We have been warned that the world we knew on March 12 will never return. One hears that when the pandemic ends that there will be a “new normal.” There have been many who have tried to imagine what our world will be like when we step out into the sunlight of that new normal. I fear that many Americans have imagined that what we have endured for the last month arose from the president’s announcement of a national emergency on March 13, and that there would be some date in the near future when he would announce that the emergency was over and we would be back to the world we put on hold that day.
The president has talked recently in ways that suggest that he has the fantasy that he can just declare an end to the nightmare. It is hard to imagine now that we are approaching 600,000 confirmed cases and have endured more than 23,000 deaths (as of 1 PM today) that on March 13 there were only 2,287 confirmed cases and 48 deaths. As a prelude to the new normal, I find nothing of interest on the sports pages. Instead of checking the baseball standings or the personal stats of my favorite players, I now go directly to the we web page of the Johns Hopkins University Coronavirus Resource Center looking for the last international, national, and local statistics. The header on this post is the first view of what I see as I began the process of getting oriented to the day. You might click on the link to see how much things have changed since I wrote this paragraph.
I think that we all are challenged to remain oriented to our role and responsibility to the collective effort to mitigate the impact of the pandemic. I have found myself asking about the point, the purpose, and duration of our collective ordeal. The data that I can trust reminds me of my need to continue with the inconveniences that benefit us all. Our best epidemiologists and economists have been trying to tell the president and the rest of us something that is very hard to grasp and hold onto without doubt. This sad reality that we don’t want to hear, and that frustrates the president, is that the necessity of the inconvenience will continue into the foreseeable future.
The virus may plague us for more than a year or even longer until we have either effective antiviral treatment or a vaccine. Once we have a vaccine there will still be a time lag to the end of our concerns because we will need to produce and deliver hundreds of millions of doses for our own use and many billions of doses for use worldwide. The advantage of an effective antiviral treatment, if we had one, would be that even before we have a vaccine we could treat those who were sick enough to need hospitalization, and allow everyone else to be managed as if they had the flu. It is a sad fact that we must accept that the likely end of our challenge and the beginning of the new normal will not occur until we have effective antiviral drugs and a useful vaccine. The fight against AIDS is a good reminder of the process we must follow against a lethal virus. Attempts to limit behaviors that were associated with increased risk were our only defense until we had effective antivirals. After more than thirty years of effort, we still do not have an AIDS vaccine.
One need not be either an epidemiologist or an economist to know that the last month has been devastating for the economy. Collectively, individuals and businesses have lost trillions of dollars. Over eighty five years ago during the Great Depression, almost 25% of the population was unemployed. It is estimated that the unemployment rate now is now about 13%, which is higher than it has been at any time since the Great Depression ended when world War II brought full employment. Given the economic losses that have occured and the coming ones that will be impossible to avoid as long as the majority of the population is confined to their homes, it is not a surprise that the president is frustrated and is tired of the economic losses associated with “social distancing,” His frustration has led him to proclaim that the cure should not be worse than the disease. Cooler heads did prevail last month when he made his proclamation on March 23 that things would be back to normal by Easter, but it is now clear that he was just backing off for the moment and remains frustrated. Now the president’s patience with the social distancing that the epidemiologists prescribe seems to be coming to an end.
All of us can understand the president’s frustration. Many of us wonder how long we will be able to tolerate our confinement. We wonder whether this is the only way. Many governors have now joined in the president’s frustration, and are trying to figure out how to safely restart at least some of the normal economic activity. Governors like Andrew Cuomo, Gavin Newsom and Larry Hogan have been trying to broker a responsible conversation about how to take those first steps toward easing the restrictions on movement and business before we have a proven vaccine or effective therapy for severely ill victims of the coronavirus.
As the governors on both coasts begin to ask how to move carefully away from the social distancing that kills business, the president has erupted with the assertion that he is in charge. The governors contend that the president does not have the right to “open the country” when it is the legal authority of mayors and governors to determine what local measures are best for the safety of their citizens. We may be moving toward a standoff. It is further evidence that the world as it was is gone, and a new world awaits us.
As I thought about the uncertainties of our new world, I remembered a line from “The Creation” by the great African American poet and social activist, James Weldon Johnson – 1871-1938.
And far as the eye of God could see
Darkness covered everything
Blacker than a hundred midnights
Down in a cypress swamp.
I have never been in a cypress swamp at midnight, but I have been in the deep woods in New Hampshire without a flashlight or a candle on a night so dark that I was not sure where the trail was or where my feet were. It was a strangely disorienting experience. When walking in the dark and uncertain of where you are and what is to come, it is best to take small steps, and lead with your hands to protect yourself from unseen dangers. On my one journey into the darkness of the night, I was trying to get from the parking lot at a camp on Lake Winnipesaukee down to a gathering on the beach at the end of Moultonboro Neck more than a half a mile away. I had been away on an extended errand all day and returned late, but wanted to rejoin my family and enjoy the experience of the bonfire and festivities down by the water. I knew that my friends would be singing songs around the campfire while they roasted marshmallows and created “smores.” Since I couldn’t see my hand in front of my face, I realized that the only way I would get to the beach would be to try to try to hear the singing and move slowly toward it. Time became distorted as I stumbled along in the total darkness desperately hoping to hear voices and laughter that would tell me where to go. I was not even sure that I was going in the right direction until I heard their singing. It was a great relief when I finally caught a glimpse of the bonfire through the thicket of bushes and trees that were then visible as backlit shadows before me.
You may consider my walk in the dark to be a tortured metaphor for the challenges we will face as we begin the journey toward the “new normal,” but I see similarities. Just as I could not see the way forward and needed to come up with a new way to plot my course through the blackness of the forest, thoughtful people are trying to come up with strategies that will allow us to move toward reopening the economy before we have defeated the virus, or before we joyfully discover that it has miraculously gone away.
Since the president’s eruption that the cure should not be worse than the disease, there has been a growing effort to come up with a workable strategy to loosen the restrictions that are killing business and costing jobs. Perhaps the first useful public response to the president’s pronouncement back on March 23rd about the disease/cure paradox came from Tom Friedman, the New Times columnist, who published an open letter to the president on March 26. Based on good advice from experts he described a three step process:
Step 1: First, you need to call for a 50-state sheltering-in-place/social-distancing program. While the experts differ on how long that national lockdown should be — two weeks, four weeks, eight weeks, whatever the C.D.C. recommends, I say — they virtually all agree that it is needed to manifestly slow the spread of the coronavirus, to prevent our hospitals from being overwhelmed and to buy us the critical time we need to collect the data required to inform all future decision-making.
We are making progress with “Step 1.” The total number of new hospitalizations in New York has been coming down, and there is evidence of success elsewhere as well. Since step 1 seems to be working, several governors are encouraged and are seeking advice from experts about what to do next. We have not completed “Step 2.”
Step 2: We use this period of lockdown to gather as much data as possible about who has the coronavirus, where they live, what their ages and degrees of illness are, what the mortality rate is at what ages, and what other ailments or immune deficiencies they may have.
To complete step 2 we need a lot more testing. In Germany the death rate is much lower than in most countries. They have done a much more vigorous job of following the people with positive tests, and their contacts. They are also testing asymptomatic people. We have not yet gotten to the level where we can test all of the people with symptoms. The sad tale of our inability to adequately test and follow up is one reason that we are approaching 600,000 cases and 25,000 deaths. Our inability to test enough, especially asymptomatic people, should cause us to pause before we get to step three.
Step 3: : This data can then be the foundation of …“the pivot.” Once we have slowed the transmission of the coronavirus nationally — and developed a stratified national risk map — we can then, on the basis of that data…begin phasing people back into the workplace to get the economy humming again.
That’s a very slim formula, but it is the basic core of four proposals that have been published over the past few weeks that deserve your attention. It is my hunch that the articles will be resources, and that perhaps the authors will be called upon for advice in the meetings of the governors of Pennsylvania, New York, Connecticut, New Jersey, Delaware, Massachusetts, and Rhode Island on the East Coast while on the West Coast the governors of California, Oregon, and Washington are meeting to consider their collective strategy. While the governors have begun to collaborate, the president has been claiming that he alone, and not the governors, would determine when the restraints went away. President Trump has defiantly proclaimed that he has the authority to be “the decider.” He has proclaimed that he would depend on facts, though he does not specify which facts, and his own instincts as he makes the “toughest decision” of his life.
For reference the four plans come from the right, from the middle, and from the left of the political spectrum and one from a respected Nobel Prize winning economist, but all share areas of consensus. They are:
- From the right, the American Enterprise Institute: “National coronavirus response: A road map to reopening” by Scott Gottlieb, Caitlin Rivers, Mark McClellan, Lauren Silvis, and Crystal Watson. Gottlieb led the FDA earlier in the Trump administration. McClellan was the Administrator of the FDA and CMS under Bush II, he now leads a health policy institute at Duke.
- From the left, the Center for American Progress: “A National and State Plan To End the Coronavirus Crisis” by Zeke Emanuel, Neera Tanden, Topher Spiro, Adam Conner, Kevin DeGood, Erin Simpson, Nicole Rapfogel, and Maura Calsyn. Emanuel is currently the Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania.
- From the middle, presumably academia is an objective middle: The Edmond J. Safra Center at Harvard University has convened a rapid response initiative in response to the COVID-19 threat and has presented suggestions for lifting the confinement and a return to more normal economic activity. The series includes “A ‘Mobilize and Transition’ Strategy Could Reduce COVID-19 Mortality while Cushioning the Economic Decline,” by Danielle Allen, E. Glen Weyl, Rajiv Sethi, and Santa Fe Institute
- From a Nobel Prize winner for Economics, Paul Romer who offers: “Even A Bad Test Can Help Guide the Decision to Isolate: Covid Simulations Part 3”
If you are not interested, or don’t have the time, let me suggest that after giving them a view from forty thousand feet, check out “I’ve read the plans to reopen the economy: They’re scary.There is no plan to return to normal” by Ezra Klein of Vox. Klein points out three things.
- The plans do not lead to a return to normal, if by “normal” we mean the way things were before March 13. That is not possible.
- Testing at levels we can not currently reach will be required no matter which plan we attempt to follow. There will be challenges to privacy that will offend many Americans, and perhaps not be politically feasible. The outcome of these realities will produce much uncertainty. There will always be a significant possibility of failure followed by a resurgence of the virus.
- None of the plans envision a return in the near future of mass gatherings like sporting events, cruises, concerts, gatherings in bars and restaurants, or even an easy return to gatherings like church and the classroom. Dr. Scott Gottlieb, lead author of the American Enterprise Institute plan, suggests that the best outcome would be a return to 80% of the economic activity that existed before the virus.
Klein separated Romer’s plan from the others because it requires an amazing amount of testing. Romer suggests testing everybody every two weeks. That would be 22 million tests a day! Can you imagine what it would take to get everybody tested once, let alone once every two weeks. So far, as of today, we have done less than three million tests. We have done 2,964,726 test to be exact, according to Johns Hopkins data. That means we have tested less than one person out of every 100. The CDC website shows some graphs that demonstrate the ramp up, but that curve from those data points has flattened because we are reaching the limit of our current testing resources. Gottlieb says that we have reached our maximum capacity until we develop more facilities and better supply chains for the fundamental supplies that are needed. One barrier is that there is not much profit margin in making swabs and pipets and the president is not using the power he has to direct production. Testing is the roadblock to all feasible plans. Ezra Klein offers us a great podcast conversation with Scott Gottlieb, the author of the recommendation coming from the most conservative plan. In the introduction to the conversation he writes:
Two themes drive this conversation. First, what are the challenges to simply getting out of lockdown? Why don’t we have enough tests yet? What’s stopping us from making more? And second, what does the world look like out of lockdown but before we get to a vaccine? What’s being imagined here isn’t a return to normal, either socially or economically, but a kind of limbo that it’s not clear we have the political will to sustain and that has few answers for the most vulnerable among us.
Yes, whatever happens we will be walking in the dark because testing is the guiding light that we need, and we have a very weak source of light. What I fear most is the president’s impatience that will be ramped up by his fear of losing the election. I think we do have experts who can provide advice that will minimize the risks we face. What we don’t have is competent leadership that has the wisdom and managerial skill to use those critical resources to get us beyond social distancing and its deadly companion of economic distress. Patience is a virtue, and in a pandemic where the only useful tool is separation, we must steel ourselves for a longer confinement with the possibility of some of us going back to work when tests show that it is safe, but I doubt that I will go to Fenway in 2020 to see the Red Sox, or that my wife and I will be in Boston on August 31 to use the tickets we purchased months ago with friends to see John Legend perform. To do either one might be lethal. For sure, it would be nuts and socially irresponsible. I wish it was not so, but it is.
We are involved in a great challenge. It may be inappropriate as a reference, but I am reminded of the sentiment of Abraham Lincoln’s words in the Gettysburg Address when as the leader of our nation he tried to put the losses that were sustained into an appropriate perspective. He reminded the nation of what it had accomplished, and the debt it owed to those who had already made sacrifices to continue the work of creating a better nation in a better world where the work of moving toward the ideals that had been articulated at our founding could be continued. There was no easy way out of the struggle then, and he was asking the nation to maintain its perspective as the need for sacrifice would continue. No one knew it then, but Lee’s surrender at Appomattox was almost two years in the future. Many more would die before that day came. We were blessed then to have a leader up front. Now we must listen to saner voices from behind our president. We are walking in the dark, but we can listen for the music of a better moment that can draw us toward some light.
