March 27, 2020
Dear Interested Readers,
It’s Been Another Mega VUCA Moment. What’s Up Next? How Will It End? What Will We Learn?
This last week can be summarized quite succinctly as yet another mega VUCA moment in our nation’s history. It has felt to me like we are all caught in the same bad dream where we are riding in a bus that is careening into a slow motion crash. Will throwing two trillion dollars out the window allow us to avoid a fatal accident? If you are a regular reader of these notes you know that VUCA has become a cliche with me. Volatile, Uncertain, Complex, and Ambiguous is a quick description of the tsunami of “never before” events that we have witnessed over the last few weeks. The quartet applies to the physical and fiscal health of the nation. There is no one single cure for a VUCA world, but without leadership our outlook is determined by chance and momentum, and not by purpose and plan. The question that everyone asks in the anxious atmosphere of a VUCA world is, “What is going to happen–and what is going to happen to me and my loved ones?”
The Atlantic published an article by Ed Yong on Wednesday that was ominously 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.” It’s a long article that attempts to answer the question on everybody’s mind, “What is going to happen?” Since most of us are skeptical about the president’s assertion that everything will be fine soon, and it will be safe to go to work by Easter, I would encourage you to read an alternative analysis. After a very well written introduction of several pages that sets stage, the remainder of the article is divided into three sections:
- The Next Months
- The End Game
- The Aftermath
Yong’s introduction is a quick overview of the blur of the last two months that also includes some push back against the president’s pronouncement that “no one imagined” that this could happen which is the core of his defense for why we are still not adequately prepared for the impending unknowns that we will experience over the coming months. Yong asserts that the huge economic losses and the growing number of lives lost will only increase as the spread that has already occurred is revealed by the daily rise in known cases and deaths. The existence of the virus is nobody’s fault, but the extent of the damage and harm to which we are vulnerable from the virus are partly the result of our president’s misguided policies over the last three years, his current denial of facts, and his failure to act in a timely manner despite the warnings of experts. His wishful thinking that everything can be back to normal by Easter is an absurdity and a distortion of the truth that is his latest “shoot from the hip” self serving fantasy. His fabrications still have an eager audience that multiplies the damage he can do.
I have become weary of listening to the president’s daily rambling mix of serial self congratulatory pronouncements and complimentary comments on the performance of Vice President Pence and the “team.” These daily televised campaign rallies are thinly disguised as press conferences to update us on his management of the pandemic. Against that background Yong writes:
Three months ago, no one knew that SARS-CoV-2 existed. Now the virus has spread to almost every country, infecting at least 446,000 people whom we know about, and many more whom we do not. It has crashed economies and broken health-care systems, filled hospitals and emptied public spaces. It has separated people from their workplaces and their friends. It has disrupted modern society on a scale that most living people have never witnessed. Soon, most everyone in the United States will know someone who has been infected. Like World War II or the 9/11 attacks, this pandemic has already imprinted itself upon the nation’s psyche.
A global pandemic of this scale was inevitable. In recent years, hundreds of health experts have written books, white papers, and op-eds warning of the possibility. Bill Gates has been telling anyone who would listen, including the 18 million viewers of his TED Talk. In 2018, I wrote a story for The Atlantic arguing that America was not ready for the pandemic that would eventually come. In October, the Johns Hopkins Center for Health Security war-gamed what might happen if a new coronavirus swept the globe. And then one did. Hypotheticals became reality. “What if?” became “Now what?”
So, now what?
“We will see soon,” is the only answer to Yong’s question, “So, now what?”
I urge you to listen to the TED talk by Bill Gates. A lot of people have, a few million people have listened to it in the last couple of days, and it has now been seen by over 20 million people. That’s 20 million people who know that Trump does not know what he should know, or he is distorting reality when he chants his mantra:
“Nobody knew. Nobody told me. Who could have imagined?”
In just a little over eight minutes Gates tells us what we should have done to avoid an epidemic that may kill millions, and has already cost us trillions of dollars, and will result in the loss of trillions more before the natural end comes. Gates’ talk is an accurate prediction of what is happening now, and it is coupled with an avoidance plan that it is now too late to implement. We had time in 2015 or 2016, but the chance to avoid what lies ahead is now in the rear view mirror. Gates’ suggested plan was built on a foundational concept that it is in America’s best interest to lead the world. As the world leader that we were in 2015, it was in our best interest to care about the world. As a nation we are guilty of abandoning that position by electing a man in 2016 who won by selling the false idea that it was in America’s best interest to withdraw from leadership of the world, and send a bill for services rendered for anything that we did do. Now that same man appears dazed and confused on a daily basis as he spouts misinformation and shoots from the hip with his nonsensical pronouncements.
So what does Yong predict about “The Next Months?” He predicts that they are likely to be grim. As wonderful as Dr. Fauci has been, and will continue to be, he offers advice that can only mitigate and not end the ordeal. His words must be followed by actions from those who have authority. As potentially powerful a force for protection that the CDC may have once been, it was damaged and is struggling to recover its lost capabilities while under enormous pressures. Things are different now. The president and those who have sustained and emboldened him are the ones who are chiefly accountable for the difference between what they once were and could have been, and the current state. Yong gives us the basis for his dim view of what is to come:
Partly, that’s because the White House is a ghost town of scientific expertise. A pandemic-preparedness office that was part of the National Security Council was dissolved in 2018. On January 28, Luciana Borio, who was part of that team, urged the government to “act now to prevent an American epidemic,” and specifically to work with the private sector to develop fast, easy diagnostic tests. But with the office shuttered, those warnings were published in The Wall Street Journal, rather than spoken into the president’s ear. Instead of springing into action, America sat idle.
Rudderless, blindsided, lethargic, and uncoordinated, America has mishandled the COVID-19 crisis to a substantially worse degree than what every health expert I’ve spoken with had feared. “Much worse,” said Ron Klain, who coordinated the U.S. response to the West African Ebola outbreak in 2014. “Beyond any expectations we had,” said Lauren Sauer, who works on disaster preparedness at Johns Hopkins Medicine. “As an American, I’m horrified,” said Seth Berkley, who heads Gavi, the Vaccine Alliance. “The U.S. may end up with the worst outbreak in the industrialized world.”
Here is how Yong sees the “next months.”
Having fallen behind, it will be difficult—but not impossible—for the United States to catch up. To an extent, the near-term future is set because COVID-19 is a slow and long illness. People who were infected several days ago will only start showing symptoms now, even if they isolated themselves in the meantime. Some of those people will enter intensive-care units in early April. As of last weekend, the nation had 17,000 confirmed cases, but the actual number was probably somewhere between 60,000 and 245,000. Numbers are now starting to rise exponentially: As of Wednesday morning, the official case count was 54,000, and the actual case count is unknown. Health-care workers are already seeing worrying signs: dwindling equipment, growing numbers of patients, and doctors and nurses who are themselves becoming infected.
It’s worse. As of 9:30 PM yesterday there were over 80,000 cases and 1000 deaths. I bolded but not impossible because we are getting leadership from many governors from both parties. There is a hope that we might “catch up” with our shortages of medical supplies and respirators. We are expanding the number of hospital beds and many of our governors have issued “stay-at -home” emergency orders that may prevent further transmission. At 5:45 PM yesterday my cell phone pinged with a message from the state emergency center. It read:
(Stay at Home Order from Governor Sununu) The Governor of the State of New Hampshire, Chris Sununu, will place New Hampshire in a “stay-at-home” emergency order starting Friday, March 27, until May 4.
In 2005 I read River Town: Two Years on the Yangtze by Peter Hessler. My son who had just graduated from Reed College was headed to Tsinghua University in Beijing for a year of immersion in Manderin. The book gave me a window into the world he was entering. I made two trips to China that year. The first to help him get settled into his apartment. The second trip at the end of his year included my wife, his fiancee, and his brother. It was a grand tour of his favorite places that he had visited in China. The sight I enjoyed most was watching him speak to people on the street and haggle in fluent Mandarin for a better price on items in the open markets.
After coming home I read a second book by Hessler, Oracle Bones (2006). Hessler had been a Peace Corps volunteer teaching English at a provincial college in Fuling, a small city on the Yangtze River, when he wrote River Town. He was living in Beijing and writing for the New Yorker when he wrote the second book. This week’s New Yorker has a new piece by Hessler written from his confinement with his family in Chengdu, a city of 16 million in southwestern China, where he is teaching literature at the university. The article, “Life on Lockdown in China: Forty-five days of avoiding the coronavirus,” is an excellent account of the experience of the isolation that so many of us now face. The good news is that Chengdu avoided most of the disease and death that was experienced in Wuhan. The piece ends with Hessler and his family enjoying a nice night out at a local restaurant when the stay at home order is lifted. Hessler’s books gave me cultural insight on my trips to China. I am hoping that his article will give us insight as we enter our “confinement.” If you like audiobooks, there is a 45 minute “reading” attached to the link that you can enjoy to fill some of the long hours that may lie ahead at home.
Yesterday morning the board of the Guthrie Clinic met utilizing “Skype for Business.” The good news is that there has been only one death in the Twin Tiers and fewer than ten documented infections. The system is prepared. All elective admissions have been cancelled. Supplies are being collected. We are increasing the number of telehealth encounters everyday, and soon Guthrie will have more than 1500 telehealth encounters every week.
There is a trail of positive tests running down the interstate highways from Binghamton and other larger population centers in the New York area. It’s amazing that New York has about 50,000 cases and Pennsylvania has less than 1500. The system has lost a few weeks of cash already, but still has strong reserves. The feeling was similar to the way we feel as we prepare for a hurricane that is coming up the coast. The sky is clear. The sun is out. The windows are boarded up. Everything you can think of is being done, and now everyone is waiting for the predicted storm to arrive, while wondering when it will hit, and not quite sure that we are really ready. During the meeting, I made the comment that the situation would be quite different if we had prepaid contracts for the care of a population. If that were true, we would not be so concerned about the loss of revenue from all the cancelled elective admissions and cancelled ambulatory visits.
I got an email from the Chief of Staff, Donnie Skerpon, an “Interested Reader,” after the meeting adjourned.
Gene: I think you will enjoy this brief editorial … link below.
Thanks, Donnie
The link was to a Harvard Business Review article by Sean Nicholson and David A. Asch entitled “Hospitals Need Cash. Health Insurers Have It.” Sean Nicholson is a professor at Cornell University in Ithaca where Guthrie has an ambulatory site and not far from Cortland where the hospital is now part of the Guthrie system. Professor Nicholson is the director of Cornell’s Sloan Program in Health Administration, and a Research Associate at the National Bureau of Economic Research. He is also a member of the board of the largest hospital in our system, The Robert Packer Hospital. The idea behind the article is that employers have given insurance companies money for the fee for service payment for the care of their employees. The hospitals now need that money to prepare to do a job that will not be adequately compensated in a fee for service system. The irony is that in these unusual times taking care of the nation’s needs and diverting resources away from the usual business of elective procedures will leave money in the vaults of the insurance industry. The idea is summed up in the last paragraph:
Alongside the many heartwarming stories of people acting selflessly to help their fellow citizens are disheartening stories of people or companies trying to profit excessively on the health crisis. Health insurers are not in this latter group, but they do potentially face a windfall because the high clinical costs of caring for infected patients is almost certainly more than offset by the reduced costs from other care foregone. Those extra funds shouldn’t be theirs; they were there for our health care, and our health care system needs them now.
The “next months” are still ours to shape, but what will be the “end game?” The pandemic will end. All pandemics end, but how will this one pass? We are told that there are three possibilities:
“…one that’s very unlikely, one that’s very dangerous, and one that’s very long.”
The unlikely possibility is one that we would all love:
…every nation manages to simultaneously bring the virus to heel, as with the original SARS in 2003. Given how widespread the coronavirus pandemic is, and how badly many countries are faring, the odds of worldwide synchronous control seem vanishingly small.
The very dangerous possibility is more likely than the first but it is grim. The US now has more cases than China and we may be on a road that we can’t exit:
…the virus does what past flu pandemics have done: It burns through the world and leaves behind enough immune survivors that it eventually struggles to find viable hosts. This “herd immunity” scenario would be quick, and thus tempting. But it would also come at a terrible cost: SARS-CoV-2 is more transmissible and fatal than the flu, and it would likely leave behind many millions of corpses and a trail of devastated health systems. The United Kingdom initially seemed to consider this herd-immunity strategy, before backtracking when models revealed the dire consequences. The U.S. now seems to be considering it too.
The third possibility, the very long road, may be the journey that we are on:
The third scenario is that the world plays a protracted game of whack-a-mole with the virus, stamping out outbreaks here and there until a vaccine can be produced. This is the best option, but also the longest and most complicated.
All storms finally end and we emerge from shelter to view the damage. What will be the “aftermath” in the wake of COVID-19? Will there be an epidemic of despair? Yong writes:
The cost of reaching that point [the end of the storm], with as few deaths as possible, will be enormous. … “the economy is experiencing a shock “more sudden and severe than anyone alive has ever experienced.” About one in five people in the United States have lost working hours or jobs. … Inequalities will widen: People with low incomes will be hardest-hit by social-distancing measures, and most likely to have the chronic health conditions that increase their risk of severe infections…
After infections begin ebbing, a secondary pandemic of mental-health problems will [? may]follow. At a moment of profound dread and uncertainty, people are being cut off from soothing human contact. Hugs, handshakes, and other social rituals are now tinged with danger. People with anxiety or obsessive-compulsive disorder are struggling. Elderly people, who are already excluded from much of public life, are being asked to distance themselves even further, deepening their loneliness. Asian people are suffering racist insults, fueled by a president who insists on labeling the new coronavirus the “Chinese virus.” Incidents of domestic violence and child abuse are likely to spike as people are forced to stay in unsafe homes. Children, whose bodies are mostly spared by the virus, may endure mental trauma that stays with them into adulthood.
There may also be an upside to the ordeal:
… “there is also the potential for a much better world after we get through this trauma,” …Already, communities are finding new ways of coming together, even as they must stay apart. Attitudes to health may also change for the better. …washing your hands for 20 seconds, a habit that has historically been hard to enshrine even in hospitals, “may be one of those behaviors that we become so accustomed to in the course of this outbreak that we don’t think about them,”…
Pandemics can also catalyze social change. …working from home, conference-calling to accommodate people with disabilities, proper sick leave, and flexible child-care arrangements. …Perhaps the nation will learn that preparedness isn’t just about masks, vaccines, and tests, but also about fair labor policies and a stable and equal health-care system. Perhaps it will appreciate that health-care workers and public-health specialists compose America’s social immune system, and that this system has been suppressed.
We can hope for a quick end game and a positive aftermath, but both are dependent on most of us adopting a “Chengdu” lifestyle for an indefinite period of time. It is possible that we can use newly acquired knowledge about this virus, intensive testing, and a highly coordinated approach to loosen up the restraints that allow low risk people to return to work in some areas sooner than happened in Chengdu and Wuhan, but there are risks, and that road would require a leader who has a very different personality and a very different appreciation for science and strategic planning than has been demonstrated so far by President Trump. It will take more than inconsistently following Dr. Fauci’s lead while spouting “alternative facts.”
Yesterday, Thomas Friedman laid out advice to the president on a possible process that moves us toward business as “almost usual” in an “An Open Letter To President Trump: The nation craves a plan, not hunches.” Friedman and his collaborators describe looking for a moment in the future which is defined by data when it will be time to slowly begin to shift back toward business as usual. He describes that moment as “the pivot.” The piece ends with straightforward advice to our tone deaf president:
By letting the epidemiological data drive that pivot, Mr. President, you will reassure people that your pronouncements are based on science and the strategic logic of a plan, and you will be able to bring the whole country, not just your base, along with you.
Your presidency and our immediate future are inextricably intertwined. You need to rise above what sustained you during your first three years — dividing, misleading and impugning experts and the deep state — and give the country what it so desperately needs and craves now: a science-based plan.
I like the idea, but I doubt the likelihood of the message getting through the noise of the outgoing traffic of nonsense flowing from this “very stable genius.” It’s time to hunker down and hope to survive the storm. Hope is not a plan, but it is an asset that might sustain us through the current challenge and the eventual resolution. Hope, data, and a focus on how we might all work together to preserve what is really valuable in life can come together and form the foundation for something better when the storm finally passes. There is a purpose in this moment. The challenge is to find it, and go forward.
Winter Does An Encore
The coronavirus is topic number one in my little town. In a distant second place was the topic of the winter weather. We did have some cold weather. There was a snow cover from early December to well into March. The lake was quite frozen. But, we also had lots of warm weather. Sixty degree days in January, February, and March are not the usual fare. By last weekend, the only snow was in very shaded north facing places, or where the plows had piled it up in my driveway and in the parking lot at the circa 1950 shopping center next to the post office.
Late Monday afternoon it began to snow. When I woke up on Tuesday, the sun was out and we were back in a winter wonderland, as the picture in today’s header shows. As you can see, we are in a transitional period. There is still some ice on the lake, but there is also a lot of open water. We have even seen a few ducks paddling around!
The governor greatly restricted us yesterday. We can go to the post office, grocery store, and the pharmacy, and we can get out for exercise if we practice social distancing. I am wondering if fishing is an allowed activity, if I go alone. Yesterday was to have been the opening day of major league baseball, and the opening day of the fishing season is April 15. The confinement period ordered by the governor lasts until May 4. Does exercise include fishing? This is a serious question that needs an answer soon!
Be well! Practice social distancing. Wash your hands frequently. Don’t touch your face. Cover your cough. Stay home unless you are an essential provider. Follow the advice of our experts. Assist your neighbor when there is a need you can meet without getting too close. Demand leadership that is thoughtful, truthful, capable, and inclusive. Let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
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Whether 50 million or more Americans get the virus and even if more than a million people in my demographic die despite the heroic efforts of healthcare providers.
