It is St. Patrick’s Day, but the bars are closed, and there will be no parade. It feels as if we are in one of those pivotal moments that we will talk about for years to come. Some people say that America comes together in moments of crisis. We will be testing that theory in a new way. I hope that those who hold that view will be proven to be right.
In a time of crisis, I find that my mind keeps jumping about to each member of my family, as I try to assess what is happening in their location. I remember that my mother always knew the weather report for the homes of her four children who were scattered around the country. Like her, my distress is enhanced by the fact that we are so far apart. The concerns of the moment are heightened, as they were on 9/11, by the distance in miles between us. It is so painful to accept the reality that as much as we would like to make things better for all of our family members, there is not much that we can do to help our children out as they adjust to the inconveniences and isolation of “social distancing” and working from home.
Our son and daughter in law in Santa Cruz are probably pretty typical of many American families across the country. Their usual daily stress of getting two little boys to school and daycare while they alternate their turns at business travel, and try to support one another when the unexpected demands of professional life disrupt a schedule that makes every moment together precious, has been exchanged for the new challenges of working from home while the kids are with them and want their attention. The parents take turns working and tending to the needs of their two little boys, aged five and two. They are ahead of the curve because they have had an order for the last few days from the county to “shelter in place until April 7.” The kids are disoriented by the changes in their schedules. Yesterday, our son called and asked if we could help settle the boys down with a video chat. Have you ever tried to do a conference call with your coworkers while a two year old was sitting on your shoulders? The picture in today’s header is a fuzzy screenshot of that circus act taken by a coworker of my son who understood the problem, or at least found it to be amusing. Where would we be now without the ability to offer school, work, and medical appointments online?
In the president’s news conference this morning, CMS Administrator Seema Verma announced that Medicare and Medicaid would cover all visits of all types that can be done online. The president also implied that to facilitate the rapid transition to online care prosecution of potential violations of HIPAA would be suspended. We are moving into a new world. I think that using 9/11 as a guide, it is likely that when this storm ends we will emerge into a new world that will be very different from the world we knew before something happened in Wuhan.
I will not bore you with a further update on my far flung family, except to say that they are all staying close to home and trying to move as much of their world as possible online. I will add that my youngest son and his wife are fleeing Brooklyn today, and will self quarantine in our garage apartment. That son puts a new song and a little essay on the Internet every Monday, and his post this week describes his emotional reaction to what they have experienced in New York. My family, like yours, and like everyone in America is learning a “new way of walking.” As the words of the early sixties hit song “Walk Right In” says:
Everybody’s talking ’bout a new way of walking
Do you want to lose your mind?
Walk right in, sit right down, daddy let your mind roll on
By the time this over over it is likely that we will all have learned a new way of walking from necessity. The rapid transition to “new ways of walking” is being driven by our government’s sudden realization of an uncomfortable reality that it can no longer ignore. These transitions have become more urgent as modeling from Britain suggests that without an aggressive strategy we could have 2.2 million deaths. That sounds excessive to some of the people on the president’s task force, but they are “looking at it very closely.”
The biggest tragedy in my family is the fact that with gatherings limited to ten people, my nephew’s wedding in South Carolina which has been on our calendars for six months for March 28, is not going to happen as planned. All of this is stressful, but I am lucky. I do not need to go out because I am retired. No one that I know is sick, and most of my friends, like me, can absorb a little more loss in the market, and still be fine. Our friends reassure each other that in time this storm will pass, and our retirement funds will recover.
I can imagine that your story is more frustrating than my story. Many of the readers of these notes are dealing with all of the uncertainty that I feeI, and are also involved in the direct care of patients, or have the responsibility to prepare your system of care for the uncertainties of the next few months. Some of you have children who can’t go to school or to daycare while you go to the hospital or your office where online and in person there will be many worried, and some sick people, who are desperate for answers and reassurance that all will be well.
I can imagine the increasing frustration you must feel as you try to explain the delays in testing, or explain once again the precautions that you believe are warranted, and for the sake of progress, will simultaneously create great inconvenience for the patient that you are counseling. It is hard work to deal with uncertainty and fear. In good times most of what we do is routine, but I am sure that there have been very few “routine encounters” over the last week or so. The increased burden you feel today is enhanced by the reality that no one really knows how long this will go on, and it is becoming clear that we are all on a new learning curve.
What is happening in Washington and at our state capital in Concord is creating uncertainty and driving change at home for everyone, but especially for those who live on the periphery of our society and suffer the greatest vulnerability to the social determinants of health. Over the past three years, I have gotten into community service as I have realized more and more the needs that exist around me. Don Berwick always has said to think globally and act locally. I have discovered that there are many like minded souls in my community, and we have been having “emergency teleconferences” as we try to craft ways to mitigate the inevitable financial strain on the least prepared and most vulnerable members of our community. The part of the work that I enjoy most is the “doing.” Delivering a load of wood, helping someone fill out a ridiculous welfare request form, or taking someone’s garbage to the dump for them, provides the sort of action and interaction with others that I enjoyed in the best days of medical practice.
One organization that I work with, and have mentioned before, dispenses emergency funds to people and families in need. Yesterday, I fielded a call from a woman who is already a casualty of the economics of the coronavirus. Like many people in New Hampshire, she has been working two jobs while the children are in school. Like many others, she is a single mother getting minimal child support payments from an ex who is also a hard worker. Last Friday, both of her employers decided they needed to do layoffs, and in one day she lost both jobs. Fortunately for her, Eversource, the predominant local supplier of electricity, has decided that they are not going to cut off the electricity of those who are behind in their payments while the COVID-19 problems persist. Unfortunately, her supplier of propane is not so generous, and wants over $350 for a minimal delivery. She is almost out of propane, and she is also out of firewood. She has a mountain of paperwork to do to get any assistance. We will fill her propane tank, and deliver wood to her. Another organization which we recently formed will “walk with her as a good neighbor” as she tries to work her way through the social services barriers that long predate COVID-19. I expect that she will be the leading edge of a growing aspect of our experience with COVID-19.
My other recently acquired community activity is as the moderator of my congregation. We are fortunate because we are an affluent community, and over the years our members have remembered the church and the community in their wills. We also have a very prudent board that has invested in a diversified way that will mitigate the impact of the downturn in the stock market. Yesterday, we had an emergency meeting to brainstorm how we could support the community with our resources. We provide space for our local food bank, but there is much more that we might do since it seems that our local senior center will be closed, and we have many people in our community who may have problems with transportation, and with childcare. We are particularly concerned about the childcare needs of the medical professionals in our community.
We have food banks like the one that uses space in our church, in most of the towns in our state. Unfortunately, retirees provide much of the volunteer work that keeps them going. Two of our area food banks closed today because the volunteers are afraid of their risk of exposure to COVID-19. Simultaneous with the closure of the local schools by the governor, “backpack” programs that supply weekend food for school children who depend on meals at school for their nutrition have been thrown into a state of uncertainty. Eighty percent of the children in one of the communities in our region qualify for free or reduced cost meals at school. There is concern that the children won’t get food at school, and won’t have adequate food for the weekends. It is hard to imagine how such need might be true in such a wealthy nation as ours, but it is a fact.
One is left to conclude that our nation, like at least forty percent of its citizens, is unprepared for unexpected financial or medical events. Many people appear to be healthy and secure consumers, but they are getting by paycheck to paycheck, and they depend on a system of acute and chronic care that may not have the reserve capacity that it needs. Many of our neighbors are “economic posers” who appear to be doing well but are without any real savings or family resources when a test comes. There is much wealth in our country, but much of it is sequestered under the control of a small minority. My wife and I should be secure, and we would like to think we are not vulnerable to the economics of the moment, but the lesson imposed on all of us by a pandemic is that no one is secure until we are all secure. We only have varying degrees of uncertainty and insecurity. If we are vulnerable because of our lack of investment, planning, or willingness to act for political reasons to prevent the loss of 2.2 million lives, then we all are at risk. To survive all threats, we must learn to make sure that we prospectively spread our resources in a way that assures a chance for survival of the most vulnerable among us. In the midst of uncertainty one of the few things that is certain is that we are all vulnerable.
I have listened to each of the daily updates provided by the team that President Trump has pulled together to guide us through this crisis. His message is improving, but it has been painful to listen to his responses to the questions presented by the press. If you listened to the presentations over the weekend. and then listened yesterday and today, you heard a crescendo of concern, but you never heard that he was accepting responsibility for any fraction of where we are now due to maneuvers and misinformation about testing, an amazing Google product, and his failure to deal with the facts and act responsibly until the potential disaster of the moment could no longer be denied.
Last week he feigned concern as he presented a parade of CEOs from large retailers, plus the promise of economic stimulation from the government in an attempt to shore up the stock market which is his favorite index of his greatness. His preferential efforts to shore up the stock market while real delaying real efforts to dealing with the realities that many others understood did allow the stock market to rally on Friday, but once again the misinformation, excuses, and the actual fact of the rising numbers of cases and deaths lead to the huge sell off yesterday, and a need for a dramatic reversal of policy and acceleration of real efforts to contain the virus. I understand that from the moment yesterday’s briefing that began at about 3 PM, until the market closed at 4 PM, the market fell about a thousand points. It was the worst sell off since 1987.
Through it all, I have come to appreciate Dr. Anthony Fauci, and a couple of his colleagues who have been speaking truth to power with courage. Dr. Fauci appears to have succeeded where other members of the administration, even respected military leaders like Jim Mattis and John Kelly have failed. Perhaps Dr. Fauci has credibility and capability that is the product of the fact that he is a veteran of serving seven presidents. He seems not only to have the emotional stability to “suffer fools,” but he also has the grace and experience to know how to guide them toward the acceptance of realities that can’t be disguised by the usual lies and misinformation.
Over the weekend James Fallows published an analysis in The Atlantic of why Dr. Fauci has succeeded in making progress with Trump when a brilliant general like Mattis failed. In his The Atlantic review and analysis of Dr. Fauci’s success with his seventh president, Fallows makes three points to answer the question that he poses.
Why is Anthony Fauci now, even more than James Mattis before him, in a different position from any other publicly visible associate of Trump’s?
- Pre-Trump credibility, connections, and respect. Fauci has been head of the National Institute of Allergy and Infectious Diseases, at the National Institutes of Health, since Ronald Reagan’s first term, in 1984…Through his long tenure at NIH, which spanned the early days of the HIV/AIDS devastation and later experience with the SARS and H1N1 epidemics, Fauci has become a very familiar “public face of science,” explaining at congressional hearings and in TV and radio interviews how Americans should think about the latest threat. He has managed to stay apart from any era’s partisan-political death struggles…Thus, in contrast to virtually all the other figures with whom Trump has surrounded himself, Fauci is by any objective standard the best person for the job — and is universally seen as such…Put another way: Very plainly, Trump needs Fauci more than Fauci needs Trump. This is not a position Donald Trump has ever felt comfortable in— witness the denouement with Mattis.
- The ability not to abase himself before Trump. The first Cabinet meeting Donald Trump held, nearly three years ago, was unlike any other conducted in U.S. history, and very much like subsequent public appearance of Trump in company with his appointees.
In that meeting, on June 12, 2017, as TV cameras were rolling, Trump went around the table and one-by-one had his appointees gush about how kind, wise, and far-sighted he was—failing only to compliment him on his humility. After praising himself, Trump called on others to praise him, starting with the reliable Mike Pence. “It is the greatest privilege of my life to serve as the vice president to a president who is keeping his word to the American people,” Pence began. All the others followed his example—with the prominent exception of Mattis. He spent his “praise” time instead complimenting the men and women in uniform he led.
No public event like that Cabinet meeting had happened before in the United States, simply because no other president has been as needy for in-public adulation as Trump is… There is one exception: Anthony Fauci. He has occasionally said that he agrees with aspects of the administration’s or the president’s policies, but he has avoided the ritual self-abnegation…But Fauci’s polite but consistent reluctance to grovel cannot have gone unnoticed by the audience-of-one for all the other appointees: Trump himself.
- Daring to contradict Trump, in public. This is a step beyond anything Mattis attempted…there is no precedent, from Mattis or anyone else, for what we have seen these past few weeks from Fauci at the podium. Is the coronavirus problem just going to go away (as Trump had claimed)? No, from Fauci. It is serious, and it is going to get worse. Is the testing system “perfect” (as Trump had claimed)? No, it is not working as it should. Is the U.S. once again the greatest of all nations in its response to the threat? No, it is behind in crucial aspects, and has much to learn from others.
Fauci is saying all these things politely and respectfully. As an experienced Washington operator he knows that there is no reason to begin an answer with, “The president is wrong.” You just skip to the next sentence, “The reality is…” But his meaning—“the president is wrong”—is unmistakable.
Anthony Fauci has earned the presumption-of-credibility for his comments. Donald Trump has earned the presumption that he is lying or confused. A year ago that standoff—the realities, versus Trump-world obeisance—worked out against James Mattis. Will the balance of forces be different for Fauci? …
I am rooting for Dr. Fauci. I think that his philosophy that we must work hard and accept inconvenience because the problem is always worse than it appears to be at the moment is consistent with my experience as a clinician. I was frequently worried when I had an ill patient where there was ambiguity in the numbers. I worried that there was some piece of data, or a new problem brewing that I was missing and needed to find. The only cure for the “it might be worse than it appears to be blues” is some indication of the certainty that the storm has passed. It was always great to see my patient who had been blue and gasping for air in the EW the night before, sitting in the chair beside his bed reading the newspaper while he ate a hearty breakfast when I came by on my rounds the next day. The “Hey Doc, I am feeling much better” was worth the several hours of lost sleep the night before. The “hey doc” moment with COVID-19 will not come until long after we are able to accurately test for those who are infected, and follow the strategies that will cause the numbers of new cases and deaths to begin to fall dramatically. I think Dr. Fauci has finally convinced the president that the “all better” moment may not come until July or August, and that the president’s persistent denial of that reality would only push the “it’s over moment” further into the future.
The president may be accepting advice, but he is not accepting any responsibility for the moment. Unlike the irascible, sometimes profane, but always responsible Harry Truman, the buck never stops with Donald Trump. At the news conference on Monday, after the president finally signed on to the serious nature of the problem, a brave reporter asked the president to rate his performance in managing the crisis on a scale of one to ten. Without hesitation the president gave himself a perfect “ten.” He continued to blow his own horn today as he presented plans and actions that could have been even more effective a month ago.
Peter Wehner, a conservative writer, and a veteran of the administrations of Ronald Reagan and both Bush presidents, wrote a review in The Atlantic last Friday, entitled “The Trump Presidency Is Over: It has taken a good deal longer than it should have, but Americans have now seen the con man behind the curtain.” In his article Wehner gave the president an equivalent of a “one or two” rating, not the generous ten that the president awarded to himself. The positives are in the first paragraph, and the “not so good” part that undermines the president’s self awarded “ten” starts in the second paragraph. I bolded some points to ponder.
To be sure, the president isn’t responsible for either the coronavirus or the disease it causes, COVID-19, and he couldn’t have stopped it from hitting our shores even if he had done everything right. Nor is it the case that the president hasn’t done anything right; in fact, his decision to implement a travel ban on China was prudent. And any narrative that attempts to pin all of the blame on Trump for the coronavirus is simply unfair. The temptation among the president’s critics to use the pandemic to get back at Trump for every bad thing he’s done should be resisted, and schadenfreude is never a good look.
That said, the president and his administration are responsible for grave, costly errors, most especially the epic manufacturing failures in diagnostic testing, the decision to test too few people, the delay in expanding testing to labs outside the Centers for Disease Control and Prevention, and problems in the supply chain. These mistakes have left us blind and badly behind the curve, and, for a few crucial weeks, they created a false sense of security. What we now know is that the coronavirus silently spread for several weeks, without us being aware of it and while we were doing nothing to stop it. Containment and mitigation efforts could have significantly slowed its spread at an early, critical point, but we frittered away that opportunity.
Well, that’s water under the bridge, spilt milk, and a wave missed. The good news is that we can still mitigate the experience of lives lost, if not the damage that will occur to the economy. It would be good if Dr. Fauci could give the president a referral to someone who might help him with the economy. I have no confidence in Steven Mnuchin and Larry Kudlow.
I think that the next few weeks will be hard for all of us. I keep thinking about Cormac McCarthy’s dystopian novel of 2006, The Road. If you have not read it, now is not the time. It is a downer. In the book, the world has changed and there are few survivors, although we never learn what really happened, but it is clear that whatever it was, was not good. The other literary piece that bugs me is “The Hollow Men” by T. S. Eliot. You may remember the last four lines of this 98 line poem.
This is the way the world ends
This is the way the world ends
This is the way the world ends
Not with a bang but a whimper.
I pull myself out of my downer thoughts when I contemplate the moment as an opportunity for us to come together in a collective effort to support each other while being mindful of the exercise of “social distancing,” and never forgetting the less fortunate among us. I don’t know what is going to happen to the rest of the Presidential Primaries since at the last moment Ohio joined Louisiana and Georgia in canceling its primary today. Easter will be online this year. But, if we do the right thing, perhaps, we can all enjoy a little bit of Japan’s Olympics, a month or so of baseball, have a Labor Day picnic, a little bit of football once we learn where Tom Brady will be playing, and then choose a new leader in November.
I have read that in his later life, T.S. Eliot recanted his end of the world image, and that was in the fifties after the atomic bombs had been dropped, and many were predicting a nuclear holocaust as our final act. Apparently, he had also discarded the idea of the world ending in a whimper. Perhaps his opinion changed because although he was an atheist when he wrote his poem, he had became religious. Somehow, he had come to believe that the world would endure, despite our failings. Each of us has choices to make. We are all vulnerable to one another. One way or another on this small planet that we share, this too will pass, and then we will be able to talk about what we have learned from the experience. In the interim, we need to take care of one another, and listen to the good doctor.
