During the past six weeks, but especially over the last couple of weeks as the discussion about ending social isolation has gained momentum, the nation has been united in a curious way. We are united by a shared state of confusion and a lack of clarity about what we should do as individuals. As I mentioned a few weeks ago, we are all “walking in the dark.” Our questions and our inability to get answers that allow us to know for sure what will happen next is what “unites us.” There is no divide in our uncertainty. We are all asking the same questions. What happens next? Does it make sense to end social distancing and place our bet on “herd immunity”? What was the origin of this virus? Is the cure really worse than the disease? Will we have school in the fall? What about the NFL? Will we have football in the fall? What about the economy? What about the future of medical practice? What will the “new normal” be like? What divides us is manifested by the actions we are individually willing to take when there are no certain answers to our questions. Ambiguity creates anxiety. We vary in how our inherent biases, our previous circumstances, our self control, our personal fears, and our relationships lead us to respond to the disorienting uncertainties that challenge us.
Ed Jong, a writer for The Atlantic, has emerged as a reliable source of organizing questions into buckets of concern. At the end of March he presented us with a thoughtful article entitled “How the Pandemic Will End: The U.S. may end up with the worst COVID-19 outbreak in the industrialized world. This is how it’s going to play out.” He is back now with “Why the Coronavirus Is So Confusing: A guide to making sense of a problem that is now too big for any one person to fully comprehend.” His article underlines my contention that what unites us now is a shared reality that we are all confused and overloaded with information that does not add up to a dependable view of the future. What continues to divide us is how we react to the overwhelming uncertainties that face us. Near the end of the article he offers us one paragraph that nails the reality of the moment.
The coronavirus not only co-opts our cells, but exploits our cognitive biases. Humans construct stories to wrangle meaning from uncertainty and purpose from chaos. We crave simple narratives, but the pandemic offers none. The facile dichotomy between saving either lives or the economy belies the broad agreement between epidemiologists and economists that the U.S. shouldn’t reopen prematurely. The lionization of health-care workers and grocery-store employees ignores the risks they are being asked to shoulder and the protective equipment they aren’t being given. The rise of small anti-lockdown protests overlooks the fact that most Republicans and Democrats agree that social distancing should continue “for as long as is needed to curb the spread of coronavirus.”
When we crave answers and facts it seems that rather than the resolution of confusion and the emergence of clear patterns and facts that guide next steps, our level of confusion continues to rise. It seems that the more we think we know the higher our levels of doubt about our own health and our personal finances rise. Many of us have invested hours and hours of reading, watching inane updates from our president and more insightful analysis from the voices of some of our governors. We have been studying the charts and graphs that tell us what has happened with the hope that they will reveal what will happen.
The whole process reminds me of the funny phrase that my father would use when he was confronted by increasing frustration despite great effort, “The harder I try, the behinder I get!” I always thought that it was an expression of his unique wisdom. It turns out that he was repeating a phrase that he had heard somewhere. If you Google “The harder I try, the behinder I get!” you will find many interpretations, some of which have theological inferences. Perhaps what I am trying to say is that COVID-19 is such a challenge it feels like the more information we have, the less we know for sure, but sadly the less we know for sure becomes the basis for more division as we apply our own tendencies to the shared uncertainties.
I once heard about people having anxiety attacks at the Louvre. Surrounded by some of the greatest art in the world some people are overwhelmed. It seems bizarre, but I remember getting anxious at the Louvre, and also at the Musee d’Orsay. Apparently, like many other excited tourists, I entered the Louvre full of enthusiasm for the experience that I was about to have, but I was soon overwhelmed by the enormous volume of beauty that I could not process. There was so much to see that I have difficulty remembering much more than that I once visited the Louvre on a rainy day. Surrounded by the beauty that was evidence of the geniuses among us for centuries, I was could not process the what I saw. I was filled with uncertainty and the anxiety that is its sibling. Where should I look first? I was continuously asking myself questions about how much time I should spend with each exhibit. I was worried that if I waited in line to see the Mona Lisa, the museum would close before I saw the Venus de Milo or the sixteenth century Dutch Masters. In my attempt to see it all, I saw almost nothing. As the clock ticked and closing time got closer and closer, my “fear of missing out’ intensified, and I was even more unsure about where to go next. New questions arose out of my anxiety and added fuel to the fire. I wondered, “If I don’t see it all today, will I ever come this way again?” When the museum did close and I found myself standing dazed and confused in the Tuileries Gardens, I realized that it was too late to plan my visit to the Louvre.
I admit that it is a stretch to equate my museum anxieties with our COVID-19 experience, but let me try. I had been to Paris for quick trips in 1969, 1974, and 1978. I did not do much on any of those trips but walk around. I was doing it Europe On Five Dollars A Day style. I certainly did not analyze how I could have had a better trip next time. In 1995, I returned with the idea of seeing the finer things I had missed on the first three trips, but again I did not do much pre work. We were traveling with friends who were fluent in French and I was rather passive about the whole thing. I was not prepared to make the most of my experience. Likewise, we had relatively easy experiences with SARs in 2002-2004, and MERs beginning in 2012 , both coronavirus, but like my earlier Paris trips we did not use those experiences to help us prepare for the next experience. Now in the midst of uncertainty that has created great individual and collective anxiety much like I experienced at the Louvre, we see our nation’s resources being taxed by huge unexpected expenses and our own lives threatened by an enemy that we failed to prepare to manage, and about which we have so many unanswered questions. The big question that we ask each day is “what now?” Do we continue to practice some form of quarantine, or do we just wait for some medical breakthrough or failing that, accept an enormous number of deaths as the price for “herd immunity?”
In this week’s New Yorker you can read an “Annals of Medicine Article” by David Quammen entitled “Why Weren’t We Ready for the Coronavirus? The U.S. has fared worse than other countries not because it lacked information or funding but because it failed to learn the lessons of the last outbreaks.” Quammen’s article is built on the experience of Dr. Ali Khan the former director of the National Center for Zoonotic, Vector-Borne, and Enteric Diseases at the CDC before he became the dean of the College of Public Health at the University of Nebraska Medical Center, in Omaha.
Dr. Khan led our responses to SARs and MERs. He was involved in our international responses to these viruses and others like Ebola, Marburg, and the Lassa virus. He left the CDC in 2014, and his analysis of why we are having so much trouble is that there was a “lack of imagination.” That sounds like my trip to Paris. Quammen writes:
I asked Khan about covid-19. What went so disastrously wrong? Where was the public-health preparedness that he had overseen at the C.D.C.? Why were most countries—and especially the U.S.—so unready? Was it a lack of scientific information, or a lack of money?
“This is about lack of imagination,” he said.
A lack of imagination! 68,919 Americans have died and the number is predicted to soon be higher than 100,000 because of a “lack of imagination?” We can’t decide to stay home or go out to get a haircut because of a “lack of imagination?” We have lost trillions of dollars of national treasure because of a “lack of imagination?”
As I read on, I was not so sure that “lack of imagination” was the right three word explanation for our greatest medical disaster of the last hundred years. I failed to make the most of my trip to Paris. Was the explanation a “lack of imagination?” I think not. My trip could have been better with attention to detail and better planning. I think that a “lack of imagination” is an overly generous attempt to forgive gross incompetence that led to a lack of preparation. Further on, Quammen quotes another scientist who has been involved in many of the same epidemics who used a different word. She called the flaw “complacency. “
Quammen also seems to move on from ‘“lack of imagination” and ups the ante of his criticism by becoming much more descriptive. He writes:
The disastrously tardy, inadequate, confused, and (for many citizens) confusing response of the federal government to covid-19, both before and after the first case, derives from too many factors to list here, but I’ll mention two: failure to appreciate the sars and mers warnings, both delivered by other coronaviruses; and loss of capacity at high government levels, within recent years, to understand the gravity and immediacy of pandemic threats. The result of that loss is what Ali Khan means by lack of imagination. Beth Cameron, a former head of the Directorate for Global Health Security and Biodefense on the National Security Council staff, calls it the absence of “the smoke alarm.” Those in power who are charged with “keeping watch to get ahead of emergencies” need to smell the smoke and smother the fire while it’s small, Cameron told me. “You’re not going to stop outbreaks from happening. But you can stop outbreaks from becoming epidemics or pandemics.”
Bill Gates makes the same points in an article published recently in the “Perspectives” section of the New England Journal of Medicine entitled, Responding to Covid-19 — A Once-in-a-Century Pandemic? He deserves credit for not saying, “I told you so!” Because back in 2015 he did tell us trouble was coming. He had no lack of imagination, and he has “put his money where his mouth is with billions of dollars to fund the development of vaccines. In his eight minute 2015 TED talk, “The next outbreak? We’re not ready,” that has now been viewed by 34 million people, he clearly saw what would happen. When we were enthusiastic about electing a smart businessman to be our president, he would have been a better choice than someone who needed the title as a balm for his narcissism. Gates writes:
The long-term challenge — improving our ability to respond to outbreaks — isn’t new. Global health experts have been saying for years that another pandemic whose speed and severity rivaled those of the 1918 influenza epidemic was a matter not of if but of when. The Bill and Melinda Gates Foundation has committed substantial resources in recent years to helping the world prepare for such a scenario.
He described the severity of the virus, and we can infer that if our leader and his administration had possessed just a little of Gate’s “imagination,” we would have had a better response. What he writes is even more remarkable because his article was written in February, and shows that even then he knew more than most of the government officials who were suffering from a lack of “imagination” as they told us not to worry:
There are two reasons that Covid-19 is such a threat. First, it can kill healthy adults in addition to elderly people with existing health problems. The data so far suggest that the virus has a case fatality risk around 1%; this rate would make it many times more severe than typical seasonal influenza, putting it somewhere between the 1957 influenza pandemic (0.6%) and the 1918 influenza pandemic (2%).
Second, Covid-19 is transmitted quite efficiently. The average infected person spreads the disease to two or three others — an exponential rate of increase. There is also strong evidence that it can be transmitted by people who are just mildly ill or even presymptomatic. That means Covid-19 will be much harder to contain than the Middle East respiratory syndrome or severe acute respiratory syndrome (SARS), which were spread much less efficiently and only by symptomatic people. In fact, Covid-19 has already caused 10 times as many cases as SARS in a quarter of the time.
So, let’s get back to our dilemma. We have been immersed in numbers that heighten our anxieties because they lead to no certainty about what to expect. We have been whipsawed by the president’s contradictory statements. There is nothing that should induce more anxiety than realizing that you are on a bus that is being driven by someone who does not know how to drive and can’t read a map. Sometimes it seems that our president is so befuddled that he can contradict himself within the same paragraph. Against the background of this awful event, and despite the rising death count which is predicted by his own advisers to be over 200,000 by June, we are told that it is time to loosen the restrictions on the economy and carefully return to work, to restaurants, to hair salons, and to even imagine that within months all will be well with a vaccine. The article in the Times that informs us what Trump’s adviser are really saying begins:
As President Trump presses for states to reopen their economies, his administration is privately projecting a steady rise in the number of coronavirus cases and deaths over the next several weeks. The daily death toll will reach about 3,000 on June 1, according to an internal document obtained by The New York Times, a 70 percent increase from the current number of about 1,750.
We have made rules and created pathways about how we will return to normal, but even before every state has begun the long trek, some are disregarding their own rules. The fire is not out.
We have recorded at least 1000 deaths a day since April 2. As of today there are twenty states plus the District of Columbia where the seven day average count of new cases is rising. In eighteen states the seven day averages have plateaued, but are not falling. In only twelve states, plus Puerto Rico and Guam, is the number falling. It is good that in the states that have the highest case counts, New York, New Jersey, and Massachusetts, the numbers are falling. It is not good that the seven day average of new cases is rising in places like Illinois, Texas, Maryland, Tennessee, and in New Hampshire, where I live. In several of our largest states like California, Michigan, Pennsylvania, Florida, and Georgia the number of new cases remains on a high plateau. The idea that reason and data are driving the reopening process is a cruel joke. The link above where the data is reported is in today’s New York Times. The analysis is chilling:
The outbreak in this country, which now has the highest number of known cases in the world, has exploded over the last two months. In recent weeks, more than 20,000 new cases have been announced across the United States each day, keeping the country on a stubborn plateau instead of the sharp downward curve scientists had hoped for.
American life has been fundamentally reordered because of the virus. Concerts, parades and baseball games have been called off. Unemployment claims have spiked. Some governors have imposed quarantine requirements on Americans who cross state lines. And even as portions of the country reopen, officials have warned that the return to communal life would come in stages, and that the virus was likely to remain a persistent threat.
There are those, including the president, who would have us believe that we are near the end of the pandemic and it is time to get back to business, but the virologists, epidemiologists and the historians tell us that until we have a vaccine or an amazing treatment, the end lies far in the future even though our patience is exhausted and their fears of public rejection at election time are rising. Since many of us are way beyond our ability to delay gratification, it seems inevitable that many of us are just going to “do it.” Across the nation anxious, terrified, impatient neighbors are shouting their rejection of facts and reason. On my Saturday walk, I passed a house on the road that runs around the lake where a dozen cars lined a long drive and spilled out onto the shoulders of the road. On the large front lawn of this very comfortable “mini” estate, about twenty young men were showing their ability to simultaneously drink beer, violate common sense, and play “touch” football. before an audience of young laies who were standing around shoulder to shoulder laughing as they hugged each other in the warm spring sunshine. And we wonder why the case levels continue to rise? Is there so much uncertainty, and so much “data” that we are overwhelmed, like I was at the Louvre, that we just say “party on!”?
It seems that even in states like Georgia that seem to be rushing into the arms of disaster there are many store owners and customers who are saying “no thank you” to the invitation to dance with the grim reaper. Click here to see an article and view a short video from the Wall Street Journal that presents the less than enthusiastic embrace of the opportunity that Governor Kemp is offering to Georgians to exit the gene pool. I heard one salon owner in Albany, Georgia, which has a higher COVID-19 case rate than New York, say that she was not going to offer her customers the opportunity to look good in their casket. Will Albany, in the far southwest corner of Georgia, be the forerunner to other small cities in Tennessee, Alabama, Iowa, and Arkansas, or even Maine and New Hampshire. We don’t know, but it seems that there are those among us who don’t care to be prudent. Will a face mask become the new sign of our national divide?
Too much art can make us anxious. Too much data that doesn’t add up to a certainty can make us anxious. Too little leadership can make us anxious. Too much death or the pictures of too many people on gurneys or too many caskets being buried in a potter’s field can make us anxious. Contemplating our own vulnerability as we see so many others on the brink of financial collapse can make even the richest among us nervous and anxious. Wanting it too be over, or fearing that it will never end, is understandable. I would be nice to think that those who can manage their own anxieties and deal with the ambiguities will surely survive, but what makes many of us so very anxious is that what our neighbors will do that changes our personal odds is almost as uncertain as what the virus will do. Something tells me that there will be no serendipity in the combination of the imprudent action of the anxious among us, and the virus that doesn’t really care about who we are or how great America wants to be. Just because you can get a haircut does not mean you must exercise the option. Be prudent. Be well.
