Anthony Fauci’s at the pool, but Donald Trump’s in deep.
Never mind Johnny Depp and Amber Heard.
You want to see a real can’t-look-away train wreck of a relationship? Look to the nation’s capital, where a messy falling out is chronicled everywhere from the tabloids to a glossy fashion magazine, replete with a photo shoot by a swimming pool.
The saga has enough betrayal, backstabbing, recrimination, indignation and ostracization to impress Edith Wharton.
The press breathlessly covers how much time has passed since the pair last spoke, whether they’re headed for splitsville, and if they can ever agree on what’s best for the children.
It was always bound to be tempestuous because they are the ultimate odd couple, the doctor and the president.
- One is a champion of truth and facts. The other is a master of deceit and denial.
- One is highly disciplined, working 18-hour days. The other can’t be bothered to do his homework and golfs instead.
- One is driven by science and the public good. The other is a public menace, driven by greed and ego.
- One is a Washington institution. The other was sent here to destroy Washington institutions.
- One is incorruptible. The other corrupts.
- One is apolitical. The other politicizes everything he touches — toilets, windows, beans and, most fatally, masks.
After a fractious week, when the former reality-show star in the White House retweeted a former game-show host saying that we shouldn’t trust doctors about Covid-19, Donald Trump and Anthony Fauci are gritting their teeth.
What’s so scary is that the bumpy course of their relationship has life-or-death consequences for Americans.
Who could even dream up a scenario where a president and a White House drop oppo research on the esteemed scientist charged with keeping us safe in a worsening pandemic?
The administration acted like Peter Navarro, Trump’s wacko-bird trade adviser, had gone rogue when he assailed Dr. Fauci for being Dr. Wrong, in a USA Today op-ed. But does anyone believe that? And if he did, would he still have his job?
No doubt it was a case of Trump murmuring: Will no one rid me of this meddlesome infectious disease specialist?
Republicans on Capitol Hill privately confessed they were baffled by the whole thing, saying they couldn’t understand why Trump would undermine Fauci, especially now with the virus resurgent. They think it’s not only hurting Trump’s re-election chances, but theirs, too.
As though it couldn’t get more absurd, Kellyanne Conway told Fox News on Friday that she thinks it would help Trump’s poll numbers for him to start giving public briefings on the virus again — even though that exercise went off the rails when the president began suggesting people inject themselves with bleach.
“How did we get to a situation in our country where the public health official most known for honesty and hard work is most vilified for it?” marvels Michael Specter, a science writer for The New Yorker who began covering Fauci during the AIDs crisis. “And as Team Trump trashes him, the numbers keep horrifyingly proving him right.”
When Dr. Fauci began treating AIDs patients, nearly every one of them died. “It was the darkest time of my life,” he told Specter. In an open letter, Larry Kramer called Fauci a “murderer.”
Then, as Specter writes, he started listening to activists and made a rare admission: His approach wasn’t working. He threw his caution to the winds and became a public-health activist. Through rigorous research and commitment to clinical studies, the death rate from AIDs has plummeted over the years.
Now Fauci struggles to drive the data bus as the White House throws nails under his tires. It seems emblematic of a deeper, existential problem: America has lost its can-do spirit. We were always Bugs Bunny, faster, smarter, more wily than everybody else. Now we’re Slugs Bunny.
Can our country be any more pathetic than this: The Georgia governor suing the Atlanta mayor and City Council to block their mandate for city residents to wear masks?
Trump promised the A team, but he has surrounded himself with losers and kiss-ups and second-raters. Just your basic Ayn Rand nightmare.
Certainly, Dr. Fauci has had to adjust some of his early positions as he learned about this confounding virus. (“When the facts change, I change my mind. What do you do, sir?” John Maynard Keynes wisely observed.)
“Medicine is not an exact art,” Jerome Groopman, the best-selling author and professor at Harvard Medical School, put it. “There’s lots of uncertainty, always evolving information, much room for doubt. The most dangerous people are the ones who speak with total authority and no room for error.”
Sound like someone you know?
“Medical schools,” Dr. Groopman continued, “have curricula now to teach students the imperative of admitting when something went wrong, taking responsibility, and committing to righting it.”
Some are saying the 79-year-old Dr. Fauci should say to hell with it and quit. But we need his voice of reason in this nuthouse of a White House.
Despite Dr. Fauci’s best efforts to stay apolitical, he has been sucked into the demented political kaleidoscope through which we view everything now. Consider the shoot by his pool, photographed by Frankie Alduino, for a digital cover story by Norah O’Donnell for InStyle magazine.
From the left, the picture represented an unflappable hero, exhausted and desperately in need of some R & R, chilling poolside, not letting the White House’s slime campaign get him down or silence him. And on the right, some saw a liberal media darling, high on his own supply in the midst of a deadly pandemic. “While America burns, Fauci does fashion mag photo shoots,” tweeted Sean Davis, co-founder of the right-wing website The Federalist.
It’s no coincidence that the QAnon-adjacent cultists on the right began circulating a new conspiracy theory in the fever swamps of Facebook that Dr. Fauci’s wife of three and a half decades, a bioethicist, is Ghislane Maxwell’s sister. (Do I need to tell you she isn’t?)
Worryingly, new polls show that the smear from Trumpworld may be starting to stick; fewer Republicans trust the doctor now than in the spring.
Forget Mueller, Sessions, Comey, Canada, his niece, Mika Brzezinski. Of the many quarrels, scrapes and scraps Trump has instigated in his time in office, surely this will be remembered not only as the most needless and perverse, but as the most dangerous.
As Dr. Fauci told The Atlantic, it’s “a bit bizarre.”
More than a bit, actually.
The U.S. may end up with the worst COVID-19 outbreak in the industrialized world. This is how it’s going to play out.
Three months ago, no one knew that SARS-CoV-2 existed. Now the virus has spread to almost every country, infecting at least 446,000 people whom we know about, and many more whom we do not. It has crashed economies and broken health-care systems, filled hospitals and emptied public spaces. It has separated people from their workplaces and their friends. It has disrupted modern society on a scale that most living people have never witnessed. Soon, most everyone in the United States will know someone who has been infected. Like World War II or the 9/11 attacks, this pandemic has already imprinted itself upon the nation’s psyche.
A global pandemic of this scale was inevitable. In recent years, hundreds of health experts have written books, white papers, and op-eds warning of the possibility. Bill Gates has been telling anyone who would listen, including the 18 million viewers of his TED Talk. In 2018, I wrote a story for The Atlantic arguing that America was not ready for the pandemic that would eventually come. In October, the Johns Hopkins Center for Health Security war-gamed what might happen if a new coronavirus swept the globe. And then one did. Hypotheticals became reality. “What if?” became “Now what?”
So, now what? In the late hours of last Wednesday, which now feels like the distant past, I was talking about the pandemic with a pregnant friend who was days away from her due date. We realized that her child might be one of the first of a new cohort who are born into a society profoundly altered by COVID-19. We decided to call them Generation C.As we’ll see, Gen C’s lives will be shaped by the choices made in the coming weeks, and by the losses we suffer as a result. But first, a brief reckoning. On the Global Health Security Index, a report card that grades every country on its pandemic preparedness, the United States has a score of 83.5—the world’s highest. Rich, strong, developed, America is supposed to be the readiest of nations. That illusion has been shattered. Despite months of advance warning as the virus spread in other countries, when America was finally tested by COVID-19, it failed.
“No matter what, a virus [like SARS-CoV-2] was going to test the resilience of even the most well-equipped health systems,” says Nahid Bhadelia, an infectious-diseases physician at the Boston University School of Medicine. More transmissible and fatal than seasonal influenza, the new coronavirus is also stealthier, spreading from one host to another for several days before triggering obvious symptoms. To contain such a pathogen, nations must develop a test and use it to identify infected people, isolate them, and trace those they’ve had contact with. That is what South Korea, Singapore, and Hong Kong did to tremendous effect. It is what the United States did not.
As my colleagues Alexis Madrigal and Robinson Meyer have reported, the Centers for Disease Control and Prevention developed and distributed a faulty test in February. Independent labs created alternatives, but were mired in bureaucracy from the FDA. In a crucial month when the American caseload shot into the tens of thousands, only hundreds of people were tested. That a biomedical powerhouse like the U.S. should so thoroughly fail to create a very simple diagnostic test was, quite literally, unimaginable. “I’m not aware of any simulations that I or others have run where we [considered] a failure of testing,” says Alexandra Phelan of Georgetown University, who works on legal and policy issues related to infectious diseases.
The testing fiasco was the original sin of America’s pandemic failure, the single flaw that undermined every other countermeasure. If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases. None of that happened. Instead, a health-care system that already runs close to full capacity, and that was already challenged by a severe flu season, was suddenly faced with a virus that had been left to spread, untracked, through communities around the country. Overstretched hospitals became overwhelmed. Basic protective equipment, such as masks, gowns, and gloves, began to run out. Beds will soon follow, as will the ventilators that provide oxygen to patients whose lungs are besieged by the virus.
With little room to surge during a crisis, America’s health-care system operates on the assumption that unaffected states can help beleaguered ones in an emergency. That ethic works for localized disasters such as hurricanes or wildfires, but not for a pandemic that is now in all 50 states. Cooperation has given way to competition; some worried hospitals have bought out large quantities of supplies, in the way that panicked consumers have bought out toilet paper.Partly, that’s because the White House is a ghost town of scientific expertise. A pandemic-preparedness office that was part of the National Security Council was dissolved in 2018. On January 28, Luciana Borio, who was part of that team, urged the government to “act now to prevent an American epidemic,” and specifically to work with the private sector to develop fast, easy diagnostic tests. But with the office shuttered, those warnings were published in The Wall Street Journal, rather than spoken into the president’s ear. Instead of springing into action, America sat idle.
Rudderless, blindsided, lethargic, and uncoordinated, America has mishandled the COVID-19 crisis to a substantially worse degree than what every health expert I’ve spoken with had feared. “Much worse,” said Ron Klain, who coordinated the U.S. response to the West African Ebola outbreak in 2014. “Beyond any expectations we had,” said Lauren Sauer, who works on disaster preparedness at Johns Hopkins Medicine. “As an American, I’m horrified,” said Seth Berkley, who heads Gavi, the Vaccine Alliance. “The U.S. may end up with the worst outbreak in the industrialized world.”
I. The Next Months
Having fallen behind, it will be difficult—but not impossible—for the United States to catch up. To an extent, the near-term future is set because COVID-19 is a slow and long illness. People who were infected several days ago will only start showing symptoms now, even if they isolated themselves in the meantime. Some of those people will enter intensive-care units in early April. As of last weekend, the nation had 17,000 confirmed cases, but the actual number was probably somewhere between 60,000 and 245,000. Numbers are now starting to rise exponentially: As of Wednesday morning, the official case count was 54,000, and the actual case count is unknown. Health-care workers are already seeing worrying signs: dwindling equipment, growing numbers of patients, and doctors and nurses who are themselves becoming infected.
Italy and Spain offer grim warnings about the future. Hospitals are out of room, supplies, and staff. Unable to treat or save everyone, doctors have been forced into the unthinkable: rationing care to patients who are most likely to survive, while letting others die. The U.S. has fewer hospital beds per capita than Italy. A study released by a team at Imperial College London concluded that if the pandemic is left unchecked, those beds will all be full by late April. By the end of June, for every available critical-care bed, there will be roughly 15 COVID-19 patients in need of one. By the end of the summer, the pandemic will have directly killed 2.2 million Americans, notwithstanding those who will indirectly die as hospitals are unable to care for the usual slew of heart attacks, strokes, and car accidents. This is the worst-case scenario. To avert it, four things need to happen—and quickly.
The first and most important is to rapidly produce masks, gloves, and other personal protective equipment. If health-care workers can’t stay healthy, the rest of the response will collapse. In some places, stockpiles are already so low that doctors are reusing masks between patients, calling for donations from the public, or sewing their own homemade alternatives. These shortages are happening because medical supplies are made-to-order and depend on byzantine international supply chains that are currently straining and snapping. Hubei province in China, the epicenter of the pandemic, was also a manufacturing center of medical masks.In the U.S., the Strategic National Stockpile—a national larder of medical equipment—is already being deployed, especially to the hardest-hit states. The stockpile is not inexhaustible, but it can buy some time. Donald Trump could use that time to invoke the Defense Production Act, launching a wartime effort in which American manufacturers switch to making medical equipment. But after invoking the act last Wednesday, Trump has failed to actually use it, reportedly due to lobbying from the U.S. Chamber of Commerce and heads of major corporations.
Some manufacturers are already rising to the challenge, but their efforts are piecemeal and unevenly distributed. “One day, we’ll wake up to a story of doctors in City X who are operating with bandanas, and a closet in City Y with masks piled into it,” says Ali Khan, the dean of public health at the University of Nebraska Medical Center. A “massive logistics and supply-chain operation [is] now needed across the country,” says Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health. That can’t be managed by small and inexperienced teams scattered throughout the White House. The solution, he says, is to tag in the Defense Logistics Agency—a 26,000-person group that prepares the U.S. military for overseas operations and that has assisted in past public-health crises, including the 2014 Ebola outbreak.
This agency can also coordinate the second pressing need: a massive rollout of COVID-19 tests. Those tests have been slow to arrive because of five separate shortages: of
- masks to protect people administering the tests; of
- nasopharyngeal swabs for collecting viral samples; of
- extraction kits for pulling the virus’s genetic material out of the samples; of
- chemical reagents that are part of those kits; and of
- trained people who can give the tests.
Many of these shortages are, again, due to strained supply chains. The U.S. relies on three manufacturers for extraction reagents, providing redundancy in case any of them fails—but all of them failed in the face of unprecedented global demand. Meanwhile, Lombardy, Italy, the hardest-hit place in Europe, houses one of the largest manufacturers of nasopharyngeal swabs.
Some shortages are being addressed. The FDA is now moving quickly to approve tests developed by private labs. At least one can deliver results in less than an hour, potentially allowing doctors to know if the patient in front of them has COVID-19. The country “is adding capacity on a daily basis,” says Kelly Wroblewski of the Association of Public Health Laboratories.
On March 6, Trump said that “anyone who wants a test can get a test.” That was (and still is) untrue, and his own officials were quick to correct him. Regardless, anxious people still flooded into hospitals, seeking tests that did not exist. “People wanted to be tested even if they weren’t symptomatic, or if they sat next to someone with a cough,” says Saskia Popescu of George Mason University, who works to prepare hospitals for pandemics. Others just had colds, but doctors still had to use masks to examine them, burning through their already dwindling supplies. “It really stressed the health-care system,” Popescu says. Even now, as capacity expands, tests must be used carefully. The first priority, says Marc Lipsitch of Harvard, is to test health-care workers and hospitalized patients, allowing hospitals to quell any ongoing fires. Only later, once the immediate crisis is slowing, should tests be deployed in a more widespread way. “This isn’t just going to be: Let’s get the tests out there!” Inglesby says.
These measures will take time, during which the pandemic will either accelerate beyond the capacity of the health system or slow to containable levels. Its course—and the nation’s fate—now depends on the third need, which is social distancing. Think of it this way: There are now only two groups of Americans. Group A includes everyone involved in the medical response, whether that’s treating patients, running tests, or manufacturing supplies. Group B includes everyone else, and their job is to buy Group A more time. Group B must now “flatten the curve” by physically isolating themselves from other people to cut off chains of transmission. Given the slow fuse of COVID-19, to forestall the future collapse of the health-care system, these seemingly drastic steps must be taken immediately, before they feel proportionate, and they must continue for several weeks.Persuading a country to voluntarily stay at home is not easy, and without clear guidelines from the White House, mayors, governors, and business owners have been forced to take their own steps. Some states have banned large gatherings or closed schools and restaurants. At least 21 have now instituted some form of mandatory quarantine, compelling people to stay at home. And yet many citizens continue to crowd into public spaces.
In these moments, when the good of all hinges on the sacrifices of many, clear coordination matters—the fourth urgent need. The importance of social distancing must be impressed upon a public who must also be reassured and informed. Instead, Trump has repeatedly played down the problem, telling America that “we have it very well under control” when we do not, and that cases were “going to be down to close to zero” when they were rising. In some cases, as with his claims about ubiquitous testing, his misleading gaffes have deepened the crisis. He has even touted unproven medications.
Away from the White House press room, Trump has apparently been listening to Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases. Fauci has advised every president since Ronald Reagan on new epidemics, and now sits on the COVID-19 task force that meets with Trump roughly every other day. “He’s got his own style, let’s leave it at that,” Fauci told me, “but any kind of recommendation that I have made thus far, the substance of it, he has listened to everything.”But Trump already seems to be wavering. In recent days, he has signaled that he is prepared to backtrack on social-distancing policies in a bid to protect the economy. Pundits and business leaders have used similar rhetoric, arguing that high-risk people, such as the elderly, could be protected while lower-risk people are allowed to go back to work. Such thinking is seductive, but flawed. It overestimates our ability to assess a person’s risk, and to somehow wall off the ‘high-risk’ people from the rest of society. It underestimates how badly the virus can hit ‘low-risk’ groups, and how thoroughly hospitals will be overwhelmed if even just younger demographics are falling sick.
A recent analysis from the University of Pennsylvania estimated that even if social-distancing measures can reduce infection rates by 95 percent, 960,000 Americans will still need intensive care. There are only about 180,000 ventilators in the U.S. and, more pertinently, only enough respiratory therapists and critical-care staff to safely look after 100,000 ventilated patients. Abandoning social distancing would be foolish. Abandoning it now, when tests and protective equipment are still scarce, would be catastrophic.
If Trump stays the course, if Americans adhere to social distancing, if testing can be rolled out, and if enough masks can be produced, there is a chance that the country can still avert the worst predictions about COVID-19, and at least temporarily bring the pandemic under control. No one knows how long that will take, but it won’t be quick. “It could be anywhere from four to six weeks to up to three months,” Fauci said, “but I don’t have great confidence in that range.”
II. The Endgame
Even a perfect response won’t end the pandemic. As long as the virus persists somewhere, there’s a chance that one infected traveler will reignite fresh sparks in countries that have already extinguished their fires. This is already happening in China, Singapore, and other Asian countries that briefly seemed to have the virus under control. Under these conditions, there are three possible endgames: one that’s very unlikely, one that’s very dangerous, and one that’s very long.
- The first is that every nation manages to simultaneously bring the virus to heel, as with the original SARS in 2003. Given how widespread the coronavirus pandemic is, and how badly many countries are faring, the odds of worldwide synchronous control seem vanishingly small.
- The second is that the virus does what past flu pandemics have done: It burns through the world and leaves behind enough immune survivors that it eventually struggles to find viable hosts. This “herd immunity” scenario would be quick, and thus tempting. But it would also come at a terrible cost: SARS-CoV-2 is more transmissible and fatal than the flu, and it would likely leave behind many millions of corpses and a trail of devastated health systems. The United Kingdom initially seemed to consider this herd-immunity strategy, before backtracking when models revealed the dire consequences. The U.S. now seems to be considering it too.
- The third scenario is that the world plays a protracted game of whack-a-mole with the virus, stamping out outbreaks here and there until a vaccine can be produced. This is the best option, but also the longest and most complicated.
It depends, for a start, on making a vaccine. If this were a flu pandemic, that would be easier. The world is experienced at making flu vaccines and does so every year. But there are no existing vaccines for coronaviruses—until now, these viruses seemed to cause diseases that were mild or rare—so researchers must start from scratch. The first steps have been impressively quick. Last Monday, a possible vaccine created by Moderna and the National Institutes of Health went into early clinical testing. That marks a 63-day gap between scientists sequencing the virus’s genes for the first time and doctors injecting a vaccine candidate into a person’s arm. “It’s overwhelmingly the world record,” Fauci said.
But it’s also the fastest step among many subsequent slow ones. The initial trial will simply tell researchers if the vaccine seems safe, and if it can actually mobilize the immune system. Researchers will then need to check that it actually prevents infection from SARS-CoV-2. They’ll need to do animal tests and large-scale trials to ensure that the vaccine doesn’t cause severe side effects. They’ll need to work out what dose is required, how many shots people need, if the vaccine works in elderly people, and if it requires other chemicals to boost its effectiveness.
“Even if it works, they don’t have an easy way to manufacture it at a massive scale,” said Seth Berkley of Gavi. That’s because Moderna is using a new approach to vaccination. Existing vaccines work by providing the body with inactivated or fragmented viruses, allowing the immune system to prep its defenses ahead of time. By contrast, Moderna’s vaccine comprises a sliver of SARS-CoV-2’s genetic material—its RNA. The idea is that the body can use this sliver to build its own viral fragments, which would then form the basis of the immune system’s preparations. This approach works in animals, but is unproven in humans. By contrast, French scientists are trying to modify the existing measles vaccine using fragments of the new coronavirus. “The advantage of that is that if we needed hundreds of doses tomorrow, a lot of plants in the world know how to do it,” Berkley said. No matter which strategy is faster, Berkley and others estimate that it will take 12 to 18 months to develop a proven vaccine, and then longer still to make it, ship it, and inject it into people’s arms.It’s likely, then, that the new coronavirus will be a lingering part of American life for at least a year, if not much longer. If the current round of social-distancing measures works, the pandemic may ebb enough for things to return to a semblance of normalcy. Offices could fill and bars could bustle. Schools could reopen and friends could reunite. But as the status quo returns, so too will the virus. This doesn’t mean that society must be on continuous lockdown until 2022. But “we need to be prepared to do multiple periods of social distancing,” says Stephen Kissler of Harvard. Much about the coming years, including the frequency, duration, and timing of social upheavals, depends on two properties of the virus, both of which are currently unknown.
- First: seasonality. Coronaviruses tend to be winter infections that wane or disappear in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect. “Much of the world is waiting anxiously to see what—if anything—the summer does to transmission in the Northern Hemisphere,” says Maia Majumder of Harvard Medical School and Boston Children’s Hospital.
- Second: duration of immunity. When people are infected by the milder human coronaviruses that cause cold-like symptoms, they remain immune for less than a year. By contrast, the few who were infected by the original SARS virus, which was far more severe, stayed immune for much longer. Assuming that SARS-CoV-2 lies somewhere in the middle, people who recover from their encounters might be protected for a couple of years. To confirm that, scientists will need to develop accurate serological tests, which look for the antibodies that confer immunity. They’ll also need to confirm that such antibodies actually stop people from catching or spreading the virus. If so, immune citizens can return to work, care for the vulnerable, and anchor the economy during bouts of social distancing.
Scientists can use the periods between those bouts to develop antiviral drugs—although such drugs are rarely panaceas, and come with possible side effects and the risk of resistance. Hospitals can stockpile the necessary supplies. Testing kits can be widely distributed to catch the virus’s return as quickly as possible. There’s no reason that the U.S. should let SARS-CoV-2 catch it unawares again, and thus no reason that social-distancing measures need to be deployed as broadly and heavy-handedly as they now must be. As Aaron E. Carroll and Ashish Jha recently wrote, “We can keep schools and businesses open as much as possible, closing them quickly when suppression fails, then opening them back up again once the infected are identified and isolated. Instead of playing defense, we could play more offense.”Whether through accumulating herd immunity or the long-awaited arrival of a vaccine, the virus will find spreading explosively more and more difficult. It’s unlikely to disappear entirely. The vaccine may need to be updated as the virus changes, and people may need to get revaccinated on a regular basis, as they currently do for the flu. Models suggest that the virus might simmer around the world, triggering epidemics every few years or so. “But my hope and expectation is that the severity would decline, and there would be less societal upheaval,” Kissler says. In this future, COVID-19 may become like the flu is today—a recurring scourge of winter. Perhaps it will eventually become so mundane that even though a vaccine exists, large swaths of Gen C won’t bother getting it, forgetting how dramatically their world was molded by its absence.
III. The Aftermath
The cost of reaching that point, with as few deaths as possible, will be enormous. As my colleague Annie Lowrey wrote, the economy is experiencing a shock “more sudden and severe than anyone alive has ever experienced.” About one in five people in the United States have lost working hours or jobs. Hotels are empty. Airlines are grounding flights. Restaurants and other small businesses are closing. Inequalities will widen: People with low incomes will be hardest-hit by social-distancing measures, and most likely to have the chronic health conditions that increase their risk of severe infections. Diseases have destabilized cities and societies many times over, “but it hasn’t happened in this country in a very long time, or to quite the extent that we’re seeing now,” says Elena Conis, a historian of medicine at UC Berkeley. “We’re far more urban and metropolitan. We have more people traveling great distances and living far from family and work.”
After infections begin ebbing, a secondary pandemic of mental-health problems will follow. At a moment of profound dread and uncertainty, people are being cut off from soothing human contact. Hugs, handshakes, and other social rituals are now tinged with danger. People with anxiety or obsessive-compulsive disorder are struggling. Elderly people, who are already excluded from much of public life, are being asked to distance themselves even further, deepening their loneliness. Asian people are suffering racist insults, fueled by a president who insists on labeling the new coronavirus the “Chinese virus.” Incidents of domestic violence and child abuse are likely to spike as people are forced to stay in unsafe homes. Children, whose bodies are mostly spared by the virus, may endure mental trauma that stays with them into adulthood.
After the pandemic, people who recover from COVID-19 might be shunned and stigmatized, as were survivors of Ebola, SARS, and HIV. Health-care workers will take time to heal: One to two years after SARS hit Toronto, people who dealt with the outbreak were still less productive and more likely to be experiencing burnout and post-traumatic stress. People who went through long bouts of quarantine will carry the scars of their experience. “My colleagues in Wuhan note that some people there now refuse to leave their homes and have developed agoraphobia,” says Steven Taylor of the University of British Columbia, who wrote The Psychology of Pandemics.
But “there is also the potential for a much better world after we get through this trauma,” says Richard Danzig of the Center for a New American Security. Already, communities are finding new ways of coming together, even as they must stay apart. Attitudes to health may also change for the better. The rise of HIV and AIDS “completely changed sexual behavior among young people who were coming into sexual maturity at the height of the epidemic,” Conis says. “The use of condoms became normalized. Testing for STDs became mainstream.” Similarly, washing your hands for 20 seconds, a habit that has historically been hard to enshrine even in hospitals, “may be one of those behaviors that we become so accustomed to in the course of this outbreak that we don’t think about them,” Conis adds.
Pandemics can also catalyze social change. People, businesses, and institutions have been remarkably quick to adopt or call for practices that they might once have dragged their heels on, including working from home, conference-calling to accommodate people with disabilities, proper sick leave, and flexible child-care arrangements. “This is the first time in my lifetime that I’ve heard someone say, ‘Oh, if you’re sick, stay home,’” says Adia Benton, an anthropologist at Northwestern University. Perhaps the nation will learn that preparedness isn’t just about masks, vaccines, and tests, but also about fair labor policies and a stable and equal health-care system. Perhaps it will appreciate that health-care workers and public-health specialists compose America’s social immune system, and that this system has been suppressed.Aspects of America’s identity may need rethinking after COVID-19. Many of the country’s values have seemed to work against it during the pandemic. Its individualism, exceptionalism, and tendency to equate doing whatever you want with an act of resistance meant that when it came time to save lives and stay indoors, some people flocked to bars and clubs. Having internalized years of anti-terrorism messaging following 9/11, Americans resolved to not live in fear. But SARS-CoV-2 has no interest in their terror, only their cells.
Years of isolationist rhetoric had consequences too. Citizens who saw China as a distant, different place, where bats are edible and authoritarianism is acceptable, failed to consider that they would be next or that they wouldn’t be ready. (China’s response to this crisis had its own problems, but that’s for another time.) “People believed the rhetoric that containment would work,” says Wendy Parmet, who studies law and public health at Northeastern University. “We keep them out, and we’ll be okay. When you have a body politic that buys into these ideas of isolationism and ethnonationalism, you’re especially vulnerable when a pandemic hits.”
Veterans of past epidemics have long warned that American society is trapped in a cycle of panic and neglect. After every crisis—anthrax, SARS, flu, Ebola—attention is paid and investments are made. But after short periods of peacetime, memories fade and budgets dwindle. This trend transcends red and blue administrations. When a new normal sets in, the abnormal once again becomes unimaginable. But there is reason to think that COVID-19 might be a disaster that leads to more radical and lasting change.
The other major epidemics of recent decades either barely affected the U.S. (SARS, MERS, Ebola), were milder than expected (H1N1 flu in 2009), or were mostly limited to specific groups of people (Zika, HIV). The COVID-19 pandemic, by contrast, is affecting everyone directly, changing the nature of their everyday life. That distinguishes it not only from other diseases, but also from the other systemic challenges of our time. When an administration prevaricates on climate change, the effects won’t be felt for years, and even then will be hard to parse. It’s different when a president says that everyone can get a test, and one day later, everyone cannot. Pandemics are democratizing experiences. People whose privilege and power would normally shield them from a crisis are facing quarantines, testing positive, and losing loved ones. Senators are falling sick. The consequences of defunding public-health agencies, losing expertise, and stretching hospitals are no longer manifesting as angry opinion pieces, but as faltering lungs.
After 9/11, the world focused on counterterrorism. After COVID-19, attention may shift to public health. Expect to see a spike in funding for virology and vaccinology, a surge in students applying to public-health programs, and more domestic production of medical supplies. Expect pandemics to top the agenda at the United Nations General Assembly. Anthony Fauci is now a household name. “Regular people who think easily about what a policewoman or firefighter does finally get what an epidemiologist does,” says Monica Schoch-Spana, a medical anthropologist at the Johns Hopkins Center for Health Security.Such changes, in themselves, might protect the world from the next inevitable disease. “The countries that had lived through SARS had a public consciousness about this that allowed them to leap into action,” said Ron Klain, the former Ebola czar. “The most commonly uttered sentence in America at the moment is, ‘I’ve never seen something like this before.’ That wasn’t a sentence anyone in Hong Kong uttered.” For the U.S., and for the world, it’s abundantly, viscerally clear what a pandemic can do.
The lessons that America draws from this experience are hard to predict, especially at a time when online algorithms and partisan broadcasters only serve news that aligns with their audience’s preconceptions. Such dynamics will be pivotal in the coming months, says Ilan Goldenberg, a foreign-policy expert at the Center for a New American Security. “The transitions after World War II or 9/11 were not about a bunch of new ideas,” he says. “The ideas are out there, but the debates will be more acute over the next few months because of the fluidity of the moment and willingness of the American public to accept big, massive changes.”
One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trump’s approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero. During the second term of his presidency, the U.S. turns further inward and pulls out of NATO and other international alliances, builds actual and figurative walls, and disinvests in other nations. As Gen C grows up, foreign plagues replace communists and terrorists as the new generational threat.One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of “America first” politics. The nation pivots, as it did after World War II, from isolationism to international cooperation. Buoyed by steady investments and an influx of the brightest minds, the health-care workforce surges. Gen C kids write school essays about growing up to be epidemiologists. Public health becomes the centerpiece of foreign policy. The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.
In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.
The president has become increasingly concerned as Dr. Anthony S. Fauci has grown bolder in correcting his falsehoods about the spread of the coronavirus.
President Trump has praised Dr. Anthony S. Fauci as a “major television star.” He has tried to demonstrate that the administration is giving him free rein to speak. And he has deferred to Dr. Fauci’s opinion several times at the coronavirus task force’s televised briefings.
But Dr. Fauci, the director of the National Institute of Allergy and Infectious Diseases since 1984, has grown bolder in correcting the president’s falsehoods and overly rosy statements about the spread of the coronavirus in the past two weeks — and he has become a hero to the president’s critics because of it. And now, Mr. Trump’s patience has started to wear thin.
So has the patience of some White House advisers, who see Dr. Fauci as taking shots at the president in some of his interviews with print reporters while offering extensive praise for Mr. Trump in television interviews with conservative hosts.
Mr. Trump knows that Dr. Fauci, who has advised every president since Ronald Reagan, is seen as credible with a large section of the public and with journalists, and so he has given the doctor more leeway to contradict him than he has other officials, according to multiple advisers to the president.
When Mr. Trump knows that he has more to gain than to lose by keeping an adviser, he has resisted impulses to fight back against apparent criticism, sometimes for monthslong interludes. One example was when he wanted to fire the White House counsel, Donald F. McGahn II, in 2017 and early 2018. Another was Jeff Sessions, the former attorney general. Mr. Trump eventually fired both when he felt the danger in doing so had passed.
So far, the president appears to be making the same calculation with Dr. Fauci, who was not on the briefing room podium on Monday evening. When asked why, Mr. Trump said he had just been with Dr. Fauci for “a long time” at a task force meeting. Officials, asked about the doctor’s absence, repeated that they were rotating officials who appear at the briefings.
“He’s a good man,” Mr. Trump said. Dr. Fauci was scheduled to be on Fox News wit
Still, the president has resisted portraying the virus as the kind of threat described by Dr. Fauci and other public health experts. In his effort to create a positive vision of a future where the virus is less of a danger, critics have accused Mr. Trump of giving false hope.
Dr. Fauci and the president have publicly disagreed on how long it will take for a coronavirus vaccine to become available and whether an anti-malaria drug, chloroquine, could help those with an acute form of the virus. Dr. Fauci has made clear that he does not think the drug necessarily holds the potential that Mr. Trump says it does.
In an interview with Science Magazine, Dr. Fauci responded to a question about how he had managed to not get fired by saying that, to Mr. Trump’s “credit, even though we disagree on some things, he listens. He goes his own way. He has his own style. But on substantive issues, he does listen to what I say.”
But Dr. Fauci also said there was a limit to what he could do when Mr. Trump made false statements, as he often does during the briefings.
“I can’t jump in front of the microphone and push him down,” Dr. Fauci said. “OK, he said it. Let’s try and get it corrected for the next time.”
In an interview with CBS’s “Face the Nation” on Sunday, Dr. Fauci played down the idea that there was a divide between him and the president. “There isn’t fundamentally a difference there,” he said.
“The president has heard, as we all have heard, what are what I call anecdotal reports that certain drugs work. So what he was trying to do and express was the hope that if they might work, let’s try and push their usage,” Dr. Fauci said. “I, on the other side, have said I’m not disagreeing with the fact anecdotally they might work, but my job is to prove definitively from a scientific standpoint that they do work. So I was taking a purely medical, scientific standpoint, and the president was trying to bring hope to the people.”
A White House spokesman and Dr. Fauci did not respond to requests for comment.
Dr. Fauci came to his current role as the AIDS epidemic was exploding and President Reagan was paying it little attention. He and C. Everett Koop, the surgeon general, were widely credited with spurring the Reagan administration to action against AIDS, a fact that underscores Dr. Fauci’s ability to negotiate difficult politics.
He has recognized Mr. Trump’s need for praise; in the president’s presence and with audiences that are friendly to him, Dr. Fauci has been complimentary. He told the radio host Mark Levin on Fox News of the administration’s response to the virus: “I can’t imagine that under any circumstances that anybody could be doing more.”
And Dr. Fauci is savvy not just about the inner workings of the government but about the news media that covers it.
When Vice President Mike Pence took over as the lead of the coronavirus task force, his advisers wanted to put a 24-hour pause on interviews that administration officials were giving as they assessed where the administration was after a chaotic few weeks. They were initially fine with Dr. Fauci’s appearances, meeting with him before interviews to get a sense of what he planned to say.
But in the past two weeks, as Dr. Fauci’s interviews have increased in frequency, White House officials have become more concerned that he is criticizing the president.
Officials asked him about the viral moment in the White House briefing room, when he put his hand to his face and appeared to suppress a chuckle after Mr. Trump referred to the State Department as the “Deep State Department.” Dr. Fauci had a benign explanation: He had a scratchy throat and a lozenge he had in his mouth had gotten stuck in his throat, which he tried to mask from reporters.
Some officials have not questioned that Dr. Fauci is giving interviews, but they have wondered how he has so much time for so many requests from the news media.
Dr. Fauci, for his part, has been dismissive of some questions about whether he was at odds with the president, treating it as a news media obsession.
“I think there’s this issue of trying to separate the two of us,” he said on CBS.
Scientists who have fought pandemics describe difficult measures needed to defend the United States against a fast-moving pathogen.
Terrifying though the coronavirus may be, it can be turned back. China, South Korea, Singapore and Taiwan have demonstrated that, with furious efforts, the contagion can be brought to heel.
Whether they can keep it suppressed remains to be seen. But for the United States to repeat their successes will take extraordinary levels of coordination and money from the country’s leaders, and extraordinary levels of trust and cooperation from citizens. It will also require international partnerships in an interconnected world.
There is a chance to stop the coronavirus. This contagion has a weakness.
Although there are incidents of rampant spread, as happened on the cruise ship Diamond Princess, the coronavirus more often infects clusters of family members, friends and work colleagues, said Dr. David L. Heymann, who chairs an expert panel advising the World Health Organization on emergencies.
No one is certain why the virus travels in this way, but experts see an opening nonetheless. “You can contain clusters,” Dr. Heymann said. “You need to identify and stop discrete outbreaks, and then do rigorous contact tracing.”
But doing so takes intelligent, rapidly adaptive work by health officials, and near-total cooperation from the populace. Containment becomes realistic only when Americans realize that working together is the only way to protect themselves and their loved ones.
In interviews with a dozen of the world’s leading experts on fighting epidemics, there was wide agreement on the steps that must be taken immediately.
Those experts included international public health officials who have fought AIDS, malaria, tuberculosis, flu and Ebola; scientists and epidemiologists; and former health officials who led major American global health programs in both Republican and Democratic administrations.
Americans must be persuaded to stay home, they said, and a system put in place to isolate the infected and care for them outside the home. Travel restrictions should be extended, they said; productions of masks and ventilators must be accelerated, and testing problems must be resolved.
But tactics like forced isolation, school closings and pervasive GPS tracking of patients brought more divided reactions.
It was not at all clear that a nation so fundamentally committed to individual liberty and distrustful of government could learn to adapt to many of these measures, especially those that smack of state compulsion.
“The American way is to look for better outcomes through a voluntary system,” said Dr. Luciana Borio, who was director of medical and biodefense preparedness for the National Security Council before it was disbanded in 2018.
“I think you can appeal to people to do the right thing.”
In the week since the interviews began, remarkable changes have come over American life. State governments are telling residents they must stay home. Nonessential businesses are being shuttered.
The streets are quieter than they have been in generations, and even friends keep a wary distance. What seemed unthinkable just a week ago is rapidly becoming the new normal.
What follows are the recommendations offered by the experts interviewed by The Times.
The White House holds frequent media briefings to describe the administration’s progress against the pandemic, often led by President Trump or Vice President Mike Pence, flanked by a rotating cast of officials.
Many experts, some of whom are international civil servants, declined to speak on the record for fear of offending the president. But they were united in the opinion that politicians must step aside and let scientists both lead the effort to contain the virus and explain to Americans what must be done.
Just as generals take the lead in giving daily briefings in wartime — as Gen. Norman Schwarzkopf did during the Persian Gulf war — medical experts should be at the microphone now to explain complex ideas like epidemic curves, social distancing and off-label use of drugs.
The microphone should not even be at the White House, scientists said, so that briefings of historic importance do not dissolve into angry, politically charged exchanges with the press corps, as happened again on Friday.
Instead, leaders must describe the looming crisis and the possible solutions in ways that will win the trust of Americans.
Above all, the experts said, briefings should focus on saving lives and making sure that average wage earners survive the coming hard times — not on the stock market, the tourism industry or the president’s health. There is no time left to point fingers and assign blame.
“At this point in the emergency, there’s little merit in spending time on what we should have done or who’s at fault,” said Adm. Tim Ziemer, who was the coordinator of the President’s Malaria Initiative from 2006 until early 2017 and led the pandemic response unit on the National Security Council before its disbanding.
“We need to focus on the enemy, and that’s the virus.”
The next priority, experts said, is extreme social distancing.
If it were possible to wave a magic wand and make all Americans freeze in place for 14 days while sitting six feet apart, epidemiologists say, the whole epidemic would sputter to a halt.
The virus would die out on every contaminated surface and, because almost everyone shows symptoms within two weeks, it would be evident who was infected. If we had enough tests for every American, even the completely asymptomatic cases could be found and isolated.
The crisis would be over.
Obviously, there is no magic wand, and no 300 million tests. But the goal of lockdowns and social distancing is to approximate such a total freeze.
To attempt that, experts said, travel and human interaction must be reduced to a minimum.
Italy moved incrementally: Officials slowly and reluctantly closed restaurants, churches and museums, and banned weddings and funerals. Nonetheless, the country’s death count continues to rise.
The United States is slowly following suit. International flights are all but banned, but not domestic ones. California has ordered all residents to stay at home; New York was to shutter all nonessential businesses on Sunday evening.
On Friday, Dr. Anthony S. Fauci, chief medical adviser to the White House Coronavirus Task Force, said he advocated restrictive measures all across the country.
In contrast to the halting steps taken here, China shut down Wuhan — the epicenter of the nation’s outbreak — and restricted movement in much of the country on Jan. 23, when the country had a mere 500 cases and 17 deaths.
Its rapid action had an important effect: With the virus mostly isolated in one province, the rest of China was able to save Wuhan.
In a vast, largely closed society, it can be difficult to know what is happening on the ground, and there is no guarantee that the virus won’t roar back as the Chinese economy restarts.
But the lesson is that relatively unaffected regions of the United States will be needed to help rescue overwhelmed cities like New York and Seattle. Keeping these areas at least somewhat free of the coronavirus means enacting strict measures, and quickly.
Stop transmission within cities
Within cities, there are dangerous hot spots: One restaurant, one gym, one hospital, even one taxi may be more contaminated than many identical others nearby because someone had a coughing fit inside.
Each day’s delay in stopping human contact, experts said, creates more hot spots, none of which can be identified until about a week later, when the people infected there start falling ill.
To stop the explosion, municipal activity must be curtailed. Still, some Americans must stay on the job: doctors, nurses, ambulance drivers; police officers and firefighters; the technicians who maintain the electrical grid and gas and phone lines.
The delivery of food and medicine must continue, so that people pinned in their homes suffer nothing worse than boredom. Those essential workers may eventually need permits, and a process for issuing them, if the police are needed to enforce stay-at-home orders, as they have been in China and Italy.
People in lockdown adapt. In Wuhan, apartment complexes submit group orders for food, medicine, diapers and other essentials. Shipments are assembled at grocery warehouses or government pantries and dropped off. In Italy, trapped neighbors serenade one another.
It’s an intimidating picture. But the weaker the freeze, the more people die in overburdened hospitals — and the longer it ultimately takes for the economy to restart.
South Korea avoided locking down any city, but only by moving early and with extraordinary speed. In January, the country had four companies making tests, and as of March 9 had tested 210,000 citizens — the equivalent of testing 2.3 million Americans.
As of the same date, fewer than 9,000 Americans had been tested.
Everyone who is infected in South Korea goes into isolation in government shelters, and phones and credit card data are used to trace their prior movements and find their contacts. Where they walked before they fell ill is broadcast to the cellphones of everyone who was nearby.
Anyone even potentially exposed is quarantined at home; a GPS app tells the police if that person goes outside. The fine for doing so is $8,000.
British researchers are trying to develop a similar tracking app, albeit one more palatable to citizens in Western democracies.
Fix the testing mess
Testing must be done in a coordinated and safe way, experts said. The seriously ill must go first, and the testers must be protected.
In China, those seeking a test must describe their symptoms on a telemedicine website. If a nurse decides a test is warranted, they are directed to one of dozens of “fever clinics” set up far from all other patients.
Personnel in head-to-toe gear check their fevers and question them. Then, ideally, patients are given a rapid flu test and a white blood cell count is taken to rule out influenza and bacterial pneumonia.
Then their lungs are visualized in a CT scanner to look for “ground-glass opacities” that indicate pneumonia and rule out cancer and tuberculosis. Only then are they given a diagnostic test for the coronavirus — and they are told to wait at the testing center.
The results take a minimum of four hours; in the past, if results took overnight, patients were moved to a hotel to wait — sometimes for two to three days, if doctors believed retesting was warranted. It can take several days after an exposure for a test to turn positive.
In the United States, people seeking tests are calling their doctors, who may not have them, or sometimes waiting in traffic jams leading to store parking lots. On Friday, New York City limited testing only to those patients requiring hospitalization, saying the system was being overwhelmed.
Isolate the infected
As soon as possible, experts said, the United States must develop an alternative to the practice of isolating infected people at home, as it endangers families. In China, 75 to 80 percent of all transmission occurred in family clusters.
That pattern has already repeated itself here. Seven members of a large family in New Jersey were infected; four have already died. After a lawyer in New Rochelle, N.Y., fell ill, his wife, son and daughter all tested positive.
Instead of a policy that advises the infected to remain at home, as the Centers for Disease and Prevention now does, experts said cities should establish facilities where the mildly and moderately ill can recuperate under the care and observation of nurses.
Wuhan created many such centers, called “temporary hospitals,” each a cross between a dormitory and a first-aid clinic. They had cots and oxygen tanks, but not the advanced machines used in intensive care units.
American cities now have many spaces that could serve as isolation wards. Already New York is considering turning the Jacob K. Javits Convention Center into a temporary hospital, along with the Westchester Convention Center and two university campuses.
Gov. Ron DeSantis of Florida said on Saturday that state officials were also considering opening isolation wards.
In China, said Dr. Bruce Aylward, leader of the World Health Organization’s observer team there, people originally resisted leaving home or seeing their children go into isolation centers with no visiting rights — just as Americans no doubt would.
In China, they came to accept it.
“They realized they were keeping their families safe,” he said. “Also, isolation is really lonely. It’s psychologically difficult. Here, they were all together with other people in the same boat. They supported each other.”
Find the fevers
Because China, Taiwan and Vietnam were hit by SARS in 2003, and South Korea has grappled with MERS, fever checks during disease outbreaks became routine.
In most cities in affected Asian countries, it is commonplace before entering any bus, train or subway station, office building, theater or even a restaurant to get a temperature check. Washing your hands in chlorinated water is often also required.
“They give you a sticker afterward,” said Dr. Heymann, who recently spent a week teaching in Singapore. “I built up quite a collection.”
In China, having a fever means a mandatory trip to a fever clinic to check for coronavirus. In the Wuhan area, different cities took different approaches.
Cellphone videos from China show police officers knocking on doors and taking temperatures. In some, people who resist are dragged away by force. The city of Ningbo offered bounties of $1,400 to anyone who turned in a coronavirus sufferer.
The city of Qianjiang, by contrast, offered the same amount of money to any resident who came in voluntarily and tested positive.
Some measures made Western experts queasy. It is difficult to imagine Americans permitting a family member with a fever to be dragged to an isolation ward where visitors are not permitted.
“A lot of people’s rights were violated,” Dr. Borio said.
Voluntary approaches, like explaining to patients that they will be keeping family and friends safe, are more likely to work in the West, she added.
Trace the contacts
Finding and testing all the contacts of every positive case is essential, experts said. At the peak of its epidemic, Wuhan had 18,000 people tracking down individuals who had come in contact with the infected.
At the moment, the health departments of some American counties lack the manpower to trace even syphilis or tuberculosis, let alone scores of casual contacts of someone infected with the coronavirus.
Dr. Borio suggested that young Americans could use their social networks to “do their own contact tracing.” Social media also is used in Asia, but in different ways.
China’s strategy is quite intrusive: To use the subway in some cities, citizens must download an app that rates how great a health risk they are. South Korean apps tell users exactly where infected people have traveled.
When he lectured at a Singapore university, Dr. Heymann said, dozens of students were in the room. But just before he began class, they were photographed to record where everyone sat.
“That way, if someone turns up infected later, you can find out who sat near them,” Dr. Heymann said. “That’s really clever.”
Contacts generally must remain home for 14 days and report their temperatures twice a day.
Make masks ubiquitous
American experts have divided opinions about masks, but those who have worked in Asia see their value.
There is very little data showing that flat surgical masks protect healthy individuals from disease. Nonetheless, Asian countries generally encourage people wear them. In some cities in China where masks are compulsory, the police even used drones to chase individuals down streets, ordering them to go home and mask up.
The Asian approach is less about data than it is about crowd psychology, experts explained.
All experts agree that the sick must wear masks to keep in their coughs. But if a mask indicates that the wearer is sick, many people will be reluctant to wear one. If everyone is required to wear masks, the sick automatically have one on and there is no stigma attached.
Also, experts emphasized, Americans should be taught to take seriously admonitions to stop shaking hands and hugging. The “W.H.O. elbow bump” may look funny, but it’s a legitimate technique for preventing infection.
“In Asia, where they went through SARS, people understand the danger,” Dr. Heymann said. “It’s instilled in the population that you’ve got to do the right thing.”
Preserve vital services
Federal intervention is necessary for some vital aspects of life during a pandemic.
Only the federal government can enforce interstate commerce laws to ensure that food, water, electricity, gas, phone lines and other basic needs keep flowing across state lines to cities and suburbs.
Mr. Trump has said he could compel companies to prioritize making ventilators, masks and other needed goods. Some have volunteered; the Hanes underwear company, for example, will use its cotton to make masks for hospital workers.
He also has the military; the Navy is committing two hospital ships to the fight. And Mr. Trump can call up the National Guard. As of Saturday evening, more than 6,500 National Guard members already are assisting in the coronavirus response in 38 states, Puerto Rico and the District of Columbia.
High-level decisions like these must be made quickly, experts said.
“Many Western political leaders are behaving as though they are on a tightrope,” said Dr. David Nabarro, a W.H.O. special envoy on Covid-19 and a veteran of fights against SARS, Ebola and cholera.
“But there is no choice. We must do all in our power to fight this,” he added. “I sense that most people — and certainly those in business — get it. They would prefer to take the bitter medicine at once and contain outbreaks as they start rather than gamble with uncertainty.”
Produce ventilators and oxygen
The roughly 175,000 ventilators in all American hospitals and the national stockpile are expected to be far fewer than are needed to handle a surge of patients desperate for breath.
The machines pump air and oxygen into the lungs, but they normally cost $25,000 or more each, and neither individual hospitals nor the federal emergency stockpile has ever had enough on hand to handle the number of pneumonia patients that this pandemic is expected to produce.
New York, for example, has found about 6,000 ventilators for purchase around the world, Governor Cuomo said. He estimated the state would need about 30,000.
The manufacturers, including a dozen in the United States, say there is no easy way to ramp up production quickly. But it is possible other manufacturers, including aerospace and automobile companies, could be enlisted to do so.
Ventilators are basically air pumps with motors controlled by circuits that make them act like lungs: the pump pushes air into the patient, then stops so the weight of the chest can push the air back out.
Automobiles and airplanes contain many small pumps, like those for oil, water and air-conditioning fluid, that might be modified to act as basic, stripped-down ventilators. On Sunday, Mr. Trump tweeted that Ford and General Motors had been “given the go-ahead” to produce ventilators.
Providers, meanwhile, are scrambling for alternatives.
Canadian nurses are disseminating a 2006 paper describing how one ventilator can be modified to treat four patients simultaneously. Inventors have proposed combining C-PAP machines, which many apnea sufferers own, and oxygen tanks to improvise a ventilator.
The United States must also work to increase its supply of piped and tanked oxygen, Dr. Aylward said.
One of the lessons of China, he noted, was that many Covid-19 patients who would normally have been intubated and on ventilators managed to survive with oxygen alone.
Hospitals in the United States have taken some measures to handle surges of patients, such as stopping elective surgery and setting up isolation rooms.
To protect bedridden long-term patients, nursing homes and hospitals also should immediately stop admitting visitors and do constant health checks on their staffs, said Dr. James LeDuc, director of the Galveston National Laboratory at the University of Texas Medical Branch.
The national stockpile does contain some prepackaged military field hospitals, but they are not expected to be nearly enough for a big surge.
In Wuhan, the Chinese government famously built two new hospitals in two weeks. All other hospitals were divided: 48 were designated to handle 10,000 serious or critical coronavirus patients, while others were restricted to handling emergencies like heart attacks and births.
Wherever that was impractical, hospitals were divided into “clean” and “dirty” zones, and the medical teams did not cross over. Walls to isolate whole wards were built, and — as in Ebola wards — doctors went in one end of the room wearing protective gear and left by the other end, where they de-gowned under the eyes of a nurse to prevent infection.
Decide when to close schools
As of Saturday, schools in 45 states were closed entirely, but that is a decision that divided experts.
“Closing all schools may not make sense unless there is documented widespread community transmission, which we’re not seeing in most of the country,” said Dr. Thomas R. Frieden, a former C.D.C. director under President Barack Obama.
It is unclear how much children spread coronavirus. They very seldom get sick enough to be hospitalized, which is not true of flu. Current testing cannot tell whether most do not even become infected.
In China, Dr. Aylward said, he asked all of the doctors he spoke to whether they had seen any family clusters in which a child was the first to be infected. No one had, he said, which astonished him.
That leaves a quandary. Closing schools is a normal part of social distancing; after all, schools are the workplaces for many adults, too. And when the disease is clearly spreading within an individual school, it must close.
But closing whole school districts can seriously disrupt a city’s ability to fight an outbreak. With their children stuck at home, nurses, doctors, police officers and other emergency medical workers cannot come to work.
Also, many children in low-income families depend on the meals they eat at schools.
Cities that close all schools are creating special “hub schools” for the children of essential workers. In Ohio, the governor has told school bus drivers to deliver hot meals to children who normally got them at school.
China’s effort succeeded, experts said, in part because of hundreds of thousands of volunteers. The government declared a “people’s war” and rolled out a “Fight On, Wuhan! Fight On, China!” campaign.
Many people idled by the lockdowns stepped up to act as fever checkers, contact tracers, hospital construction workers, food deliverers, even babysitters for the children of first responders, or as crematory workers.
With training, volunteers were able to do some ground-level but crucial medical tasks, such as basic nursing, lab technician work or making sure that hospital rooms were correctly decontaminated.
Americans often step forward to help neighbors affected by hurricanes and floods; many will no doubt do so in this outbreak, but they will need training in how not to fall ill and add to the problem.
“In my experience, success is dependent on how much the public is informed and participates,” Admiral Ziemer said. “This truly is an ‘all hands on deck’ situation.”
Prioritize the treatments
Clinicians in China, Italy and France have thrown virtually everything they had in hospital pharmacies into the fight, and at least two possibilities have emerged that might save patients: the anti-malaria drugs chloroquine and hydroxychloroquine, and the antiviral remdesivir, which has no licensed use.
There is not proof yet that any of these are effective against the virus. China registered more than 200 clinical trials, including several involving those treatments, but investigators ran out of patients in critical condition to enroll. Italy and France have trials underway, and hospitals in New York are writing trial protocols now.
One worry for trial leaders is that chloroquine has been given so much publicity that patients may refuse to be “randomized” and accept a 50 percent chance of being given a placebo.
If any drug works on critical cases, it might be possible to use small doses as a prophylactic to prevent infection.
An alternative is to harvest protective antibodies from the blood of people who have survived the illness, said Dr. Peter J. Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston.
The purified blood serum — called immunoglobulin — could possibly be used in small amounts to protect emergency medical workers, too.
“Unfortunately, the first wave won’t benefit from this,” Dr. Hotez said. “We need to wait until we have enough survivors.”
Find a vaccine
The ultimate hope is to have a vaccine that will protect everyone, and many companies and governments have already rushed the design of candidate vaccines. But as Dr. Fauci has explained multiple times, testing those candidate vaccines for safety and effectiveness takes time.
The process will take at least a year, even if nothing goes wrong. The roadblock, vaccine experts explained, is not bureaucratic. It is that the human immune system takes weeks to produce antibodies, and some dangerous side effects can take weeks to appear.
After extensive animal testing, vaccines are normally given to about 50 healthy human volunteers to see if they cause any unexpected side effects and to measure what dose produces enough antibodies to be considered protective.
If that goes well, the trial enrolls hundreds or thousands of volunteers in an area where the virus is circulating. Half get the vaccine, the rest do not — and the investigators wait. If the vaccinated half do not get the disease, the green light for production is finally given.
In the past, some experimental vaccines have produced serious side effects, like Guillain-Barre syndrome, which can paralyze and kill. A greater danger, experts said, is that some experimental vaccines, paradoxically, cause “immune enhancement,” meaning they make it more likely, not less, that recipients will get a disease. That would be a disaster.
One candidate coronavirus vaccine Dr. Hotez invented 10 years ago in the wake of SARS, he said, had to be abandoned when it appeared to make mice more likely to die from pneumonia when they were experimentally infected with the virus.
In theory, the testing process could be sped up with “challenge trials,” in which healthy volunteers get the vaccine and then are deliberately infected. But that is ethically fraught when there is no cure for Covid-19. Even some healthy young people have died from this virus.
Reach out to other nations
Wealthy nations need to remember that, as much as they are struggling with the virus, poorer countries will have a far harder time and need help.
Also, the Asian nations that have contained the virus could offer expertise — and desperately needed equipment. Jack Ma, the billionaire founder of Alibaba, recently offered large shipments of masks and testing kits to the United States.
Wealthy nations ignored the daily warnings from Tedros Adhanom Ghebreyesus, the W.H.O.’s director general, that far more aggressive efforts at isolation and contact tracing were urgently needed to stop the virus.
“Middle income and poorer nations are following the advice of international organizations while the most advanced nations find it so hard to implement it,” Dr. Nabarro said. “That must change.”
In declaring the coronavirus a pandemic, Dr. Tedros called for countries to learn from one another’s successes, act with unity and help protect one another against a threat to people of every nationality.
“Let’s all look out for each other,” he said.