Yesterday, I scored two rolls of toilet paper at the one grocery store in my town. I felt good about my accomplishment until I got home and thought about what it meant to find joy in toilet paper. I had volunteered to do the shopping, and my wife’s last request before I walked out the door was to be sure to look and see if I could find some toilet paper. I was surprised and delighted to find four lonely roles on an otherwise empty shelf. There was also a sign that said only two per customer. I took my two, and felt like I had won a prize. It was a moment of joy that faded fast. In a very short time, I found that I felt sad, and thought that perhaps I should have left one or both for some other person. I wasn’t really hoarding. We were running low. Who would have thought two weeks ago that buying toilet paper would create a moral dilemma? These days things change fast. Today will not be like either yesterday or tomorrow. Things have changed a lot since I wrote the last paragraph of the main section of last Friday’s “Healthcare Musings. I wrote:

 

Sometimes, I get off track in these notes. I had planned to write to you about the upside of the trauma that we are currently experiencing. I do believe that there will be many positive changes and some innovations that evolve as we solve our current problems. I just got side tracked by the Crimson Contagion report in the New York Times, and the president’s overblown assertions about the hope of chloroquine. I hope that you will return next Tuesday when I promise to give you my perspective on what our hopes might be, and what we can embrace with joy at this time. In the meantime follow the advice that you can get if you listen to the professionals who stand behind the president. I wonder what is going through their heads as he presents his word salad of self acclaim, his inflated assertions about progress, and his denial of responsibility for anything but his innate heroic genius. 

 

Now, I think that it is too soon for me to complete the assignment that I gave myself last Friday. What has become clearer as each day passes is that we are watching a daily geometric increase in the numbers of people who probably have the virus. There is a very long road ahead of us that will be measured in months, not weeks or days. The number of known cases is probably still a fraction of those who have an asymptomatic or minimally symptomatic case, but they are capable of unwittingly spreading the disease to others who may become much more symptomatic and may eventually die of their infection after spreading the virus to still others. It has been encouraging to see that after more than three months it appears to be true that China is past the peak of its process, and even Italy appears to have a flattening curve. That good news is blunted by some experts who talk about “rebounds” as it appears may have happened in Hong Kong, or the possibilities of the virus returning in a few months.

 

Our challenge now is to continue to show the resolve that will “flatten the curve” and shorten the time until the threat subsides. As I will explain later, the biggest threat to our road ahead may be the impatience and self centered concerns of our president. That said, I do believe that we can begin to give some thought to how things may be different after the pandemic finally subsides. To try to understand what I am suggesting just think back to what happened in the years following 9/11. For starters, after 9/11 we were left with TSA, and travel was forever transformed. Rather than a lengthy discussion of my perspective on what our hopes might be, and what we can embrace with joy at this time, I will offer a list of things that could be better in the post COVID-19 world:

 

• We will be better prepared for future pandemics. 

 

• We will be more aware of the complex interconnections of our healthcare system and the importance of supply chains that can be quickly enhanced when needs occur.

 

• We will recognize that we have been using a nineteenth century operations model. 

 

• We will recognize that being paid piecemeal for each service performed is an outdated finance mechanism that dates back hundreds of years and is no longer efficient or appropriate .

 

• We will replace our predominate face to face operating model that requires enormous investments in bricks and mortar with one where the largest number of encounters occur as “virtual touches.”

 

• Health systems will see that accepting responsibility for a population and negotiating the resources that the optimal care for that population requires will be a finance system that is more consistent with quality and the goal of continuous improvement than a system that depends on how many elective procedures can be “sold.”

 

• We will have a more robust understanding of how better care for more people at less expense requires investment in improving the “social determinants of health.”

 

• We will redefine roles and responsibilities to better utilize our human resources.

 

• We will be better at partnering with our patients to enable “self care” where appropriate. 

 

• We will be much better at forming effective “public/private partnerships” that enable innovation and the equitable distribution of those better products and services. 

 

In the depths of despair from worrying about what will happen next as we learn to cope with the isolation and confusion associated with the loss of restaurants, gyms, hairdressers, gatherings for social events, the absence of sporting events, and disappointment from the cancellations of weddings, graduations, and even adequate funerals, it is easy to feel disoriented by the rapidity of change. It is easier to look back through the rapid dissolution of normality with blame and anger than it is to look forward to the possibilities of improvement that lie in a very near future where our world will be changed in ways we did not anticipate. Nevertheless, to avoid errors in the moment and the near future it is important to realize how geometric change varies from linear change, and how leadership that is reliable and has the ability to make difficult decisions is increasingly important if we are to avoid further loss.

 

My son, who is a thoughtful trial attorney who depends on his ability to assess facts and connect points in time, points out to me that the public’s sudden turn of opinion about the virus and the falling market, and not the exercise of genius by the president, explains where we are today. In his analysis, the events that really accelerated the change was not the declaration that COVID-19 was a pandemic by the WHO, and not insight gained from the pain and suffering of China, Iran, Korea, or even Italy. The public finally “got it,” and we entered the rapid transition to this world  after two startling events occurred on March 11: the cancelation of the NBA season, and the news that Tom Hanks and his wife had been infected by the coronavirus. It may be coincidence, but the S&P 500 fell 22% on March 12. Do you remember through the catecholamine blitz of the last 10 days that it was on March 13 that the president held his news conference in the Rose Garden to announce that he was shifting his opinion on the severity of the coronavirus from “no problem, fake news” to “we have an emergency”?

 

David Remnick of the New Yorker has written a piece that accurately describes the president’s role in bringing us to where we are now. He begins:

 

Early last week, the Trump era—which defined itself by a lurid celebration of “alternative facts,” a contempt for science, and an assault on global institutions and the “administrative state”—came to an end. Regrettably, Donald Trump remains in office, but, at least for the moment, he appears to have ceded the argument: he cannot bend the harshest realities of the world to his fantasies. The aggressive and deadly coronavirus is unimpressed and unimpeded by the bluster of a con. Yet the prolonged process of Trump’s humbling, the time it took him to recognize the power of the global pandemic that has emptied our streets, has put untold numbers of Americans at risk.

 

Remnick is right to a point, but his scathing analysis could go further, and we should use the president’s past performance to enable us to predict what he might do going forward. The president is accountable for a huge amount of lost opportunity, but let’s not accept that he has been transformed into a new and improved version of himself. He has not acknowledged his failures. Since he appears to still be at war with his scientific advisers, we are still vulnerable to his self serving mismanagement. It is dangerous to assume that his errors are past history and water under the bridge. The continuing potential harm to the country from the president’s personality flaws and his lack of judgement and strategic capabilities are magnified by his continuing anxieties over his ability to be reelected as the economy folds. His flawed character and continuing presence in office position us for even greater harm. The president has begun to signal again as a fact what is a fantasy. He does not have the energy or the forbearance to fake being presidential for a sustained period of time. If for a moment he accepts the good judgement of the experts around him, that information seems to have a very short half life. The overall dominance of his self interest soon overcomes any evidence of enlightenment. As evidence of his inability to sustain good judgment, he announced at his press conference yesterday that in a few weeks we would be back to normal. In a New York Times article entitled “Trump Considers Reopening Economy, Over Health Experts’ Objections: The president is questioning whether stay-at-home orders have gone too far. But relaxing them could significantly increase the death toll from the coronavirus, health officials warn” written by Jim Tankersley, Maggie Haberman and Roni Caryn Rabin, we read:

  

As the United States entered Week 2 of trying to contain the spread of the coronavirus by shuttering large swaths of the economy, President Trump, Wall Street executives and many conservative economists began questioning whether the government had gone too far and should instead lift restrictions that are already inflicting deep pain on workers and businesses.

Consensus continues to grow among government leaders and health officials that the best way to defeat the virus is to order nonessential businesses to close and residents to confine themselves at home. Britain, after initially resisting such measures, essentially locked down its economy on Monday, as did the governors of Virginia, Michigan and Oregon. More than 100 million Americans will soon be subject to stay-at-home orders.

Relaxing those restrictions could significantly increase the death toll from the virus, public health officials warn. Many economists say there is no positive trade-off — resuming normal activity prematurely would only strain hospitals and result in even more deaths, while exacerbating a recession that has most likely already arrived.

 

The president is a testy, impatient man who believes that he can define truth and force others to accept what he believes at the moment is best for him. The “what is good for the president is in the best interest of the country” was the nonsensical defense that Alan Dershowitz offered for the president during the impeachment trial in the Senate. It is clear now that it is not in the president’s best interest for the economy to suffer more from the public health necessity that businesses be locked down and for the public to be restricted in its movement. A little further down in the article Tankersley, Haberman and Rabin write:

 

…Mr. Trump said his administration would reassess whether to keep the economy shuttered after the initial 15-day period ends next Monday, saying it could extend another week and that certain parts of the country could reopen sooner than others, depending on the extent of infections.

“Our country wasn’t built to be shut down,” Mr. Trump said during a briefing at the White House. “America will, again, and soon, be open for business. Very soon. A lot sooner than three or four months that somebody was suggesting. Lot sooner. We cannot let the cure be worse than the problem itself.”

 

It is probably not a surprise that as we await the presentation of the two trillion dollar bailout bill from Congress, the president is getting impatient. His impatience was probably augmented by the fact that on Monday the market fell to the level where it was in November 2016 when he was elected. It rallied a little late in the day and finished a few points higher, perhaps based on his suggestion that restrictions would soon be lifted against the advice of Dr. Fauci, who was noticeably not present. On Sunday, an interview with Dr. Fauci was published by Science. In the interview Dr Fauci had described how he tried to manage the president’s education. Is it possible that the president has decided that he is “a very stable genius” that no longer needs guidance by a thoughtful physician?

 

Dr. Fauci and other experts have a simple series of points. We have a core problem that can’t be denied. Our only current defense against spread and the possibility of over 2 million deaths is the strategy of social distancing. The economy is a derivative problem. Treating the economy as the primary problem and lifting the restraints is a dangerous move that disregards the enormous risk of prolonging the pandemic and creating even greater economic and human losses. The president has a lethal influence over the many people who are in his base, and respond to his positions. There will likely be many business leaders who are focused on their losses, and distressed and frightened citizens who will agree with the president and be willing to follow him over the cliff. Many workers will be happy to re enter their workplaces to become the victims or vectors of further spread. 

 

David Remnick had another important insight for us in the New Yorker piece that I quoted earlier. What Trump has done once, he can do again. He was reluctant to accept the inconvenient facts of this terrible pandemic, and his impatience and his fear of the failure to be re elected may become an even greater threat to us all. Remnick’s analysis describes our collective jeopardy. As a nation, we may be at greater risk from the president’s impatience and self serving manipulations than we individually at risk from the virus.

 

Trump cannot be forgiven for his preening and his belatedness. And yet this least trustworthy of Commanders-in-Chief is entrusted by the authority of his office to make a series of critical decisions. In order to “flatten the curve,” we have rightly set in motion a set of edicts that, while necessary to control the pandemic, will continue to batter the economy, create deep atomization, and cause all manner of suffering. The human need for solidarity is frustrated by the need for social distancing. An economy that seizes up entirely could, in theory, produce nearly as much suffering as the virus itself, particularly for the most vulnerable among us. A host of well-judged policy decisions must be made and executed effectively if the country is to be spared the worst…

 

Last night Trevor Noah of the Daily Show of Comedy Central was back on TV broadcasting from his apartment. He commented on the president’s sarcasm at the press conference associated with the announcement that Senator Mitt Romney, who voted for his impeachment, was in quarantine. Noah continued by saying, “Even if we all get wiped out by the virus, I feel like Trump’s pettiness is the only thing that will survive this pandemic.” There is a note of warning in that observation. What led the president to resist the fact of the danger ahead back in February and early March, may lead him to lift the restrictions too soon and exacerbate the pandemic. 

 

Remnick sums up the the past and future danger to us all that is inherent in this president in his last paragraph: 

 

Right now, as we sit in our homes, washing our hands yet again, as we try to read the querulous expressions of our children, scientists and pharmaceutical companies are racing to develop antiviral treatments and—what will be our most valuable weapon—a vaccine. But no such deliverance is likely to arrive in this calendar year. In the meantime, another form of protection has become more urgent than ever. Misinformation and cant, along with a kindred scorn for science and professional expertise: these things are pathogens, too. Counterfeit facts can polarize, alienate, disaffect, rouse misdirected rage, and foment social division. They have long come at a cost to our civility; at a time of pandemic, especially, they also come at a cost in human lives. 

 

At every press conference the president introduces the idea that it was his genius to limit travel from China in late January. It is great that he did that, and sad that there was so much more that he could have done. It will be even sadder if he is allowed to revert to his natural tendencies. Remember:

 

Misinformation and cant, along with a kindred scorn for science and professional expertise: these things are pathogens, too. 

 

I want to finish on a positive note. To do that I will direct you to Don Berwick’s op ed that appeared yesterday in the Times, entitled “They Don’t Hide From the Coronavirus, They Confront It: Millions of health care workers are running to where they are needed, sometimes risking their lives.” In his article, he presented many examples of clinician courage and dedication. Those stories of heroic healthcare professionals and the sad ones where the healthcare worker becomes a fatality in the fight against the virus are at risk of becoming more common if the president treats the economy as more important than the disease. Don writes:

 

As the world writhes in the grip of Covid-19, the epidemic has revealed something majestic and inspiring: millions of health care workers running to where they are needed, on duty, sometimes risking their own lives. I have never before seen such an extensive, voluntary outpouring of medical help at such a global scale.