Coronavirus: Top scientist who battled COVID-19 says we will never live normally without vaccine! Nursing Homes, Packed Coffee Houses, and When will it Be Over?

As anyone else noticed the advertisements on television? They are mainly auto dealerships who will delivery your new car to your home and more attorney companies who will sue whomever you want and will not get charged unless they will your case. One of my former professors during my MBA program is a federal judge who warned me that judges are expecting to see many cases of malpractice cases coming to the courts secondary to the COVID-19 cases. Unbelievable!

 Ross McGuinness reported that a top scientist who fell ill with COVID-19 has said the world will never return to normal unless there is a coronavirus vaccine.

Peter Piot, director of the London School of Hygiene & Tropical Medicine, spent a week in hospital after contracting the virus in March. The Belgian virologist, who led the Joint United Nations Program on HIV/AIDS between 1995 and 2008, said climbing a flight of stairs still leaves him breathless.

Last week, a World Health Organization (WHO) official warned there may never be a coronavirus vaccine.

Prof Piot, one of the discoverers of the Ebola virus, is currently a coronavirus adviser to European Commission president Ursula von der Leyen. In an interview with Belgian magazine Knack, later translated by Science Magazine, he warned that a vaccine is needed for people to live normally again.

“The Commission is strongly committed to supporting the development of a vaccine,” he said. “Let’s be clear: Without a coronavirus vaccine, we will never be able to live normally again. “The only real exit strategy from this crisis is a vaccine that can be rolled out worldwide.

“That means producing billions of doses of it, which, in itself, is a huge challenge in terms of manufacturing logistics. And despite the efforts, it is still not even certain that developing a COVID-19 vaccine is possible.”

Prof Piot criticized anti-vaxxers, saying: “Today there’s also the paradox that some people who owe their lives to vaccines no longer want their children to be vaccinated. “That could become a problem if we want to roll out a vaccine against the coronavirus, because if too many people refuse to join, we will never get the pandemic under control.”

He said he hoped the coronavirus pandemic can help ease political tensions, citing how polio vaccination campaigns have led to truces between countries. He said he hoped the WHO could be “reformed to make it less bureaucratic”, saying it too often resembles a “political battleground”.

According to Johns Hopkins University, the US is the worst-hit country by coronavirus, with more than 79,500 deaths, followed by the UK with more than 31,900 and Italy with more than 30,500.

On Sunday, British prime minister Boris Johnson announced a range of new measures to ease the UK out of its COVID-19 lockdown. However, his announcement of the government’s measures was criticized by scientists, opposition politicians and workers’ unions, who called it confusing.

The government was left scrambling on Monday to bring some kind of clarity to the new measures. A 50-page document outlining the easing of restrictions was published on Monday. From Wednesday, people will be able to meet one person from another household in a park as long as they stay two meters apart.

Covid-19: nursing homes account for ‘staggering’ share of US deaths, data show

Reporter Jessica Glenza noted that residents of nursing homes have accounted for a staggering proportion of Covid-19 deaths in the US, according to incomplete data gathered by healthcare researchers.

Privately compiled data shows such deaths now account for more than half of all fatalities in 14 states, according to the Kaiser Family Foundation. Only 33 states report nursing home-related deaths.

“I was on a phone call last week, where four or five patients came into our hospital just in one day from nursing homes,” said infectious disease specialist Dr Sunil Parikh, of Yale School of Public Health in Connecticut. “It’s just a staggering number day to day.”

Despite early warnings that nursing homes were vulnerable to Covid-19, because of group living settings and the age of residents, the federal government is only beginning to gather national data.

In Connecticut, 194 of 216 nursing homes have had at least one Covid-19 case. Nearly half the Covid-19 deaths in the state – more than 1,200 people – have been of nursing home residents. The proportion is higher elsewhere. In New Hampshire, 72% of deaths have been nursing home residents.

Parikh said limited testing and a lack of personal protective equipment such as masks hampered efforts to curb the spread of Covid-19 in care homes. Due to limited testing capacity, most state nursing homes are still only able to test residents with symptoms, even though the disease is known to spread asymptomatically.

“What I would like to see is the ability to test the entire nursing homes,” Parikh said. “This symptomatic approach is just not cutting it. Many states, including Connecticut, are starting to move in that direction … but I hope it becomes a national effort.”

Nursing homes have been closed to the public for weeks but a bleak picture has nonetheless emerged. In New Jersey, Governor Phil Murphy called in 120 members of the state national guard to help long-term care facilities, after 17 bodies piled up in one nursing home.

In Maine, a 72-year-old woman who went into a home to recover from surgery died just a few months later, in the state’s largest outbreak.

“I feel like I failed my mom because I put her in the wrong nursing home,” the woman’s daughter, Andrea Donovan, told the Bangor Daily News. “This facility is responsible for so much sadness for this family for not protecting their residents.”

Fifteen states have moved to shield nursing homes from lawsuits, according to Modern Healthcare.

Nursing home residents were among the first known cases of Covid-19 in the US. In mid-February in suburban Kirkland, Washington, 80 of 130 residents in one facility were sickened by an unknown respiratory illness, later identified as Covid-19.

Statistics from Kirkland now appear to tell the national story. Of 129 staff members, visitors and residents who got sick, all but one of the 22 who died were older residents, according to the US Centers for Disease Control and Prevention (CDC).

By early March, most Covid-19 deaths in the US could still be traced to Kirkland.

“One thing stands out as the virus spreads throughout the United States: nursing homes and other long-term care facilities are ground zero,” wrote Dr Tom Frieden, the former head of the CDC, for CNN on 8 March.

That day, Frieden called on federal authorities to ban visitors from nursing homes. US authorities announced new measures to protect residents several days later.

The CDC investigation into Kirkland was released on 18 March. It contained another warning: “Substantial morbidity and mortality might be averted if all long-term care facilities take steps now to prevent exposure of their residents to Covid-19.”

It was not until 19 April that the head of the Centers for Medicare and Medicaid Services promised to track all deaths in nursing homes. That requirement went into effect this Friday, but there is still a two-week grace period for compliance. During the period from 19 April to 8 May, 13,000 people died, according to an NBC News analysis.

“This is really decimating state after state,” said Parikh. “We have to have a very rapid shift [of focus] to the nursing homes, the veteran homes … Covid will be with us for many months.”

Texas begins to reopen after Covid-19 quarantine – but political controversy and health risks await

Three reporters contributed to this article, Erum Salam, Nina Lakhani and Oliver Laughland, where they noted that Tim Handren, the chief executive of Santikos Entertainment, a small cinema chain in San Antonio, admits his business is not essential. But while the giants of the industry keep their screens closed, he has taken a different approach.

Since last weekend, three of nine Santikos cinemas have reopened to the public, among the first in America to do so during the coronavirus pandemic.

“Take your mask off and relax,” Handren said in a recorded message to customers. “Breathe in some great buttery popcorn smells, watch a great movie, and just enjoy some time with your family.”

The reopening is among the starker examples in Texas, where one of the quickest and most expansive efforts to reignite the economy has drawn significant controversy.

On the one hand, some civil liberty advocates have argued that their right to drink at bars, have their hair cut and dine at restaurants has been curtailed. On the other, many public health experts warn thousands will become infected as the state reopens.

Handren, who is also the mayor of the small town of Boerne, said that although his cinemas would keep patrons 6ft apart and offer a reduced menu there remained debate in the community about whether the shutdown had been necessary at all.

“Unfortunately, I still interact with people that believe Covid-19 is a hoax concocted by the media after all this time. That’s the extreme on that side of the equation … ‘We should have never shut down’. Even the lieutenant governor said that. And then there are others who want to hunker down and hibernate for the next six months. I’ve had to, as a mayor, balance health and economics.”

Abbott, a Republican, last week ended a stay-at-home order and allowed businesses including barber shops and retail outlets to open. The move followed decisions in other southern states including Florida and Georgia, and earned praise from Donald Trump.

The president told reporters: “Texas is opening up and a lot of places are opening up. And we want to do it, and I’m not sure that we even have a choice. I think we have to do it. You know, this country can’t stay closed and locked down for years.”

In private, Abbott has acknowledged that his decision to reopen is likely to cause an increase in coronavirus cases. Leaked audio obtained by the Daily Beast captured comments during a private call with state lawmakers.

Abbott, who has sought to downplay the increased risk to the public, said: “The more that you have people out there, the greater the possibility is for transmission. The goal never has been to get transmission down to zero.”

Infectious disease experts predict the average daily Covid-19 positive test rate in Texas could rise from 1,053 at the beginning of May to up to 1,800 by June.

As of this weekend, Texas had an estimated 16,670 active cases and 1,049 deaths. With the occasional dip, the number of cases continues to rise even while testing lags behind other states.

Harris county, which includes Houston, has 157 coronavirus cases per 100,000 people – 31% higher than the state average. Last month, officials said African Americans accounted for two-thirds of Covid-19 deaths in the city despite making up only 22.5% of the population.

Harris county judge Lina Hidalgo, a Democrat, has attempted to enforce a mandatory mask order. Abbott has publicly criticized her.

Dr Andrew Miller, a pediatric ophthalmologist in Harris county, reopened his clinic last week with social distancing in place. He told the Guardian that even after his decision to reopen, because of the pressing needs of patients, he was experiencing significant anger from those who refuse to wear masks.

He said: “We’ve had some pushback from families because we won’t let them in without a mask. They’ve been ugly to the staff. While I respect their civil liberties, I am entitled to not see them.”

Last week, Abbott took power away from officials who arrest Texans for certain Covid-19 violations. The move was prompted by a conservative backlash against the arrest of a salon owner in Dallas – another hotspot – who opened up against local rules. In an act that exacerbated the divisions on the case, Texas senator Ted Cruz appeared at the salon to receive a haircut from the recently released owner.

Houston lies in a sprawling industrial region with more than 500 petrochemical facilities, a busy shipping channel, large highways and commercial railroads, and one of the highest densities of polluting industries in the country, if not the world.

Air quality, specifically particulate matter, which increases the risk of multiple lung and heart conditions also associated with Covid-19 complications, has been worse in some parts of the city despite the lockdown, leading environmentalists to criticize the decision to reopen so quickly.

“It’s a blind, uninformed decision based on optimism that everything will be better, even though the evidence points to the contrary,” said Elena Craft, senior director at the Environmental Defense Fund (EDF), which coordinates a local project tracking air quality.

The meatpacking industry is also linked to several emerging hotspots in the Texas panhandle, a semi-rural region of 26 northern counties where Trump won 79.9% of the vote in 2016 and the Republican party dominates every level of government.

Moore county has the highest infection rate in Texas. Its death rate is 28 per 100,000 people, almost 10 times higher than Harris county and the state average.

Moore, where around 55% of residents identify as Latino or Hispanic, is home to the massive Brazilian-owned JSB meatpacking plant, which employs mostly Hispanic and migrant workers, many bussed in on company shuttles from towns including Amarillo. Nationwide, industrial meat plants have emerged as incubators for coronavirus spread.

Amarillo, the region’s largest city, situated across Potter and Randall counties, had 1,304 cases as of last Wednesday, including at least 18 deaths. The infection rate is rapidly rising. Potter county has the second worst rate in Texas, with infections doubling every seven or eight days.

Just to the south, in the city of Odessa, a group of armed militia men were arrested last week as they protested alongside bar owner Gabrielle Ellison, who attempted to reopen in violation of an executive order which mandates bars should remain closed.

The six men were members of a militia named Open Texas, which according to reports has operated across the state, offering armed support to business owners.

Ellison, who was also arrested, told local news from jail: “I think some rights were taken away from us, which one of them was like a right to survive. We have to survive and I think those rights were stripped from us.”

But looked what happened in Colorado!

Customers in Packed Colorado Coffee Shop Ignore Mask and Distancing Advice

 We have many stupid people as this next story proves. Customers in a Colorado coffee outlet on Sunday, May 10, resisted official calls for people to wear face masks and gloves – and to distance from one another – when in public.

This video shows the crowded scene inside a C&C Coffee and Kitchen store in Castle Rock on Mother’s Day morning. Few customers appear to be wearing face masks or distancing from one another to the extent suggested by federal and state officials.

Colorado Gov Jared Polis’s ‘Safer at Home’ order, which encourages six feet of distance between people, remains in effect until May 27.

As of May 10, Colorado had reported 19,703 confirmed cases of the coronavirus and 971 deaths.

Opinion: The coronavirus is accelerating America’s decline

Arvind Subramanian reported that the federal government’s response to the pandemic exposes incompetence and decay. The consequences will play out over years to come.

The COVID-19 crisis augurs three watersheds: the end of Europe’s integration project, the end of a united, functional America, and the end of the implicit social compact between the Chinese state and its citizens.                                                                                                                    As a result, all three powers will emerge from the pandemic internally weakened, undermining their ability to provide global leadership.                                                           Europe                                                                                                                                                Start with Europe. As with the 2010-12 eurozone crisis, the bloc’s fault line today runs through Italy. Drained over decades of dynamism and fiscally fragile, it is too big for Europe to save and too big to let fail. During the pandemic, Italians have felt abandoned by their European partners at a moment of existential crisis, creating fertile ground for populist politicians to exploit. The images of Bergamo’s COVID-19 victims being carried in body bags by military convoy to their anonymous, unaccompanied burials, will long remain etched in the Italian collective psyche.                                                                                    Meanwhile, when addressing how to help pandemic-stricken member states, the European Union’s technocratic, ostrich-like elites lapse into the institutional alphabet soup — ECB, ESM, OMT, MFF and PEPP — that has become their default language. The continent’s leaders have faltered and dithered, from European Central Bank President Christine Lagarde’s apparent gaffe in March — when she said that the ECB was “not here to close spreads” between member states’ borrowing costs — to the bickering over debt mutualization and COVID-19 rescue funds and the reluctant, grudging incrementalism of the latest agreement.                                                                                                                          Suppose, as seems likely, that the successful economies of the EU core recover from the crisis while those on the bloc’s periphery falter. No political integration project can survive a narrative featuring a permanent underclass of countries that do not share their neighbors’ prosperity in good times and are left to their own devices when calamity strikes.                             U.S.                                                                                                                                                      The United States’ decline, meanwhile, is over-predicted and under-believed. Even before the COVID-19 crisis, key U.S. institutions signaled decay: the incontinent presidency of Donald Trump, a gerrymandered Congress, a politicized Supreme Court, fractured federalism and captured regulatory institutions (with the U.S. Federal Reserve being an outstanding exception).                                                                                                                          Deep down, however, many of those Americans who see the decay reject the thesis of decline. They remain convinced that the country’s thick web of non-state institutions and underlying strengths — including its universities, media, entrepreneurial spirit, and technological prowess, as well as the global supremacy of the dollar — provide the resilience America needs to maintain its pre-eminence.

But so far, the world’s richest country has been by far the worst at coping with the pandemic. Although the US has less than 5% of the world’s population, it currently accounts for about 24% of total confirmed COVID-19 deaths and 32% of all cases.

In rapid succession, therefore, America’s credibility and global leadership have been buffeted by imperial overreach (the Iraq war), a rigged economic system (the global financial crisis), political dysfunction (the Trump presidency), and now staggering incompetence in tackling COVID-19. The cumulative blow is devastating, even if it is not yet fatal.                                                                                                                                                              Many of these pathologies in turn stem from the deep and poisonous polarization in US society. Indeed, Trump is now goading his supporters into insurrection. Come November, even the basic democratic criterion of holding free and fair elections could end up being flouted.                                                                                                                                         This is a critical moment. Prepare for the trading day with MarketWatch’s Need to Know newsletter. Our flagship email guides investors to the most important, insightful items required to chart the trading a day ahead.                                                      Of course, it would be alarmist and premature to see America’s far-reaching failures in the face of the COVID-19 crisis as threatening U.S. democracy or nationhood. But clinging adamantly to American exceptionalism at such a time seems like dangerous denialism.    China                                                                                                                                         Finally, there is China. Since the time of Deng Xiaoping, the country has thrived on a simple, implicit agreement: citizens remain politically quiescent, accepting curbs on freedom and liberties, and the state — firmly under the control of the Communist Party of China — guarantees order and rising prosperity. But the COVID-19 crisis threatens that grand bargain in two ways.                                                                                         First, the Chinese authorities’ terrible initial handling of the pandemic, and in particular their catastrophic suppression of the truth about the COVID-19 outbreak in Wuhan, has called the regime’s legitimacy and competence into question. After all, the social contract looks less attractive if the state cannot guarantee citizens’ basic well-being, including life itself. China’s true COVID-19 death toll, which is almost certainly higher than the authorities are admitting, will eventually come to light. So, too, will the stark contrast with the exemplary response to the pandemic by the freer societies of Taiwan and Hong Kong.  Second, the pandemic could lead to an external squeeze on trade, investment, and finance. If the world deglobalizes as a result of COVID-19, other countries will almost certainly look to reduce their reliance on China, thus shrinking the country’s trading opportunities. Similarly, more Chinese companies will be blocked from investing abroad, and not just on security grounds — as India has recently signaled, for example. And China’s Belt and Road Initiative — its laudable effort to boost its soft power by building trade and communications infrastructure from Asia to Europe — is at risk of unraveling as its pandemic-ravaged poorer participants start defaulting on onerous loans.                              The COVID-19 crisis will therefore probably hurt China’s long-term economic prospects. Widespread internal rumblings have begun, even if they are less evident externally. Domestic disorder is unlikely, because President Xi Jinping could ratchet up repression even more ruthlessly and effectively than he already has. But the current social contract will seem increasingly Faustian to the average Chinese citizen.

Command of resources is a prerequisite for power. But, as international-relations theory reminds us, projecting power beyond one’s borders requires a modicum of cohesion and solidarity within them. Weak, fractured societies, no matter how rich, cannot wield strategic influence or provide international leadership — nor can societies that cease to remain models worthy of emulation.                                                                                                     We have been living for some time in a G-minus-2 world of poor leadership by the U.S. and China. Both have been providing global public “bads” such as trade wars and erosion of international institutions, instead of public goods such as stability, open markets, and finance. By further weakening the internal cohesion of the world’s leading powers, the COVID-19 crisis threatens to leave the world even more rudderless, unstable, and conflict-prone. The sense of three endings in Europe, America, and China is pregnant with such grim geopolitical possibilities.                                                                                                            And Now Wuhan reported its first new coronavirus case in more than a month                                                                                                                      Aly Song from Reuters reported that Wuhan reported their first new COVID case.

  • The central Chinese city of Wuhan has reported its first new coronavirus case in more than a month.
  • The Wuhan Municipal Health Commission said Sunday that an 89-year-old man was confirmed to have the virus on Saturday. His wife, along with several members of the community, were recorded as asymptomatic cases, which are not included in official case tallies.
  • On Sunday, the National Health Commission revealed that 14 new symptomatic cases were reported on Saturday, marking the largest increase since April 28.

The central Chinese city of Wuhan, where the coronavirus first appeared last year, reported its first new case in more than a month on Sunday. The Wuhan Municipal Health Commission announced Sunday an 89-year-old male with a history of various health problems, tested positive for the virus on Saturday after showing symptoms.

His wife, who tested positive without symptoms, has been recorded as an asymptomatic case. Several other members of the community were also recorded as asymptomatic cases. The health commission said the elderly man, who resides in the Dongxihu district, lived in an area where 20 other people previously tested positive for the virus. The risk level for his district was raised to medium on Sunday. The new case is, according to multiple outlets, the first case reported in Wuhan since April 3.

Wuhan, the Chinese city hardest hit by the virus, has reported a total of 50,334 coronavirus cases and at least 3,869 deaths. In mid-April, the city revised its death toll, increasing it by 50%. The numbers coming out of China have repeatedly been called into question, especially by US officials, including the president.

China has argued that numbers are low because it took decisive action. The strict quarantine of Wuhan, a sprawling city of 11 million people, began on Jan. 23 and ended on April 8. Similar action was taken in cities across China.

On Sunday, China’s National Health Commission announced that there were 14 new coronavirus cases reported nationwide on Saturday, marking the largest single-day increase since April 28, according to Reuters. The majority of the new cases were reported in Shulan, a city in China’s northeastern Jilin province. Local officials raised the risk level to high in response.

China also reported 20 new asymptomatic cases, which are not included in the total tally. The country has reported 82,901 cases and 4,633 deaths.

How a COVID-19 Testing Model No One Is Talking About Could Save Thousands of Lives

Andrea Galeotti noted that with solid data in short supply relating to the characteristics and spread of COVID-19, many governments and health officials are struggling to formulate suitable health and economic policies. As a consequence, some although not all, countries are effectively waging a war against the coronavirus based on the dynamics of a game of chance. This in turn is producing considerable anxiety about when lockdowns might end and the first steps towards economic activity might begin to occur.

This absence of data and resultant lack of concrete purpose is perhaps best illustrated in the U.S. where the federal government has left individual states to decide when to reopen in phases, without clarity on how widespread COVID-19 actually is. What state governments should be doing is formulating a reopening procedure that is based on selecting and testing a representative sample of the population.

There is now abundant evidence that asymptomatic individuals are the key diffusers of COVID-19 and as such firmly locating those individuals is the only way to stop further waves of contagion. Testing has always been of paramount importance, but this should not be seen as a mandate to test on a massive scale. That option is clearly not practicable and should urgently be substituted for well-designed testing strategies that determine the rate of infection in the local communities of individuals being tested, as well offering a firmer bearing on the general prevalence and diffusion of the virus within the greater population. Based on this information, contact tracing and smart containment strategies can be designed in order to ensure that contagion curve is kept flat and the health system can operate within its capacity.

COVID-19 has shown it can infect people regardless of age, race, gender, and geography, and therefore has proved unpredictable and difficult to contain. This unpredictability has been mirrored by the divergent testing strategies of different governments around the world. Countries such as Italy, U.K., and the U.S. have principally been testing patients with severe symptoms and have largely withheld testing asymptomatic individuals. By contrast, in countries such as Germany, Iceland and South Korea, the testing regimen has quickly expanded to mildly symptomatic cases, and to asymptomatic individuals who work in jobs where, should the become infected, have a high chance of spreading the virus to many others. That includes, for example, medical staff and workers in transportation hubs.

These different approaches may have been dictated by different logistical constraints, yet it is clear those countries that have employed intelligent testing and contact tracing strategies have in turn been more successful in containing COVID-19. For example, Iceland, South Korea, Australia, and Singapore all have strong testing and contact tracing initiatives and their infection and mortality numbers are a fraction of the U.S.’s.

A key piece of the exit strategy for countries like the U.S., Italy, and the U.K., then, seems simple: develop a serological testing program on a representative sample of the population, while also gathering information on demographic characteristics such as age, gender, number of children, type of working sector, skills, social and working associations.

Serological tests detect the presence of antibodies for COVID-19 and make sense for this purpose for a few reasons. PCR tests, which detect RNA evidence of a virus, can only reveal a current or recent infection. Antibody tests, on the other hand, can, in theory, identify someone who was exposed to the virus months ago. By testing with this method, governments will be able to capture a clear picture to what extent the virus has already spread and identify trends across geographical regions as well as across individual characteristics such as age, gender, working sectors and skills.

Gathering this representative sample would be relatively easy and cost-effective to implement. It is also easy because countries can use representative samples of the population that are regularly used for socio-economic surveys. For example, the U.S. Bureau of Labor Statistics’ “Labor Force Statistics from the Current Population Survey” could be adapted to run such tests. Secondly, the data collected can be analyzed though standard statistical methods, which will help to infer a body of valuable analysis related to the spread across the wider population.

There are aspects of the design of such test programs that will need to be very carefully managed. For example, they could be vulnerable to outcomes that wrongly indicate the presence of COVID-19 in a given region, or, conversely, identify regions that notionally suggest low infection rates. In both examples, test validation is critical.

Through the collection and statistical analysis of such data, governments will be in a position to make an informed choice and evaluate the advantages and the disadvantages that are inherent in any policy that will relax social distancing before a vaccine is available. Formulating an exit strategy without this information amounts to flipping a coin—the proverbial game of chance and is the new cases of COVID-19 a signal of what we could see in this country as we ease self-quarantine and the “severe” lock-down in states and cities?

We need a comprehensive collection of data using contact as well as post infection patient tracing to get a handle on this pandemic and the possible recurrent waves!

Telehealth use, Coverage by Insurers Soaring in Response to COVID-19; COVID Testing, Contact Tracing and How to Reopen the US and Pandemic Resilience?

Dr. Sarah-Anne Schumann, UnitedHealthcare’s chief medical officer for employer and individual health care plans in North Texas and Oklahoma, says telehealth visits are soaring.

The growth of telemedicine is apparent at UnitedHealthcare’s sister company, Optum, which went from 1,000 telemedicine-trained care providers to 5,000 in a matter of weeks. That number is expected to grow to 10,000 providers by the end of April.

In the interview that follows, Schumann, who is a family doctor in addition to her role with UnitedHealthcare, gives us a look at the growth of telemedicine during the coronavirus from the viewpoint of both the insurer and the physician.

How has the acceptance and reliance on telehealth grown given the COVID-19 pandemic?

Telehealth has been around for a long time, and basically what telehealth does is it allows people to see a doctor anywhere and anytime on a mobile device or computer. It’s available 24 hours a day, seven days a week. People can get their medical conditions diagnosed and treated that way. With the coronavirus, now that there’s a lot of risk with going into a doctor’s office — a risk of you exposing other people or you being exposed to coronavirus — more and more doctors’ practices have very quickly scaled up their technology to allow their doctors to provide telehealth.

Can you quantify the growth?

I have some statistics. Seventy-six percent of hospitals can connect patients and care providers using digital and other technology. On the employer side, nearly nine out of 10 employers offer telemedicine to their employees.

When did UnitedHealthcare start allowing for telehealth visits?

We did allow for telehealth before COVID, but our policies have changed. We have much broader coverage since COVID. Our policy now is we are covering telehealth with no cost-sharing at all. That started on March 31. As of now through June 18, we are waiving all cost-sharing for in-network health visits for our Medicaid, Medicare Advantage and our fully insured individual and group health plans. For self-funded employers, they can opt in to telehealth with no cost-sharing.

That’s not just for COVID-related visits, but for absolutely any telehealth visits. It’s not just primary care and urgent care, but also for outpatient behavioral health and physical therapy, occupational therapy and speech therapy.

Did UnitedHealthcare broaden the coverage because of the COVID-19 pandemic?

Yes. Some primary care offices are closed right now both for safety and because there’s decreased volume for a lot of the businesses. This is a very safe way to get people assessed when they’re feeling sick but not sick enough to go to an emergency room.

It’s my understanding that insurance won’t pay the same for a telehealth visit vs. an in-person doctor visit. Is that true with UnitedHealthcare?

They are covered at a different rate, but there are many ongoing conversations. Right now, with COVID, for the doctors’ practices that have moved over to provide telehealth, they are being reimbursed at the same rate as an in-person visit. Another change, because the doctor’s offices had to pivot so quickly to start offering this, right now, there can even be phone-only visits that are covered.

Typically, do you Facetime or how do the providers get the visuals from the patient?

If you have a smartphone, which most people have, or a tablet or computer, that’s usually how it works. But right now, you can do phone-only visits.

How does a patient find out if their existing doctor is signed up and licensed to practice telemedicine?

Call the practice or go on their website. It’s best to try your own doctor first, but if that doesn’t work, try your (insurance company’s) website and it will connect you with a national provider.

What should employers know about telehealth?

Telehealth, of course, is not for everything. But for simple, urgent medical issues like allergy symptoms or pink-eye or rashes or fever, telehealth is a great way for their employees to access care. It reduces the burden on the health care system and it reduces cost and improves accessibility to care. Another thing for employers to think about is, right now while people are at home, there’s a lot of increased stress and anxiety, and virtual visits can be a way to connect with a therapist or psychologist or psychiatrist.

Do you think the COVID-19 pandemic will cause permanent changes in how people access health care?

A lot of the changes that we are experiencing in society because of the pandemic are going to be permanent changes. Things like people working from home. Some people are more productive when they’re working from home. It’s the same thing with telemedicine. Now that people are introduced to this, I think in the cases where telemedicine is a good substitute, waiting to see the doctor for urgent-care type visits where you don’t need to have a blood test done or get IV medication or things like that, people are going to see that telemedicine is a great substitute.

How to reopen the US, according to Johns Hopkins and Harvard: Test 20 million people a day, hire an army of contact tracers, and expand healthcare coverage

Hilary Bruek reported that experts from Harvard and Johns Hopkins, as well as the former FDA commissioner, have each released their plans for how to reopen the country safely.

The plans suggest the US will need to massively ramp-up its disease testing and tracing capabilities to allow people to return to work and school. 

Collectively, the reports suggest the US will need: around 5 million tests a day by July, 100,000 public health workers to contact trace, and a “national infectious disease forecasting center.” 

Most Americans are still stuck at home, but a trio of reports, out from Harvard, Johns Hopkins, and former US Food and Drug Administration Commissioner Scott Gottlieb, are starting to lay a foundation for what reopening the country might look like, if done safely.

Though staying inside is certainly keeping more infections at bay right now, it’s not without its costs.

Aside from the strain stay-at-home orders are putting on families, friends and communities, the newfound national quiet means the US is “hemorrhaging $100 billion to $350 billion a month,” according to the new Harvard analysis, which was released on Monday.

A hasty, careless reopening would be a deadly disaster, though.

If everyone rushed back into the streets, hugging, kissing, shaking hands, and entirely abandoning social distancing measures, more than 300,000 people nationwide could die, according to federal documents from the Department of Health and Human Services, first released in a report from the Center for Public Integrity on Tuesday.

That’s why any thoughtful plan to reopen the country must involve massive additional investments in public health, especially the testing and tracing of US coronavirus cases.

Here are the key topline suggestions from the experts for not only emerging from the coronavirus crisis successfully and safely, but also, as the Harvard report put it, becoming a “pandemic resilient” nation.

Harvard’s Roadmap to Pandemic Resilience says more testing is fundamental to recovery 

Broadly, the Harvard report suggests the task ahead of us is “bigger than most people realize.”

“We need to massively scale-up testing, contact tracing, isolation, and quarantine—together with providing the resources to make these possible for all individuals,” the authors write. 

Here’s how:

In the coming months, the US should rapidly ramp up its capacity to test for the coronavirus, eventually testing upwards of 2 to 6% of the population on any given day. (Currently, the US tests around 150,000 people per day, or about 0.04% of the population.) The plan starts with: 5 million tests per day by early June, and continues trending upward towards 20 million tests a day nationwide, by late July. That kind of widespread testing would be on a scale larger than Germany (testing 0.06% of the country per day, with more than 50,000 coronavirus tests), and would even surpass South Korea, which so far has tested more than 1.1% of the country, overall, for COVID-19.

But “even this number may not be high enough to protect public health,” the report authors warn.

“Given that 40% of the economy is already open,” the report says, “our first priority for a massively scaled up pandemic testing program should be to stabilize the essential workforce.” Policy makers should listen to worker voices, the report also said, “because workers have expert knowledge about how to make their jobs safe and when safety-related rules are not being followed.” 

Tests will eventually also be needed for others, including:

  1. Everyone with coronavirus symptoms, and their close contacts.
  2. People with presumed exposure (healthcare workers, essential workers, etc.)
  3. Nursing home residents and staff.
  4. Incarcerated people.
  5. Companies and schools.
  6. Those who have tested negative within a very recent window and those who show immunity in reliable antibody tests (assuming these prove feasible) should be free to return to work,” the report said.
  7. The authors were cautious about the idea of immunity cards or passports, though. “Certificates of immunity should be used only in contexts where people have equal access to testing and where a recent negative test result provides the same access to mobility as immunity,” the report says. “Any other use of immunity certificates would be likely to violate constitutional equal protection requirements.” 
  8. In order to be able to follow 14-day quarantine orders successfully, people will need to be supported with more job protection and healthcare, the report added.
  9. The cost of testing and tracing at this scale is an estimated $50 – 300 billion over two years, which, the authors write is still far cheaper than “the economic cost of continued collective quarantine,” at $100 to 350 billion a month. 
  10. Pandemic Testing Board should also be established by the federal government, the report suggests, with a National Director of Testing Supply appointed to help ramp up testing efforts. “In virtually every successful historical example of such rapid coordination, a central authority has set goals and ensured that each part of the chain meets the interlocking goals required for the chain to succeed,” the report authors add.  

There’s just one problem, though: the Harvard approach relies on all coronavirus tests being accurate, but some are not

Claudio Furlan/LaPresse noted that the swab-the-nose-and-throat coronavirus testing delivers about 30% false negatives, which means that roughly 3 in 10 people who have the virus could wrongly assume they don’t after they’re tested, and then could go on to infect others at work or at school.

Coronavirus blood tests, which are meant to determine whether a person has been infected in the past with the coronavirus and developed disease-fighting antibodies, have so far performed much worse than the swab tests, with some operating at just 30% accuracy, the New York Times recently reported.

Johns Hopkins’ ‘National Plan to Enable Comprehensive COVID-19 Case Finding and Contact Tracing in the US’ adds an army of contact tracers to the Harvard testing plan

The goal of deploying thousands of contact tracers across the US, the report authors write, is to “find every COVID-19 case in the midst of a national epidemic … and then work quickly to contain spread through intensive case and contact tracing interventions,” by warning others who might’ve been exposed to those sick people to stay home.

“This entire operation has never been done before,” New York Governor Andrew Cuomo said Wednesday, as he announced during a news conference that his state would be partnering with Johns Hopkins to roll out a new army of contact tracers in the tri-state area, to the tune of $10 million.

“You’ve never heard the words testing, tracing, isolate before,” Cuomo said. “No one has. We’ve just never done this.”

Here’s how the plan could work, nationwide:

  • Hire “an extra 100,000 contact tracers across the United States,” the report says. “While this figure may be stunning, it is still the equivalent of less than half the number [of contact tracers] employed in Wuhan,” the authors point out. 
  • Contact tracers will need to be trained by existing state and territorial public health departments on: disease transmission, principles of case isolation and quarantine, ethics of public health data collection and use, risk communication, cultural sensitivity, and more. 
  • The plan could provide jobs for: former government employees, retired public health and public safety workers & medical personnel, medical and public health students, Medical Reserve Corps or Peace Corps members, community health workers, and others “seeking employment—especially those who have lost their jobs due to COVID-19.” People with good communication and interviewing skills would be especially well-qualified for the task.
  • The new workforce will cost the US an estimated $3.6 billion, and the report authors urge Congress to fund this idea in its fourth stimulus package.
  • The cost of not tracing is also high: “It is estimated that each infected person can, on average, infect two to three others,” the authors write. “This means that if one person spreads the virus to three others, that first positive case can turn into more than 59,000 cases in 10 rounds of infections.” 

Apple and Google have also released their own plans to make contact tracing and surveillance happen more automatically on our phones

Apple and Google are both working on new apps and other press-of-a-button opt-in functionalities for phones that would harness Bluetooth technology to track where we’ve been, and then warn others who’ve been near us, in the event we get sick with the coronavirus, in a new brand of push notification-friendly contact tracing.

The companies promise that “user privacy and security” will be paramount in any forthcoming app design.

Other countries have already tried out similar Bluetooth-reliant tracing techniques, but they’re not always very successful, as you need a large percentage of the population to use them in order to have any major impact on transmission. 

Scott Gottlieb’s ‘Road Map to Reopening’ from the American Enterprise Institute adds in the element of a weather forecasting service for pandemics 

James Gathany reviewed that Scott Gottlieb reviewed the “Road Map to Reopening” from the American Institute and reported that Gottlieb calls it a “National Infectious Disease Forecasting Center,” and says “this permanent federal institution would function similarly to the National Weather Service, providing a centralized capability for both producing models and undertaking investigations to improve methods used to advance basic science, data science, and visualization capabilities.” 

Gottlieb also cautioned that we should not rush to return the US to business-as-usual, even as some restrictions are lifted. As schools and businesses reopen, “teleworking should continue where convenient” he said, and “social gatherings should continue to be limited to fewer than 50 people wherever possible.”

‘It’s going to be brutal,’ billionaire Mark Cuban says of economy’s recovery from coronavirus, and ‘there’s no way to sugarcoat it’

‘It’s going to be brutal. There’s no way to sugarcoat it at all.’

That is outspoken billionaire and Dallas Mavericks owner Mark Cuban, who has been increasingly visible as the National Basketball Association has been temporarily suspended due to the deadly COVID-19 pandemic.

Reporter DeCambre reviewed an interview with Mark Cuban with Maria Bartiromo. Cuban, speaking with Fox Business anchor Maria Bartiromo, explained why he thought the recovery from the economic fallout wrought by the illness caused by a novel coronavirus strain could be a long and ugly one for the average American and small businesses in particular.

“It’s going to be brutal. There’s no way to sugarcoat it at all. And when we get to the other side, companies are going to be operating differently,” Cuban said on the business network.

The entrepreneur, who boasts a net worth of $4.3 billion, according to Forbes, says that challenges for businesses are manifold and include additional costs that will be incurred to sanitize and retrofit spaces as nearly shutdown economies attempt to reboot after a virus-imposed hibernation.

“Companies are going to have to be agile … Companies are going to have to build from the bottom up,” Cuban said.

The “Shark Tank” star said he remains confident that some normalcy will return in two to three years but predicts that investors and business owners will need to endure some pain to get to the other side.

His comments came as Robert Redfield, director of the Centers for Disease Control and Prevention, was quoted in the Washington Post as saying in an interview published on Tuesday that “there’s a possibility that the assault of the virus on our nation next winter will actually be even more difficult than the one we just went through.”

The deadly contagion that was first identified late last year in Wuhan, China, has, infected more than 2.6 million people globally and killed about 179,000, according to data aggregated by Johns Hopkins University, as of Wednesday morning.

On Thursday, investors and others will be watching for a House vote on a nearly $500 billion aid package for small businesses amid the coronavirus pandemic, after the Senate passed the measure on Tuesday.

The passage of the bill and the possibility of restarting stalled economies may be conferring some optimism on markets, with the Dow Jones Industrial Average DJIA, +1.10%, the S&P 500 SPX, +1.39% and the Nasdaq Composite Index COMP, +1.64% all closing sharply higher Wednesday.

That said, Cuban believes that small businesses may require at least a third installment of funds to operate through the crisis, and he is looking to invest in companies that sit outside the criteria for obtaining government-backed loans.

“We haven’t talked about those companies that are 501 and up. They are suffering the most,” he said, referring to language that stipulates that businesses need to have 500 or fewer employees to qualify for the small-business recovery funding. 

So, when do we really reopen the economy and back to the “new” normal and do we use scientific data? I think as we can see we need data based on more testing, but the testing has to be accurate and more sensitive and then we need comprehensive contact tracing and case follow-up tracing. Also, what technology will we use for contact tracing and could it be the use of APPS on our phones or other home health and fitness wearables or other real time monitors?

This technology needs to integrate multiple longitudinal electronic medical records across all sources including healthcare providers and healthcare facilities, labs, clinics, pharmacies, long-term care facilities, etc. with nationwide coverage and interoperability and more important it needs to be HIPPA compliant to respect personal information.

Big wishes and needs, which will lead the way to solutions and attaining our goals of defeating COVID-19 and also prepare the US for whatever the next possible pandemic may raise its ugly head!

When This War Is Over, Many of Us Will Leave Medicine and the Stresses of Healthcare Workers on All Fronts

One ER physician recounts the stress of constant intubations and PPE shortages

Michele Harper reviews the stress of our frontline healthcare workers and here is a case.

I couldn’t see. My face shield was blurred by a streaky haze. I tilted my neck back and forth in an effort to peer beyond it, beneath it, through it, whatever might work. Was it condensation? I started to raise my hands to my face to wipe it away before I remembered and yanked them back down: I cannot touch my face, can’t ever touch my face — neither inside this room nor outside it.

As I stood at the head of the patient’s bed in ER Room 3, her nurse, Kate, secured a mask over the patient’s face to deliver additional oxygen. I checked to ensure the oxygen was cranked up to the maximum flow rate while we waited for the respiratory therapist. Even with that increased oxygen, the patient was saturating 85% at best, and her blood pressure was dropping.

Ninety minutes earlier, the patient — a woman of 68 years with significant impairment from a stroke — had been fine. The nurse at her nursing home called to inform us they were sending the patient to the ER for evaluation of “altered mental status” because she was less “perky” than usual. Her oxygen level on arrival was normal with no shortness of breath. Her blood pressure was a little low, but her blood glucose read high. Nothing a little IV fluid couldn’t fix, and initially, it did.

I had requested a rectal temperature; it read 103 degrees. The combination of her being a nursing home resident and running a fever was a red flag during these coronavirus times. I placed her on respiratory isolation and asked Kate to be extra vigilant for any decline. I ordered broad-spectrum antibiotics to kill any likely source of infection while I awaited her chest X-ray, urine, and blood tests. Her portable chest X-ray was done first and revealed what I had already anticipated: diffuse atypical infiltrates, a presumed telltale sign of Covid-19. Although our understanding of this viral infection is ever-evolving, it seems the only observation we can reliably conclude is that we have not yet identified anything pathognomonic about it.

Seventy-five minutes later, another nurse, Charlene, called, “They need you in Room 3.”

“Okay,” I replied as I entered orders on the next chest pain patient with shortness of breath.

“Dr. Harper, they need you in Room 3 now,” Charlene called again.

“Room 3? The nursing home patient? I’ll be right there. What happened?”

“Her oxygen is at 67%.”

I asked the clerk to call respiratory therapy for intubation. I then turned back to Charlene to ask her to help Kate prepare for the procedure.

Then the personal protective equipment (PPE) sequence. I grabbed gloves to remove my N95 mask from its paper bag and placed it over my face, checking it was snug over my nose and lower jaw. After removing those gloves, I donned my face shield, then walked to the cart for a new gown. Lastly, a fresh set of gloves before entering the patient’s room.

I was scared, and I don’t get scared. Other doctors do, but not ER doctors. We don’t scare easily.

Now I waited for the respiratory therapist. It was good that she needed extra time to get the ventilator and then don her PPE because I had to figure out why I couldn’t see without manually manipulating my face shield. My thoughts were pierced by the sound of panting. I checked the patient who was taking the oxygen quietly, rapidly, ineffectively at regular intervals that didn’t register a sound. Her eyes remained closed—no flip of an eyelash, no wince of her forehead, no twitch in a limb. Despite her instability, the patient was in no visible distress. No heaving breath there. The nurse to my left was concentrating on the patient’s oxygen. I heard only the crinkle of her gown as she adjusted her stance. The panting wasn’t hers. The nurse to my right prepared to administer the intubation medications. He read out my orders — the name and dose of the medication in each syringe and the order in which they were to be pushed. His voice was steady. It wasn’t him hyperventilating. The nurse just outside of the room kept documentation of the procedure on scrap paper she used to carefully transcribe each detail onto her laptop. She was too far away to be heard unless she yelled, so that audible breathing certainly wasn’t hers.

The panting was my own.

A hailstorm of thoughts ensued. Was my breath the fog on my face shield? If so, my N95 mask had a leak. Unsuspecting, had I already inhaled the virus? Would I be intubated next?

The respiratory therapist had arrived with the ventilator and put on her face shield. She was almost ready, so there was little time to pull myself together.

Breathe in, I commanded myself: One, two, three. Breathe out. I obeyed: One, two, three, four.

Was I already short of breath? Had I not noticed my symptoms when I drove to work this morning? Yesterday? Last night?

Breathe in. One two, three. Breathe out. One, two, three, four.

I was scared, and I don’t get scared. Other doctors do, but not ER doctors. We don’t scare easily. We’re a type of special forces who step in when everything else has failed. Typically, we do our job anonymously then leave when the mission is complete. Any injury to ourselves incurred in the line of duty is dealt with after we’re off the clock.

Once in a while, however, there are circumstances when the capacity to compartmentalize is overwhelmed, when the chronic stress breaks through so that the fear works on you. Now, as I stood at the patient’s bed with the video laryngoscope blade in one hand and the endotracheal tube in the other, panic pushed its way through me in involuntary. forceful. rapid. shallow. breaths.

Breathe in on one, two, three. Breathe out on one, two, three, four.

The respiratory therapist slapped on her gloves and in moments was at my side. It was time for intubation.

Breathe in on three and out on four.

At last, my breathing was smooth, measured, sound.

I looked through my mask again. It wasn’t condensation. It was streaks from the sanitizing wipes because we had to reuse our equipment.

I adjusted my eyes to the clear spaces. Finally, I could see. My N95 mask fit. I could breathe.

The room was relatively quiet, what I like to call “ER calm.” All was still, save for the bagging of respiratory therapy, save for the swoosh of oxygen jetting from its port aerosolizing everything.

I requested that the intubation medications be administered then checked for a response. After visualizing the vocal cords easily with the video laryngoscope, I slid in the endotracheal tube, and respiratory connected it to the vent. The patient’s oxygen increased to 100% on the monitor.

Those of us who survive will return each day to battle. But when this war is over, this is why many of us will leave.

Doffing my gown and gloves, I put on new gloves to remove and sanitize my face shield. I couldn’t imagine there was a way to effectively clean the foam band across the forehead. I hoped to remove the streaks. I also hoped the impossible: to remove the virus, because it was the same shield I had to use repeatedly during my shift. I took off the N95. We’re now told that we can reuse it, too, numerous times before getting a new one due to the PPE shortages, so I put the contaminated mask back in the bag until I would need to do it again for the next patient.

This is how we get infected. This is how we die.

Those of us who survive will return each day to battle because we do not walk away from war until it’s done. But when this war is over, this is why many of us will leave.

I walked to the back of the ER to use the restroom in the seven minutes before the patient was ready for CT and saw my ER director standing in the lounge. I waved hello.

“How did it go?” she asked, her eyes gentle, her smile sympathetic.

“It went,” I replied.

“How did you feel in the PPE? Did you feel protected?”

I paused to regulate my answer. Her intentions were good. She was an ER doctor who did her best to walk the fine line between the docs on the front lines and the administrators who notified me that “doctors don’t get paid sick leave” and “thank you for your service,” which were graciously sent out in two separate emails. Just another reminder that we health care providers are regarded as more disposable than our PPE. But this wasn’t her fault, so I felt responsible, in that moment, for her feelings too.

I pulled in my tone. “No. That equipment doesn’t protect us. There’s no way that we’re not all covered in Covid, but we’re following the ‘guidelines.’”

She nodded and frowned.

“Honestly,” I continued, “and I hate to say this, but my feeling is that the majority of people will have contracted this virus. Most people will get through it, and others won’t. Many will die. I don’t want any of us to die, but many health care providers will. The thing is, it’s impossible to know which camp we’re in until it happens.”

She nodded again.

We smiled at each other, and I continued to the bathroom. I washed my hands, turning them over each other, lathering the soap along each finger, under each nail. As I dried my hands, I looked up at the mirror, noting that my breath was now imperceptible when my phone rang.

A FaceTime request from my nine-year-old nephew, Eli.

My policy used to be to not answer the phone at work unless it was critical. But this is a different era. Eli is sheltering-in-place at a military base in California while his mother, my sister, is away for deployment.

I swiped the phone to answer. “Hi, Eli!”

“Hello, Aunt,” he announced more softly than usual. His eyelids hovered low, and his eyes weren’t their typical bright.

“How are you, Eli?” I inquired, masking my concern.

“I’m good.” He smiled with sleepy eyes. “I just woke up.” He yawned; his bushy eyebrows raised high. Years ago, he said his eyebrows were the indisputable evidence that Frida Kahlo was his great, great grandmother so he had to meet her forthwith. Upon being told that she had already passed away, he cried for the woman he had decided was his long-lost ancestor. Now, as he yawned again, his thick eyelashes shut tight. His head drifted back and his mouth reeled open expelling the strongest exhale of the bravest lion cub.

Smiling to myself, I sighed easily.

He breathed.

I breathed.

Today we are OK.

Anxiety on the Frontlines of COVID-19 

It’s not just healthcare workers’ physical health but also their mental health that’s suffering

Richard van Zyl-Smit, M.D./PhD described to a friend this week the current feeling of being in the hospital with COVID-19, as like sitting under a 1,000V high-tension electricity cable: there is a constant humming above your head, which is unnerving and just does not go away.

Two years ago, he published a book called They Don’t Award Nobel Prizes to Dead People about my experience as an academic clinician with a stress-induced anxiety disorder. The context is very different now, but the lessons I learned in that time might be of help to those of you feeling this intangible “humming” — a sense of anxiety that is neither defined nor visible even with no COVID patient contact — and for those of you who are caring daily for COVID-19 patients.

The first and most important aspect of this time is to recognize that anxiety is real. This is not something you might have experienced before. For those of us who have previously or currently suffer from anxiety, it is easily recognizable for what it is, but you may never have experienced it quite like this. You are not losing your mind or losing control, you are experiencing a loss of control of your environment. In many ways, the daily changing updates, the ever-changing schedules and call rosters are unsettling at best and can be completely unnerving as we can’t be certain from one day to the next. There is not a lot you can do about it, except to acknowledge it and talk about it.

The second aspect relates directly to that gnawing “hum.”

I learned previously the benefit of and strongly believe in “downtime.” Getting away from the humming, which is not so easy anymore as we don’t have rugby or soccer scores to get excited or depressed about, we don’t have news about politics or current affairs — except COVID, COVID, COVID. I used to play Candy Crush to get my mind off work and to get away from the “hum,” but recognized that did not accomplish much — it just kept my mind going, and the anxiety was still there. I now try to be creative, to garden, draw, write, crochet (see below), paint, anything that I can do that takes the focus off my work.

Exercise is great too — but now restricted to indoors! I don’t look at the hundreds of WhatsApp group messages unless I am at work; the latest medical publication of how I should treat my ventilated COVID-19 patient on my next week on call is not important when I am at home.

I am convinced that switching off the social media, medical media, and media media when you are not working is vital for your mental health. For some, it might mean no social media, for others less, but getting out from under the electricity cable when you can, is an important way to ensure your own sustainability over the next few months.

The last aspect relates to relationships: physical distance is key — but find, and seek out the people who can support you; keep talking to each other, be kind to each other and to yourself, and talk about the anxiety, fears, worries, or stress. Professional services are available to those feeling very out of control, but simply talking with someone is a fantastic way to get the humming out of your head.

As much as we need to care for our COVID-19 patients and protect ourselves with PPE, we also need to look after ourselves and protect our mental health. It is not a sign of weakness but requires courage and bravery to ask for help.

“Asking for help is not giving up, it is refusing to give up.” — Charlie Mackesy

We are all in this together — we need to be kind to each other and to ourselves.

India coronavirus doctors: Notes on hope, fear and longing Reporter Vikas Pandey shows us how the Corona virus is affecting doctors in India. Dr Milind Baldi was on duty in a Covid-19 ward when a 46-year-old man was wheeled in  with severe breathing difficulty.

The man was scared for his life and kept repeating one question: “Will I survive?”

The question was followed by a plea: “Please save me, I don’t want to die.” Dr Baldi assured the man that he was going to do “everything possible to save him”.

These were the last words spoken between the two men. The patient was put on a ventilator, and died two days later. The doctor, who works in a hospital in the central Indian city of Indore, vividly remembers the 30 “terrifying minutes” after the patient was brought to his hospital.

“He kept holding my hands. His eyes were full of fear and pain. I will never forget his face.”

His death deeply affected Dr Baldi. “It ate away my soul from inside and left a lacuna in my heart.” Seeing patients die in critical care wards is not uncommon for doctors like him. But, he says, nothing can compare to the psychological stress of working in a Covid-19 ward.

Most coronavirus patients are kept in isolation, which means, if they become critically ill, doctors and nurses are the only people they see in their final hours.

“No doctor ever wants to be in this scenario,” says Dr A Fathahudeen, who heads the critical care department at Ernakulam Medical College in southern India.

Doctors say they usually share the emotional burden of treating someone with that person’s family. But Covid-19 doesn’t allow that. Dr Fathahudeen says he will never forget “the blankness in the eyes” of a Covid-19 patient who died in his hospital.

“He wasn’t able to talk. But his eyes reflected the pain and the fear he was experiencing.” Dr Fathahudeen felt helpless because the patient was going to die alone. But there was a tiny sliver of hope: the man’s wife was being treated for coronavirus in the same hospital.

So, Dr Fathahudeen brought her to the ward. She stood still and kept looking at him and said her goodbye. She never thought her 40-year marriage would end so abruptly.

The experienced doctor says the incident left him “emotionally consumed”. But, he adds, there was “some satisfaction that he didn’t die without seeing his wife”. “But that won’t always happen. The harsh truth is that some patients will die without saying goodbye to their loved ones.”

The emotional toll is made much worse as many doctors are themselves in a form of isolation – most are staying away from their families to protect them. As a result, Dr Mir Shahnawaz, who works at the Government Chest Hospital in Srinagar, says it’s “not just the disease we are fighting with”.

“Imagine not knowing when you will see your family next, add that to the constant fear that you may get infected and you will begin to understand what we are going through.”

Adding to the stress, is the fact that they also have to constantly deal with the emotional outbursts of patients. “They are very scared and we have to keep them calm – be their friend and doctor at the same time.”

And doctors also have to make phone calls to the families of patients, and deal with their fears too. The whole process, Dr Shahnawaz says, is emotionally draining.

“It hits you when you go back to your room in the night. Then there is the fear of the unknown – we don’t know how bad the situation will get.”

Doctors are used to saving lives, he adds, and “we will continue to do that no matter what”. “But the truth is that we are also human beings and we are also scared.” He says that the first coronavirus death in his hospital made his colleagues break down: it was when they realized that Covid-19 doesn’t afford the family a final glimpse of their loved one.

“Family members want to remember the final moments of a patient – a faint smile, a few last words, anything really to hold on to. But they can’t even give a proper burial to the dead.”

Dr Fathahudeen says such psychological pressure needs to be addressed and each hospital needs to have a psychiatrist – both for doctors and patients. “This is something I have done in my hospital. It’s important because otherwise the emotional scars will be too deep to heal. We are staring at cases of PTSD among frontline workers.”

Doorstep doctors

It is not just those working in Covid-19 wards who are on the front line, but also the doctors, community health workers and officials who are involved in contact tracing and screening suspected patients by going door-to-door in virus hotspots.

Dr Varsha Saxena, who works in the badly affected northern city of Jaipur, says she walks into grave danger knowingly every day. Her job is to screen people for possible symptoms. “There is no other option. It’s the fight of our lifetime, but one can’t ignore the risks,” she says. “But it poses great risk because we don’t know who among the ones, we are screening is actually positive,” she adds.

She says doctors like her don’t always get proper medical-grade personal protective equipment. “The fear of getting infected is always there and we have to live with it. It does play on our mind and we have to fight hard to keep such negative thoughts away.”

But her biggest fear, she says, is getting infected and not showing any symptoms. “Then the risk is that we may end up infecting others. That is why field doctors also need PPE,” she adds. And the stress, sometimes, also comes home.

“It’s so draining. My husband is also a doctor, most nights we don’t even have energy to cook and our dinner involves just bread.”

Aqueel Khan, a bureaucrat and a colleague of Dr Saxena, acknowledges that psychological stress is a reality for all frontline workers, including officers like him who are embedded with medical teams. The fear really comes home for these workers when somebody close to them dies.

“I lost my uncle and a friend recently. It shook me, I can’t stop thinking about them. You can’t stop thinking that it can easily happen to you,” he says.

Mr. Khan is also staying away from his family: this year is the first time he will miss his daughter’s birthday. “My heart says to go home and see her from far, but the mind tells me otherwise. This constant struggle is very stressful.

“But we can’t turn our backs on the job. We just have to just keep at it, hoping that we come out alive on the other side of this fight.” ‘The risk is always there’

There is no respite for doctors and nurses even when they are not directly involved in the fight against coronavirus. People with other ailments are continuing to come to hospitals. And there has also been a surge in the number of people who are turning up at hospitals with coronavirus-like symptoms.

Dr Mohsin Bin Mushtaq, who works at the GMC Hospital in Indian-administered Kashmir, says coronavirus has “fundamentally changed our lives”. “We are seeing patients every day for other ailments. But the risk is always there that some of them could be infected,” he said.

And it worries him even more when he reads about doctors getting infected despite wearing PPE and dying. A number of doctors have died in India and dozens have tested positive. There is nothing we can do about it, he says, adding that “we just have to be mentally strong and do our jobs”.

Dr Mehnaz Bhat and Dr Sartaz Bhat also work in the same hospital, and they say that the “fear among patients is too much”. Dr Sartaz says people with a slight cold end up thinking they have coronavirus, and rush to the hospital. “So apart from treating them, we also have to deal with their fear,” Dr Sartaz adds.

He recently diagnosed Covid-19 symptoms in a patient and advised him to go for testing. But his family refused and took him away. The patient was brought back to the hospital after Dr Sartaz called the police. He says he had never imagined doing something like this in his medical career. “This is the new normal.”

The way patients are examined has also changed for some doctors. “We really have to try and limit close interactions with patients,” Dr Mehnaz Bhat says. “But it’s not what we have been trained for. So much has changed so quickly, it’s stressful,” she says.

And several attacks on doctors and nurses across the country have made them even more worried. She says it’s difficult to understand why anybody would attack doctors. “We are saving lives, risking our lives every day. We need love, not fear.” she adds.

And even worse:

E.R. doc on COVID-19 ‘front lines’ died by suicide                             To show how serious the stress is seen in this report by Cory Siemaszko reported that a New York City emergency room doctor who was on the “front lines” of the fight against the coronavirus has died by suicide, police said Monday. Dr. Lorna Breen, 49, who worked at New York-Presbyterian Allen Hospital, was in Virginia when she died on Sunday, said Tyler Hawn, a spokesman for the Charlottesville Police Department.

“The victim was taken to U.V.A. Hospital for treatment, but later succumbed to self-inflicted injuries,” Hawn said.

It was her father, Dr. Phillip Breen, who revealed the first details about his daughter’s tragic death. “She tried to do her job, and it killed her,” he told The New York Times. “She was truly in the trenches of the front line.”

He said his daughter seemed very detached of late and that she had described some of the horrors she had witnessed at the hospital while battling the virus. “Make sure she’s praised as a hero, because she was,” Phillip Breen said. “She’s a casualty just as much as anybody else who has died.”

The hospital confirmed Lorna Breen’s death in a statement released by chief spokesperson Lucky Tran, but gave few other details. “Words cannot convey the sense of loss we feel today,” the statement said. “Dr. Breen is a hero who brought the highest ideals of medicine to the challenging front lines of the emergency department. Our focus today is to provide support to her family, friends, and colleagues as they cope with this news during what is already an extraordinarily difficult time.”

NewYork-Presbyterian Allen Hospital has 200 beds, is in northern Manhattan and is one of the seven hospitals that make up NewYork-Presbyterian Hospital.

Infectious Disease Expert Makes Chilling Prediction for States Reopening Amid Pandemic                                                                 Reporter Lee Moran noted that infectious disease expert Michael Osterholm warned that the states starting to reopen amid the coronavirus pandemic “will pay a big price later on.”

Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told CNN’s Jake Tapper on Thursday that states like Georgia, Colorado and others that are easing social distancing restrictions were “putting gasoline on fire.”

“I think right now, this is one of the things we’ve learned, if we’re going to learn to live with this, then you just don’t walk in the face of it and spit in its eye, because it will hit you,” said Osterholm. “And I think that that’s a really important issue right now,” he continued. “When we have transmission increasing, when our hospitals are not able to take care of it and we don’t have enough testing to even know what’s going on, then that’s not the time to loosen up.”

Osterholm suggested it was “the worst example of how to start this discussion” about the “loosening” of society. “I wouldn’t do it,” he added. “I fear that these states will have to pay a big price later on because of what they’re doing.”

COVID-19: National Psychiatrist-Run Hotline Offers Docs Emotional PPE                                                                                              Emily Sohn reported that Mona Masood, DO, a Philadelphia-area psychiatrist and moderator of a Facebook forum called the COVID-19 Physicians Group, reviewed post after post about her colleagues’ fears, anxieties, and the crushing pressure to act like a hero, inspiration struck. Would it be possible, she wondered, to create a resource through which psychiatrists would be available to provide frontline physicians with some emotional personal protective equipment (PPE)?

She floated the idea in the Facebook forum, which has more than 30,000 members. The response was immediate. “All these psychiatrists just started contacting me, saying, ‘Please let me be a part of this. I want to volunteer,’ ” she told Medscape Medical News.

On March 30, Masood launched the Physician Support Line, a free mental health hotline exclusively for doctors. Within the first 3 weeks, the hotline logged more than 3000 minutes of call time. Some physicians have called repeatedly, and early feedback suggests the resource is meeting a vast need.

“Most of the cases have a lot of emotion from both sides. There are a lot of tears, a lot of relief,” said Masood.

“If Not Me, Then Who?”

Physicians have been facing mental health challenges long before the pandemic, and doctors have long struggled with stigma in seeking psychological help, says Katherine Gold, MD, a family medicine physician at the University of Michigan, Ann Arbor, who studies physician well-being, suicide, and mental health.

As a whole, physicians tend to be perfectionists and have high expectations of themselves. That combination can set them up for mental distress, Gold notes. Studies that have focused mainly on medical students and residents show that nearly 30% have experienced depression. Physicians are also at significant risk of dying by suicide.

Compounding the issue is the fact that physicians are also often reluctant to seek help, and institutional stigma is one persistent reason, Gold says. Many states require annual license renewal applications in which physicians are asked questions about mental health. Doctors fear they’ll lose their licenses if they seek psychological help, so they don’t pursue it.

A study conducted by Gold and colleagues that analyzed data from 2003 to 2008 showed that compared to the general public, physicians who died by suicide were less likely to have consulted mental health experts, less likely to have been diagnosed with mental health problems, and less likely to have antidepressants in their system at the time of death.

The COVID-19 pandemic may exacerbate these trends, suggests a recent study from China in which investigators surveyed 1257 healthcare workers in January and February.

Results revealed that a significant proportion of respondents had symptoms of depression, anxiety, insomnia, and distress. This was especially true among women, nurses, those in Wuhan, and frontline healthcare workers who were directly engaged in diagnosing, treating, or caring for patients with suspected or confirmed cases of COVID-19.

As Masood watched similar concerns accumulate on the COVID-19 Physicians Group Facebook forum, she decided to take action. She says her mentality was, “If not me, then who?”

Assisted by a team of experts, she created the hotline without any funding but with pro bono contributions of legal and ethical work, and she received a heavy discount from a company called Telzio, which developed the hotline app.

The hotline is open daily from 8:00 AM to midnight Eastern Time, and calls are free. Services are available only to physicians, in part because as a group, doctors tend to harbor guilt about asking for help that someone else might need more, Masood says.

When other types of healthcare workers call in, volunteers redirect them to hotlines set up for first responders and other healthcare providers.

So far, more than 600 psychiatrists have volunteered. They sign up for hour-long shifts, which they fit in between their own patients. Two or three psychiatrists are available each hour. Calls come directly through the app to their phones. There is no time limit on calls. If calls run long, psychiatrists either stay on past their shifts or pass the call to another volunteer.

Since its launch, the number of calls has steadily increased, Masood says. Callers include ICU doctors, anesthesiologists, surgeons, emergency department doctors, and some physicians in private practice who, Masood says, often express guilt for not being on the front lines.

Some physicians call in every week at a certain time as part of their self-care routine. Others call late at night after their families are in bed. If indicated, psychiatrists refer callers for follow-up care to a website that has compiled a list of psychiatrists across the United States who offer telehealth services.

There are no rules about what physicians can discuss when they call the hotline, and popular topics have evolved over time, says Masood. In the first week after the hotline’s launch, many callers were anxious about what the future held, and they saw other hospitals becoming overwhelmed. They worried about how they could prepare themselves and protect their families.

By the second week, when more doctors were in the thick of the pandemic and were working long hours, sometimes alone or covering shifts for infected colleagues, there were concerns about coworkers. Some were grieving the loss of patients and family members. The lack of personal protective equipment (PPE), says Masood, has been a common topic of conversation from the beginning.

Given the many unknowns about the virus, physicians have also grappled with the uncertainty around safety protocols for patients and for themselves.

On a deeper level, physicians have expressed a desire to run away, to stop going to work, or to quit medicine altogether. These escape fantasies are a normal part of the fight-or-flight response to stress, Masood says.

Doctors often feel they can’t share their fears, even with family members, in part because of societal pressures to act like heroes on the front lines of what has been framed as a war, she adds.

Heroes aren’t supposed to complain or show vulnerability, Masood says, and this can make it hard for physicians to get the support they need. Through the hotline, psychiatrists give doctors permission to feel what they are feeling, and that can help motivate them to go back to work.

“They don’t want to look like cowards, because that’s the opposite of a hero,” she said. “Saying it to another doctor feels much better because we get it, and we normalize that for them. It’s normal to feel that way.”

Each week, Masood conducts debriefing sessions with volunteers, who talk about conversations filled with raw emotion. When conversations wind down, most physicians express gratitude.

They tell volunteers that just knowing the hotline is there provides them with an emotional safety net. Masood says many physicians tell volunteers, “I know that if anything’s going wrong, I can just call and somebody will be there.” Volunteers, too, say they are benefiting from being involved.

“We are all really having this desperate need to be there for one another right now. We truly feel like no one gets it as much as we get one another,” said Masood.

Long-term Fallout

The need for psychiatric care is unlikely to end after the pandemic retreats, and Masood’s plan is to keep the hotline running as long as it’s needed. Like the rest of the world, physicians are in survival mode, but she expects a wave of grief to hit when the immediate danger ends. Some might blame themselves for patient deaths or question what they could have done differently. The long-term impact of trauma is definitely a concern, Gold says. Physicians in the ER and ICU are seeing many patients who decline quickly and die alone, and they witness young, previously healthy people succumb to the virus.

They’re seeing these kinds of cases over and over, and they’re often doing it in an environment where they don’t feel safe or supported while people in many places stage protests against the measures they feel are helping protect them.

Like veterans returning from war, they will need to reflect on what they’ve experienced after the adrenaline is gone and there is time to think.

“Even when things calm down, it will be great to have resources like this still functioning that can help folks think back through what they’ve been through and how to process that,” Gold said. “Things are going to remind them of experiences they had during COVID, and they can’t predict that right now. There will be a need for the support to go on.”

Masood is optimistic that the pandemic will bring the issue of physicians’ mental health out of the shadows.

“We have a really deep feeling of hope that that there’s going to be a lot more empathy for one another after this,” she said. “There’s going to be a willingness to not take mental health for granted. Doctors are people, too.”

We understand about those on the frontline of this pandemic. But do you all realize that many physicians and nurses are being furloughed during this pandemic due to elimination of elective surgery, many of which are necessary such as transplants and cancer treatments and surgery as well as limitation of their practice during this pandemic.

How do physicians pay their malpractice insurance and pay their staff and overhead and their huge education loans?

I fear that we may see a mass quitting/retirement of many nurses and physicians in our country and maybe world wide or many suffering from PTSD (Post Traumatic Stress Syndrome).

What then happens to our healthcare system? Will this pandemic force Congress to finally get serious regarding improving our healthcare system for All?

What It’s Like to Watch Your Business Fail? The New Labor Movement and Comicon!

I discussed previously regarding the stress and anxiety of self-isolation, state-wide lockdowns and quarantine, but what about the effect on business owners? Chris Thompson noted that his wife’s job has always been to keep people relaxed. The stress of keeping that dream alive is agonizing. Chris Thompson noted that the widespread crumbling of American small businesses in the year 2020 will ultimately be a second- or third-order concern, at best, as millions of people are infected by the novel coronavirus and some horrifying percentage succumb to Covid-19. It’s worth observing, though, that just as the ultimate tally of lives lost will be bloated by a slapdash governmental response that left many folks to balance for themselves the danger of multiple existential threats, so too will the eventual failure of hundreds of thousands of small businesses reflect the confusion, incompetence, and indifference of the people whose job it is to manage this crisis.

My wife has owned and operated a boutique day spa in the Virginia suburbs of Washington D.C. for going on 15 years now. A dozen practitioners tend to rosters of dedicated clients; a small handful of support and administrative staffers keep things organized. Because it’s a very small operation, my wife is both the main administrator and also a practitioner who sees clients. It’s a demanding job, and it eats up much more of her time than a full-time job in someone else’s spa would, but she’s very good at it and is fulfilled by the opportunity to execute her own vision of how a spa should operate.

Turns out when a novel virus leaps oceans and uses close human contact to navigate its way to the most vulnerable, businesses that make their money via direct physical contact between workers and customers are put in a uniquely difficult situation. The spa industry is loaded down with standards designed to limit the transmission of diseases between parties, but zero transmission is not possible, and this isn’t the common cold. Somewhere around 200 people come into the spa each week, and all 200 are in direct physical contact with a staff person; half or more are there to have another person’s hands and fingers directly applied to their face for an hour or longer, in services where steam is applied and hangs in the air. There is no such thing as social distancing inside a spa. Even with every safety measure applied as fastidiously as possible, two perfectly healthy seeming clients sharing a waiting room can trade illnesses in the time it takes to fill out a single-page intake form.

The spa industry is loaded down with standards designed to limit the transmission of diseases between parties, but zero transmission is not possible, and this isn’t the common cold.

The right thing to do, then, is to suspend operations at least until widespread testing has begun, if not until the spread of the virus is fully understood and the brunt of the pandemic has been absorbed. While no one knows who the hell has the virus and while hospitals are having their asses kicked by the surge of infections, operating a serene little coronavirus distribution center in a densely populated area would be a very shitty thing to do for the public good.

But closing the business, even for just a few weeks, presents some immediate challenges. Practitioners depend upon commissions from services in order to pay their bills. A cut of service income is set aside to pay administrative staff. Shuttering the business for a couple of months means coming up with tens of thousands of dollars to help keep these people afloat, or setting them adrift to fend for themselves. And there are other expenses applying considerable pressure to that primary concern: Lease payments are due on expensive machinery; professional insurance cannot be allowed to lapse; the landlord is expecting another rent payment, and another, and then another.

The Trump administration directed the Small Business Administration on March 12 to offer a special reduced interest rate on get-me-over “recovery” loans to businesses affected by the pandemic, money that at least in theory could provide a source of cash with which to pay staffers to stay home. But there’s a rub—or several. For absolutely no good reason, the disaster rate is contingent on a given state’s emergency posture. So, for example, if your business is in, say, Kansas, where prominent politicians have said coronavirus is not a threat because there is not a large Chinese population, you would not qualify for the disaster rate without a statewide disaster declaration. If you want to do the right thing for your staff and community and temporarily suspend the operations of your small business ahead of this declaration, any loans you seek to increase your cash on hand will not be protected from predatory rates.

As it happens, Virginia declared a state of emergency on March 12, which meant the “recovery loans” should’ve been available within hours of the executive directive to the SBA. But here we encounter the second and third rubs. First, it turns out no one at the SBA had been given much direction about what exact governmental declaration qualified businesses in a given state for the special rate, and so no one at the SBA and none of the SBA-linked banks could say for sure whether a Virginia small business qualified. Second, and most horrifying of all, the recovery loans were not available for businesses “with credit available elsewhere.” If the SBA determined that a business had opportunities to borrow money without its protections, it was happy to dropkick that business out into the wilderness.

It’s worth noting how backward and screwy it is that a once-in-a-lifetime pandemic would force otherwise perfectly successful small businesses to take on crippling debt and pay interest to lenders, in order to provide disaster pay to workers who, like their employers, did absolutely nothing wrong. If there’s going to be a thing called a Small Business Administration — hell, if there’s going to be a thing called a federal government — it ought to have better tools at its disposal than a Rolodex of carrion-circling lenders and a negotiated interest rate. In fact, it does! It’s just that the real help is being shifted to billion-dollar companies with tycoon CEOs, while small businesses are being fed to the sharks.

The next-best option for my wife’s efforts at keeping her staff on their feet involved emptying savings accounts used for reserving money for taxes and liabilities (think gift certificates, which accrue impressively but which are not payment for services rendered, cannot expire, and are refundable). A day spa, even a reasonably successful one, is a low-margin business: A savings account reserved for liabilities holds roughly $10,000; another savings account reserving estimated tax money holds another $4,500; one single payroll for half a month’s regular work runs $23,000 to $32,000. Emptying those accounts would mean dealing a grievous self-wound for very fleeting, dubious benefits. It would cover somewhere around half of a paycheck per staff person but would make it far more likely that the business would fold before the end of the current crisis, depriving these people of a job to which they would otherwise happily return.

So, this is all pointing at layoffs — a strategic termination so that her people could collect unemployment and the company could still be around to gather them back up again in a few months. But first, my wife had to see if she could lower her non-payroll expenses to as close to zero as possible if she was to have any chance of avoiding the devastating defeat of cutting loose a good and loyal and dedicated staff of excellent people, many of whom have families to support. This meant seeking forbearance from lenders, banks, and the landlord.

The only thing that seems to matter to anyone with any power is whether money continues to flow upward. It only ever flows upward; the only thing that trickles down is pressure.

The first two calls were to lenders, and they were not encouraging. The first lender said my wife could go through the usual payment deferral process, but that her interest rate would increase and penalties would accrue, and there would be an eventual balloon payment at the end of her loan period. The second lender had disconnected their telephone and was unreachable for four days. Both lenders ultimately settled on limited forbearance through April — payments could be missed, but hundreds of dollars in penalties would accrue per payment missed, and the sum of missed payments, plus penalties, would be added to payments beginning in May. Her interest rate would jump, per the original agreement, to reflect missed payments.

The word from the landlord was even more troubling. My wife pays $4,500 in monthly rent to a developer that manages an impressive spread of commercial real estate. Their representative announced in a bemused tone that they had not even considered whether they would need to offer any sort of relief or forbearance to their tenants. After having the situation explained to them, their best offer was one month of forbearance in exchange for extending the lease period by a full year, and they indicated they’d be offering this deal to their tenants on a case-by-case basis. Two days later, they sent a form email to their tenants announcing that the deal would, in fact, be two months of forbearance in exchange for two years added to existing leases.

What has been lacking in all this is firm direction from the federal government. It has been in their power all along to suspend collection of rent, mortgage, and debt payments, and to mandate two or three months of social distancing and a halt on all nonessential business. Hilariously, they’ve managed to suspend rent payments for airlines at airport terminals, once again directing relief at massively profitable, publicly-traded, billion-dollar businesses and ignoring everyone else. They’ve left it up to governors and mayors to determine how much traffic and business to permit; they’ve left it up to banks and landlords to determine how much relief is appropriate; they’ve left it up to business owners to figure out how to balance the threat to the public of staying open versus the threat to the business of shutting down; they’ve left it up to individuals to hammer out arrangements for keeping a roof overhead and food on the table. There are no right answers. The only thing that seems to matter to anyone with any power is whether money continues to flow upward. It only ever flows upward; the only thing that trickles down is pressure.

What is likely to finally kill my wife’s business, in a blast of dark cosmic humor, will be the administration’s favoring of the market over public health. While society was settled on indefinite self-isolation and a hiatus for all nonessential work — something the federal government never quite got around to championing but which was nonetheless taken for granted by all nonsociopaths — it was possible to make limited headway negotiating forbearance from banks and lenders and landlords, using phrases like “act of God” and “force majeure.” If and when the president arbitrarily declares the battle won after a few short weeks of half-assed social distancing — long before a framework for widespread testing has been established, to say nothing of any formal measures to quickly increase the stockpile of masks and ventilators — small businesses will be forced to ignore the urgent pleas of the scientific and medical communities and reopen for business or face down creditors and landlords without the backing of an official mandate. Small businesses will have to choose between operating as coronavirus distribution centers or sinking immediately under the weight of debt.

Here is where things stand for my wife and her business: Her rent has been deferred for one month, at the cost of another full year on her lease; her two loans have been deferred for two months each, but not without penalty. Insurance for her company and its practitioners has not been deferred. Bills will begin piling up in earnest, thousands and tens of thousands of dollars at a time, beginning [checks watch] uhh yesterday. An end to social distancing is months and possibly a year away; Virginia’s current stay-at-home order runs into June. There is no telling how soon it will be anything other than catastrophically reckless to reopen her doors and accept business, but the people upstream have drawn their line. The clock is ticking.

Most painfully, the staffers who could not survive without immediate income have agreed to have their employment terminated, so that they can collect unemployment and seek Medicaid. My wife, who is a good practitioner and a good business owner and has not done anything wrong to put her business at risk, is in an impossible, untenable position. Because she will have to start paying rent again in one month, and because she will have to start making loan payments by summertime, and because she has several very talented and qualified and hardworking staff people in the wind, there will be enormous pressure on her to turn the lights back on before the end of April. If she does, she and all the other small businesses forced into the same position will be active vectors for coronavirus, despite every possible effort. If she doesn’t, it is very likely she never will again.

America Is About to Witness the Biggest Labor Movement It’s Seen in Decades

It took 40 years and a pandemic to stir up a worker revolution that’s about to hit corporate America!

Steve LeVine remembered that in September 1945, a little-remembered frenzy erupted in the United States. Japan had surrendered, ending World War II, but American meat packers, steelworkers, telephone installers, telegraph operators, and auto assemblers had something different from partying in mind. In rolling actions, they went on strike. After years of patriotic silence on the home front, these workers, along with unhappy roughnecks, lumberjacks, railroad engineers, and elevator operators — some 6 million workers in all — shut down their industries and some entire cities. Mainly they were seeking higher pay — and they got it, averaging 18% increases.

The era of raucous labor is long past, and worker chutzpah along with it. That is, it was — until now. Desperately needed to staff the basic economy while the rest of us remain secluded from Covid-19, ordinarily little-noticed workers are wielding unusual leverage. Across the country, cashiers, truckers, nurses, burger flippers, stock replenishers, meat plant workers, and warehouse hands are suddenly seen as heroic, and they are successfully protesting. For the previous generation of labor, the goal post was the 40-hour week. New labor’s immediate aims are much more prosaic: a sensible face mask, a bottle of sanitizer, and some sick days.

The question is what happens next. Are we watching a startling but fleeting moment for newly muscular labor? Or, once the coronavirus is beaten, do companies face a future of vocal workers aiming to rebuild lost decades of wage increases and regained influence in boardrooms and the halls of power?

For now at least, some of the country’s most powerful CEOs are clearly nervous. Late last month, Apple, faced with reporters asking about a company decision to furlough hundreds of contract workers without pay, did a quick about-face. Those employees, Apple now said, would receive their hourly wages. A few weeks earlier, after Amazon warehouse workers demanded better benefits during the virus pandemic, that company also reversed course, offering paid sick days and unlimited unpaid time off.

The backdrop is a country at a standstill and uncertain over which businesses will survive the current economic shakeout, and in what form. With some notable exceptions, very few companies seem prepared to risk riling their employees, especially given broad popular support for workers at their grocery stores, nurses at their hospitals, and drivers who are keeping supply arteries open.

The past four decades have been perhaps labor’s weakest since the Industrial Age.

But if companies are responding to those who are protesting, they might also think ahead and preempt festering trouble down the road. “I like to believe people will say, ‘We treat these people as disposable, but they are pretty indispensable. Maybe we should do what we can to recognize their contribution,’” says David Autor, a labor economist at MIT and co-director of the school’s Work of the Future Task Force.

Until the 1980s, layoffs were barely a thing, writes Louis Uchitelle in The Disposable American: Layoffs and Their Consequences. Companies tended to avoid large-scale dismissals, because they violated a red line of publicly accepted practice and also could finger the company for blame. The United States was still in the age of company as community and societal patron, and even when workers went on strike, they were generally not replaced, because the optics would be bad.

But in 1981, President Ronald Reagan changed all that. Some 12,000 air traffic controllers went on strike, demanding higher pay and a shorter workweek. In a breathtaking decision, Reagan fired all but a few hundred of them. The Federal Labor Relations Authority decertified the controllers’ union entirely. The era of strong labor was over.

In the subsequent age of the no-excuses layoff, the number of major strikes has plunged. Starting in 1947, when the government began keeping such data, there were almost always anywhere from 200 to more than 400 big strikes every year. But in 1982, the year after the air traffic controllers debacle, the number for the first time fell below 100. In 2017, there were just seven. “There was damage to self-esteem every time there was a layoff. It took the militancy out of organized labor, and I don’t think it ever recovered,” Uchitelle says.

The past four decades have been perhaps labor’s weakest since the Industrial Age. For a half century, those working for hourly wages have won almost no real gains. The real average hourly wage in 2018 dollars adjusted for inflation was $22.65 in 2018, compared with $20.27 in 1964 — just an 11.7% gain, according to Pew Research. Real median hourly wages rose by only another 0.6% last year despite the sharp tightening of the job market and an increase in the minimum wage across the country, according to the Bureau of Labor Statistics.

The current revival of worker activism precedes Covid-19 in the unlikeliest of places. In 2018, West Virginia teachers, among the lowest paid in the nation and four years without a raise, went on strike for nine days in a demand for higher pay. That they won a 5% increase was one astonishing thing. But the walkout itself was stunning, specifically because of the state where it occurred — a former bedrock of ultramilitant coal miners who had repeatedly gone to actual war for better pay and safety but more recently were a bastion of worker passivity.

If teachers are an indicator of what is coming, Amazon, fast food restaurants, hospitals, and gig companies have a long, hot few years ahead.

Last year, the West Virginia teachers were on the picket lines again. This time, they stopped the state legislature from funding private schools in what they saw as an attempt to weaken their newly revived strength. Officials buckled after just a day. The strikes meanwhile spread to a dozen red and blue cities and states. Often wearing red shirts as the symbol of the strikes, the teachers were demanding more money — from 2000 to 2017, teachers’ real salaries actually shrunk by 1.6% nationally, according to the National Center for Health Statistics — as well as more supplies and help in the classroom. In Arizona, teachers won a 20% raise, and Los Angeles teachers won a 6% raise. That triggered more strikes through much of 2019, with Chicago teachers, for one, winning a 16% pay raise. Strikes seemed likely this year, too, in Detroit and Philadelphia, for starters.

If teachers are an indicator of what is coming, Amazon, fast food restaurants, hospitals, and gig companies have a long, hot few years ahead. On April 6 alone, the employees of a Los Angeles McDonald’s walked out when a co-worker was diagnosed positive for the coronavirus. For the second time in a month, workers at a Staten Island Amazon warehouse went on strike after 26 co-workers came down with the virus. And outside Chicago, employees of two plants walked out because management failed to immediately announce that co-workers had been diagnosed with Covid-19.

Across the country, workers are on the march over safety, pay, and sick days. The picture is jarring at a time when 16 million people are newly out of work. Companies and CEOs need to prepare for a new post-Covid-19 reality where workers will recognize their power — and use it.

 “Business models based on ridiculous labor rates plus arbitrage where you foist all your costs onto the employee are coming to an end.”

When the virus struck Hilton Hotels starting in January, its global occupancy plummeted to somewhere between 10% and 15%, and most of its 6,100 managed and franchised properties closed. Executives were convinced that the travel industry would eventually rebound, but from there they faced a conundrum: They did not want to lose a trained workforce, but they also knew they and their franchisees could not afford to keep their approximately 260,000 employees on the payroll. So, on March 24, the decision was announced to, in effect, loan them out.

Staff in Hilton’s human relations unit contacted counterparts at Amazon, Albertson’s, CVS, and Walgreens, says Nigel Glennie, vice president of corporate communications at Hilton. These retailers were experiencing Covid-19 boomlets and, combined, were in the market for hundreds of thousands of workers. Were they interested in some already trained workers, Hilton asked, who are expert specifically in catering to exceedingly particular customers? So an expedited hiring portal was set up, ultimately connecting Hilton’s workforce with 28 retailers that were suddenly responsible for almost the entire working economy.

The outcome was ideal for Hilton: It would not lay off but instead furlough its workers, thus allowing them to collect unemployment checks or work elsewhere. Once the crisis ended, they could return to Hilton. “We have a commercial interest in this decision. We know we have well-trained people who we want back,” Glennie says. “We wanted to make sure they were looked after. We want to do the right thing by our people.”

Jeff Lackey, vice president of talent acquisition for CVS Health, says his company was seeking 50,000 new employees at the time. Albertson’s says it was hiring 30,000. Neither know exactly how many of Hilton’s workforce are now working for their respective companies, but Lackey says the hiring process was being completed in as little as a single day. “I understand what it’s like to live paycheck to paycheck,” he says.

Less flattering attention has gone to companies that have violated an unwritten set of rules that have emerged for corporate behavior. Hospital management has been upbraided for suspending nurses who try to protect themselves by buying their own equipment and disciplining those who speak out. Former employees of Bird, the scooter company, described drawn-out hours of uninformed dread prior to an announced Zoom meeting, followed by a short announcement by someone they did not know. And Dig Inn, the fast-casual chain, sprung the news by text.

Sephora, too, has been faulted publicly by recently laid-off employees. At first, the retail beauty chain closed but promised to keep paying everyone for as long as the stores remained shuttered. Then, on March 31, it laid off part-time staff anyway. The decision caught a lot of Sephora employees by surprise. In tweets and online videos, some workers said they had been on calls with their managers that very day discussing the opposite — how they would go ahead in the new environment. Suddenly, though, employees received texts saying that in 15 minutes, they were to participate in a mandatory audio call.

When Lydia Cymone, a Sephora makeup artist in Alpharetta, Georgia, heard the call, she was right in the middle of videotaping a makeup tutorial and posted the tearful video. Brittney Coorpender, who did facial treatments at a Sephora store in San Jose, California, told me in an email exchange that she felt misled. “Women/men who forgot to mute themselves could be heard sobbing right before I ended the call,” Coorpender wrote. “They promised and promised us we were fine and gave zero indication we weren’t, until that call.”

In response to a request for comment, Sephora sent the March 31 statement it posted to its website. Dan Davenport, president of recruiter Randstad RiseSmart, says, “If you’re making a statement that you’re not going to be laying anyone off, you better be right about that.”

If corporate America does face a post-Covid-19 reckoning from workers, the gig economy seems like one of the top probable targets. Jim Chanos, president of Kynikos Associates, a hedge fund that shorts stocks, was made famous in the early 1990s for blowing the whistle on Enron. Today, Chanos is shorting Uber and Grubhub, among other gig companies. In an interview, he said he had already been shorting the two companies but has added to these bets since the virus struck.

What makes them weak, in Chanos’ view, is the optics of their business model, which is based on paying an arguably miserly cut of revenue to their workers and a refusal to make them actual employees. While allowing these companies to avoid a lot of the conventional costs of doing business, the strategy has also always left the gig companies at risk of their workers and the public turning against them. Chanos predicts that’s exactly what’s going to happen in the post-coronavirus era. The public is “going to look askance” at companies that have relied on taxpayers to fully cover their workers’ jobless benefits, since they do not pay into unemployment insurance funds. “Business models based on ridiculous labor rates plus arbitrage where you foist all your costs onto the employee are coming to an end,” he says.

Until the virus, the notion of unionized tech workers was just that — a notion that seemed to violate the very spirit of Silicon Valley. It’s still hard to imagine unionized software engineers. But it’s equally difficult to say where the boundaries of the possible lie.

White-collar tech activism goes back two years, when Google workers around the world walked off the job in a protest against sexual harassment. More workers are griping now. Last month, some Instacart workers walked off the job in a bid for a higher share of the revenue and better safety; in some cities, they are starting to join unions like the United Food and Commercial Workers local in Chicago. In San Francisco, Uber and Lyft drivers protested last month in front of Uber headquarters.

The tremors, though, will be felt not just in the gig economy but also tech at large: In February, employees at Kickstarter, the crowdfunding platform, voted to unionize, becoming the first white-collar tech company staff to do so, according to a database at Cal Berkeley. The Teamsters are making an open run at organizing other Silicon Valley workers. If you put Covid-19 out of your mind, the move is mind-blowing. Until the virus, the notion of unionized tech workers was just that — a notion that seemed to violate the very spirit of Silicon Valley. It’s still hard to imagine unionized software engineers. But it’s equally difficult to say where the boundaries of the possible lie.

The biggest fish of all in terms of tech unionization is Amazon. The e-commerce giant is beset with worker complaints just as it has begun to transcend its barbarian image, repositioning itself as a public good at the very center of the U.S. economy. An issue that has drawn particular heat is its decision on March 30 to fire Chris Smalls, a worker at an Amazon warehouse on Staten Island who loudly complained about health safety. On April 8, a group of Democratic U.S. senators wrote a letter to Amazon CEO Jeff Bezos raising skeptical questions about Smalls’ dismissal and Covid-19 safety generally at company warehouses. Amazon has seemed generally conflicted: On one hand, it has responded with added pay and off-days for sick employees. But Amazon has also repeatedly fired workers it has deemed disloyal — three employees just over the past week who had criticized health conditions. Whole Foods, too, owned by Amazon and run by John Mackey, the devotee of “conscious capitalism,” faced a sick-out in March and look, now a number of Amazon facilities are seeing sick outs. In a statement, an Amazon spokesperson said the points raised in the senators’ letter were unfounded and that Smalls was dismissed for violations of social distancing guidelines. “Nothing is more important than the safety of our teams,” the spokesperson said.

Robert Shiller, the Nobel Prize–winning economist at Yale, compares labor’s newfound position to its stature in the Great Depression, when workers also suddenly were conferred with vast public sympathy.

While complaints and denunciation of Amazon abound, no one has gone so far as to try an old-style shutdown of any of the company’s operations — the kind of display of strength that typified unions in their heyday. For that matter, no rabble-rousing worker is known to have recently banged on the desk of a major company executive — or a leading politician — and demanded the production of a plant be kept open and workers on the job. Even if one did, would the public go along? Would large numbers of people stop shopping at Amazon? If they did, Amazon would have to concede quickly, just as railroad workers shut down transportation across the country in labor’s peak. “If you could really shut down a warehouse, that would really shock Amazon and get them to address the worker concerns,” says Steven Greenhouse, author of Beaten Down, Worked Up, a history of American labor.

Robert Shiller, the Nobel Prize–winning economist at Yale, compares labor’s newfound position to its stature in the Great Depression, when workers also suddenly were conferred with vast public sympathy. “The narrative was that it wasn’t their fault. There was something in the system,” Shiller told me. “This is another case where obviously it’s not their fault. And there is heroism in how they are delivering to us through this.”

In a way, labor’s resurgence is not all that surprising. The age of Trump and Brexit is, at its crux, an uprising against globalization, the movement that, after Reagan and his contemporaneous British counterpart, Margaret Thatcher, diminished labor and championed worldly capitalism at whatever the local cost. If we are spurning globalization, it stands to reason that the local comes back into focus. And what is more local than the grocery bagger, the postman, the nurse?

Where workers have advantage today has been in keeping their demands modest, drawing the public to their side, and making it very difficult for management to refuse. Worker efforts could be blunted by high unemployment, at least until jobs return. But their pluck, beaten out of them by the years of layoffs, has returned with Covid-19.

A class war? A global power shift? A world isolated? How experts see the future after coronavirus.

Joel Shannon noted that what will “normal” be like after coronavirus? Experts imagine a different world.

The coming weeks hold plenty of uncertainty as the world reels from the coronavirus pandemic, but some experts are already thinking about how the current crisis will impact society for years to come.

A report from Deloitte and Salesforce released this month presents four scenarios for the next three to five years — and they all tell a story of a world radically changed by the virus with the intent of helping leaders prepare for a variety of possible futures. “Even their best-case scenario looks pretty bad,” trends expert and keynote speaker Daniel Levine told USA TODAY.

Rather than making specific predictions, the scenarios in “The world remade by COVID-19” report focus on what we don’t know at this time, Andrew Blau — managing director of Deloitte Consulting and a leader on the project — told USA TODAY.

When will life return to normal? Expert says US testing is too far behind to know, expects second wave of cases. The end result: An intentionally fuzzy picture of several possible futures, varying based on how several unknowns — such as the duration of the pandemic — unfold. Those possible futures highlight trends that may soon define our times.

On one end of the spectrum: A short-lived pandemic that will batter small and medium-sized businesses. It leaves consumers — grateful to once again gather with friends, loved ones and coworkers in person — reevaluating some of their pre-pandemic habits. On the other end: A prolonged, nearly impossible to contain virus that leaves the world isolated, distrustful and suffering.

Levine, who was not involved with the project, said the report approached the difficult task of looking years into the future the right way. While none of the scenarios described in the report are likely to pan out as authors imagine them today, Levine said the future will likely hold a mix of them. 

Here’s the authors’ four scenarios:

The passing storm

In this possible future, our fight against the virus goes better than expected — but still at great economic cost, especially to the middle class and small businesses.

The pandemic “leaves its mark on society, but doesn’t change everything,” Blau said. 

Governments’ plans to contain the virus generally work and citizens comply with the measures. The success leads to a greater trust in our institutions, but class tensions simmer as the lower and middle classes bear the brunt of the economic damage. 

What might life be like in this future? In many ways, daily life would remain relatively stable, Blau said. Life under lockdown will remind many people about the value of community and companionship. Weeks of increased teleworking and online retail will lead many people to alter some of their behaviors. 

Sunrise in the east

Authors note the possibility that China and other East Asian counties will be able to manage the virus more effectively, through what western nations may see as heavy-handed tactics. Aggressively enforced lockdowns and surveillance technology have shown promise in multiple East Asian countries’ fight against the virus. If western countries’ uneven response proves less effective, global power could shift to China and its neighbors, authors speculated.

What might life be like in this future? The political impacts of this are hard to pin down for Blau, although he suspects eastern Asian countries would be looked to as a positive example in how western governments are run. Clearer to him: Our relationship with technology could change. For years, many people have held deep privacy concerns and a suspicion of artificial intelligence. If technology proves invaluable in our fight against the virus, those perceptions could evolve.

Good company

This scenario imagines a world where many factors — such as the severity of the disease and the economic impacts — are not as bad as they could be, but only because corporations stepped up when governments were ineffective.

It’s an expansion of a trend seen to some extent in the today — public-private partnerships where big corporations step in when governments can’t handle the crisis alone. There are threads of this in the daily news of today: Tech companies fixing broken ventilators for the government; Apple and Google developing apps to help fight the pandemic.

What might life be like in this future? Corporations would play an even bigger role in our lives than they currently do — and Blau suspects we would come to embrace that, since those companies helped us through the crisis. The report says this future could lead to an era of greater corporate responsibility and trust.

Lone wolves

This is the future “no one wants to happen,” Blau said. This scenario could happen if the virus proves impossible to contain and spreads in long-lasting waves around the globe. “Mounting deaths, social unrest, and economic freefall become prominent,” the report says. 

As a result, nations turn inward and limit contact with the outside world in the interest of national security. It’s a future where even allies feel like they cannot trust each other.

What might life be like in this future? Different nations will feel the impacts in different ways, but Blau imagines we’d live in a less connected, less trusting, less prosperous world, focused on survival. It’s a “dark scenario” where technology is used for surveillance and control, nations limit trade with each other and paranoia is common among citizens.

Will any of these scenarios actually happen?

The good news: The future isn’t written yet, and we have a say in how it plays out.

Report authors listed how citizens of nations responded to the crisis as one of their top unknowns. Nations that work together and “think big and act fast” will fare better, they predicted.

The scenarios in the report are meant to confront you with a possible reality that might surprise or unsettle you — and that’s part of the point, Blau said. The goal is to get readers thinking and mentally preparing for a wide variety of possible futures, even ones that don’t seem intuitive.

Instead of believing specific predictions for the future, he suggested embracing the uncertainty we are all living at this moment.

“We’re all imagining the future,” Blau said. “None of us actually know.” 

Coronavirus Forces Organizers to Cancel San Diego Comic-Con

Brakkton Booker reported that the continued spread of the coronavirus claimed yet another big event on the 2020 entertainment calendar this Friday, when the San Diego Comic-Con announced the annual entertainment and comic book convention would be postponed until 2021.

In a statement on its website, organizers said it is “with deep regret that there will be no Comic-Con in 2020,” marking the first time in the event’s 50-year history it would not be held.

“Extraordinary times require extraordinary measures and while we are saddened to take this action, we know it is the right decision,” said Comic-Con spokesperson David Glanzer. “We eagerly look forward to the time when we can all meet again and share in the community we all love and enjoy.”

The event, which was expected to draw more than 100,000 people, was scheduled to be held July 23-26. It will now take place almost a year to the day later, kicking off July 22-25, 2021.

Comic-Con — which launched as a small comic-book themed event — is now a powerhouse summer festival that attracts major figures from movies and television. It’s one of the biggest fan events of the year; last year more than 135,000 people attended, and not just for comics, but for interactive experiences, signings and big announcements about the latest Marvel movies.

SDCC officials said fans who bought passes for Comic-Con 2020 can either request a refund or transfer their badges to next year. The same offer is being made to the event’s exhibitors.

Organizers also announced that a previously postponed event, Anaheim WonderCon — originally set for April 10-12 — will also be pushed to 2021. It will be held at California’s Anaheim Convention Center from March 26-28.

The spread of the coronavirus has decimated the festival and sporting calendar, with many states implementing broad social distancing guidelines and stay at home orders that have shuttered all but essential businesses from operating.

In March, California governor Gavin Newsom issued a stay at home order, and banned gatherings of more than 250 people.

What will happen next as more and more states consider “getting back to “normal” and as more and more groups push back with non-social gathering demonstrations. Don’t be idiots and follow science and our public healthcare teams!

The questions are when will this end, which prediction model do we believe and what will the new normal be?

In isolation, worries and stress are magnified During the Coronavirus Pandemic. COVID-19 could lead to an epidemic of clinical depression!

Jonathan Kanter wrote in the Conversation that Isolation, social distancing and extreme changes in daily life are hard now, but the United States also needs to be prepared for what may be an epidemic of clinical depression because of COVID-19.

We are clinical psychological scientists at the University of Washington’s Center for the Science of Social Connection. We study human relationships, how to improve them, and how to help people with clinical depression, emphasizing evidence-based approaches for those who lack resources.

We do not wish to be the bearers of bad news. But this crisis, and our response to it, will have psychological consequences. Individuals, families and communities need to do what they can to prepare for a depression epidemic. Policymakers need to consider – and fund – a large-scale response to this coming crisis.

A perfect storm of depression risks

Most of us know the emotional components of depression: sadness, irritability, emptiness and exhaustion. Given certain conditions, these universal experiences take over the body and transform it, sapping motivation and disrupting sleep, appetite and attention. Depression lays waste to our capacity to problem-solve, set and achieve goals and function effectively.

The general public understands depression as a brain disease. Our genes do influence how easily we may fall into clinical depression, but depression is also, for most of us, substantially influenced by environmental stress. The unique environmental stressors of the COVID-19 crisis suggest that an unusually large proportion of the population may develop depression. This pain is likely to be distributed inequitably.

Stress and loss

Exacerbating the widespread stress of this crisis, many of us are suffering significant personal losses and grief reactions, which are robust predictors of depression. The ongoing and unpredictable course of these stressors adds an additional layer of risk.

As this crisis unfolds, death tolls will rise. For some, especially those on the front lines, acute experiences of grief, trauma and exhaustion will compound the stress and place them at even greater risk.

Interpersonal isolation

Prolonged social isolation – our primary strategy to reduce the spread of the virus – adds another layer of risk. Our bodies are not designed to handle social deprivation for long. Past studies suggest that people forced to “shelter in place” will experience more depression. Those living alone and lacking social opportunities are at risk. Loneliness breeds depression.

Families, who must navigate unusual amounts of time together in confined spaces, may experience more conflict, also increasing risk. China experienced an increase in divorce following their COVID-19 quarantine. Divorce predicts depression, especially for women, largely due to increased economic hardship over time.

Financial difficulties

The biggest stressor for many is financial. Unemployment and economic losses will be severe. Research on past recessions suggests that rising unemployment and financial insecurity lead to increased rates of depression and suicide. debt and financial deprivation during recessions are at significant risk for depression due to increased stress and difficult life circumstances. Minority-owned businesses may be at particular risk for buckling under the strain.

Recovery will be harder

Home foreclosures during the 2008 recession produced a 62% increased risk of depression among those foreclosed.

The mental health burden of economic recession will be distributed inequitably. When the stock market crashed in 2008, the rich experienced large wealth losses but not increased rates of depression. In contrast, those who experience unemployment,

While the COVID-19 crisis increases risk for depression, depression will make recovery from the crisis harder across a spectrum of needs.

Given depression’s impact on motivation and problem-solving, when our economy recovers, those who are depressed will have a harder time engaging in new goal pursuits and finding work. When the period of mandated social isolation ends, those who are depressed will have a harder time re-engaging in meaningful social activity and exercise.

When the threat of coronavirus infection recedes, those who are depressed will face increased immunological dysfunction, making it more likely they will suffer other infections. Depression amplifies symptoms of chronic illness. The inequitable distribution of the burden of the crisis will exacerbate existing racial health disparities, including disparities in access to depression treatment.

What to do?

Self-help suggestions are readily available. A good list, more evidence-based than most, is here. It is our experience, however, that such self-help encouragements for depression are not enough, and at times even insulting, for those who are truly struggling.

We need higher-level shifts in policy and how we approach the problem. Economic relief measures from the federal government are crucial responses both to economic recession and psychological depression. We call for a public health campaign to increase awareness of depression and treatment options, and for improvements in mental health sick-leave policies and insurance reimbursement to minimize barriers to treatment access.

How we talk about depression must change. The distress we feel is a normal human response to a severe crisis. Acknowledging and accepting these feelings prevents distress from turning into disorder. Describing depression solely as a brain disease increases helplessness and substance use among those who are depressed and decreases help-seeking. Emphasizing the causal role of our environmental context, in contrast, matches how depressed individuals across different ethnicities view the causes of their suffering, decreases stigma and increases help-seeking.

Finally, we recommend specific treatment options be prioritized. As we have discussed elsewhere, easy-to-train, cross-culturally applicable and effective treatment options exist. We wish for an army of practitioners to be trained and embedded in community and treatment centers across the country, and this army should represent the great diversity of our country.

Some specific suggestions to help us all:

Protect Your Family’s Mental Health During the COVID-19 Pandemic. 

Begin the Day with Gratitude

Before your feet hit the floor in the morning, think of something that you’re grateful for. Making this a focus for yourself, and teaching your kids to do the same, can have a significant impact on your emotional health. The heaviness of our current situation can quickly weigh us down, and if we begin our day with doom and gloom, then we have set the negative feeling pendulum into full swing.

A study published in the journal Psychotherapy Research found that writing a gratitude letter can improve a person’s outlook and emotional well-being. It even seems to change brain activity in a positive way, based on MRI scans of study participants.

Get into a Routine and Make a Daily Schedule

Depression and anxiety can keep you from feeling in control of your life. One way to counteract that feeling is by making a regular schedule and sticking with it. When you organize and structure your life, you know what to expect. Make sure you have a family routine.

Remember, kids are used to routine and structure in schools. Many thrive on having consistency in their lives, which consequently helps them feel in control, something kids need now more than ever.

Not only will having a plan can help you stay centered, it will keep you focused on the tasks at hand. A study published in the Annual Review of Psychology on psychological habits showed people rely on their routines and habits when they are stressed. That helps them get through difficult times, suggesting that establishing healthy routines could help with physical, emotional and mental health during difficult times like these.

So, go ahead and make a schedule. The first item on the list should be to make your bed. According to a survey by OnePoll and Sleepopolis, which provides mattress reviews, people who make their beds regularly tend to report feeling happier and more productive. Plus, if making your bed is on your to-do list, you can accomplish your first goal of the day.

How to Cope with Coronavirus Anxiety. 

Get a Good Night’s Sleep

According to the National Sleep Foundation, adults need between seven and nine hours of sleep each night. And research shows the amount and quality of sleep we get has a significant impact on mental health. The amount of sleep kids need varies considerably by their age. That ranges from newborns snoozing away most of the day (14 to 17 hours recommended), to preschoolers splitting time awake and asleep (11 to 13 hours in la la land recommended), to teens who are advised to get eight to 10 hours of sleep daily, though they rarely do.

Researchers have discovered that those suffering from mental health conditions, such as anxiety and depression, are at an increased risk of insomnia. And not getting adequate rest can raise one’s risk for mental health problems.

So, during times of high stress, sleep is of utmost importance. In addition to following a routine, another way that you can ensure a healthy night’s rest for you and your kids is by making sure the whole family is active during the day.

Go Outside

Research from Sweden suggests that being outside is associated with a lower risk of developing psychiatric disorders. In a separate study published in the International Journal of Environmental Health Research, researchers showed that spending about 20 minutes in the park can improve your overall well-being.

Even if you can’t get to a park, just getting some fresh air – while keeping 6 feet from others outside your household – can do you a world of good.

Eat Healthy

During this stressful time, it’s important to watch what you eat. That’s because what you put into your body will affect how you think and feel. Research has long documented the positive impact nutrition has on mood and that eating well is associated with lower levels of anxiety and stress.

Research has demonstrated the benefits of eating unprocessed food and having a diet that’s high in vegetables, fruits, unprocessed grains, with fish and only modest amounts of lean meats and dairy. Studies suggest that those who eat this way have depression rates 25% to 35% lower than those who consume a traditional Western diet characterized by processed foods, lots of red meat and high intake of unhealthy fats and carbs. The saying “you are what you eat” applies as much to mental health as it does to your physical health.

In a time of uncertainty, you need to take care of your mental health. Sure, you may be more confined than you usually are, but you don’t have to let anxiety and depression consume you. Make your mental health a priority by following the measures outlined above.

Also, if you need professional help, please reach out, as there are trained professionals who would like to assist you. Don’t forget, with COVID-19, you are not alone in how you are feeling. More importantly, remember this, too, shall pass.

Depression costs the U.S. economy US$210 billion yearly. That is under normal conditions. An epidemic of depression requires a multi-faceted, multi-level response.

Are We Only Going to See More Substance Abuse and Bad Behavior Including Gambling?

I was amazed that when our Governor of the great state of Maryland shut done businesses yesterday that the liquor stores were exempt, but not my medical offices. I also noticed that the substance abuse/methadone clinic next store to my office was still open for business and as usual, very busy. I continued to wonder when my oldest daughter asked how the pandemic will affect individuals suffering from substance use problems, particularly now that many of these individuals are in forced isolation.

Yale University professor Adrian Bonenberger noted that the coronavirus quarantine means different things to different people: A necessary inconvenience. A fusion of work and home life. A leap into social media, or virtual meetings once held face-to-face. For some, it’s possible to see a silver lining: more time with one’s family, and a change to the regular routine. But for people who suffer from substance use disorder, gambling addiction, or problematic video gaming—otherwise known as internet gaming disorder—the quarantine is fraught with danger.

“People will likely be practicing social distancing per the government’s recommendation,” said Marc Potenza, Ph.D., MD, HS, professor of psychiatry, who directs Yale’s Center of Excellence in Gambling Research, the Women and Addictive Disorders Core at Women’s Health Research at Yale, and the Yale Research Program on Impulsivity. “Oftentimes stress is linked to addictive behaviors, and there can be little question that the social distancing around coronavirus or COVID-19 has been a stressful interruption of routine for many.”

For people in treatment for substance use disorder, COVID-19 could lead to the type of stress and isolation most likely to result in risky behavior.

“Everyone is trying to protect the vulnerable from COVID-19, and the only way to make that happen is social distancing,” said Ellen Edens, MD, MPH, associate professor of psychiatry. “But social distancing can also be especially harmful for people with mental conditions or substance use disorder.”

According to Edens, there is a related concern: those who depend on medications to treat a substance use disorder may fall through the cracks. Like those with an opioid use disorder who take methadone or buprenorphine, both of which block cravings, treat opioid withdrawal and prevent opioid overdose; or those with a prescription for disulfiram, a medication that causes people to become sick if they drink alcohol and is most effective when taken under direct observation. Disulfiram is unavailable nationwide, according to Edens, though the intensively monitored in-person treatment often required for best outcomes, particularly early in treatment, is also unlikely in the current context.

Edens also notes that the most vulnerable moment for someone with substance use disorder is at the beginning of treatment, when they are deliberately and intensely plugged into group therapies and peer support groups like those popularized by Alcoholics Anonymous or AA. “With social distancing, one of the key components of addiction treatment—the reforging of family, social, or professional connections that may have been severed, exemplified by ‘network therapy’ or a ‘community reinforcement approach’—is lost,” she said. “The psychiatric community is doing what it can to make up for the sudden disruption of tested and effective in-person programs with things like old fashioned telephone calls. But between the technology gap with older patients and specific challenges faced by patients for whom disconnection is essentially the greatest danger, it’s difficult. Many AA groups that have closed their doors to comply with the injunction against gatherings of numerous people, and while it’s certainly prudent, it also leaves many attendees adrift.”

Another possible fallout from COVID-19 stems from the shutdown of casinos across the United States, coupled with the postponement or cancellation of professional sporting events including the NBA, NHL, MLS, and MLB (suspended), the Masters (postponed), the Boston Marathon (postponed), and the NCAA men’s and women’s basketball tournaments (canceled). Although gambling and sports gambling have been online and lightly regulated for years, there has never been an absolute vacuum of physical gambling locations. It’s likely that in the absence of a physical space in which to gamble, and without many of the typical outlets for gambling in place, some people with gambling addition will make their way to the internet.

The rise of e-sports is one possible place where online gambling and problematic video gaming could converge. A growing field with audiences for a single event in the millions, and over $1 billion in revenue as of 2019, e-sports, in which people play video games online competitively, requires no crowds, and can be accessed by anyone with a smartphone or laptop.

“A quarantine, particularly at home, may lead to bingeing on video games, alcohol, or drugs given the significant change to routine life. It could also lead to a relapse for those who had been doing well previously. Second, those who may have been considering coming to treatment now may suddenly be hesitant given possible exposure to the virus in a hospital or treatment setting and have decided to delay getting help,” said Brian Fuehrlein, MD, Ph.D., FW ’13, associate professor of psychiatry and director, Psychiatric Emergency Room, VA Connecticut Health Care System. Fuehrlein was careful to echo his colleagues in underlining the necessity of home quarantine and the importance of following it, and was unequivocal about the dangers posed to vulnerable populations like those who will be significantly economically impacted by social distancing.

There has already been an observable change in normal behavior at the VA, according to Fuehrlein—and the opposite of what one might expect, which is more cases. Fewer patients have been coming in for any reason, which does not bode well for long-term mental wellness. “Currently, we are seeing an uptick in those who were considering treatment for substance use disorder but have now decided to stay home instead (and thus are likely continuing to drink or use). Our census in the psych ER has actually been running lower than average,” said Fuehrlein.

In the long run, this will almost certainly turn into a large problem, or even a secondary epidemic for people already suffering from the various diseases of addiction. “I think in the long run we will see a sharp increase in depression, anxiety, and addictions of all types as a direct consequence of the current pandemic,” said Fuehrlein. “This may be due to the death of a loved one, a financial crisis, the loss of a job or housing, or some related tragedy. At the moment those consequences have yet to play out.”

Potenza echoes Fuehrlein and Edens’ concerns for people suffering from substance use or gambling problems at home, away from the usual forms of treatment. He brought up another population that will be at risk—in addition to the tens of millions of American workers (over 18% of the work force, according to an article published March 17, 2020 in the Los Angeles Times), millions of school children who have been cut loose with weeks of unstructured time. Without supervision, these groups will be especially vulnerable to what the DSM-5 defines as internet gaming disorder, on top of the better-known associated substance use disorder.

Said Potenza, “Oftentimes, it appears that people who are experiencing negative mood states or life stressors may turn to gambling, gaming, or use various substances including alcohol and drugs. COVID-19 is almost certainly creating more stress, and while health professionals and the government are mobilizing to address the threats posed by the virus, some of the recommended actions like social distancing and staying at home seem likely to lead to more gambling, more gaming, and more substance use.”

Almost 20 million American adults suffered from substance use disorder in 2017, while nearly 10 million American adults struggled with a gambling problem as of 2016. Both groups, in which there is almost certainly some overlap, rely on a therapeutic model that relies on person-to-person meetings. Potenza, Edens, and Fuehrlein all agreed that patients suffering from mental illness and substance use disorder could receive effective treatment via phone or computer, and that technology was racing to keep up with the changing demands of quarantine and the patient population. Any mechanism by which a connection could be forged, according to them, was preferable to isolation during the search for an effective vaccine and perhaps a cure.

“Ultimately,” said Potenza, “we don’t know what will happen. And that’s a source of stress for most if not all of us.”

It’s stockpiling, but not as you know it. Why coronavirus is making people hoard illegal drugs

Ms. Emma Reynolds of London (CNN) wrote that it’s not just toilet roll that people are panic buying. Some illegal drug users are reportedly stockpiling their substance of choice as restrictions intended to stop the spread of coronavirus disrupt the international supply chain.

And the consequences could be devastating, with experts concerned that people will adopt riskier habits, substitute unfamiliar drugs or enter withdrawal, which can be dangerous if unmanaged. Since heavy users often have other health problems, this could mean increased strain on services that are already near breaking point.

UK drug policy and crime experts told CNN they were worried over a growing number of reports of shortages and escalating prices for drugs, as international borders close and supply lines are cut off.

“There are reports coming through of people stockpiling their favorite drug or their drug of choice, and of course, that just creates a shortage, which has inevitably led to price increases,” Ian Hamilton, senior lecturer in addiction and mental health at the University of York, told CNN. He said he expected to see heroin “disappearing very, very quickly” in the UK.

Steve Rolles, senior policy analyst at the Transform Drug Policy Foundation, told CNN there was “anecdotal evidence of price rises… and that doesn’t seem surprising.”

“It does seem likely that the supply of drugs that these people are using, in particular heroin, is going to be restricted … it’s going to be more challenging to move drugs around.

“As weeks stretch into months, I think we’re likely to see a drought, a heroin drought.”

Alex Stevens, criminal justice professor at the University of Kent, told CNN that in areas including Birmingham and Bristol, users of heroin and synthetic cannabinoids “are reporting that they’re getting less in a £10 ($12) bag than they would have done four or five weeks ago.”

But this is an industry that operates on supply and demand. The dark web and sites including Craigslist are still active, with many users buying drugs through the mail at a time when police are not focused on monitoring post, according to several experts. “If the heroin isn’t available, they will probably find another route, whether it’s alcohol or inhalants, or benzodiazepines or something else,” said Rolles.

Rolles has even heard reports of dealers dressing in nurse’s uniforms and supermarket uniforms to make deliveries unnoticed.

What happens during a drought?

When the UK last experienced a heroin drought in 2010-11, the drug’s purity at “local dealer level” fell to 18%, according to the National Crime Agency. Street prices reportedly increased, and there was a reduction in the number of deaths involving heroin and a simultaneous (but smaller) increase in deaths involving methadone.

That may sound positive, but the experts say the effects could be different this time. Users may move from less dangerous drug-taking methods to injecting. They may use lethal combinations of drugs. They may use too much of their stockpile. And they may be more likely to overdose alone because of social distancing.

Women are using code words at pharmacies to escape domestic violence during lockdown

One vital difference between 2010 and 2020 that is causing anxiety among the experts is the proliferation of fentanyl, a synthetic opioid that is up to 50 times stronger than heroin and can therefore be transported in much smaller quantities. The drug has not yet become widespread in countries including Britain, but is wreaking havoc in the United States.

Fentanyl is the drug most often involved in overdoses in the US, according to the National Center for Health Statistics. The rate of overdoses involving the opioid skyrocketed by about 113% each year from 2013 through 2016. If you’re used to heroin and you take fentanyl, “the risk of overdose is extreme,” said Hamilton.

The drug is often manufactured in China, but little is moving out of the original coronavirus epicenter. It is also manufactured in Mexico and possibly Eastern Europe.

With many drug users dealing with mental health issues such as depression and anxiety, coronavirus isolation presents an unprecedented challenge.

“People who have an active disorder, addiction disorder, they’re going to look for ways to get a drug,” Cynthia Moreno Tuohy, executive director at NAADAC in the US (National Association for Alcoholism and Drug Abuse Counselors), told CNN.

Asking for help

The suicide rate in the United States has seen sharp increases in recent years. Studies have shown that the risk of suicide declines sharply when people call the national suicide hotline: 1-800-273-TALK.

There is also a crisis text line. For crisis support in Spanish, call 1-888-628-9454.

The lines are staffed by a mix of paid professionals and unpaid volunteers trained in crisis and suicide intervention. The confidential environment, the 24-hour accessibility, a caller’s ability to hang up at any time and the person-centered care have helped its success, advocates say.

The International Association for Suicide Prevention and Befrienders Worldwide also provide contact information for crisis centers around the world.

Tuohy expects more “poly-use” of readily available marijuana and alcohol, which is already seeing increased consumption worldwide.

It takes longer to build up data on illegal drug consumption, but analysts are watching closely.

Federal confidentiality laws in the US have been relaxed to allow people to access counseling and peer support faster. NAADAC is offering telehealth training, and resources to help clients find services available in their state.

“Whenever there’s a natural disaster, we know that relapse goes up, because of anxiety, the fear of the unknown,” said Tuohy. “Now we have an ongoing, natural disaster, if you will.

“The longer a crisis goes on, the less hope that people see … it doesn’t feel like there’s going to be a light at the end of the tunnel.

“Long term, we’re likely to see suicide go up as a result of depression. So I know that the suicide centers are gearing up and the suicide hotlines already are taking calls.”

A vulnerable population

Any disruption to the illicit drug supply will have the biggest effect on the most vulnerable populations. Heavy drug users are more likely to live with multiple people, have respiratory or other health issues or be homeless — and are therefore more at risk of contracting Covid-19.

“They are in a double tier of vulnerability in that they’re more likely to get the virus and they’re more likely to be affected negatively by it,” said Rolles. “So there’s a big responsibility, I think, on society to look after and protect those populations.”

If that doesn’t happen, hospitals and treatment facilities will face a huge additional strain, he warns.

Governments are conscious of the risks. The UK government has asked local authorities to house all homeless people. Low risk and pregnant prisoners are being released across the world.

Facilities in the US, UK and Canada are allowing stable users to pick up supplies of addiction treatment medications like methadone and buprenorphine once a week or every two weeks instead of daily, but this also presents risks.

Mat Southwell, a drug user and global advocate from Bath in southwest England, told CNN he was delivering a methadone prescription to a woman who cannot pick it up for herself, is suicidal and self-harms. She had gone three days without it.

Coronavirus is revealing how badly the UK has failed its most vulnerable

Will Haydock, from Public Health Dorset also in southwest England, told CNN that UK clinics were seeing an increase in people accessing treatment. He said this was encouraging but warned that for providers already making “significant changes to service design” this was adding to pressure. “It’s going to be a real challenge to deal with that influx of people who want support,” he said.

“This is a particularly vulnerable group of people, and you’re looking at services that are already really stretched.

“If we’re not able to offer the kind of level of support that we would like to, we will see more people die earlier than they need to.”

A spokesperson for the UK’s Home Office told CNN it is “monitoring the impacts of coronavirus” and law enforcement are “continuing to prevent drug trafficking and are successfully disrupting the drugs supply within the UK.”

The world was already facing a drug crisis before the coronavirus pandemic. The US is in the throes of an opioid epidemic. An estimated 10.3 million Americans ages 12 and older misused opioids in 2018. In 2017, there were more than 70,200 overdose deaths in the US and 47,600 of those deaths involved opioids.

The UK has seen near-record levels of drug-related deaths for six years in a row, and Scotland’s death rate is the highest in the European Union.

“I’m very apprehensive about what’s happening right now and what’s going to happen over the next few weeks to this group of our society who are extremely vulnerable, who’ve been exposed to adverse experiences, neglect and abuse from childhood onwards, and now risk being put at the back of the queue for support when in fact, they should be in front of it,” said Stevens, from the University of Kent.

The coming weeks and months will be crucial in identifying the effects of coronavirus on illegal drug use, alcoholism, suicide, domestic abuse, anxiety, and depression — and what it means for all of us as well as how we need to compromise, care and treat each other.

The Increasing Infection Rate and Tips for Running Your Practice or Your Business in a Coronavirus/Pandemic Crisis

Dr. Deborah Birx, the White House’s coronavirus response coordinator, expressed recently that 200,000 Americans could die even “if we do things perfectly.” However, the Society of Critical Care Medicine has projected that more than 960,000 people in the United States may require ventilators during the course of this pandemic. A study from the Intensive Care National Audit and Research Center in the UK gathered data from a sample of those on advanced respiratory support as treatment for COVID-19. Sixty-six percent of those patients died. If these numbers are correct, then we may see over 600,000 deaths in the United States by the time this pandemic is over, and those numbers may increase if we are unable to produce enough ventilators for our response. Each day the numbers get worse.

We need a national strategy

Local government officials across the nation are implementing curfews and extreme social distancing measures. However, in these same states, we continue to see people congregating on beaches, at parks and in other public areas. The federal government’s inability to take decisive action will lead to a wave of death that in many ways will be much worse than the disaster seen on 9/11. Federal officials have plucked the low-hanging fruit of mitigation — and now it’s time to reach deeper and enact a national quarantine.

Part of that strategy is a plan for our practices as healthcare givers and other small and medium business owners and managers. 

I found an interesting article written by Debra A. Shute included in a Medscape email. As I was reviewing the article and editing it for my use I found that during these difficult times, when businesses are being cut back or shut down that many of these suggestions can be applied to all of us in our times of financial and healthcare needs. 

We all have the same requirements as small or medium sized businesses. We want to survive, protect our businesses and our employees, assist our clients, so that when the pandemic is over, we can get back to what we do best, running our business, whatever that might be.

I was also amazed this morning when I went in to the office to take a look at what additional PPEs that I had to give to the local hospitals and clinics. I already loaded up a full SUV of gloves, surgical gowns and masks. Anyway, I noticed an office, a vein clinic, still open with at least 14 cars in their office parking lot. Is this office a necessity? I think not and what are they thinking driving from an area of increasing COVID-19 infection to our “neck of the woods” where so far, we have a low incidence of COVID-19 infection. More importantly our area has a larger population of older patients. Think of Italy and their mortality due mostly to the fact that they have the second oldest population in the world.

What is this physician thinking? Evidently the greed factor plays a role here and not the safety of her patients, her staff and yes, even herself as a physician. I am amazed and disheartened to see this idiocy in such a serious crisis.

Considerations to consider in this time of a pandemic:

  1. Do you or your practice need to continue to keep your practice doors open to see patients? Many states are mandating shutting all nonessential businesses including physician and nurse practitioner offices unless essential emergent care is needed. The same questions can be applied to most businesses if you think your business is essential and the state government hasn’t shut down with threats of jail time and fines.
  2. What patients are you going to see in this time of crisis and what are the challenges. i.e. eighty or older patients with no suspicious symptoms for the COVID-19 virus.
  3. The safety of three parts of your practice- a. your patients, b. your staff and c. you the treating practitioner.

If you need to continue to run your practice what tips can we provide? Debra Shulte, a freelance writer, summarized it in her article: 7 Tips for Running Your Practice in the Coronavirus Crisis, which appeared on the Medscape Web post. The rapidly increasing numbers of COVID-19 cases in the US raises the possibility that some physician and nurse practitioner offices will need to decide or be forced to close temporarily, as occurred in London last month as well as many areas in the U.S. Just recently, Maryland’s Governor Hogan sent out through the Health Department new regulations closing offices. So, now many practices across the country have to adjust to the way they operate, amid daily changes in this pandemic. The question is-what should you do to adapt to this new way of operating your practice?

  1. Create a Task, Practitioner and Staff Force or Core Team to Manage Change

“The readiness of medical practices to address the myriad challenges posed by this crisis has so far been a mixed bag”, said Owen Dahl, MBA, a Texas-based medical management consultant. Leadership is going to have to access what’s happening in the community, what’s happening with staff members who may or may not have the disease and may or may not have to self-quarantine.” Dahl said.

The physicians, the administrator, CEO, or managing partner should be involved in decision making as the global crisis unfolds, added Laurie Morgan, MBA, a California-based practice management consultant. And depending on the size of the practice, it may be useful to delegate specific components of this work to various department managers or other individuals in the group.

The Team should assess:

  1. Recommendations and/ or mandates from local, state, and federal governments
  2. Guidance from specialty and state medical societies
  3. How to triage patients over the phone, i.e. what questions to ask? Can they participate in Virtual visits and do they and your office have the hardware and software technology? Or can or should they be referred to an alternate site of care (culture sites).
  4. Where to send patients, if necessary, for testing?
  5. The practice’s inventory of personal protective equipment (PPE)
  6. Review of and possible revision of current infection control policies
  7. Possible collaborations within the community including hospitals, clinics and Health Departments, etc.
  8. Reimbursement policies for suspected COVID-19 triage, testing, and follow-up treatment- in office or virtually. Interestingly enough there is a new ICD-10 code for COVID-19 for coding visits and treatment.
  9. Whether some employees’ work (e.g. billing, coding) can be done remotely
  10. Options for paying personnel in the case of a temporary shutdown
  11. What’s covered and excluded by the group’s business interruption insurance
  12. Consider Postponing Nonessential Appointments

What’s more, it is critical for practices to form a strategy that does not involve bringing patients into the office, said Javeed Siddiqui, MD, MPH, an infectious disease physician, epidemiologist, and chief medical officer of TeleMed2U. “One thing we really have to recognize in this pandemic is that we don’t want people going and sitting in our waiting room. We don’t want people coming, and not only exposing other patients, but also further exposing staff. Forward triaging is going to be essential in this type of pandemic.”

One medical group, with multiple locations in Massachusetts, for example, announced to patients recently that it will postpone appointments for some routine and elective procedures, as we have done in my practice, as determined by the group’s physicians and clinical staff.

“Taking this step will help limit the number of people passing through our facilities, which will help slow the spread of illness (as recommended by the CDC),” noted in an email blast to patients.

  1. Overcommunication to Patients

With a situation as dynamic and unprecedented as this, constant and clear communication with patients is crucial. “said Morgan. “In order to be effective and get the word out, you have to be overcommunicating.”

Today’s practices have ways to communicate to keep people informed, including email, text messaging, social media patient portals, and even local television and radio.

One email or text message to the patient population can help direct them to the appropriate streams of information. Helping direct patients to updated information is critical.

In contrast, having the front desk field multitudes of calls from concerned patients ties up precious resources, according to Siddiqui. “Right now, practices are absolutely inundated, patients are waiting on hold, and that creates a great deal of frustration,” he said. Work out how to manage the crisis calls!

“We really need to take a page from every other industry in the United States, and that is secure SMS, email communication, and telehealth,” Siddiqui said. “Healthcare generally tends to be a laggard in this because so many people think, ‘Well, you can’t do that in healthcare,’ as opposed to thinking, ‘How can we do that in healthcare?”

  1. Take Advantage of Telemedicine

Fortunately, technology to interact with patients remotely is almost ubiquitous. Even for practices with little experience in this arena, various vendors exist that can get secure, HIPAA-compliant technologies up and running quickly. Many of the practice management electronic medical records systems already have the capacity for telemedicine including patient portals.

Various payers have issued guidance regarding reimbursement for telemedicine specific to COVID-19, and on March 6, Congress passed a law regarding Medicare coverage and payment for virtual services during a government-declared state of emergency. Some of the rules about HIPAA compliance in telemedicine have been eased for this emergency.

But even with well-established telemedicine modalities in place, it’s crunch time for applying it to COVID-19. “You need to find a way to have telemedicine available and use it, because depending on how this goes, that’s going to be clearly the safest, best way to care for a huge number of people,” said Darryl Elmouchi, MD, MBA, chief medical officer of Spectrum Health System and president of Spectrum Health Medical Group n Michigan.

 “What we recognize now, both with our past experience with telehealth for many years and specifically with this coronavirus testing we’ve done, is that it’s incredibly useful both for the clinicians and the patients,” Elmouchi said.

One possibility to consider is the tactic used by Spectrum, a large integrated healthcare system. The company mobilized its existing telemedicine program to offer free virtual screenings for anybody in Michigan showing possible symptoms of COVID-19. “We wanted to keep people out of our clinics, emergency rooms, and urgent care centers if they didn’t need to be there, and help allay fears,” he said.

Elmouchi said his company faced the problems that other physicians would also have to deal with. “It was a ton of work with a dedicated team that focused on this. The hardest part was probably trying to determine how we can staff it,” he said.

With their dedicated virtual team still seeing regularly scheduled virtual patients, the system had to reassign its traditional teams, such as urgent care, and primary care clinicians, to the virtual screening effort. “Then we had to figure out how we could operationalize it. It was a lot of work,” Elmouchi said.

Telemedicine capabilities are not just limited to screening patients, but can also be used to stay in touch with patients who may be quarantined and provide follow-up care, he noted.

Luckily in my practice we have used forms of telemedicine for many years either email or texts are the patient’s favorite mode of communication and virtual video chat only if necessary due the fact that my practice is a surgical practice. However, in these critical times I only want to see those needing urgent attention. If they report suspicious symptoms then we need to consider where to refer them. 

Therefore-

  • Identify COVID-19 Testing sites

Access to tests remains a problem in the U.S., but is improving by the week. Just consider the most recent announcement that they now have a test that can give results in 15 minutes. For practices that can attain the tests themselves, not in my practice, it will still require some creativity to administer them with as little risk as possible. In South Korea, for example, and increasingly in the U.S, healthcare organizations are instructing patients waiting to be tested to stay in their cars and have a practitioner wearing the proper PPE go out to patients to test them there. Alternatively, some practices may opt to have PPE-wearing staff members bring PPE to patients in their cars and then escort them to a designated testing area in the building-through the back door if noninfected patients are still being seen. I don’t recommend this last option because of the shortage of PPE equipment unless the patient is such a high risk and has multiple co-morbidities and needs a in depth exam. Here I suggest an in car rapid culture/test and if the need warrants to refer to the medical center better setup to manage the patient.

“Once in the office, you still need to isolate virus patients in any way you can,” Dahl said. “In fact, you may want a negative-pressure environment if possible, with the air being sucked out rather than circulating,” he said, adding that a large restroom with a ventilation system could be repurposed as a makeshift exam room. Here I am adamant! If you are going to see sick viral patients your practice should have negative pressure rooms. This protects the staff, other patients and you the practitioners.

Community testing sites are another possibility, my favorite option, given proper coordination with other healthcare organizations and community officials. Siddiqui has been working with several communities in which individual clinics and hospitals are unable to handle testing on their own, and have instead collaborated to create community-testing sites in tents on local athletic fields.

“One of our communities is looking at using the local college parking lot to do drive-through testing there,” he said. “We really need to embrace collaboration much more than we’ve ever done.”

 This is in fact what we have set up in our small town, using the local community college parking lots, etc.

Collaboration also requires sharing supplies and PPE, noted Dahl. “Don’t hoard them because of the shortage. Look at your inventory and make sure you can help whomever you may be sending patients to. “And if your office is falling short, Dahl advises checking with offices in your community that may be closing, such as dentists or plastic surgeons, for supplies you can purchase or simply have. I did this in my office, donating an SUV full of surgical gowns, facemasks and boxes of gloves to the hospital to deliver to whom needs them most.

The U.S. Food and Drug Administration has issued some guidance to healthcare providers about shortages of surgical masks and gowns, including advice about reusable cloth alternatives to gowns.

In addition, some hospitals have asked clinicians to keep their masks and provide guidance on how to conserve supplies. Our medical facility set up a Task Force to analyze, assess and allocate supplies calling on physicians and dentists, etc.

  • Preparing to Potentially Shut Down

A temporary closure may be inevitable for some practices. “Maybe the physician owners will not feel like they have a choice,” said Morgan. “They feel like they want to stay open for as long as they can; but if it’s not safe for patients or not safe for employees, maybe they’ll feel it’s better if they check out for a bit.” And remember if you are sick or one of your partners is sick or a member of your staff the stress becomes multiplied and, potential errors occur and everyone suffers!

Handling the financial ramifications of closure is a top priority as well, and will require a full understanding of what is and isn’t covered by the practice’s business interruption insurance. Practices that don’t have a line of credit should reach out to banks and the Small Business Administration immediately, according to Dahl and of course me. Practices that have lines of credit already may want to ask for an increase. Although the 2 trillion-dollar COVID-19 rescue bill may assist healthcare facilities. Meet and work with your account to review your financial liabilities, losses and needs for the future!

My other suggestion and that of many experts is to Apply for an SBA loan (CARES Act loan) to acquire working capital.

  • See: U.S. Small Business Administration, Disaster Loan Assistance
    Due to current traffic, non-peak hours are optimal 7pm – 7am EST.

Loan Application Checklist

Forecasting Cash Inflows for 13 Weeks

  • You may not have all of the information; however, don’t let that keep you from conducting this exercise. Use your best estimates, evaluate your forecast real-time (daily), and adjust the forecast as you go.
  • It may be easiest to start with the prior year’s weekly revenue and adjust accordingly. 
  • When determining cash inflows, consider any ongoing operations, accounts receivable, retained earnings, owner loans, and/or financial support from lenders (such as lines of credit or SBA above).
  • Decide how you will manage late fees/ waivers from your patients, customers and clients.

Forecasting Cash Obligations for 13 Weeks- Leverage your Networks. 

  • Watch and prepare for outside influences including landlords, local, state, and   federal actions
  • Determine where obligations may need to be reduced
  • Negotiate with Vendors and seek extensions* 
    – If this seems daunting, start with those you spend the most money. 
  • Negotiate with Credit Card Companies
    – Can you reduce your minimum payment or increase your line of credit?
  • Negotiate rent with Landlords 
    – Consider evaluating any lease agreements that include Force Majeure clauses (freeing both parties from liability or obligation when an extraordinary event or circumstance beyond the control of the parties) and work with your legal counsel to evaluate options and/or circumstances that may invoke this provision.
    – If you own the building, contact your lender to evaluate term extensions, etc.
  • Develop Staffing Plan with the Assistance of Legal Counsel
    – What can you afford based on your forecast? 
    – Do you need to reduce hours, reduce staff through lay-offs or furloughs? 
    – Consider job sharing options (1 staff member M, W, 2nd staff member works T, Th)

Protecting employees’ income is challenging as well. For employees who are furloughed, consider allowing them to use their sick leave and vacation time during the shutdown-and possibly let staff “borrow” not yet accrued paid time off. I went through this discussion with my staff and ended the discussion with the assurance that if we cut back hours or let people go their jobs were secure when this was all over and that I guaranteed them financial support for rent and food, etc. for however long the shutdown lasts. Our practice sets aside a savings account for emergencies.

        Considerations for Furlough/Layoff
– If you are to keep staff, identify specific job responsibilities. 
– If your staffing plan includes remote employment, which I will discuss in the next section, you may need to determine how to utilize your staff in a remote capacity. For example, can they work on updating your practice’s website and/or before & after galleries, build out social media marketing calendars, mine your practice management system, etc. More discussion will be found in the next section where I discuss working from home.

Marketing
– Determine ROI on current efforts. What’s working/what’s not/what’s the plan moving forward?

However, there’s a risk with certain jobs in a medical practice that tend to have extremely high turnover, so physicians and administrators may be reluctant to pay people too much because they don’t know for sure those employees will come back to those jobs,” Morgan said. “On the other hand, if you have had a stable team for a very long time and feel confident that those employees are going to stay, then you may make a different decision.” Therefore, if you need to cut back staff temporarily, when things stabilize you will have able and willing staff and not need to find new employees who will need to be trained, etc.

  1. Seize Work-From- Home Opportunities

“Even if the practice isn’t seeing patients, there may be opportunities for some employees, such as billers, coders and schedulers, to continue to work from home.” Morgan noted. Particularly if a practice is behind on it’s billing, a closure or slowdown is an ideal time to catch up. This measure will keep at least some people working-perhaps including some individuals who can be cross-trained to do other tasks-and maintain some cashflow when the practice needs it most.

Other remote-friendly jobs that often fall by the wayside when practices are busy include marketing tasks such as setting up or updating Google business pages, Healthgrades’s profiles, and so on, noted Morgan.  And make sure your staff has the software and hardware to support Work-from Home strategies.

“Another thing that can be even more important, and is often overlooked, is making sure health plan directories have correct information about your practice,” she added. “These are pesky, often tedious tasks that may require repeated contact with health plans to fix things-perfect to do when the office is not busy or closed.”

For administrators and billers, if the practice is able to keep paying these employees while partially or fully closed, it can also be an excellent time to do the sort of analysis that takes a lot of focused attention and is hard to do when busy. Some examples: a detailed comparison of payer performance, analysis of referral patterns, or a review of coding accuracy. Morgan suggested. 

We had an excellent opportunity to have our staff analyze our practice and plan our future move to a new facility and start packing, etc. Make use of your employees and the opportunities that you have been putting off due to your busy practice!

As with many, HIPAA is a leading concern, though it needn’t be, according to Morgan and the notification of the relaxation of some HIPAA regulations to allow various forms of communication with our patients.

Finally, as the crisis begins to abate, practices and businesses must keep working in teams to evaluate and structure an orderly return to business as usual, gleaning best practices from colleagues whenever possible. Strategize how to re-boot your practice or any of the other businesses. Consider what the world will look like when the crisis is over and plan how to rebuild and reschedule, etc.

“I would tell practices this is not a time when anyone is competing with anyone.” Said Elmouchi. The more collaboration between practices and health systems that have larger resources the better.”

I would add that the physicians and other practitioners as well as the other businesses who were forced to close need to support your staff though these difficult times and acknowledge their importance and your gratitude for their hard work and sacrifices during this crisis. Save some time AFTER the pandemic is over and there is no possibility of health risk to have lunch or dinner or just time to celebrate surviving.

As I mentioned any small or medium business can use this set of tips to survive in this tempestuous time. As the restaurants are doing, create a pickup system, or use your employees to create a delivery system to keep as many of your employees on the job. You can also evaluate your marketing and do some strategic planning. It is the time to use your staff to plan the future together and

Engage in Team building so that when the pandemic is over you will create a more effective, efficient system to deliver what ever you goal or goals are to your patients, clients or customer want and need. Be creative and this is the time to consider process improvement. 

Use the time wisely. Over communicate with your patients, clients and customers and more important your staff including document your plans and use a decision tree for staff and referral businesses including possible Web site announcements.

Also, realizing the there are many that may need federal aid/loans, if you decide that you may need assistance apply now!! And don’t let all this stress you or your staff out! Work together with your staff and your patients and network through this pandemic crisis and for the future.

American life has been transformed in a few short weeks and the Cost to Economies and the Ethics in Decision Making in a Pandemic

Italy a country at the heart of the Corona virus outbreak in Europe — watched its number of cases and deaths due to the novel Corona virus astronomically leap once again, up 793 deaths with 6,557 newly confirmed cases recorded in just 24 hours.

Saturday’s jump marks the worst day for fatalities since the crisis began just four months ago. The country now counts 53,578 diagnosed infections, up 13.9 percent, with 4,825 deaths — the highest in the world.

More than 60 percent of the most recent deaths occurred in the northern region of Lombardy. Hospitals in the area have been reeling under a staggering caseload that has left intensive care beds scarce and respirators in extremely limited supply.

According to the Financial Times, 2,857 people were in intensive care in Lombardy on Saturday, up from 2,655 on Friday. The new increases come almost two weeks into a nationwide lock down in an attempt to stop the COVID-19 virus in its tracks there.

There were also 943 full recoveries tallied yesterday — another record for the country.

On Thursday, Italy was witness to yet another grim milestone in its fight against the deadly disease by overtaking China to become the country with the highest number of deaths.

On Friday the government banned the last types of outdoor exercise Italians were able to participate in under the lock down measures by deciding that running and bicycle rides were no longer permitted. In addition, the Italian military has also been dispatched to Milan to ensure that citizens follow the new lock down measures.

The Italian interior ministry reported that more than 223,633 people were inspected by the Italian police nationwide on Friday, with 9,888 people reported for breaking the lock down measures and 260 for false declarations about why they were outside.

Across the Atlantic, the number of cases in the United States has now exceeded 22,000 with more than 270 deaths. New York tops the list with at least 10,000 confirmed cases; Washington state follows with just over 1,500 cases, and California is in tow with more than 1,200.

Thus far, the global pandemic has infected more than 287,000 people and killed over 11,900. More than 90,000 people have recovered so far, mostly in China.

The Associated Press and The Financial Times contributed to this report.

I found this article in the Economist discussing what the economic influence would be from the COVID-19 pandemic. The titular conceit of “28 Days Later”, as with many contagion-style horror films, is of a man waking up after a month-long coma only to find society upended by a rampaging virus. Many Americans are experiencing something similar. On March 3rd there were just 122 confirmed cases of COVID-19—the disease currently sweeping the world—and only seven deaths. By March 17th there were 7,786 confirmed cases (even these were a sure underestimate given the dearth of testing) and 118 deaths. Twenty-eight days later, on March 31st, what might America look like?

cap.gifp-a8GHW19EK4IzY.gif“We don’t know whether we’re going to look like Italy or the provinces outside Hubei” in China where the spread of COVID-19 was fairly effectively contained, says David Blumenthal, president of the Commonwealth Fund, a health-policy think-tank. “But the likelihood is—given the slowness with which we responded to the epidemic—that we look more like Italy,” he adds. Jerome Adams, the surgeon-general, has warned of the same.

Can America’s health system cope? The structural problems that make pandemic response more difficult—lack of paid sick pay, a large uninsured population and a significant number of insured people nonetheless worried about out-of-pocket medical bills—cannot be mended overnight. Instead, public-health experts and doctors are increasingly worried about sheer capacity constraints. In China, 5% of those diagnosed needed intensive care. There are roughly 97,000 beds in intensive care units (ICUs), of which one-third are empty. Though America has relatively few total hospital beds per person compared with other countries, it ranks among the highest for ICU beds per person, with nearly three times as many as Italy.

“The real limiting factors are likely to be the ventilators or the staff,” says Greg Martin, a professor of medicine at Emory University and president-elect of the Society of Critical Care Medicine. There are roughly 50,000 physicians trained in critical care and 34,000 similarly specialized nurses and assistants. This could be insufficient in the face of hundreds of thousands of cases at peak rates of infection.

Then there is the problem of kit. In China, half of those in critical care required the use of ventilators, machines that help people breathe. There are thought to be 62,000 full-featured mechanical ventilators in the country, many of which are already in use. Older stocks of perhaps 100,000 devices—including CPAP machines used for those with sleep apnea—could be called upon if needed, but would provide only basic functions. Ramp-ups in ventilator production are being pondered, including through emergency powers given to the president under the Defense Production Act of 1950, but there has been little actual action yet. On a phone call with state governors, President Donald Trump urged “respirators, ventilators, all of the equipment—try getting it yourselves”, which could spark an unhelpful competition between states for scarce resources.

“Under almost any basic scenario, things look tough. Hospital beds will be completely full many times over if we don’t substantially spread the load,” warns Ashish Jha, director of the Global Health Institute at Harvard. To head that off, Mr Jha has called for an Italy-style national quarantine, lasting for at least two weeks, in which all non-essential businesses are closed and gatherings of more than five people are barred to give time for testing to become widespread. After a dismally slow start to testing, the numbers are finally heading up—although the best estimates come not from public-health agencies, but volunteer trackers using a Google sheet—to an estimated 12,535 tests conducted on March 17th. Given the expected scope of the disease, and the reported obstacles to people with symptoms actually getting tested, much more will be needed.

Most hospitals are making contingency plans. There are plans to add physical beds by cancelling elective surgeries that can be postponed, converting recovery rooms into added beds and building tents to house some patients. The Cleveland Clinic, a prominent hospital, says it has plans in place to add 1,000 beds of capacity within 72 hours if needed. Teams of doctors and nurses with other specialties could be conscripted into critical-care work, supervised by critical-care doctors who handle the trickiest cases—like respiratory distress coupled with organ failure in the kidneys or heart. If this is insufficient, recently retired doctors could be drafted into service. Some teaching hospitals are using simulation centers to prepare medical staff for the inevitable surge in cases.

Testing? Testing?

Whether it will come to all this is still unclear. Testing capacity remains constrained, limiting the information epidemiologists have to feed both their models and their willingness to speculate. Their policy recommendations—social distancing, closure of schools and large gatherings—are nevertheless clear. One team of researchers has concluded that an epidemic resembling that of Wuhan, where the novel Corona virus first broke out, would overwhelm hospitals many times over, while one resembling Guangzhou, a city that locked down in the early days of the virus, could be dealt with.

On March 16th, however, a team of scientists based at Imperial College London, who have been advising the British government, also published forecasts of the epidemic’s trajectory in America. As with Britain, the figures look grim. Without any mitigation, America would experience 2.2m deaths, they predict. Even in the case of some mitigation—isolation of the sick, social distancing for the elderly, but an otherwise normal society—American hospital and ICU capacity would be exceeded eight times over, and the country would be on track for at least 1.1m deaths. Averting this through “suppression”—isolation of sick, closing of schools and universities, social distancing for everyone—would require months until therapeutics or vaccines can be developed.

America is therefore turning towards suppression of the virus. Millions of pupils and university students have been sent home and left to take classes online. Mr. Trump has advised that people not congregate in gatherings of more than ten people. San Francisco and surrounding counties have issued a “shelter-in-place” order that requires 7m to remain in their homes unless necessary. New York City is expected to do the same for its 8m residents. In 22 states, bars and restaurants have been ordered to close their seating and only serve takeaway. The state of New York is setting up drive-through testing centers, starting in New Rochelle, a commuter town in Westchester County that was one of the early sites of a COVID-19 cluster, and is urging federal troops to build emergency, temporary hospital facilities. New Rochelle’s mayor says he is surviving the lock down there on “adrenalin, coffee and M&Ms”.

The goal is to increase general hospital capacity by a factor of two and ICU capacity by a factor of ten within two months. Elections have been postponed in a few states for the Democratic primary, which now seems a dull, distant affair. America’s devolved system means that the shuttering will happen at different rates in different places, but the trajectory is clear. “You want a single national response. But when the federal government completely fails, as it has so far, then you can get states and cities to step up,” says Mr. Jha.

The question is how long this can go on for. Unmitigated, the epidemic would not peak for at least another three months. Suppression can reduce the spread of the disease, as China’s experiment with locking down most of its population showed, but relaxing these measures will inevitably bring another surge in cases. Mr. Trump, who a few weeks ago was suggesting the virus was the latest hoax invented to damage him, is now warning that this could be the start of a months-long reorientation in American life. And while these extraordinary actions should smother the disease, they will also smother the economy.

The dismal economic forecasts will require further action from Congress. It spent the last week haggling over a bill that would make testing for the disease free, increase the flow of safety-net benefits and grant paid sick leave to more workers (though this provision appears to be hollowing out with every iteration). Even before that bill was finalized, Washington’s attention had already turned to the even bigger economic stimulus package that must come next. Senators, both Democrats and Republicans, are tripping over themselves issuing plans to send cash directly to American families.          

The total package, which could be worth $1trn or more, dwarfs the $100bn-or-so bill recently signed into law and every other stimulus package in history. The Trump administration has proposed sending $500bn in direct cash to taxpayers, $300bn to keep firms afloat, and $200bn to bail out critical industries like airlines. The typical partisan bickering from Congress and even from Mr. Trump has been muted. Every politician seems to now realize that the country faces an unprecedented crisis, first of public health and then of the economy, that will last for months. Whether this action will look sufficient 28 days later is, as with seemingly every aspect of the Covid-19 pandemic, deeply uncertain. ■

Ethicists agree on who gets treated first when hospitals are overwhelmed by Corona virus 

As a member of our Ethics Committee I thought that the decisions that physicians and staff in other countries were facing regarding who gets the ventilators was an interesting conundrum. This article contributed by Oliva Goldhill in her article, The Aging Effect, is a great introduction into the decisions that we may have to make here in the US. Pandemics bring ethical dilemmas into sharp, terrible focus. Around the world, hospitals have been unable to cope with the millions who need treatment for Corona virus. China created makeshift hospitals and denied treatment to those who needed non-Corona virus care; Italians wait an hour on the phone to get through to emergency services. Few countries will fare better: The United States has fewer than 100,000 ICU beds, and is expected to need a minimum of 200,000 to cope with Corona virus; the UK has just 8,200 ventilators and is getting an extra 3,800.

As health care systems are overwhelmed with more patients than they can feasibly treat, medical personnel are forced to decide who should get the available ventilators and ICU beds. Quartz spoke with eight ethicists, all of whom agreed that in such dire situations, those who have the best chance of surviving get priority. Despite the unanimity, all agreed that this decision is far from easy and should not be taken lightly.

Different moral theories, same answer

The decision to prioritize those with good survival odds is reinforced by several moral theories. Utilitarianism, for example, argues that morality is determined by the consequences of actions, and so we should strive to create the maximum good for the maximum number of people. “If we give scarce treatments to those who don’t stand to benefit (and have a high chance of dying anyway), then not only will they die, but those with higher likelihood of survival (but require ventilator support) will also die,” says Lydia Dugdale, professor of medicine and director of the center for clinical medical ethics at Columbia University. “It’s not fair to distribute scarce resources in a way that minimizes lives saved.”

A contrarian theory, which bases ethics on the social contract we would agree to if we didn’t know our status in society, arrives at the same conclusion. Joshua Parker, a trainee general practitioner (primary care doctor) who co-wrote an article on the ethics of Corona virus care for the Journal of Medical Ethics, points to philosopher John Rawls’ concept of a “veil of ignorance” as a way to determine the just action: “Behind the veil of ignorance, I am stripped of any knowledge of my position. I don’t know if I’ll be old, young, rich, poor, well, unwell, male or female; and I don’t know if I will catch COVID-19 or if I do, what resources I will need,” he writes in an email to Quartz. This thought experiment makes it easier to judge what’s fair for society as a whole. Alex John London, director of the Center for Ethics and Policy at Carnegie Mellon University, agrees: “Such agents might agree that in a pandemic, when not everyone can be saved, health care systems should use their resources to save as many lives as possible—because that is the strategy that allows each person a fair chance of being able to pursue their life plan.”

Even typically diverging ethical theories are likely to point to this conclusion. Utilitarianism, which focuses on the consequences of an action, is typically opposed to deontology, which says morality is determined by the act itself. “The deontologist might well start with a justice argument: each person is individually valuable and should have an equal chance of health care,” says Anders Sandberg, a philosopher at the Future of Humanity Institute at the Oxford University. But if this is simply impossible, then the theory doesn’t hold. “As Kant said, “ought implies can,” and if one cannot do an action it cannot be obligatory.” A deontologist approach to treat everyone equally falls short when there simply isn’t enough medical equipment to treat everyone; if some will have access and some won’t, then we have to face the question of who gets preferential treatment. And so “even the most die-hard deontologist will usually agree” that it’s wrong to treat people who are unlikely to benefit while others are in need, agrees Brian D. Earp, associate director of the Yale-Hastings Program in Ethics and Health Policy at Yale University and The Hastings Center.

Doctors have reckoned with the need to allocate resources in the face of overwhelming demand long before Corona virus. Dugdale points out that the New York department of health’s ventilator allocation guidelines, published in November 2015 to address the issue amid a flu epidemic, states that first-come first-serve, lottery, physician clinical judgment, and prioritizing certain patients such as health care workers were explored but found to be either too subjective or failed to save the most lives. Age was rejected as a criterion as it discriminates against the elderly, and there are plenty of cases in which an older person has better odds of survival than someone younger.

So the decision was to “utilize clinical factors only to evaluate a patient’s likelihood of survival and to determine the patient’s access to ventilator therapy.” In tie-breaking circumstances, though, they did approve treating children 17 and younger over an adult where both have an equal odds of surviving. Dugdale adds that there’s talk of applying these guidelines to address Corona virus treatment in New York.

No good answer

The dire consequences of any decision made under such extreme circumstances means that, despite agreement, the best course of action is hardly favorable. “I would say that leaving some to die without treatment is NOT ethical, but it may be necessary as there are no good options,” David Chan, philosophy professor at the University of Alabama at Birmingham, writes. “Saying that it is ethical ignores the tragic element, and it is better that physicians feel bad about making the best of a bad situation rather than being convinced that they have done the right thing.”

Rather, it’s simply the least bad option. Alternatives, such as a lottery system or prioritizing the sickest, are likely to lead to more deaths. “There is a good chance that we invest resources into patients who don’t survive, and we have thus doomed not just the patient we tried to save, but also the patient who was passed over for care, because the resources have been used up,” says Vanessa Bentley, philosophy professor at the University of Alabama at Birmingham. “Lives that could have been saved were lost.”

Although there’s broad agreement on the best approach, the nuances of applying this decision will always be difficult. Not only must doctors accurately assess and prioritize those with the best chance of survival, but there could also be times when the hospital doesn’t have enough equipment to help even those with equal odds. Italy has prioritized treatment for those with “the best chance of success” but adds as a second criterion those “who have more potential years of life.” This secondary factor is not so easily agreed upon but, in the face of Corona virus, it’s an ethical question doctors will have to face.

Governments are spending big to keep the world economy from getting dangerously sick

The help is targeted at companies and individuals. More will be needed

In the recent edition of the Economist Today it was noted a character in a novel by Ernest Hemingway once described bankruptcy as an experience that occurs “two ways: gradually, then suddenly”. The economic response to the COVID-19 pandemic has followed this pattern. For weeks policymakers dithered, even as forecasts for the likely economic damage worsened. But in the space of just a few days the rich world has shifted decisively. Many governments are now on a war footing, promising massive state intervention and control over economic activity.

The new phrase on politicians’ lips is “whatever it takes”—a line borrowed from Mario Draghi, president of the European Central Bank (ECB) in 2011-19. He used it in 2012 to convince investors he was serious about solving the euro-zone crisis, and prompted an economic recovery. Mr Draghi’s promise was radical enough. Politicians are now proposing something of a different magnitude: sweeping, structural changes to how their economies work.

There are unprecedented promises. On March 16th President Emmanuel Macron of France declared that “no company, whatever its size, will face the risk of bankruptcy” because of the virus. Germany pledged unlimited cash to businesses hit by it. Japan passed a hastily compiled spending package in February, but on March 10th supplemented it with another one that included over ¥430bn ($4bn) in spending and almost four times as much in cheap lending. Britain has said it will lend over £300bn (15% of GDP) to firms. America may enact a fiscal package worth well over $1trn (5% of GDP). The most conservative estimates of the total extra fiscal stimulus announced thus far put it at 2% of global GDP, more than was shoveled out in response to the global financial crisis of 2007-09.

That sinking feeling

In part this radical action is motivated by the realization that the Corona virus, first and foremost a public-health emergency, is also an economic one. The jaw-dropping bad economic data coming out of China hint at what could be in store for the rest of the world. In the first two months of 2020 all major indicators were deeply negative: industrial production fell by 13.5% year-on-year, retail sales by 20.5% and fixed-asset investment by 24.5%. GDP may have declined by as much as 10% year-on-year in the first quarter of 2020. The last time China reported an economic contraction was more than four decades ago, at the end of the Cultural Revolution.

Grim numbers are starting to pile up elsewhere, not so much in the official statistics, which take time to be published, as in “real-time” economic data produced by the private sector. Across the world, attendance at restaurants has fallen by half, according to OpenTable, a booking platform. International-passenger arrivals at the five biggest American airports are down by at least 30%. Box-office receipts have crumpled (see chart 2).

The disruption to international travel will hurt trade, since over half of global air freight is carried in the bellies of passenger planes. The combination of disrupted supply chains and depressed demand from shoppers should hit trade far harder than overall GDP, if the experience of the last financial crisis is anything to go by. Already, the American Association of Port Authorities, an alliance of the ports of Canada, the Caribbean, Latin America and the United States, has warned that cargo volumes during the first quarter of 2020 could be down by 20% or more from a year earlier.

Official data are now starting to drip out. The Empire manufacturing index, a monthly survey covering New York state, in March saw its steepest drop on record, and the lowest level since 2009. In February Norway’s jobless rate was 2.3%; by March 17th it was 5.3%. State-level numbers from America suggest that unemployment there has been surging in recent days.

All this is fueling grim forecasts. In a report on March 17th Morgan Stanley, a bank, estimated that GDP in the euro area will fall by an astonishing 12% year-on-year in the second quarter of the year. The Japanese economy is forecast to contract by 2% this quarter and 2% next. Most analysts see global GDP shrinking in the first half of the year, with barely any growth over 2020 as a whole—the worst performance since the financial crisis of 2007-09.

Even that is likely to prove optimistic. On March 17th analysts at Goldman Sachs noted that they had “not yet built a full lock down scenario” into their forecasts for advanced economies outside Europe. Forecasts for America, which is at an earlier stage than Europe and Asia when it comes to the outbreak, remain Panglossian; very slow growth in China and a big recession in Europe could by itself be enough to send the world’s largest economy the same way. Steven Mnuchin, America’s treasury secretary, warned this week that the country’s unemployment rate could reach 20% unless Congress passes a stimulus package. A negotiating ploy? With shopping malls emptying, factories grinding to a halt and financial markets buckling, lawmakers may be loath to challenge the claim.

Despite stomach-churning declines in GDP in the first half of this year, and especially the second quarter, most forecasters assume that the situation will return to normal in the second half of the year, with growth accelerating in 2021 as people make up for lost time. That judgment is in part informed by China’s experience. More than 90% of its big industrial firms are officially back in business. Its stock market had been one of the world’s worst performers in early February but is now the best (or rather, least bad). There remains, however, a risk that global containment and suppression of the virus will need to continue for a year or longer. If so, global economic output could be dragged down for much longer than most people expect.

Perhaps the greatest lesson of the global financial crisis was that it paid to act decisively and to act big, convincing markets and households that policymakers were serious about countering the slump. If done right, central banks and governments can end up doing a lot less than they actually promised. A pledge to bail out banks makes it less likely savers will withdraw deposits and make a rescue necessary.

This time around, central banks sprang into action. Since February the Federal Reserve has cut interest rates by 1.5 percentage points. Other central banks have followed suit. Further deep rate cuts are not possible, though; interest rates were very low long before the virus began to spread.

Let’s get fiscal

Not all central banks are acting as boldly as they can. China has room to cut interest rates—its benchmark rate is 1.5%—but has held back in part because inflation is quite high (largely as a result of African swine fever, which hit pig stocks, raising prices). Central banks could try more creative policies. On March 19th the ECB’s governing council agreed to launch a €750bn bond-buying program, covering both sovereign and corporate debt. But the real action is now taking place on the fiscal front.

Governments are falling over each other to offer bigger and better stimulus packages. All countries are spending more on health care, both in an effort to find vaccines and cures and to increase hospital capacity. However, the bulk of the extra spending is on companies and people.

Take companies first. China, where the outbreak has slowed, is now trying to get people out and buying things. Foshan, a city in Guangdong province, has launched a subsidy program for people buying cars. Some cities have started giving out coupons that can be spent in local shops and restaurants. Nanjing this month gave out e-vouchers worth 318m yuan ($45m).

Most countries, however, are in or about to enter the worst part of the outbreak. As customers dry up, many firms will go bust without government help. Calculations by The Economist suggest that 40% of consumer spending in advanced economies is vulnerable to people shunning social situations. Firms in leisure and hospitality are especially rattled. The Moor of Rannoch hotel, in about as rural a part of Scotland as it is possible to find, says its insurer will not be paying out a penny for lost custom, since COVID-19 is a new disease and thus not covered under its policy.

One approach is to reduce firms’ fixed costs, largely rent and labor. China’s finance ministry will exempt companies from making social-security contributions for up to five months. The government has also temporarily cut the electricity price for most companies by 5% and enacted short-term value-added-tax cuts. The British government has extended a one-year business-rates holiday to all companies operating in the retail, hospitality and leisure sectors. Yet for many firms, no matter how much the government helps them reduce costs, revenues are likely to fall further.

So, measures may be needed to allow firms to maintain cash flow. Many banks are offering hefty overdrafts to tide corporate clients over. To encourage banks to keep lending, Britain has promised them cheap funding and state guarantees against losses. For very small firms, many of which do not borrow at all, it is offering non-repayable cash grants of up to £25,000.

Other countries are enacting similar plans. The Japanese government is helping small firms by mobilizing its state-owned lenders to provide up to ¥1.6trn of emergency loans, much of it free of interest and collateral requirements. Small firms qualify for help if their monthly sales fall at least 15% below a normal month’s takings. Bavaria, a rich state in Germany, announced on March 16th that small and medium-sized companies with up to 250 employees could receive an immediate cash injection of between €5,000 and €30,000. The European Commission has already relaxed state-aid rules so that governments can channel help to ailing companies.

The second part of the fiscal response is about helping people, and in particular protecting them from being made unemployed or suffering a drastic drop in income if that does happen. Ugo Gentilini of the World Bank counts more than 25 countries that are using cash transfers as part of their economic response to the virus. Brazil will give informal workers, who make up roughly 40% of the labor force, 200 Reais ($38) each. Small businesses will be allowed to delay tax payments and pensioners will get year-end benefits early. Australia is instituting a one-time cash payment of A$750 ($434) to pensioners, veterans and people on low incomes.

Northern Europe has led the way on implementing policies that make it less likely firms lay off workers. Germany has relaxed the criteria for Kurzarbeit (“short-time work”), under which the state pays 60-67% of the forgone wages of employees whose hours are reduced by struggling firms. Applications are going “through the roof”, according to the federal labor agency. The use of Kurzarbeit probably halved the rise in unemployment during the recession of 2008-09. More firms are now eligible to use it, temporary workers are covered, and the government will also reimburse the social-security contributions companies make on behalf of affected workers.

Bringing home, the Danish bacon

In Denmark firms that risk losing 30% or more of their workforce will see the government pay 75% of the wages of employees who would otherwise be laid off, until June. Norway’s government has beefed up unemployment benefits, guaranteeing laid-off workers the equivalent of their full salary for the first 20 days. Freelancers whose work vanishes for more than a fortnight will get payments equivalent to 80% of their previous average income. In Sweden the state will cover half of the income of workers who have been let go, with employers asked to cover most of the rest.

So far America has passed more modest legislation. Federal funding for Medicaid, which provides health care for the poor, is likely to boost spending by about $30bn, assuming it remains in place until the end of December, reckons Oxford Economics, a consultancy. America also has a new paid-sick-leave policy for some 30m workers, including 10m who are self-employed, worth just over $100bn. But in that regard America is merely catching up with other rich countries, which have far more generous sick-leave policies. America also has fewer automatic economic stabilizers, such as generous unemployment insurance, than most other rich countries. As a result, its discretionary fiscal boost needs to be especially large to make a difference.

It might be. The Trump administration’s plan to funnel money directly to households, if approved by Congress, is the most significant policy. It bears some resemblance to a scheme that was introduced in February in Hong Kong, in which the government offered HK$10,000 ($1,290) directly to every permanent resident. Mr. Mnuchin is thought to favor a check of $1,000 per American—roughly equal to one week’s average wages for a private-sector worker—with the possibility of a second check later. Some $500bn-worth of direct payments could soon be in the post.

Some economists are leery about such a policy. For one thing, it would do little to prevent employers from letting people go, unlike the plans in northern Europe. Another potential problem, judging by Hong Kong’s experience, is administration of the plan: the territory’s finance secretary hopes to make the first payments in “late summer”, far too far away for people who lost work last week. Mr. Mnuchin promises that payments will happen much sooner.

Checkered past

America has done something similar before, with results that were not entirely encouraging. The government sent out checks in both 2001 and 2008 to head off a slowdown. The evidence suggests that people saved a large chunk of it. The psychological reassurance of a bit of extra cash could be significant for many Americans, but the sums involved are not especially impressive. Bernie Sanders, a Democratic presidential contender, is not known for his smart economic policy making, but his suggestion of $2,000 per household per month until the crisis is over is probably closer to what is required.

Indeed, more fiscal stimulus will be needed across the world, especially if measures to contain the spread of the virus fall short. After the Japanese government passes the budget for next fiscal year at the end of this month, it can begin work on a supplementary budget that takes the virus into full account. Britain’s Parliament has given Rishi Sunak, the chancellor of the exchequer, carte blanche to offer whatever support he deems necessary, without limit.

How much further can fiscal policy realistically go? Last year the 35-odd rich countries tracked by the IMF ran combined fiscal deficits of $1.5trn (2.9% of GDP). On the not-unrealistic assumption that the average deficit rose by five percentage points of GDP, total rich-country borrowing would rise to over $4trn this year. Investors have to be willing to finance that splurge. The yield on ten-year Treasury bonds, which had fallen as low as 0.5% as fears of the virus took hold and traders sought havens, has recently risen above 1%. This is probably due to firms and investors selling even their safest assets to raise cash, but might reflect some anxiety over the scale of planned government borrowing.

Jesse Watters began “Waters’ World” on Saturday by delivering a message of positivity to his audience, saying he’s sure America can overcome the devastation from the coronovirus. “The United States of America is rolling into a recession or a depression. What we do now will determine which one it’ll be. First, we have to stop the spread. You know what to do. Wash your hands, stay clean and practice social distancing,” Watters said, reminding people of the guidelines given to keep people safe from exposure to the virus.

“If you can stay inside this week, work from home if you can. Don’t fly if you don’t have to. The virus is mostly in 10 large counties. A very high percentage in New York, California and Washington state,” he continued. “Some of these areas recognize the threat and are shutting down everything. All of them need to do that.”

Watters talked about where the country stands medically and scientifically, assuring people the “brightest” are on the case. “All the brightest scientists in America [are] working around the clock to find a vaccine. Our people are the most innovative in the world,” Watters said.

The host also addressed the president’s leadership, urging him and American industry leaders to do whatever they can. “The president should be invoking every possible law and power available to him. He should be mobilizing the military and declaring war on the coronavirus. Rally the country around the mantra ‘made in America,'” Watters said. “Every American industry should have all hands-on deck. This isn’t a time for weakness. This is a time for strength.”

“Our country’s fighting an invisible enemy within our borders,” Watters added. “We’ll dull the spike and kill it if we all work together.” Watters expressed his optimism toward an American rebound. “We’ve had to come together by staying apart. I know one thing for sure, we’ll stop it and we’ll kill it and we’ll be a better country for it. Tough times are ahead,” Watters said. “The American character shining bright, loving our families and our neighbors and working nonstop to save lives. It’s now in your hands. We have a great spirit and we shall overcome.”

Italy reported a second successive drop in daily deaths and infections from a coronavirus that has nevertheless claimed more than 6,000 lives in a month.The Mediterranean country has now seen its daily fatalities come down from a world record 793 on Saturday to 651 on Sunday and 601 on Monday.

The number of new declared infections fell from 6,557 on Saturday to 4,789 on Monday. The top medical officer for Milan’s devastated Lombardy region appeared on television smiling for the first time in many weeks. “We cannot declare victory just yet,” Giuglio Gallera said. “But there is light at the end of the tunnel.”

Coronavirus: why the US is in a mess, and How to Fix It and How Does the Virus Affect the Body? The Economy and Do We Have Enough Ventilators?

As this Coronavirus pandemic continues to spread, infect and kill more people we need to look the effects of this crisis. Peter Drobac reported that flattening the curve is the next goal to this new viral pandemic.

It’s always been a question of when, and not whether, humanity would face another challenge on the scale of the 1918 flu pandemic. 

The novel coronavirus is shaping up to be that challenge, with events moving at an unnerving pace. Since emerging in Wuhan, China in late 2019, more than 125,000 cases and 4,600 deaths have been reported worldwide. Officially a pandemic, the virus is shining a harsh spotlight on the strengths and weaknesses of the world’s health systems.

At first glance, the US should be well positioned to respond to a disease outbreak. It spends more than any other country on its health system, boasts a high concentration of specialists and laboratories, and has some of the world’s most respected public health experts. Yet with coronavirus, the US is courting catastrophe.

Because of serious problems with testing, coronavirus has been silently spreading in the US for nearly two months. A Harvard epidemiologist has cautioned that up to 60% of the adult population could become infected. With a health system already operating near its capacity in the height of flu season, this would spell disaster.

Hospitals would be overwhelmed. Shortages of intensive care beds and ventilators would cause death rates to rise. And people with other medical conditions, from complicated pregnancies to heart attacks, would find it more difficult to access the care they need. During the West African Ebola outbreak, health system collapse meant there were nearly as many deaths due to other diseases as from Ebola itself.

Before we all panic, there are some bright spots. Countries in Asia have shown that it is possible to bring the coronavirus epidemic under control, and they’ve had success in different ways.

But first, it’s important to understand what has gone wrong in the US.

Caught flat-footed

When the first coronavirus case was reported in the US on January 20, 2020, alarm bells were already sounding around the world. Unprecedented control measures in China, including the effective quarantine of nearly 100 million people, slowed the spread of the virus and bought the rest of the world time. But while other countries began preparing for the epidemic, the US was caught flat-footed.

Rather than use WHO-approved test kits, the US Centers for Disease Control and Prevention (CDC) developed its own coronavirus test. Regulations prohibited private and university labs from developing tests themselves. Problems with the CDC’s test, along with overly narrow testing criteria, created a massive testing bottleneck.

Fewer than 10,000 tests have been conducted in the US. Compare that with over 200,000 in South Korea. Case detection is the most fundamental part of a public health response to an outbreak. When we can’t do that, we’re operating in the dark.

Meanwhile, years of attempted budget cuts and the elimination of the federal Global Health Security office left America’s vaunted public health agencies less prepared to coordinate a response across the country’s fragmented and unequal health system. Unsteady presidential leadership has sowed confusion and misinformation.

So while 1,215 cases have been reported in 42 states, actually as of Sunday there was only the state of West Virginia that didn’t have a case of the virus, the real number is probably much higher. And with an epidemic that doubles every five days when unchecked, the US may not be far behind Italy.

Flattening the curve

So, what can the US learn from the Asian countries that have managed to blunt the spread of novel coronavirus? While no country has been able to stop the spread of the virus completely, several have managed to “flatten the curve.” What does this mean?

Flattening the epidemic curve means slowing the spread of new infections. This can ensure that not too many people are infected at the same time, giving health systems a better chance to cope. It also buys time, as researchers race to develop and test treatments and vaccines.

New cases in China have gone dropped from a flood to a trickle, at least for now, where they are only reporting 8-10 cases per day since Friday. But it required putting vast swaths of the country on total lockdown, exacting enormous economic and social pain. Italy is now following suit.

Singapore responded early, employing tried-and-tested public health measures: testing, enforced quarantine, and tracing contacts with surgical precision. The US is probably too late for this approach.

Taiwan also responded briskly, establishing a central command center, implementing targeted travel bans and proactive testing, and social distancing measures such as school closures.

South Korea may offer the best example of what could be possible in the US. Like the US, they had to play catch-up, facing a surge of infections tied to a secretive church in Daegu. The pillar of their response has been widespread, free testing, including drive-through test sites. Technology has aided the tracing of contacts, using GPS tracking. Rather than creating a total lockdown, they opted for social distancing measures targeting transmission hot spots. The number of daily new cases has dropped from a peak of 851 to fewer than 250.

Such measures would be workable in the US, but there is no time to waste. The testing bottleneck appears to be loosening, but it may be weeks before testing capacity can catch up to demand. Where possible, localities are taking matters into their own hands. 

In Seattle, one of the country’s transmission hot spots, the University of Washington launched a Korea-style drive-through test centre for its employees and students. In New Rochelle, New York, schools, churches and other gathering places in a “containment area” have been closed down. And mass gatherings are beginning to be cancelled across the country.

Efforts like this need to be scaled and spread dramatically—and quickly. Financial barriers to testing and medical care need to be eliminated, particularly for America’s large uninsured population. Hospitals and healthcare workers will need support to develop parallel care systems for coronavirus patients.

And as school closures, working from home, and transport restrictions are implemented more widely, efforts are needed to protect the most vulnerable.

The Trump administration needs to put the experts in charge and ask Congress for a blank cheque to give them the resources they need. It’s time for a war footing. 

Most importantly, everyone needs to understand that life in the time of coronavirus is different. 

A recession is unlikely but not impossible

Covid-19 infects the world economy?

As reported in Finance and Economics, if the final week of February saw financial markets jolted awake to the dangers of a COVID-19 pandemic, the first week of March has seen policymakers leaping into action. The realization that global GDP will probably shrink for part of this year, and the looming risk of a financial panic and credit-crunch, has led central banks to slash interest rates at a pace last seen in the financial crisis of 2007-09.

On March 3rd the Federal Reserve lowered its policy rate by 0.5 percentage points, two weeks before its scheduled monetary-policy meeting. Central banks in Australia, Canada and Indonesia have also cut rates. The European Central Bank and the Bank of England are expected to follow. If the money-markets are right, more Fed cuts are in store. A composite measure of the global monetary-policy rate, compiled by Morgan Stanley, a bank, is expected to fall to 0.73% by June, from 1% at the start of the year and 2% at the start of 2019.

Yet there is an uneasy feeling that a flurry of rate cuts may not be the solution to this downturn. In part that reflects the fact that they are already so low. A golden rule of crisis-fighting is that in order to be credible you should always have more ammunition available. In 2008-10 the global composite policy rate fell by three percentage points. Today, outside America, rich-world interest rates are close to, at, or below zero. Even the Fed has limited scope to cut much further—one reason, perhaps, why share prices failed to revive in the hours after its latest move.

The tension also stems from the peculiarity of the shock that the economy faces—one that involves demand, supply and confidence effects. The duration of the disruption mainly depends on the severity of the outbreak and the public-health measures undertaken to contain it. Given those uncertainties, policymakers know that while interest-rate cuts are an option, they also need fiscal and financial measures to help business and individuals withstand a temporary but excruciating cash crunch.

One way the virus hurts the economy is by disrupting the supply of labour, goods and services. People fall ill. Schools close, forcing parents to stay at home. Quarantines might force workplaces to shut entirely. This is accompanied by sizable demand effects. Some are unavoidable: sick people go out less and buy fewer goods. Public-health measures, too, restrict economic activity. Putting more money into consumers’ hands will do little to offset this drag, unlike your garden-variety downturn. Activity will resume only once the outbreak runs its course.

Then there are nasty spillovers. Both companies and households will face a cash crunch. Consider a sample of 2,000-odd listed American firms. Imagine that their revenues dried up for three months but that they had to continue to pay their fixed costs, because they expected a sharp recovery. A quarter would not have enough spare cash to tide them over, and would have to try to borrow or retrench. Some might go bust. Researchers at the Bank for International Settlements, a club of central banks, find that over 12% of firms in the rich world generate too little income to cover their interest payments.

Many workers do not have big safety buffers either. They risk losing their incomes and their jobs while still having to make mortgage repayments and buy essential goods. More than one in ten American adults would be unable to meet a $400 unexpected expense, equivalent to about two days’ work at average earnings, according to a survey by the Federal Reserve. Fearing a hit to their pockets, people could start to hoard cash rather than spend, further worsening firms’ positions.

Modeling the resulting hit to economic activity is no easy task. In China, which is a month ahead of the rest of the world in terms of the outbreak, a survey of purchasing managers shows that manufacturing output in February sank to its lowest levels since factory bosses were first surveyed in 2004. It seems likely that GDP will contract in the first quarter for the first time since the death of Mao Zedong in 1976.

Forecasters are penciling in sharp falls in output elsewhere (see chart 1). Goldman Sachs, a bank, reckons global GDP will shrink at an annualized rate of 2.5% in the first quarter. With luck the slump will end once the virus stops spreading. But even if that happens the speed and size of the economic bounce-back also depends on the extent to which those costly spillovers are avoided.

That is why central bankers and finance ministries are turning to more targeted interventions (see chart 2). These fall into three broad categories: policies to ensure that credit flows smoothly through banks and money markets; measures to help companies bear fixed costs, such as rent and tax bills; and measures to protect workers by subsidizing wage costs.

Start with credit flows. Central banks and financial regulators have tried to ensure that markets do not seize up, but instead continue to provide funds to those who need them. On March 2nd the Bank of Japan conducted ¥500bn ($4.6bn) of repo operations to ensure enough liquidity in the system. The People’s Bank of China has offered 800bn yuan ($115bn, or 0.8% of GDP) in credit to banks so long as they use it to make loans to companies badly hit by the virus. Banks have been asked to go easy on firms whose loans are coming due.

Governments are also helping firms with their costs, the second kind of intervention. Singapore plans corporate-tax breaks, and rental and tax rebates for commercial property. Korea will give cash to small firms struggling to pay wages. Italy will offer tax credits to firms that experience a 25% drop in turnover. In China the government has told state landlords to cut rents and given private-sector landlords subsidies to follow suit.

The final set of measures is meant to protect workers by preventing lay-offs and keeping incomes stable. China’s government has enacted a temporary cut to social-security contributions. Japan will subsidize wages of people who are forced to take time off to care for children or for sick relatives. Singapore has announced cash grants for employers of affected workers.

Today these policies are being sporadically announced, and their implementation is uncertain. As the virus spreads, expect more interest-rate cuts—but also the systematic deployment of a more complex cocktail of economic remedies. ■

As the Pandemic Spreads, Will There Be Enough Ventilators?

Patti Neighmond noted that as the coronavirus that causes COVID-19 spreads across the United States, there are continuing concerns among hospitals, public health experts and government leaders that hospital intensive care units would be hard-pressed to handle a surge in seriously ill patients.

A key limiting factor to being able to provide good care, they say, is the number of ventilation machines — ventilators — a hospital has on hand to help the most seriously ill patients breathe.

“The coronavirus, like many respiratory viruses, can cause inflammation in the lungs,” explains Dr. William Graham Carlos a pulmonary critical care specialist at Indiana University School of Medicine “And when the lungs become inflamed, the membranes that transfer oxygen from the air into the blood become blocked.”

When patients develop this type of viral pneumonia, they often require bedside ventilators which, Carlos says “can supply higher levels of oxygen and also help push air into the lungs to open them up, and afford more opportunity to get oxygen into the patient.”

Ventilators are generally a temporary bridge to recovery — many patients in critical care who need them do get better. These machines can be crucial to sustaining life in certain emergency situations. And if there is a surge in seriously ill patients, as COVID-19 spreads, ventilators could be in short supply, from hospital to hospital or nationally.

And if there’s an increase in very sick patients on a scale like what happened in China, Dr. Eric Toner says, the U.S. is not prepared. Toner studies hospital preparedness for pandemics at the Johns Hopkins Center for Health Security.

“We are not prepared, nor is any place prepared for a Wuhan-like outbreak,” Toner tells NPR, “and we would see the same sort of bad outcomes that they saw in Wuhan — with a very high case fatality rate, due largely to people not being able to access the needed intensive care.”

Toner says all hospitals have some lifesaving ventilators, but that number is proportional to the number of hospital beds in the institution. An average-sized hospital with 150 beds, for example, might have 20 ventilators. If more were needed, hospitals that need them could rent them, he says — at least for now. But if there’s a surge of need in a particular community — patients with serious pneumonia from COVID-19 or pneumonia related to flu, for example — all hospitals in the area would be competing to rent from the same place. “So that’s a very finite resource” he says.

The latest study available estimates there are about 62,000 ventilators in hospitals nationwide. That figure is seven years old — so the actual number could be higher.

There are also some machines in federally stockpiled emergency supplies, though the exact number isn’t public.

“There is a strategic national stockpile of ventilators, but the numbers are classified,” says Toner. It’s been “publicly stated,” he says, that there are about 10,000 ventilators in the national stockpile. “That number might be a bit outdated, but it’s probably about right,” he says. Other estimates range from 4,000 to somewhat less than 10,000.

You Have A Fever And A Dry Cough. Now What?

While any extra ventilators would be an important addition, Toner says it likely wouldn’t be enough to sustain the entire country through an experience like that seen in Wuhan, China.

If there’s not enough capacity at one hospital, it may be possible to transfer patients to another, he says.

“Not every community is going to be hit simultaneously; some cities will be badly affected while others are not so badly affected and then the wave of disease will move on.” So, in some cases, Toner says, it seems likely that patients could be transferred from an area where ventilators are scarce to an area where the supply is adequate.

But if hospitals continue to be overwhelmed, he says, at that point, “tough decisions would have to be made about who gets access to a ventilator and who does not.”

All health care providers and hospitals are now working overtime to try to prevent that sort of scenario.

Dr. Craig Coopersmith with Emory University School of Medicine, and a spokesperson for the Society of Critical Care Medicine, says he sees signs all across America that medical communities are working together to prepare.

Evergreen Hospital in Washington State, for example, which treated some of the first U.S. COVID-19 patients in late February, this week posted online its own “Lessons for Hospitals.” There has been a lot of ongoing communication, Coopersmith says, between hospitals, professional societies and individuals — in person, by phone and via shared Listservs and social media.

“In multiple ways, people are linking with each other to say ‘I’m not going to do this in isolation; tell me how you’re doing this, let me tell you how I’m doing this and let’s share lessons with each other,’ ” Coopersmith says.

The pandemic, he adds, is “remarkably challenging. But he sees the health care system’s response to it as remarkably heartening, “with everyone working together to ensure what’s best for patients, caregivers and the community.”

What does the coronavirus do to your body? Everything to know about the infection process

A visual guide of coronavirus infection, symptoms of COVID-19 and the effects of the virus inside the body, in graphics

Javier Zarracina and Adrianna Rodriquez reported that as the COVID-19 pandemic spreads across the U.S. – canceling major events, closing schools, upending the stock market and disrupting travel and normal life – Americans are taking precautions against the new coronavirus that causes the disease sickening and killing thousands worldwide.

The World Health Organization and U.S. Centers for Disease Control and Prevention advise the public be watchful for fever, dry cough and shortness of breath, symptoms that follow contraction of the new coronavirus known as SARS-CoV-2.

From infection, it takes approximately five to 12 days for symptoms to appear. Here’s a step-by-step look at what happens inside the body when it takes hold. 

Coronavirus infection

According to the CDC, the virus can spread person-to-person within 6 feet through respiratory droplets produced when an infected person coughs or sneezes. 

It’s also possible for the virus to remain on a surface or object, be transferred by touch and enter the body through the mouth, nose or eyes.

Dr. Martin S. Hirsch, senior physician in the Infectious Diseases Services at Massachusetts General Hospital, said there’s still a lot to learn but experts suspect the virus may act similarly to SARS-CoVfrom 13 years ago.

“It’s a respiratory virus and thus it enters through the respiratory tract, we think primarily through the nose,” he said. “But it might be able to get in through the eyes and mouth because that’s how other respiratory viruses behave.”

When the virus enters the body, it begins to attack.

Fever, cough and other COVID-19 symptoms 

It can take two to 14 days for a person to develop symptoms after initial exposure to the virus, Hirsch said. The average is about five days.

Once inside the body, it begins infecting epithelial cells in the lining of the lung. A protein on the receptors of the virus can attach to a host cell’s receptors and penetrate the cell. Inside the host cell, the virus begins to replicate until it kills the cell. 

This first takes place in the upper respiratory tract, which includes the nose, mouth, larynx and bronchi.

The patient begins to experience mild version of symptoms: dry cough, shortness of breath, fever and headache and muscle pain and tiredness, comparable to the flu.

Dr. Pragya Dhaubhadel and Dr. Amit Munshi Sharma, infectious disease specialists at Geisinger, say some patients have reported gastrointestinal symptoms such as nausea and diarrhea, however it’s relatively uncommon. 

Symptoms become more severe once the infection starts making its way to the lower respiratory tract.

Pneumonia and autoimmune disease

The WHO reported last month about 80% of patients have a mild to moderate disease from infection. A case of “mild” COVID-19 includes a fever and cough more severe than the seasonal flu but does not require hospitalization.

Those milder cases are because the body’s immune response is able to contain the virus in the upper respiratory tract, Hirsch says. Younger patients have a more vigorous immune response compared to older patients.

Dr. Pragya Dhaubhadel and Dr. Amit Munshi Sharma, infectious disease specialists at Geisinger, say some patients have reported gastrointestinal symptoms such as nausea and diarrhea, however it’s relatively uncommon. 

Symptoms become more severe once the infection starts making its way to the lower respiratory tract.

Pneumonia and autoimmune disease

The WHO reported last month about 80% of patients have a mild to moderate disease from infection. A case of “mild” COVID-19 includes a fever and cough more severe than the seasonal flu but does not require hospitalization.

Those milder cases are because the body’s immune response is able to contain the virus in the upper respiratory tract, Hirsch says. Younger patients have a more vigorous immune response compared to older patients.

The 13.8% of severe cases and 6.1% critical cases are due to the virus trekking down the windpipe and entering the lower respiratory tract, where it seems to prefer growing.

“The lungs are the major target,” Hirsch said.

As the virus continues to replicate and journeys further down the windpipe and into the lung, it can cause more respiratory problems like bronchitis and pneumonia, according to Dr. Raphael Viscidi, infectious disease specialist at Johns Hopkins Medicine.

Pneumonia is characterized by shortness of breath combined with a cough and affects tiny air sacs in the lungs, called alveoli, Viscidi said. The alveoli are where oxygen and carbon dioxide are exchanged.

When pneumonia occurs, the thin layer of alveolar cells is damaged by the virus. The body reacts by sending immune cells to the lung to fight it off. 

“And that results in the linings becoming thicker than normal,” he said. “As they thicken more and more, they essentially choke off the little air pocket, which is what you need to get the oxygen to your blood.” 

“So it’s basically a war between the host response and the virus,” Hirsch said. “Depending who wins this war we have either good outcomes where patients recover or bad outcomes where they don’t.”

Restricting oxygen to the bloodstream deprives other major organs of oxygen including the liver, kidney and brain. 

In a small number of severe cases that can develop into acute respiratory distress syndrome (ARDS), which requires a patient be placed on a ventilator to supply oxygen. 

However, if too much of the lung is damaged and not enough oxygen is supplied to the rest of the body, respiratory failure could lead to organ failure and death. 

Viscidi stresses that outcome is uncommon for the majority of patients infected with coronavirus. Those most at risk to severe developments are older than 70 and have weak immune responses. Others at risk include people with pulmonary abnormalities, chronic disease or compromised immune systems, such as cancer patients who have gone through chemotherapy treatment. 

Viscidi urges to public to think of the coronavirus like the flu because it goes through the same process within the body. Many people contract the flu and recover with no complications. 

“People should remember that they’re as healthy as they feel,” he said. “And shouldn’t go around feeling as unhealthy as they fear.” 

Coronavirus Disease 2019: Myth vs. Fact 

There’s a lot of information circulating about Coronavirus Disease 2019 (COVID), so it’s important to know what’s true and what’s not. Lisa Maragakis, M.D., M.P.H., senior director of infection prevention at Johns Hopkins, helps clarify information to help keep you and your family healthy and safe.

TRUE or FALSE? A vaccine to cure COVID-19 is available.

FALSE.

True: There is no vaccine for the new coronavirus right now. Scientists have already begun working on one, but developing a vaccine that is safe and effective in human beings will take many months.

TRUE or FALSE? You can protect yourself from COVID-19 by swallowing or gargling with bleach, taking acetic acid or steroids, or using essential oils, salt water, ethanol or other substances.

FALSE.

True: None of these recommendations protects you from getting COVID-19, and some of these practices may be dangerous. The best ways to protect yourself from this coronavirus (and other viruses) include:

Washing your hands frequently and thoroughly, using soap and hot water.

Avoiding close contact with people who are sick, sneezing or coughing.

In addition, you can avoid spreading your own germs by coughing into the crook of your elbow and staying home when you are sick.

TRUE or FALSE? The new coronavirus was deliberately created or released by people.

FALSE.

True: Viruses can change over time. Occasionally, a disease outbreak happens when a virus that is common in an animal such as a pig, bat or bird undergoes changes and passes to humans. This is likely how the new coronavirus came to be.

TRUE or FALSE? Ordering or buying products shipped from China will make a person sick.

FALSE.

True: Researchers are studying the new coronavirus to learn more about how it infects people. As of this writing, scientists note that most viruses like this one do not stay alive for very long on surfaces, so it is not likely you would get COVID-19 from a package that was in transit for days or weeks. The illness is most likely transmitted by droplets from an infected person’s sneeze or cough, but more information is emerging daily.

TRUE or FALSE? A face mask will protect you from COVID-19.

FALSE.

True: Certain models of professional, tight-fitting respirators (such as the N95) can protect health care workers as they care for infected patients.

For the general public without respiratory illness, wearing lightweight disposable surgical masks is not recommended. Because they don’t fit tightly, they may allow tiny infected droplets to get into the nose, mouth or eyes. Also, people with the virus on their hands who touch their face under a mask might become infected.

People with a respiratory illness can wear these masks to lessen their chance of infecting others. Bear in mind that stocking up on masks makes fewer available for sick patients and health care workers who need them.

We all have to utilize the best actions to get through this pandemic with good hygiene, cleaning surfaces and social distancing. Remember, we have no vaccines, not antiviral agents proven to work. Therefore, we need to our immune systems and the health care system to flatten the outbreak curve. We need to take the police out of the equation and decision making and support our health care, our workers who will lose their jobs due to this pandemic and the economy. Now!!

Surprise medical bills, coronavirus and bad insurance: 3 arguments for Medicare for All’ Really?

As we saw Wednesday the WHO declared the Corona Virus/COID-19 a pandemic. We also heard the President role out plans for travel restrictions, increased testings and economic assistance. But what really gets me angry is that the Democrats in Congress are still making this a political battleground. Shame on them all! This is not the time for partisan politics so that they can embarrass the President and get their wishes and show the evilness of the political hate out there. Grow up Congress and let’s all get in on this battle to keep us all healthy and limit the death toll!! Philip Verhoef of USA Today reported that Congress is grappling with the problem of surprise medical bills, but will its Band-Aid approaches make a difference? As a physician, I’m trained to look beyond superficial symptoms to diagnose the underlying ailment. When patients pay thousands of dollars each year for “good” private insurance, how does a health care system allow them to walk away from a single hospital visit with debilitating medical debt? These concerns have become even more pressing with the spread of the new coronavirus and the costs associated with prevention, testing and treatment.

Most Americans assume that a commercial insurance card in their wallet protects them from unexpected medical bills. They pay their premiums and deductibles, scour the pages of insurance fine print and keep up with the revolving door of “in-network” doctors and hospitals. 

However, going to the “in-network” hospital is no guarantee that the emergency room doctor, radiologist or anesthesiologist will be “in-network.” Today, many hospitals no longer directly employ physicians but instead contract with physician staffing firms such as TeamHealth, which employs more than 16,000 clinicians at 3,300 medical facilities.

Caught unaware in a medical crisis

These agencies are extremely profitable, which is why private equity firms are so hungry to buy them. Contract physicians operate outside of insurance coverage agreements — they’re not part of any “network” — and can act like free agents, billing patients directly for services not covered by insurance, called “balance billing.”  

What does this mean for patients? Imagine you’re having a heart attack and call 911. Paramedics transport you to the nearest emergency room, which may or may not be in your insurer’s network. And because that hospital — or the ER doctor on duty —  does not have a contractual relationship with your insurer, they can essentially name their price and “balance bill” you for the amount the insurance company won’t cover. 

Here in Hawaii, many critically ill patients must use air ambulances for transportation from their home island to one that can provide emergency specialty services. For one of my patients, an air ambulance was a life-or-death necessity but deemed “out of network” by their insurance. Weeks later, the family received a balance bill for more than $25,000. They were forced to file bankruptcy and then enroll in Medicaid to cover subsequent health care costs — all with an insurance card in their wallet.

If this hasn’t happened to you, it’s just a matter of time. Over 40% of privately insured patients face surprise medical bills after visiting emergency rooms or getting admitted to hospitals. These bills punch a major hole in most family budgets: The average surprise hospital bill is $628 for emergency care and $2,040 for inpatient admission. That’s on top of the more than $20,000 families pay in premiums and deductibles each year just for the insurance policy.

If faced with a surprise $500 medical bill, half of Americans would either have to borrow money, go into debt or wouldn’t be able to pay it at all. Medical bills are a key contributor in two-thirds of personal bankruptcies, and yet the vast majority of households filing for medical bankruptcy have insurance. 

Medicare for All is the only solution-Really??

What is the value of commercial insurance if it can’t protect us from financial ruin? 

Lawmakers are considering a number of policies that would prohibit balance billing, cap the amount patients pay at out-of-network facilities and implement baseball-style arbitration when providers and insurance companies can’t agree on a payment. But surprise bills are not the real problem — they are merely one symptom of a dysfunctional system based on private insurance. And insurance companies only turn a profit by restricting patient choice, denying claims and passing costs onto enrollees.

The only policy that can end this scourge for good is single-payer Medicare for All, which would cover everyone in the nation for all medically necessary care. Medicare for All would eliminate out-of-network bills, because every doctor and hospital would be covered. Patients would never see a medical bill again, because Medicare for All would pay doctors and hospitals directly, with no deductibles, co-pays or insurance paperwork to get in the way.

Right now the current Medicare system is covering the costs of coronavirus testing, protecting patients just as it was designed to do. This health emergency is another argument for expanding such protections to all Americans.

Working in various hospitals across the country, I have met so many patients who delay or avoid needed care for fear of surprise bills and financial catastrophe. That’s risky for them and, in the face of a threat like coronavirus, for all of us. It doesn’t have to be this way. As a doctor, I prescribe Medicare for All. 

We are forgetting the huge cost of Medicare for All and the ineffectiveness and short comings of Medicare for All , which I have attempted to point out these last few weeks. Doesn’t any one read my posts?

America’s Health System Will Likely Make the Coronavirus Outbreak Worse

Abigail Abrams noted that as government officials race to limit the spread of the new coronavirus, fundamental elements of the U.S. health care system—deductibles, networks, and a complicated insurance bureaucracy—that already make it tough for many Americans to afford medical care under normal conditions will likely make the outbreak worse.

More than 140 cases of the coronavirus have been confirmed in the United States so far, according to a Johns Hopkins University tracker. But as the CDC makes the test for the virus more widely available, the structure of the U.S. health care system is complicating the response.

For one, people must actually choose to get tested—a potentially expensive prospect for millions of Americans. While the government will cover the cost of testing for Medicaid and Medicare patients, and for tests administered at federal, state and local public health labs, it’s unclear how much patients will be charged for testing at academic or commercial facilities, or whether those facilities must be in patients’ insurance networks. Just recently, a Miami man received a $3,270.75 bill after going to the hospital feeling sick following a work trip to China. (He tested positive for the seasonal flu, so did not have the new coronavirus, and was sent home to recover.)

Those who test positive for COVID-19 possibly face an even more financially harrowing path forward. Seeking out appropriate medical care or submitting to quarantines—critical in preventing the virus from spreading further—both come with potentially astronomical price tags in the U.S. Last month, a Pennsylvania man received $3,918 in bills after being released from a mandatory U.S. government quarantine after he and his daughter were evacuated from China. (Both the Miami and Pennsylvania patients saw their bills decrease after journalists reported on them, but they still owe thousands.)

More than 27 million Americans currently do not have health insurance of any kind, and even more are underinsured. But those who do have adequate health insurance are hardly out of the woods. Many current health plans feature massive deductibles—the amount you have to spend each year before your insurance kicks in. In 2019, 82% of workers with health insurance through their employer had an annual deductible, up from 63% a decade ago, according to a report from the Kaiser Family Foundation. The average deductible for a single person with employer insurance has increased 162% in that time, from $533 in 2009 to $1,396 last year.

More than one quarter of employees, and nearly half of those at small companies, have an annual deductible of at least $2,000. Those who are covered by Obamacare marketplace plans face an even bigger hurdle: the average deductible for an individual bronze plan last year was $5,861, according to Health Pocket, a site that helps consumers shop for health insurance.

For many Americans, paying down an unexpected bill of that size is almost unthinkable. Nearly 40% of U.S. adults say they wouldn’t be able to cover a $400 emergency with cash, savings or a credit card they could easily pay off, according to the Federal Reserve.

Research has shown that even in non-outbreak situations, high deductibles lead people to reduce their spending on health care and delay treatment or prescription drugs, which can pose particularly tough problems for patients with chronic illness or diseases that need early detection. The timing of the new coronavirus at the beginning of the year makes the outlook even worse: because most deductibles reset each January, millions of Americans will be paying thousands out of pocket before their insurance companies pay a cent.

“Most likely most people haven’t started paying down their deductible,” explains Adrianna McIntyre, a health policy researcher at Harvard. “For care they seek, unless it’s covered as zero dollar coverage before the deductible, they could be on the hook for the full cost of their visit, the diagnostic testing and other costs related to seeking care or diagnosis of coronavirus.”

Half of Americans report that they or a family member have put off care in the past because they couldn’t afford it. Others have gone without care because they couldn’t find an in-network provider, or couldn’t determine how much care would cost in advance, so decided not to risk seeking medical attention.

“When patients try to go to a doctor or hospital, they often don’t know how much it’s going to cost, so they get a bill that’s way more than expected,” says Christopher Whaley, a health economist at the RAND Corporation. “On a normal basis, that’s chaotic and challenging for patients. But when you add on top this situation where you have a potential pandemic, then that’s even worse.”

In the face of that kind of uncertainty, many patients may simply decide not to go to the doctor, he added, which is “exactly the opposite of what we want to happen in this type of situation.”

Public health experts and Democrats have also criticized the Trump administration’s decision to allow people to sidestep the Affordable Care Act’s rules and buy limited, short-term health insurance coverage. Such “junk plans,” said Senator Patty Murray, speaking at a Senate Health, Education, Labor and Pensions Committee hearing on Wednesday, are not required to cover diagnostic tests or vaccines.

The Trump administration’s embrace of such barebones plans “makes it much harder for people to get the care they need to keep this crisis under control,” she said. A large group of health, law and other experts also released a letter this week urging policymakers to “ensure comprehensive and affordable access to testing, including for the uninsured.”

Insurance industry trade group America’s Health Insurance Plans issued guidance on the coronavirus last week, but it did not recommend that insurance companies eliminate out-of-pocket costs related to the virus. It said insurers would be working with the CDC and “carefully monitoring the situation” to determine “whether policy changes are needed to ensure that people get essential care.”

New York Governor Andrew Cuomo issued a directive on Monday requiring New York health insurers to waive cost sharing for testing of the coronavirus, including emergency room, urgent care and office visits. This could help New Yorkers who receive coverage through Medicaid and other state-regulated plans, but it won’t apply to the majority of employer-based health insurance, which is regulated by the federal government. Other states have similar limitations on the insurance plans they can regulate, according to McIntyre.

The federal government, on the other hand, could step in. The Trump Administration is considering using a national disaster recovery program to reimburse hospitals and doctors for treating uninsured COVID-19 patients. And even Republicans, who have traditionally opposed health care paid for by the government, are warming to the idea. “You can look at it as socialized medicine,” Florida Rep. Ted Yoho, who has vocally opposed the Affordable Care Act, told HuffPost this week. “But in the face of an outbreak, a pandemic, what’s your options?”

But even if the federal government takes steps to eliminate deductibles or other cost-sharing related to the coronavirus, experts say that Americans should brace themselves for long wait times to see providers, or for having to see doctors who are out-of-network, due to the limited capacity of providers and hospitals.

Those who don’t need to be treated at a hospital may still be impacted. The CDC has recommended that people maintain a supply of necessary medications in case they are quarantined, for example. But many insurance companies do not allow patients to refill prescriptions until they are almost out. The CDC also recommends that people to stay home from work if they experience symptoms of respiratory illness, but a lack of federally mandated sick leave makes it impossible for many workers to afford to take time off.

These consequences of the country’s fragmented health care system become more visible in times of stress, says Whaley. “In a pandemic type situation, that’s harmful both for patients,” he says, “and also for the members of society.

”Coronavirus: US ‘past the point of containment’ in battle to stop outbreak spreading

Tim Wyatt reported that America is “past the point of containment” in its battle against the coronavirus, senior health officials have admitted.

There are now more than 550 confirmed cases of the virus in the United States and at least 22 deaths linked to the outbreak.

Now, the government’s strategy had to change from trying to hold the virus at bay to actively seeking to minimise its impact and slow its spread, experts said.

Speaking on US television, the former commissioner of the Food and Drug Administration Dr Scott Gottlieb, said everything had changed.

“We’re past the point of containment. We have to implement broad mitigation strategies. The next two weeks are really going to change the complexion in this country.

“We’ll get through this, but it’s going to be a hard period. We’re looking at two months, probably, of difficulty.”

A similar message came from the Surgeon General Jerome Adams who warned it was time to consider cancelling large gatherings, including sporting events, and closing schools.

Each community might take a different approach to mitigating Covid-19, but inaction was not longer an option he cautioned while speaking to CNN. “Communities need to have that conversation and prepare for more cases so we can prevent more deaths,” he said.

Those in the most at-risk groups, including the elderly or unwell, should refrain from spending time in confined spaces with large numbers of the public, Dr Adams added.“Average age of death for people from coronavirus is 80. Average age of people who need medical attention is age 60. “We want people who are older, people who have medical conditions, to take steps to protect themselves, including avoiding crowded spaces, including thinking very carefully about whether or not now is the time to get on that cruise ship, whether now is the time to take that long haul flight,” he said.

Dr Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, echoed this advice. “If you are an elderly person with an underlying condition, if you get infected, the risk of getting into trouble is considerable,” he told NBC.“So it’s our responsibility to protect the vulnerable. When I say protect, I mean right now. Not wait until things get worse. Say no large crowds, no long trips. And above all, don’t get on a cruise ship.”

A swathe of conferences, including many tech-focused events in California, have already been cancelled over fears flying in thousands of delegates from across the country and world would exacerbate the spread of Covid-19. Some schools in the US are already closing, with major sporting events such as the Indian Wells tennis tournament being cancelled.

The comments from senior Trump administration health officials marks a shift from an earlier tone of calm. Several people, including the president, had sought to downplay fears about the coronavirus, insisting it probably would not turn into a full-blown epidemic in America.

Dr Fauci even suggested limited lockdowns could be imposed on regions or towns where a serious outbreak occurs, saying the government was ready to take “whatever action is appropriate” to try and mitigate the crisis.’We’re gearing up for something extremely significant’: 

Top hospitals across the US told us how they’re preparing for the coronavirus outbreak

Lydia Ramsey and Zachary Tracer reviewed the U.S. hospitals preparation for this pandemic. Hospitals around the US are preparing for the novel coronavirus outbreak, which has sickened more than 200 people in the US and 100,000 worldwide.

They want to make sure workers and equipment are ready to go in the event of a worst-case scenario. “We’ve not yet seen an epidemic or pandemic in our lifetimes of this size and scope,” said Becca Bartles, the executive director of infectious disease prevention at Providence St. Joseph Health System. “We’re gearing up for something extremely significant.”

When the first case of novel coronavirus showed up in the US in January, Becca Bartles was ready for it. 

As the executive director of infectious disease prevention at Providence St. Joseph Health System, she had been preparing for years. Bartles helps prepare Providence, which runs 51 hospitals across the West Coast, for potential outbreaks by keeping an eye out for new pathogens that could hit the communities the health system serves. 

“We’ve not yet seen an epidemic or pandemic in our lifetimes of this size and scope,” Bartles said.  “We’re gearing up for something extremely significant.”

Hospitals and healthcare workers are already starting to feel the effects of the coronavirus outbreak as it hits communities around the US. The US has reported more than 200 cases of the novel coronavirus, which causes the disease known as COVID-19.  More than 100,000 people have come down the virus worldwide, mainly in China.

And they’re preparing for the outbreak to get worse. Some of the hospitals Bartles works with are in the Seattle area and are already treating coronavirus patients. She said the virus is positioned to be the biggest outbreaks we’ve seen in recent US history.

‘It will stretch our capacity to provide healthcare overall in the US’

“I don’t think we can appreciate, based on what we’ve seen in our lifetimes, how big that’s going to be,” Bartles said. “That does cause me significant concern.” “It will stretch our capacity to provide healthcare overall in the US,” she added.

According to the US Centers for Disease Control and Prevention, reported symptoms related to the novel coronavirus include fever, cough, and shortness of breath, appearing within 14 days of exposure to the virus.

In a presentation hosted by the American Hospital Association, which represents thousands of hospitals and health systems, one expert projected there could be as many as 96 million cases in the US, 4.8 million hospitalizations, and 480,000 deaths associated with the novel coronavirus. The American Hospital Association said the webinar reflects the views of the experts who spoke on it, not its own. 

Preparing for the worst 

Health systems like Providence perform drills and trainings in anticipation of outbreaks like the novel coronavirus. The goal is to make sure employees, especially those working in the emergency department or who might care for critically ill patients, are trained correctly and have the right protective equipment.

And they’re ramping those up now. In Philadelphia, Jefferson Health has been conducting extra protective-equipment trainings, focused on intensive care unit clinicians who might treat people with the coronavirus.

The 14-hospital system also started a coronavirus task force this week and is readying its outbreak plans. The idea is to prepare for a worst-case scenario.

“We’re saying, look, let’s plan as if there’s going to be a lot of cases, it’s going to be overwhelming to our hospital,” said Dr. Edward Jasper, an emergency medicine physician who leads the task force. “We don’t think that’s going to happen. And then whatever else comes, it’s going to be nothing compared to that. So we’re prepared.”

For now, Jasper said he’s not expecting the worst. “We watch it so closely and right now it’s not triggering keeping me awake at night,” he said.

At Providence, Bartles said leaders within the organization are now meeting multiple times a day to discuss issues like making sure the hospitals have enough supplies on hand, especially protective equipment for those working in emergency departments. 

The goal of the meetings is also to inform other hospitals across Providence’s network of what’s going on in Washington, which has been hit hard with the virus. 

How the largest health system in New York is preparing

The senior leadership at New York’s Northwell Health System, which operates 23 hospitals, has been meeting continuously for the last several weeks, chief quality officer Dr. Mark Jarrett told Business Insider.  The discussions cover what happens if one individual comes in with symptoms all the way to a pandemic. 

Northwell’s relying on some of the preparation it did in advance of the SARS epidemic in 2003, and its response to the H1N1, or Swine Flu pandemic in 2009. But, Jarrett said, the hospital has changed a lot since then.  Northwell, New York’s largest health system by revenue and the state’s largest private employer, has been steadily moving more of its services outside the four walls of a hospital. 

That means the health system will have to account for patients showing up for care in places other than the main hospital in a community — places like urgent care centers and primary care clinics.

Readying hospitals for a surge of patients

Should the outbreak intensify, hospitals are grappling with how to prepare for the surge in coronavirus patients while also keeping other patients safe. At first, hospitals will isolate patients with the coronavirus, but if lots of patients come down with the virus, hospitals will probably put them in rooms together, said Kelly Zabriskie, Jefferson’s director of infection prevention.

Dr. Kathleen Jordan, a vice president at CommonSpirit Health, a 142-hospital health system and chief medical officer at the system’s Saint Francis Memorial Hospital, told Business Insider that the health system is having conversations about what might happen if they’re confronted with an influx of patients. 

That might include setting up tents, building out larger emergency rooms or adding more beds for patients who need to stay at the hospital. For now, the health system has a few cases of the novel coronavirus under investigation.  Eventually, hospitals might have to consider reducing or pausing elective procedures to make room for the surge in patients, Northwell’s Jarrett said.  Hospitals are also thinking about staff being out, either due to the virus itself, or in the event that they have to care for their family.

Northwell on Tuesday told its employees that it’s restricting travel for business both internationally and domestically through the end of March. That’s a move other hospitals are making as well. “These updated travel guidelines are designed to help us remain in good physical health so we can most effectively care for the patients and families we serve,” Northwell said in an email to employees.  

But you shouldn’t rush to the emergency room if you start having flu symptoms.  Bartles said the plan is to focus on following CDC recommendations. As the virus continues to spread in communities, it will be harder to distinguish what might be flu from coronavirus. 

Jan Emerson-Shea, a spokeswoman for the California Hospital Association, said hospitals are encouraging patients to call ahead or use an online doctor visit, rather than show up to an emergency room with potential coronavirus. That can help prevent them from infecting others, and let hospitals focus their resources on the most serious cases.

And lastly, few have mentioned that in China they are already taking down some of the temporary housing for the quarantined patients as the infection rate decreases. Important to note as we prepare for the worst!

And next week we should discuss the economic issues resulting from the pandemic!

Can You Afford To Get Coronavirus? How to Prepare for the Virus andHow The U.S. Healthcare System Is Failing Us

This is a lengthy post but with all the fear regarding COVID-19 I thought that it would be worth the time. I became more aware as we traveled to the West Coast for a half marathon at Napa Valley. There were many people on our planes wearing masks and my wife was so worried about our planned trip to Europe in April.  The cruise companies now our offering  to either give one hundred percent refund or hold the paid fees for 2 years to allow rescheduling of the cruises.  Can you imagine what the Corona Virus scare is doing to economies around the world>

Sarah Midkiff reported that as the deadly coronavirus outbreak approaches pandemic status, the U.S. government remains in the midst of approving legislation for a $7.5 billion emergency spending bill. Meanwhile, coronavirus continues its spread in the U.S. — with 100 confirmed cases and six deaths across 15 states — so the need for these funds is more imperative than ever. The emergency bill will allocate money to the Department of Health and Human Services for vaccine development, protective and medical equipment, and aid for state and local governments affected by an outbreak, according to the Washington Post.

But, what legislators have yet to mention is whether subsidizing treatment or funding low-cost and free clinics will be part of the plan. The bill may address availability of vaccine development, but it does not directly address affordability of testing or treatment, which is of the utmost importance during a pandemic.

A report published by America’s Health Insurance Plans (AHIP) on Thursday stated that the Centers for Disease Control and Prevention (CDC) is currently the only facility equipped to test for COVID-19. The CDC is not billing for testing, but the test itself isn’t the only line item on a possible medical bill. There is the cost of the doctor’s visit; other tests they might run in conjunction with COVID-19, such as standard flu tests; treatment and medication, as well as getting the vaccine when it becomes available. And, medical bills can grow astronomically high if someone requires in-patient care, like an overnight stay in the hospital.

Stories have already begun to emerge of Americans seeking testing only to find that their insurance was insufficient to the tune of thousands of dollars in medical bills. One such example is a man in Florida who faces a $3,270 medical bill after he went through his insurance when he was concerned he might have been exposed to coronavirus. He was confirmed negative for COVID-19 after testing positive for the flu via a standard flu test rather than the more expensive CT scan which has been proven to be the most consistent test in diagnosing coronavirus.

Others have undergone government-mandated treatment and found that, despite the procedure being required, they were the ones left to foot bills that totaled thousands of dollars. Experiences like this make it easy to see why a 2018 national poll conducted by West Institute and NORC at the University of Chicago found that 44% of Americans declined to see a doctor due to cost.

Notably, the U.S. is alone among other developed countries as the only one that doesn’t offer federally mandated paid sick leave. This makes it particularly difficult to follow the CDC’s current advice that people experiencing even mild respiratory symptoms should stay home, other than when getting medical care. Between a lack of mandated paid sick leave and approximately 27 million Americans currently without health insurance, the coronavirus outbreak is at risk of exhausting our already failing public health system.

Even among people with health insurance, 29% are underinsured, according to results from a 2018 Commonwealth’s Fund survey, meaning that even though they technically have an insurance plan, the copays and deductibles make seeking care unaffordable in relation to their income. Cases of the virus could go undetected and untreated simply because Americans cannot afford to be saddled with medical debt or go without pay to take sick leave (or both), thus encouraging a rapid spread of the virus as people attempt to “power through” in spite of symptoms.

And then there are the approximately 11 million undocumented U.S. residents: Many of these people are un- or under-insured, and also have to grapple with the justified fear of coming into contact with federal authorities, therefore preventing them from seeking medical care.

If further evidence is needed that our health care system has been crippled by privatization, government officials are not debating whether or not pharmaceutical companies should be allowed to profit from a vaccine, but are just figuring out by how much. Last week, the Department of Health and Human Service secretary, Alex Azar, would not commit to price controls on a coronavirus vaccine. “We need the private sector to invest… price controls won’t get us there,” said Azar.

House Speaker Nancy Pelosi responded directly to Azar’s comments. “This would be a vaccine that is developed with taxpayer dollars…We think that should be available to everyone—not dependent on ‘Big Pharma,’” she said in a press release on February 27. She described the vaccine as needing to be “affordable,” but what does that even mean? What is affordable to some is not affordable to all. 

Still, a vaccine – affordable or not – is a ways off. In a coronavirus task force briefing with Donald Trump on Monday, experts estimated that it would take a year to a year-and-a-half before a vaccine would be effective and safe for the public, reports CNN. Until then, the economic inequality that runs rampant in America is bound to be reflected in who can afford to survive this epidemic, and who can’t.

US may pay for uninsured coronavirus patients

Washington (AFP) – The US may invoke an emergency law to pay for uninsured patients who get infected with the new coronavirus, a senior health official said Tuesday.

Public health experts have warned that the country’s 27.5 million people who lack health coverage may be reluctant to seek treatment, placing themselves at greater risk and fueling the spread of the disease.

Robert Kadlec, a senior official with the Health and Human Services department told the Senate on Tuesday that talks were underway to declare a disaster under the Stafford Act, which would allow the patients’ costs to be met by the federal government.

Under this law, their health care providers would be reimbursed at 110 percent of the rate for Medicaid, a government insurance program for people with low income, he added.

“We’re in conversations, initial conversations with CMS (Centers for Medicare & Medicaid Services) to understand if that could be utilized in that way and be really impactful,” Kadlec told a Senate committee.

President Donald Trump also touched on the issue as he headed to a briefing on the coronavirus outbreak at the National Institutes of Health in Washington on Tuesday.

“We’re looking at that whole situation. There are many people without insurance,” Trump told reporters.

The number of Americans without health insurance began falling from a high of 46.5 million in 2010 following the passage of Obamacare (the Affordable Care Act).

It climbed again to 27.5 million in 2018, or 8.5 percent of the population, from 25.6 million the year before.

The reasons include policies by Trump’s administration that made it harder to enroll in Medicaid — such as adding requirements to work — or to sign up for insurance under the marketplaces created by Obamacare.

The Republican-held Congress also repealed a penalty on people who lack insurance, which may have led people to voluntarily drop out.

The Centers for Disease Control and Prevention (CDC) has said patients who are advised by their health care providers to stay at home should do so for at least two weeks, but a work culture that emphasizes powering through while sick could compound the problem further.

The US is alone among advanced countries in not offering any federally mandated paid sick leave. While some states have passed their own laws, 25 percent of American workers lacking any whatsoever, according to official data.

Maia Majumder, an epidemiologist at Harvard, told AFP she was particularly concerned by low-wage workers in the service and hospitality sector, who cannot afford to take time off but could act as vectors to transmit the spread of the disease.

The latest coronavirus death rate is 3.4% — higher than earlier figures. Older patients face the highest risk.

The global death rate for the novel coronavirus based on the latest figures is 3.4% — higher than earlier figures of about 2%.

  • In contrast, the seasonal flu kills 0.1% of those infected.
  • A patient’s risk of death from COVID-19 varies depending on age and preexisting health conditions.
  • Though the latest numbers mark an increase in mortality, experts have predicted that the fatality rate of COVID-19 could decrease as the number of confirmed cases rises.

The latest global death rate for the novel coronavirus is 3.4% — higher than earlier figures of about 2%. 

The coronavirus outbreak that originated in Wuhan, China, has killed more than 3,100 people and infected nearly 93,000 as of Tuesday. The virus causes a disease known as COVID-19.

Speaking at a media briefing, the World Health Organization’s director-general, Tedros Adhanom Ghebreyesus, noted that the death rate was far higher than that of the seasonal flu, which kills about 0.1% of those infected.

The death rate is likely to change further as more cases are confirmed, though experts predict that the percentage of deaths will decrease in the longer term since milder cases of COVID-19 are probably going undiagnosed.

“There’s another whole cohort that is either asymptomatic or minimally symptomatic,” Anthony Fauci, the director of the US National Institute of Allergy and Infectious Diseases, said at a briefing last month. “We’re going to see a diminution in the overall death rate.”

‘It is a unique virus with unique characteristics’

Tedros noted differences between the novel coronavirus and other infectious diseases like MERS, SARS, and influenza. He said the data suggested that COVID-19 did not transmit as efficiently as the flu, which can be transmitted widely by people who are infected but not yet showing symptoms. 

He added, however, that COVID-19 caused a “more severe disease” than the seasonal flu and explained that while people around the world may have built up an immunity to the flu over time, the newness of the COVID-19 meant no one yet had immunity and more people were susceptible to infection. 

“It is a unique virus with unique characteristics,” he said. 

Tedros said last week that the mortality rate of the disease could differ too based on the place where a patient receives a diagnosis and is treated. He added that people with mild cases of the disease recovered in about two weeks but severe cases may take three to six weeks to recover.

Older patients face the highest risk 

A patient’s risk of dying from COVID-19 varies based on several factors, including where they are treated, their age, and any preexisting health conditions.

COVID-19 cases have been reported in at least 76 countries, with a vast majority in China. 

A study conducted last month from the Chinese Center for Disease Control and Prevention showed that the virus most seriously affected older people with preexisting health problems. The data suggests a person’s chances of dying from the disease increase with age.

Notably, the research showed that patients ages 10 to 19 had the same chance of dying from COVID-19 as patients in their 20s and 30s, but the disease appeared to be much more fatal in people ages 50 and over. 

About 80% of COVID-19 cases are mild, the research showed, and experts think many mild cases haven’t been reported because some people aren’t going to the doctor or hospitals for treatment. 

CDC reports 108 cases of coronavirus, including presumed infections; 4 more deaths

The Centers for Disease Control and Prevention (CDC) on Tuesday confirmed 17 new cases of the coronavirus and four more deaths due to the outbreak, bringing the total number of U.S. cases to 108, including among repatriated citizens.

Coronavirus is making some Republicans reconsider the merits of free health care

Tim O’Donnell reported that the Coronavirus has a lot of people re-thinking things. That apparently includes Republicans and government-funded health care.

With the possibility of an outbreak of the respiratory virus in the United States looming, the government is still trying to piece together its response. And it sounds like free testing could be on the table. Rep. Ted Yoho (R-Fla.), at least, thinks it’s really the only option. Yoho is normally known for opposing the Affordable Care Act, and certainly doesn’t seem likely to advocate for Medicare-for-All anytime soon. But he’s willing to blur the lines when an unforeseen circumstance like coronavirus comes to town and is even ok if you want call it “socialized medicine.”

Truly stunning to hear some Republicans advocate for free Coronavirus testing and treatment for the uninsured.

Rep. Ted Yoho (R-Fla.), one of the most anti-ACA members:

“You can look at it as socialized medicine, but in the face of an outbreak, a pandemic, what’s your options?”

The Trump administration, meanwhile, is contemplating funding doctors and hospitals so they can care for people who don’t have insurance should they become infected with the virus, a person familiar with the conversation told The Wall Street Journal. Read more at The Wall Street Journal.

The Coronavirus Outbreak Could Finally Make Telemedicine Mainstream in the U.S.

Time’s reporter, Jamie Ducharme noted that for years, telemedicine has been pitched as a way to democratize medicine by driving down costs, increasing access to care and making appointments more efficient. It sounds great—until you look at the data, and find that only about 10% of Americans have actually used telemedicine to make a virtual visit, according to one 2019 survey.

An outbreak of the novel coronavirus COVID-19 could change that. If extreme measures like mass quarantines come to pass, telehealth could finally have its bittersweet moment in the spotlight, potentially generating momentum that proponents hope will continue once life returns to normal.

“Something like having to stay home could springboard telehealth tremendously, because when we get over this—and we will—people will have had that experience, and they’ll be saying, ‘Well, why can’t I do other aspects of my health care that way?’” says Dr. Joe Kvedar, president-elect of the American Telemedicine Association (ATA).

As of March 3, more than 92,000 people worldwide have been sickened by the virus that causes COVID-19, including more than 100 in the U.S. As both numbers trend upward, the U.S. Centers for Disease Control and Prevention (CDC) has warned that increased person-to-person spread in U.S. communities is likely, and that containment measures may become increasingly disruptive to daily life. If the situation reaches the point where public health officials are encouraging or requiring people to stay home, the health care system may have to offer many medical appointments via telehealth services, the CDC’s Dr. Nancy Messonnier said during a Feb. 26 press briefing.

Kvedar says telehealth tools offered by health plans, private companies and pharmacies are ready and waiting for that possibility. There are some limitations to telehealth’s utility for COVID-19 testing—you can’t take a chest x-ray or collect a sample for lab testing remotely, after all—but Kvedar says it could be used for initial symptom assessment and questioning, as well as non-virus-related appointments that couldn’t happen in person due to precautions. If a patient turned up at an emergency room with possible COVID-19 symptoms, doctors could also do initial intake via virtual platforms, while keeping the patient in isolation to minimize spread within the vulnerable health care environment, he says.

Telehealth giants like Amwell and Teladoc are now advertising their availability for coronavirus-related appointments, and Teladoc’s stock prices spiked in late February. XRHealth, a company that makes health-focused virtual reality applications, is this week providing Israel’s Sheba Medical Center with VR headsets that will both allow doctors to monitor COVID-19 patients remotely, and enable quarantined patients to “travel” beyond their rooms using VR, says XRHealth CEO Eran Orr. The company will next week begin working with hospitals to deploy the technology in the U.S., Orr says.

All of these solutions seem logical. But in practice, there’s a “thicket of state laws and regulations that make telemedicine very complex…to implement broadly,” says Dr. Michael Barnett, an assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health. Insurers—especially Medicare—don’t always cover telehealth visits, and, since medical licenses are state-specific, there could be legal issues if a doctor is located in a different state than the patient they’re treating, Barnett says. Drug prescription and privacy laws can also complicate regulation, according to the American Hospital Association.

These regulatory issues, as well as a lack of patient awareness, have kept telehealth from being as widely adopted as it could be, Barnett says. COVID-19 could be “a good use case” for telemedicine, he says, but it will partially depend on lawmakers’ willingness to relax, or at least streamline, regulation.

The wheels are already in motion. On Feb. 28, telehealth groups including the ATA, the Personal Connected Health Alliance and the eHealth Initiative sent a letter to Congressional leaders, urging them to expand access to telehealth and to grant the Department of Health and Human Services the power to let Medicare cover telemedicine appointments during emergency situations. On March 3, Arizona Rep. Ruben Gallego announced he was introducing a bill that would allow Medicaid to cover all COVID-19-related charges, including virtual appointments.

That’s a good step, but Julia Adler-Milstein, director of the University of California, San Francisco’s Center for Clinical Informatics and Improvement Research, says there are still logistical challenges.

She says larger health systems that have invested heavily in telehealth, like Kaiser Permanente, have seen benefits from it, but providers with a less built-out infrastructure will have to grapple in real-time with questions like, “How do we know which patients are well-suited to telehealth?” and “How do we get their information into the doctor’s hands?” These issues are especially salient for patients with complex medical histories, who may have choose between seeing their regular doctor in person, potentially risking infection, or seeing a doctor virtually who does not have access to their medical records, she says.

Kvedar acknowledges that widespread adoption of telehealth during the COVID-19 outbreak may require some goodwill on the part of companies and doctors. Companies like CVS and Walgreens could waive fees for the use of their telemedicine services during the crisis, Kvedar suggests, or doctors could offer to see patients virtually for free for a few hours a week. “People pull together for all sorts of things,” he says.

Barnett is less optimistic that providers can seamlessly overcome regulations, but says patients and doctors will find a way through the outbreak with or without telemedicine, even if it means conducting many appointments over the old-fashioned telephone. “We have more pressing needs in this epidemic,” he says, “than telehealth availability.”

15 Italian tourists test positive for Covid-19, India springs into battle mode

Niharika Sharma reported that fifteen Italian tourists in India have been reportedly tested positive for the dreaded coronavirus, perhaps finally bringing home the full scale of the seriousness of the global health crisis to the country.

This is besides the six others who have been diagnosed with Covid-19 across the country, prompting India to take massive preventive measures.

The Italian tourists have been quarantined at a camp of the paramilitary, Indo-Tibetan Police Force, media reports said.

Fear and anxiety gripped India’s national capital region (NCR) after a 45-year-old man was diagnosed with the novel coronavirus infection in the city yesterday (March 3). This prompted authorities to step up the vigil.

Over 40 people in Delhi NCR, who came in contact with the patient, are under surveillance. Another 13 people have been screened in Uttar Pradesh’s Agra where he visited his family.

The man who self-reported at Delhi’s Ram Manohar Lohia Hospital had organised his son’s birthday party at Hyatt Regency on Feb. 28. The five-star hotel has asked staffers, who were on duty that day, to stay at home. “The hotel has also started to conduct daily temperature checks for all colleagues and contractors when they enter and exit the building,” the hotel said in a statement yesterday (March 3).

The school in Noida where the infected man’s son attended classes has been shut for the rest of the week, and five students are being screened.

Besides the Delhi man, an Italian tourist, and a person in Hyderabad, who travelled from Dubai to Bengaluru on Feb. 20 on an IndiGo flight, have also tested positive for the virus. ”We’re following all prescribed Airport Health Organisation guidelines,” IndiGo said in a statement yesterday. The airline has asked its four cabin crew who were on the aircraft to stay at home.

On guard

Authorities appear to be working overtime to track the footprints of all the patients and screen everyone who came in contact with them. “Our officers even visit the homes individually, taking necessary precautions, to check listed people for symptoms,” an official of the Integrated Disease Surveillance Programme (IDSP) under the health ministry told Hindustan Times on condition of anonymity. “For asymptomatic people, home quarantine for a stipulated period of time is good enough, but those who develop symptoms are moved to a hospital as per protocol.”

But the process could be tedious as the 69-year-old Italian tourist, who was tested positive in Jaipur on March 3,had travelled to six districts in India before arriving at Rajasthan. He and his wife, who has also tested positive, were part of a 21-member group, which landed in Delhi on Feb. 21. The rest of the group is in Agra, according to a Hindustan Times report.

The health ministry has now issued a travel advisory, suspending all regular visas/e-visas granted on or before March 3 to nationals of Italy, Iran, South Korea, and Japan, who have not yet entered India. The advisory also suspends visa on arrival issued until March 3 to Japanese and South Korean nationals who have not yet entered India.

The government has also made it mandatory for passengers entering India from other countries affected by coronavirus to fill forms with personal details and travel history to the health and immigration officials at 21 airports across the country and 12 major and 65 minor seaports.

Aviation watchdog Directorate General of Civil Aviation has also asked carriers to ensure that adequate protective gears like surgical masks and gloves are available in flight for passengers.

In Delhi, the Kejriwal government has reserved 230 beds in isolation wards at 25 hospitals and also sent advisories to schools mentioning precautions to tackle the situation.

On March 3, the information ministry asked all private radio and TV channels to give “adequate publicity” to the travel advisory issued by the health ministry in the wake of the coronavirus outbreak.

The health ministry has also launched a series of TV commercials as part of its awareness program against the outbreak.

Here’s what you must keep in mind:

In addition, the Narendra Modi government has asked the army, the navy and the air force to prepared quarantine facilities for over 2,500 in coming days, as per the sources quoted by various media reports.

Preventive measures

Several events, where foreign delegates were expected to participate, have been cancelled or postponed.

The Indian Navy called off a multilateral naval exercise that was scheduled from March 18 in Visakhapatnam due to coronavirus. Around 30 countries were expected to take part in the event.

On March 3, Chinese smartphone maker Xiaomi said it is cancelling all upcoming on-ground launch events in India to reduce exposure risk in the wake of Covid-19.

Italy could have more than 100,000 coronavirus cases, expert warns

Reporter Will Taylor of the Yahoo News noted that Italy could have more than 100,000 cases of coronavirus, an expert has revealed.

Professor Neil Ferguson, of Imperial College London’s faculty of medicine, said he estimates there are “at least” 50,000 to 100,000 cases of the virus in the country, which is one of the worst affected by the virus.

Italy has 2,500 confirmed cases and has suffered 79 deaths.

Prof Ferguson told the BBC’s Today programme that he expects to see measures to tackle the virus rolled out in a matter of days.

“[Italy has] I think it’s over 50 deaths now,” he said, “so those people were probably infected three weeks ago, and for every person who dies we think there might be 100, maybe even 200 people infected.

“The lethality of this virus is not completely determined but it’s in that order… so the epidemic is probably doubling every week or so in Italy, so when you put those numbers together, we’d estimate somewhere between 50,000 and 100,000 cases at the moment in Italy.

“At least, it could even be higher, cases may still be being missed even in severe cases.”

He said the UK is “several weeks” behind Italy and is in an earlier stage of an epidemic.

Authorities will be looking to slow the spread of the virus to try to relieve pressure on health systems and the UK government yesterday announced measures to tackle the virus.

Prof Ferguson said screening air passengers is imperfect and pointed out that Spanish flu spread around the world in the days before commercial air travel.

His figures mean the total number of Italy’s cases could outstrip the total number confirmed worldwide. Just over 93,000 have been reported globally as of Wednesday morning.

After mainland China – where the virus originated – South Korea is the next worst hit with 5,328 confirmed cases and 28 deaths.

Iran reports 77 deaths from its 2,300 officially reported cases.

A Coronavirus Guide for Older Adults (And Their Family Advocates)

Jeffrey Kluger noted that it’s hard enough getting old, what with all of the creeping ailments—diabetes, COPD, dementia, heart disease—that come along with age. Now add a novel coronavirus to the mix. There are more than 91,000 COVID-19 cases and 3,100 deaths as of writing, but the virus doesn’t hit all demographics equally hard—and seniors are the most vulnerable.

A late February study in the Journal of the American Medical Association showed that children 10 and under accounted for just 1% of all COVID-19 cases, for example, while adults in the 30-79 age groups represented a whopping 87%. The World Health Organization (WHO) found something similar in China, with 78% of patients falling between the ages of 30 and 69.

The older you get, the likelier you are not only to contract a SARS-CoV-2 infection (the virus that causes COVID-19), but to suffer a severe or fatal case. One study out of China found that the average age of COVID-19 patients who developed acute respiratory distress syndrome—a severe shortness of breath often caused by fluid in the lungs and requiring a ventilator—is 61. As early as January, Chinese health authorities were already reporting that the median age range for people who died of the disease was 75.

“Older people are more likely to be infected, especially older people with underlying lung disease,” says Dr. Teena Chopra, medical director of infection prevention and hospital epidemiology at Wayne State University. “For this population, mortality rates for COVID-19 are about 15%.”

In this sense, COVID-19 behaves a lot like seasonal flu. From 70% to 85% of all flu deaths and 50% to 70% of flu-related hospitalizations occur among people in the 65-plus age group, according to the United States Centers for Disease Control and Prevention (CDC). The 2002-2003 SARS outbreak similarly proved lethal for more than 50% of people over 60 who contracted the disease..

None of this is a surprise of course. With their higher risk of underlying health conditions, older people are already under physical stress, and their immune systems, even if not significantly compromised, simply do not have the same “ability to fight viruses and bacteria,” says Dr. Steven Gambert, professor of medicine and director of geriatrics at the University of Maryland School of Medicine.

What’s more, seniors’ risk of exposure to any pathogen is often higher than that of other adults. There are 48 million seniors overall in the U.S., and while only about 3% of them reside in assisted living facilities, that still factors out to more than 1.4 million already at-risk people living in communal environments in which disease can spread quickly.

“People living in long care facilities have common meetings, they share common rooms,” says Chopra. Common meetings and common rooms can too often mean common pathogens.

In the event of coronavirus infection in a residential facility, Gambert says, those living there should avoid communal rooms and even meals, and, if possible, eat in their own rooms.

Even older people living at home face communal risks, since many of them regularly visit community senior centers, which are great places for socialization and provide a means to stay active and engaged, but can serve as pathogenic petri dishes. Gambert recommends being proactive in these situations, asking the staff of the senior center if they have had any cases of coronavirus, and if so, avoid those facilities.

The health system itself may be playing a significant role in putting seniors at risk. People with multiple medical conditions typically visit multiple specialists, and every such visit means entering a health care environment that can be teeming with viruses and bacteria. For now, Chopra advises older patients to postpone doctor visits that aren’t absolutely essential, like “their annual eye visit. Dental cleaning can be avoided too.” Telemedicine—conducting doctor visits that don’t require hands-on treatment online—can be helpful too, as can e-prescribing, with drugs being delivered straight to patients, sparing them exposure to pharmacies.

Staying current on vaccines—especially flu and pneumonia—can also be critical. Patients—or their family advocates—should ask doctors if they are up to date on their vaccines, or if they need a booster, especially since vaccine formulations change and improve over time. “If you haven’t had a pneumonia vaccine now is the time to get one,” says Gambert. “Even if you have had one in the past, ask your primary care provider if you need a newer one.”

Finally, it’s important to remember that the way COVID-19 presents itself in a younger person is not always the way it presents itself in someone who’s older. “Old people may not get a fever so just checking their temperature may not reveal the infection,” says Gambert.

Instead, he says, families and seniors should be alert for “atypical presentation” of COVID-19. A fall or forgetfulness, for example, might be a sign of infection, even if other, more common symptoms aren’t in evidence. “Any reason you don’t feel the same as you usually do should not be dismissed,” Gambert says.

The coronavirus epidemic is not going away any time soon. That means continued vigilance for our own health and special vigilance for that of seniors. The people who looked after us when we were younger need the favor returned now that they are older.

AOC says that ensuring access to free coronavirus testing and treatment is ‘absolutely’ an ‘argument for Medicare for All’

According to Joseph Zeballos-Roig AOC told the Huffington Post that the government is taking steps to guarantee free coronavirus testing and medical treatment.

“What this crisis has taught us is that, our health care system and our public health are only as strong as the sickest person in this country,” she told the outlet.

Concerns are increasing that the expensive nature of American healthcare could discourage people from seeking medical treatment if they are infected with the coronavirus.

Democratic Rep. Alexandria Ocasio-Cortez  said in an interview published Tuesday that ensuring free coronavirus testing and medical treatment is “absolutely” an “argument for Medicare for All.”

The New York congresswoman told the Huffington Post that if the government took steps to guarantee public access to testing and treatments by paying for it, “then what makes coronavirus different from so many other diseases, particularly ones that are transmissible?”

“What this crisis has taught us is that, our health care system and our public health are only as strong as the sickest person in this country,” she told the outlet.

Medicare for All is the signature plan of Sen. Bernie Sanders, a leading Democratic presidential candidate that Ocasio-Cortez has thrown her support behind. It would provide comprehensive health coverage and do away with deductibles, premiums, and other out-of-pocket spending. Private insurance would be eliminated as well.

As of Wednesday, the coronavirus has infected more than 94,000 people in at least 80 countries beyond China, its point of origin. The death toll from the respiratory disease it causes, COVID-19, has killed more than 3,200 people, mostly in China. There are at least 128 confirmed cases in the US.

Over the last week, concerns have mounted that the skyrocketing costs of healthcare could form a barrier discouraging people from getting tested and receiving treatment for the virus.

Business Insider recently analyzed the medical bill of a Miami resident who tested negative for the coronavirus but still racked up a $1,400 in costs, though he was insured. The majority of it came from an emergency room visit.

The Trump administration announced on Monday it was reviewing what products and services it would cover for coronavirus under Medicare and Medicaid, the two biggest federal health insurance programs.

Vice President Mike Pence said a day later the programs would insure diagnostic testing, making it free for patients. But it was not immediately clear what additional medical care would be paid for by the government.

“People who are subject to cost sharing — they are less likely to use medical care, even if they need it,” John Cogan, a health-law expert at the University of Connecticut, previously told Business Insider.

The White House is also reportedly considering reimbursing hospitals and doctors for treating uninsured coronavirus patients. In 2018, 27.5 million Americans had no health insurance, an increase from 25.2 million the year before.

The Most Common Coronavirus Symptoms to Look Out for, According to Experts Coronavirus symptoms are similar to those associated with the flu. 

Unless you get a lab test, you can’t really distinguish between coronavirus COVID-19 and a typical cold or the flu. Dr. Wesley Long, Houston Methodist Director of Diagnostic Microbiology The severity of coronavirus

symptoms varies from person to person, Dr. Long notes. In more serious cases, the infection may lead to pneumonia, severe acute

respiratory syndrome, kidney failure, and even death, says Dr. Neal Shipley. Those most at risk of severe illness from coronavirus include the very young, the very old, and people with generally weakened or impaired immune systems. It’s difficult to pinpoint how long it takes

for coronavirus symptoms to appear. “The generally accepted window from exposure to onset of symptoms is 2-14 days,” says Dr. Long. To be clear, there’s still a lot that experts don’t know about COVID-19. And, you can only contract it if you’ve come into contact with someone who already has it.

So, rather than cause continual promotion of more fear we should all be prepared using good hand washing, cleaning surfaces with appropriate products, if you are sick seek assistance with your medical physician or nurse practitioner offices regarding the need to be tested, etc. The question looms out there, not if you will become sick with this virus, but when and how you care for yourself!

Stay well!!