Coronavirus: Roadmap to Recovery

On Friday, we once again invited our downstairs neighbor to come up for supper. We ordered takeout from Hopsfrog, one of our favorite local spots - I've known owners Costas and Maria for years and years, since they bought the original restaurant, Fritters, and renamed it. That was back in the mid 1990s. That was when Maria didn't know my name and she called me "the lady."

As always, I'm torn between the guidelines to shelter in place and not have visitors and the impulse to help a neighbor. Michael is 70, responsible, goes out once a week for groceries, and stays in like we do. In fact, I'd say my husband, Dan, probably goes out more often than Michael. But none of us are traipsing around in crowds. And Michael's cat, Frodo, is dying. So, we take the somewhat calculated risk of keeping a neighbor and long time friend from getting unbearably lonely.

Michael lost a friend to covid-19. He was a coworker who had had a stroke years ago and has been in The Virginian, a long term care facility. The last time Michael saw his friend was around Christmas time when a group of retirees from the National Archives went to visit and took him out to lunch. Michael got an email about his friend's passing. Suddenly, everything got very real, very fast.

So, I was very glad we invited Michael up. It was a mitzvah.

Over cocktails, London broil, mashed potatoes, and good Cabernet, we discussed politics, current covid events, and reminisced about our misspent youth. Michael told us about moving to Boston after college to work at Harvard Library and getting an apartment with a musician friend. Their first night there, they discovered an infestation of roaches. They left their stuff and crashed with friends and when they returned, all their stuff, including the musician's very expensive guitars had been stolen. It crushed them.

Dan regaled us with stories about how his apartment at law school in Memphis was infested with fleas, among other misadventures. Within six weeks, he'd left law school.

I didn't have any experiences that dramatic. But we all told tales about our student trials, travails, and triumphs, and howled with laughter. Somehow, it's funnier looking back than it ever was living through it at the time.

After dinner, we found reruns of the Smothers Brothers Comedy Hour from 1967 on one of those cable stations that specialize in nostalgia TV. Tommy and Dickie, and the Who all looked so impossibly young.

Sometimes nostalgia can be dangerous. It can remind you of all you've lost. After watching a reminder of that more idealistic time, I longed for the normalcy we've given up in the age of coronavirus. As much as I sometimes feel secure in my cocoon, I know what we are doing, though necessary for public health and safety, is not sustainable long term. Even with every government infusion of money to help people and businesses, there comes a point where the economy has to open back up. And it has to do it safely. A sudden spike in deaths will only wipe out every sacrifice we've made. And it will tank the economy even worse. If the number of new cases and new fatalities spike upward, I guarantee the recession will take an equally strong spike downward, plunging us into an even more serious depression.

So, what will a recovery look like?

The White House has issued some guidelines. They include a downward trajectory of new cases, declining hospital admissions and lower death rates for a fourteen day period. They also recommend robust testing for all healthcare workers and at risk populations, including new blood tests to test for antibodies so we have a better grasp of the true rate of infections and the real mortality rate from this highly contagious virus.

Reopening the economy would entail at risk populations still sheltering in place while younger people and those generally in lower risk categories begin to return to workplaces. Even in those workplaces, social distancing should be maintained. And when possible, employers should be lenient in allowing people to telework from home. Travel should remain limited to essential trips, and gathering spots should limit the numbers of people allowed to congregate.

Schools would remain closed. Theaters and gyms would be able to open if they can practice strict hygiene and social distancing. Bars would remain closed, and elective surgeries could resume only on an outpatient basis.

In phase two, vulnerable populations would continue to shelter in place. Restrictions on non essential travel would be lessened or removed. Other things would gradually open. And only in phase three would those in vulnerable populations finally be able to stop sheltering in place. But some social distancing and other precautions would remain.,

None of the phases talk about a true return to normal - crowded bars and restaurants, people moving about freely and freedom from fear (remember, one of Norman Rockwell's Four Freedoms?).

All of this happy scenario stuff is really contingent on testing. We can see when hospital admissions go down, when people stop dying, and we can assume some gradual loosening of restrictions are okay. But without widespread testing, we won't know if cases begin to uptick until they spike once again. We won't know, in other words, until an outbreak has already spilled into the hospitals and until it's too late. We could easily find ourselves back at square one, with an even weaker recovery and public trust in institutions in tatters.

The plan of gradual reopening in carefully calibrated phases is a good one, if you have testing and contact tracing. In Singapore and South Korea, they had that testing all along and were able to quickly quarantine all those infected, trace their contacts and quarantine them too, and the rest of the population never had to go into draconian lockdowns. While their economies took a hit too, it was nowhere as bad as in China, Europe, or the U.S.

Germany, generally acknowledged as the outstanding model for handling this in Western Europe, unveiled its plans to reopen. It too has done the testing and contact tracing all along. While it gradually phases in its return to work, it will continue that. With widespread testing, at the first uptick, you can get infected populations in quarantine quickly and limit infections from spreading. They have a fine tuned instrument with surgical precision. The rest of Europe, and even more, the U.S. has a blunt, dull instrument.

In the U.S., we are still grappling with severe shortages of tests. Three months into this, while Trump has been clowning in a sham of a daily update, he has still failed to come up with a true national plan to increase testing capacity. States have been struggling to do this and meet the other medical needs of their citizens on their own or in cooperation with neighboring states. The governors have provided amazing leadership in California, Washington State, New York, Maryland, Virginia, Michigan and Ohio. And in places like Florida and South Dakota pretty dismal and reckless lack of leadership as they've followed an unserious reality star president over a cliff.

The truth is the most capable governors struggling to keep their state safe and all the phased in and cautious reopenings can only do so much, though, until we get some treatments to truly cut the risks of reopening. That is going to take the scientific community. It would go a lot faster and have a greater shot of success with a competent president and a well-coordinated effort. But the states and the scientific community nationally and globally aren't waiting for the Trump administration to lead the way.  Trump already he proved he's not capable of real leadership.  We are all on our own, forging alliances despite, not because of the Trump administration.

Next Up:  The Next Horizon; The Search for the Cure

Cornavirus: Flattening the Curve and Buying Time Part 1

I have a confession. I honestly don't think I am going to survive this pandemic.

Oh, I don't want to get melodramatic. For now, I am fine. Indeed, safely ensconced in the sheltering bubble of my condo townhouse, I feel protected. I breathe in and repeat the mantra: "In this minute, right now, I am safe," I breathe it out too. Whenever I read another article on how bad it is, or some new dreadful symptom or complication caused by this still mysterious virus, whose full destructive capability we only starting to learn, I breathe in and out and remind myself that at this moment, I am safe.

But when our leaders - the president, the governor, some state senators - start to agitate for reopening businesses, lifting the shelter in place, returning to normal, I get a swift, white hot, boiling shot of cortisol and adrenaline that shoots from my limbic system right into my bloodstream, sending my heart pounding, my pulse racing, and my temples throbbing while I hyperventilate. You get the picture.

And yet on some deeper level less connected to my amygdala, I know and acknowledge that we can't stay in self-imposed quarantine for a year to 18 months. That's not realistic and the economic hardship and pain that will cause is a valid concern too. Yes, we do have to balance public health and the economy. We cannot live without paying rent and bills. We cannot live without people willing to provide services like manufacturing, selling, and delivering the goods we need even while some of us have had the luxury of huddling in our safe spaces. Somebody has already been out there every day making it possible for us shelter in place. They've been taking risks for the rest of us.

Yet, when some of our leaders privilege the economy over public health and safety it sounds offensive. When they talk about acceptable numbers of deaths and acceptable risk, it raises my hackles. Whose risk? Whose death is acceptable? Who do you want taking that risk for you? And do you know the value of life, or just the price of commodities?

Right now, it's appropriate for the federal government, the states, and the municipalities to be starting the long range planning for a reopening. But we need transparency and criteria for when all that will happen. Too often, the focus seems to be shifting to arbitrary timelines and calendar dates divorced from data.

So, it might be helpful to talk about what was our goal when we all went into quarantine. What did we hope to accomplish?

We were told it was to flatten the curve. In Wuhan, China, where the novel coronavirus first emerged, it caused pandemonium (same root as pandemic?). The virus spread like wildfire, overwhelming hospitals, creating shortages of ICU beds, medications, and all important ventilators. Patients were dying as much from shortages of supplies and medical personnel to care for them as from the actual virus. And doctors and nurses began to succumb because of lack of personal protective equipment (PPE).

Then Covid-19 spread to Italy to a prosperous region in the North. Unlike China, which for a long time kept a clamp on news about how bad the epidemic was, in Italy we got a full, unvarnished look at how coronavirus raced through the population, creating shortages of lifesaving equipment, ravaging people, bringing down medical staff. In Italy, we witnessed the sight of streets choked with coffins and frank discussions about rationing ventilators. Triage became the word of the day as bioethicists wrestled with criteria for deciding who lived and who would be allowed to die.

That's when the rest of the world came up with the strategy of sheltering in place to stop this highly contagious pathogen from spreading so quickly. China was the first to use draconian lockdowns, forcing their people to stay at home until new infections stopped rising. Italy did the same as the only solution to stop the steady march of corpses to coffins to graves.

Plotting the graphs of rising death rates and rising new infection rates, the goal became to flatten out that  line on a graph by reducing new infections. The object was to keep the rate of infection low enough that hospitals would not become so overwhelmed they couldn't care for patients or run out of lifesaving equipment. It was never to eliminate all virus cases, it was to keep the number of patients low enough to make hospital treatment manageable.

Once the rate of infection was flat for a couple of weeks, the goal would be to begin to restart life and get people back to school and work. With more testing and contact tracing, public health officials hoped to be able to monitor how well that was working. And with vigilance, they'd watch for any uptick in new infection and move quickly to re-shut school and business until it went back down. That, of course, meant halting startups, shutdowns, restarts, hope, disappointment, and maybe more hope.

It wasn't perfect. And it wouldn't guarantee anybody real safety. After all, even with robust testing, by the time you have the positive test, it may be too late for your personal health and
safety, even if your uninfected coworkers are still safe from you and the hospital still has the capacity to treat new cases. The biggest drawback, after all, is we still don't have any effective drug or treatment for those already sick. The best medical experts can offer is supportive therapy to keep the patient as comfortable as possible and to treat symptoms while the patient rides out the infection, hoping their immune system will kick in and fight the virus off. Ventilators, after all, don't kill viruses, they breathe for a patient whose lungs have been infected until the patient's immune system fights off the virus and recovers. Or doesn't recover. Ventilators treat symptoms. They don't kill viruses. About half the patients who go on ventilators don't recover. But without a ventilator, many more of those patients would die.

So, a second goal - or more a second hope - began to emerge. That is buying time. Some medical experts hold out hope of developing a vaccine in about a year to 18 months. Other researchers are racing to find an antiviral that can treat the actual pathogen. We already have antivirals and the very controversial antimalarial, hydroxychloroquine, which showed some promise in a very small clinical trial. Of course, more and better clinical trials need to be done. But it is possible to have one or even several medications that can treat and slow down the virus within several months, maybe even by the summer.

Hospitals, universities, and private labs all over the globe are sharing information and working cooperatively to find new medical treatments for the novel coronavirus. Meanwhile, testing capacity is finally ramping up. All that might be worth waiting for.

I know it's unrealistic to talk about waiting until the middle or end of 2021 to get back to normal. And I know our cratering economy is harming a lot of people. My husband, as part of his jobs, is on calls all the time about the astronomical unemployment rate. One day a few weeks ago, we went into DC so he could sign hundreds of emergency checks for unemployed union workers. So, we are cognizant of effects on the economy and the human toll that takes too.

But might buying some time for a an effective treatment be worth the extra sacrifice if what we are talking about is a few months?


In Part 2, I will talk about what a roadmap to reopening should look like