrew Cuomo, Justin Trudeau and Angela Merkel.

In a time of global emergency, we need calm, directness and, above all, hard facts. Only the opposite is on offer from the Trump White House. It is therefore time to call the president’s news conferences for what they are: propaganda.

Sometimes, I stare at Deborah Birx during these briefings and I wonder if she understands that this is the footage historians will be looking at 100 years from now — the president rambling on incoherently, vainly, angrily, deceitfully, while she watches, her face stiff with the strangled horror of a bride enduring an inappropriate toast.

If the public wants factual news briefings, they need to tune in to those who are giving them: Gov. Andrew Cuomo of New York, Prime Minister Justin Trudeau of Canada and Chancellor Angela Merkel of Germany, whose addresses appear with English subtitles on Deutsche Welle. They should start following the many civic-minded epidemiologists and virologists and contagion experts on Twitter, like Harvard’s Marc Lipsitch and Yale’s Nicholas Christakis, whose threads have been invaluable primers in a time of awful confusion.

On Friday, Cuomo said something … that was quite striking, as he was issuing his executive order for nonessential workers in New York to stay home, other than to run errands or exercise outside. “If someone wants to blame someone or complain about someone, blame me,” he said. “There is no one else who is responsible for this decision.”

Cuomo is nothing if not politically shrewd. He knows full well how this comment compares to Mr. Trump’s “I don’t take responsibility at all.”

… most dangerous of all is Trump’s insistence that things are fine, or will be shortly, that they’ll be stronger and better and greater than ever. We don’t have any evidence that this is true, and the president finds any suggestion to the contrary quite rude. When a journalist pointed out to him on Thursday that the economy had all but ground to a halt, Trump cut him off.

Here’s the truth: Things might be hard — unfathomably hard — for months, perhaps even north of a year. Anyone who’s reading or listening to other sources of news besides the president knows that. It takes sensitivity and strength and intelligence to speak truthfully to the public about imminent hardship, the prospect of enduring pain.

So I listen to Justin Trudeau, a sci-fi experience, a dispatch from an alternate universe that prioritizes the needs and anxieties of the middle class. He speaks about immediate concerns: The kids will be all right. There’ll be food. You won’t be booted out of your home. Not how our president is speaking right now, but it’s a road map for the Democratic presidential nominee in 2020 to follow.

And I listen to Cuomo, who says the same thing. His news conference on Friday was about the practical things, knowing the entire state — country, globe — had just taken a precipitous slide down Maslow’s hierarchy of needs, with food, shelter and safety now topmost on many people’s minds. No one can evict you for 90 days. We’re getting hospital beds. We’re recruiting doctors and nurses in training to fight this fight, and we’re coaxing medical professionals out of retirement.

Thanks to Roving Reporter Sherry for the tip.

No comments:

Post a Comment