The malaria drug chloroquine was developed from quinine, an alkaloid found in the bark of the cinchona tree, which grows in the tropical highlands of South America. The Incas passed the bark cure to Jesuit priests, who transported it to Europe in the mid-sixteen-hundreds. The National Institutes of Health calls quinine “the most serendipitous medical discovery of the 17th century,” but its side effects—diarrhea, vomiting, partial deafness and blindness—could be devastating. A less toxic derivative of chloroquine, hydroxychloroquine, was developed in the nineteen-forties. Doctors and pharmacists call it HCQ.
Against malaria, the drugs, which are taken as pills, essentially defend red blood cells against a parasite that is transmitted by mosquito bite. Lately, some doctors have been trying it against the novel coronavirus, which causes COVID-19. Attention to chloroquine and hydroxychloroquine—and to a third drug, the antibiotic azithromycin, a common brand name of which is Zithromax Z-Pak—intensified in mid-March, after researchers at Aix-Marseille University, in France, released a preliminary study saying that, in a clinical trial, the combination of hydroxychloroquine and azithromycin had quickly reduced the amount of the virus in COVID-19 patients.
On March 18th, on Fox News, Tucker Carlson opened a three-minute segment about the study by saying, of the United States, “This is a country of science.” He then introduced a lawyer, Gregory Rigano, whom he identified as an adviser to Stanford University’s medical school. Rigano had self-published a white paper about chloroquine, on Google Docs; his connection to the French research was otherwise unclear. He was appearing remotely, wearing a suit and sitting in front of a cold fireplace. When Carlson asked him why he thought the study was important, Rigano responded, “The President has the authority to authorize the use of hydroxychloroquine against coronavirus immediately. He has cut more red tape at the F.D.A. than any other President in history.”
According to his Web site, covidtrial.io, Rigano has experience “advancing various pharmaceutical assets through laboratory, animal, formulation, manufacturing, clinical trials,” and was hosting an “open data clinical trial for Covid-19.” (The wording on the Web site has since been changed.) He told Carlson that the French study “was released this morning on my Twitter account,” and showed a “one hundred per cent cure rate” against the coronavirus. Carlson called the revelation “remarkable.” Rigano, after a bizarre reference to hepatitis, said, “What we’re here to announce is the second cure to a virus of all time.”
Charlie Kirk, the founder of the conservative nonprofit Turning Point USA, tweeted the segment, exhorting his nearly two million followers to “RT If President @realDonaldTrump should immediately move to make this available.” Most media outlets, though, quickly challenged the credibility of Rigano and that of his white paper’s co-author, James Todaro, a cryptocurrency investor who has tweeted about having a medical degree from Columbia. HuffPost called them “hucksters.” Joan Donovan, who studies “media manipulation and disinformation campaigns” at the Shorenstein Center, at the Harvard Kennedy School, called them “bitcoin entrepreneurs” and pointed out that “neither do research on viruses.” She wrote, “This is dangerous because people are now tweeting about trying to get their doctors to prescribe anti-malaria drugs. Worse, thousands of people think they can cure coronavirus by drinking tonic water.” (Tonic water contains quinine.) Stanford Health Care posted an “IMPORTANT NOTICE” on its Web site: “A widely circulating Google document claiming to have identified a potential treatment for COVID-19 in consultation with Stanford’s School of Medicine is not legitimate.”
Donald Trump, however, ran with it. Last Thursday, at a press conference, he declared that chloroquine had “been approved” by the Food and Drug Administration as a treatment for COVID-19. (It hadn’t.) On Friday, he said that he is “a big fan” of the drug. (The F.D.A. commissioner, Stephen Hahn, issued a cautionary statement about spreading “false hope.”) On Saturday, Trump tweeted, “HYDROXYCHLOROQUINE & AZITHROMYCIN, taken together, have a real chance to be one of the biggest game changers in the history of medicine.” He added that the drugs should be used “IMMEDIATELY” to treat the coronavirus. HCQ is also used to treat rheumatoid arthritis and lupus, which are autoimmune diseases; at one of his pressers, Trump had said, “If you wanted, you can have a prescription,” adding, “What the hell do you have to lose?”
Physicians responded instantly and publicly. Sam Ghali, an emergency physician in Lexington, Kentucky, tweeted that the President’s recommendation involved “a DANGEROUS combination of drugs with tons of side effects,” and that “together they can make your heart go into abnormal rhythms and even KILL you.” Rob Davidson, an emergency physician in western Michigan, who chairs the Committee to Protect Medicare, tweeted, at Trump, “Leave the medical advice to doctors. You can’t even do your own job correctly, stop trying to do ours.”
The American Society of Health-System Pharmacists soon reported a shortage of HCQ. By Sunday, at least four state pharmacy boards—in Idaho, Ohio, Nevada, and Texas—had restricted prescriptions. (The list has now grown to include Kentucky, North Carolina, and Oklahoma.) At least one board also restricted azithromycin. Katherine Rowland, a pharmacist in Eugene, Oregon, tweeted, “Well it finally happened to me. A dentist just tried to call in scripts for hydroxychloroquine + azithromycin for himself, his wife, & another couple (friends). NOPE. I have patients with lupus that have been on HCQ for YEARS and now can’t get it because it’s on backorder.” A lupus patient in Maryland told a reporter for Undark Magazine that she never worried about a drug shortage but was now terrified that, without the medication that protects her organs from inflammation, her immune system would turn on her. “I’ll suffocate,” she said.
In recent weeks—as the number of coronavirus cases escalated to what is now half a million worldwide—the F.D.A. and the Federal Trade Commission have sent cease-and-desist letters to at least seven sellers of products that are being marketed as cures for the coronavirus. On March 6th, one such warning went to “The Jim Bakker Show,” in Blue Eye, Missouri. The television program, which is fronted by a televangelist who spent nearly five years in prison, in the early nineteen-nineties, for fraud, had been touting survivalist products, including Silver Sol Liquid, a silver solution that was purported to “mitigate, prevent, treat, diagnose, or cure COVID-19 in people.” Viewers were told that they could put the liquid “in a nebulizer which then creates a steam and you breathe it in, and it will go directly into your lungs where that virus is.” Another letter went to Herbal Amy, an L.L.C. in Nampa, Idaho, the Web site of which was selling “Coronavirus Protocol” products: Coronavirus Boneset Tea, Coronavirus Cell Protection. The suggested regimen was “rather extensive,” because “the particular corona virus that is now spreading world wide is exceptionally potent,” the Web site noted. The herbs in the protocol were “specific in one way or another” for the virus, and worked “for acute infections.”
Anthony Fauci has directed the National Institute of Allergy and Infectious Diseases since Ronald Reagan was President. As a medical professional, he has faced H.I.V., SARS, MERS, Ebola, and now Trump. At press conferences, Trump speaks of hunches (“I feel good about it”); Fauci delivers information that has been vetted by experts. On Sunday, Science magazine asked Fauci how he can tolerate statements that “aren’t true and aren’t factual”; Fauci replied, “I can’t jump in front of the microphone and push him down.” Fauci carefully explained that any clinical successes related to the cocktail that Trump was praising were anecdotal. He said, “My job is to ultimately prove without a doubt that a drug is not only safe but that it works.”
As the coronavirus continued to spread, Trump made one troubling declaration after another. A vaccine was coming “relatively soon,” he said. (It takes at least a year to develop a vaccine.) “We were very prepared” for a pandemic, he said. (The country’s hospitals were caught with such a shortage of basic protective gear that front-line health-care workers are reusing, by necessity, potentially contaminated masks). The virus “miraculously goes away” as the weather warms, he said. (Robert Redfield, the director of the Centers for Disease Control and Prevention, has said, “This virus is probably with us beyond this season, beyond this year.”) The number of coronavirus patients would be “close to zero,” Trump said. (At least a thousand people have died of the coronavirus in the United States, thirteen of them in one twenty-four-hour period, this week, at a single hospital in Elmhurst, Queens.) By Wednesday night, on Twitter, #DoctorsOnlyPressConferences was trending nationally.
Ryan Marino, one of the doctors tweeting about the dangers of Trump’s messaging, is a thirty-one-year-old medical toxicologist at University Hospitals in Cleveland. His specialty involves “the poisoned patient”—a drug overdose, lead exposure, “things that bite and sting.” Call a poison-control center and it is usually a clinician like Marino, as opposed to a laboratory toxicologist, at the other end of the line. A podcast host recently told him, “You are right out at the tip of the spear,” treating “patients at the point of care.”
A few years ago, Marino noticed rumors about fentanyl, the potent painkiller which in an illicit form, usually a powder, is often found in street drugs such as heroin. On Facebook, a Texas man warned everybody to sanitize the handles of Walmart’s shopping carts because “one drop” of fentanyl could “cause death”—“all you have to do is rub your nose or touch your child’s mouth.” (The post has been shared more than thirty thousand times.) In Grove City, Ohio, after law-enforcement officers seized three kilograms of fentanyl, one network news affiliate described that amount of drugs as “enough to kill 1.5 million people.” Law-enforcement officers and other first responders had heard that they could fatally overdose by simply inhaling or touching fentanyl during drug busts. In one town, a police officer brushed an unidentified white powder off his shirt after searching a drug suspect’s car; he fell unconscious and received naloxone, a drug that can reverse an overdose. The officer was recovering shortly thereafter, but his chief spoke to “Inside Edition” and described the potential danger, as he imagined it: “He leaves and goes home, takes off that shirt, throws it in the wash. His mom, his wife, his girlfriend goes in the laundry, touches the shirt: boom, they drop. He goes home to his kid: ‘Daddy! Daddy!’ They hug him: boom, they drop. His dog sniffs his shirt: it kills his dog.” A fentanyl-industrial complex appeared—gloves, sprays, masks, hazmat suits.
In late 2017, Marino started a hashtag, #WTFentanyl, to dispel the myths that fentanyl can be easily absorbed into the skin or inhaled after becoming airborne. The rumors had, at first, struck Marino as humorous, then absurd. Then he decided that there was “serious potential for harm.” He worried that first responders would ration naloxone for themselves, and that people would die. His tweets, though, could be darkly funny. In a news interview, the C.E.O. of an alcohol- and drug-treatment center said that anyone who “enters a room with someone who might be having an issue with fentanyl” could “instantly” become addicted. Health-care workers tweeted about it, one telling Marino, “I became addicted to fentanyl by reading this tweet.” Marino replied, “Now you’re dead,” and attached a GIF of Stewie, the baby on “Family Guy,” tossing a red rose into an open grave. After someone else tweeted about fentanyl patches that had been in her bathroom cabinet for “nearly a year,” Marino responded, “Everyone who has been to your bathroom became instantly addicted and then died.”
Poisoning, in any form, is no joke to Marino—he became a medical toxicologist partly because he lost a beloved cousin to an overdose. On a podcast, he recently said that his “end game” is “to insure that there’s less harm.” After Trump’s comments about hydroxychloroquine, Marino began tweeting about the coronavirus. Whereas before he had dispelled gross exaggerations about fentanyl, he now found himself urging politicians and the public to take the risks of HCQ more seriously. He told me, “There’s very few things that make me clench up inside, and hydroxychloroquine is on the short list, because it’s so toxic.”
HCQ can cause cardiac arrest, low blood pressure, hypoglycemia, seizures, and an altered mental state. Marino warned his nearly twenty-four thousand Twitter followers that Trump, by making “unsupportable recommendations,” praised what was in fact a combination of “extremely toxic drugs with a long history of lethality and complications that are difficult to treat in even the most advanced settings.” Retweeting Trump, he wrote that it is “a crime in all 50 United States to dispense medical advice without a license.” Later, he tweeted, “Don’t listen to the President. Listen to all the experts around the world who are in consensus that we need to continue to distance/isolate.”
Marino publicly shared a memo that he had sent to his emergency-department staff: the research paper that related to Trump’s comments sounded “promising on the surface” but involved “flawed” and “limited” science. The French study that Fox News had touted had ultimately involved a treatment group of only twenty patients. Six dropped out. Three went to intensive care. One died. In a clinical trial, “dying, and doing worse, are important outcomes to measure,” Marino told me. “When they say it was ‘a hundred per cent’ successful, they’re ignoring the fact that patients were cut out of the results.”
Something else worried Marino: sick people may hear about Trump’s “hunches” and treat their coronavirus symptoms at home with a dangerous, unproven drug. That has now happened. In Lagos, at least two people have overdosed on chloroquine. The Nigeria Centre for Disease Control tweeted that the World Health Organization had “NOT approved” the compound as a treatment for COVID-19, and exhorted, “Please DO NOT engage in self-medication.” On Monday, a man in Arizona died, and his wife was in critical condition, after ingesting the kind of chloroquine solution that is used to clean fish tanks. Marino tweeted, “ ‘Fake news’ is a term that I hate to use, but when White House press briefings are causing people to poison themselves needlessly then I can’t think of a better way to describe that.”
By Thursday morning, Kaiser Permanente had stopped filling “routine” prescriptions for chloroquine, in order to “ensure access” to the drug for “severely sick patients, including both COVID-19 and those with acute lupus.” Doctors in New York, the outbreak’s epicenter, are experimenting with the drugs; days ago, Governor Andrew Cuomo announced the impending arrival of seven hundred and fifty thousand doses of chloroquine. Physicians elsewhere have tried the medications in cases of “compassionate use,” when nothing else is working. Clinical trials are underway in Minnesota and elsewhere. Alison Bateman-House, a professor of population health at New York University, told the Washington Post that the F.D.A. is “caught between saying it wants good science, and good processes, and what evidence-based medicine requires, and this is what our bosses, the people and the president are telling us they want.”
Marino heard about New York’s experiments on Thursday, when at least two hundred and thirty-seven people died of the coronavirus nationwide. That night, Trump called “The Sean Hannity Show,” on Fox News, and repeated his claims that “there’s no risk” in using an anti-malarial drug for COVID-19 “when it’s already out there in different form, for a different purpose.” He bragged about getting “such fast turnaround,” saying, “Why would we wait?” But, seconds later, he said, “If you were a betting man, I guess you’d have to bet against it.”
Marino told me, “While superficially it seems prudent to just try anything in the face of an overwhelming crisis, there is no reason to believe that these meds will help,” unless they are proven to do so. He said, “If our response to a crisis is to ignore the scientific method that has gotten us this far, then we are setting ourselves up for additional and preventable problems.”
Covid-19 Brings Out All the Usual Zombies
Let me summarize the Trump administration/right-wing media view on the coronavirus:
- It’s a hoax, or anyway
- no big deal. Besides,
- trying to do anything about it would destroy the economy. And
- it’s China’s fault, which is why we should call it the “Chinese virus.”Oh, and epidemiologists who have been modeling the virus’s future spread have come under sustained attack, accused of
- being part of a “deep state” plot against Donald Trump,
- or maybe free markets.
Does all this give you a sense of déjà vu? It should. After all, it’s very similar to the Trump/right-wing line on climate change. Here’s what Trump tweeted back in 2012: “The concept of global warming was created by and for the Chinese in order to make U.S. manufacturing noncompetitive.” It’s all there: it’s a hoax, doing anything about it will destroy the economy, and let’s blame China.
And epidemiologists startled to find their best scientific efforts denounced as politically motivated fraud should have known what was coming. After all, exactly the same thing happened to climate scientists, who have faced constant harassment for decades.
So the right-wing response to Covid-19 has been almost identical to the right-wing response to climate change, albeit on a vastly accelerated time scale. But what lies behind this kind of denialism?
Well, I recently published a book about the prevalence in our politics of “zombie ideas” — ideas that have been proved wrong by overwhelming evidence and should be dead, but somehow keep shambling along, eating people’s brains. The most prevalent zombie in U.S. politics is the insistence that tax cuts for the rich produce economic miracles, indeed pay for themselves, but the most consequential zombie, the one that poses an existential threat, is climate change denial. And Covid-19 has brought out all the usual zombies.
But why, exactly, is the right treating a pandemic the same way it treats tax cuts and climate change?
The force that usually keeps zombie ideas shambling along is naked financial self-interest.
- Paeans to the virtues of tax cuts are more or less directly paid for by billionaires who benefit from these cuts.
- Climate denial is an industry supported almost entirely by fossil-fuel interests. As Upton Sinclair put it, “It is difficult to get a man to understand something when his salary depends on his not understanding it.”
However, it’s less obvious who gains from minimizing the dangers of a pandemic. Among other things, the time scale is vastly compressed compared with climate change: the consequences of global warming will take many decades to play out, giving fossil-fuel interests plenty of time to take the money and run, but we’re already seeing catastrophic consequences of virus denial after just a few weeks.
True, there are may be some billionaires who imagine that denying the crisis will work to their financial advantage. Just before Trump made his terrifying call for reopening the nation by Easter, he had a conference call with a group of money managers, who may have told him that ending social distancing would be good for the market. That’s insane, but you should never underestimate the cupidity of these people. Remember, Blackstone’s Steve Schwarzman, one of the men on the call, once compared proposals to close a tax loophole to Hitler’s invasion of Poland.
Also, billionaires have done very well by Trump’s tax cuts, and may fear that the economic damage from the coronavirus will bring about Trump’s defeat, and hence tax increases for people like them.
But I suspect that the disastrous response to Covid-19 has been shaped less by direct self-interest than by two indirect ways in which pandemic policy gets linked to the general prevalence of zombie ideas in right-wing thought.
First, when you have a political movement almost entirely built around assertions than any expert can tell you are false, you have to cultivate an attitude of disdain toward expertise, one that spills over into everything. Once you dismiss people who look at evidence on the effects of tax cuts and the effects of greenhouse gas emissions, you’re already primed to dismiss people who look at evidence on disease transmission.
This also helps explain the centrality of science-hating religious conservatives to modern conservatism, which has played an important role in Trump’s failure to respond.
Second, conservatives do hold one true belief: namely, that there is a kind of halo effect around successful government policies. If public intervention can be effective in one area, they fear — probably rightly — that voters might look more favorably on government intervention in other areas. In principle, public health measures to limit the spread of coronavirus needn’t have much implication for the future of social programs like Medicaid. In practice, the first tends to increase support for the second.
As a result, the right often opposes government interventions even when they clearly serve the public good and have nothing to do with redistributing income, simply because they don’t want voters to see government doing anything well.
The bottom line is that as with so many things Trump, the awfulness of the man in the White House isn’t the whole story behind terrible policy. Yes, he’s ignorant, incompetent, vindictive and utterly lacking in empathy. But his failures on pandemic policy owe as much to the nature of the movement he serves as they do to his personal inadequacies.
Lessons from Italy’s Response to Coronavirus
As policymakers around the world struggle to combat the rapidly escalating Covid-19 pandemic, they find themselves in uncharted territory. Much has been written about the practices and policies used in countries such as China, South Korea, Singapore, and Taiwan to stifle the pandemic. Unfortunately, throughout much of Europe and the United States, it is already too late to contain Covid-19 in its infancy, and policymakers are struggling to keep up with the spreading pandemic. In doing so, however, they are repeating many of the errors made early on in Italy, where the pandemic has turned into a disaster. The purpose of this article is to help U.S. and European policymakers at all levels learn from Italy’s mistakes so they can recognize and address the unprecedented challenges presented by the rapidly expanding crisis.
In a matter of weeks (from February 21 to March 22), Italy went from the discovery of the first official Covid-19 case to a government decree that essentially prohibited all movements of people within the whole territory, and the closure of all non-essential business activities. Within this very short time period, the country has been hit by nothing short of a tsunami of unprecedented force, punctuated by an incessant stream of deaths. It is unquestionably Italy’s biggest crisis since World War II.
Some aspects of this crisis — starting with its timing — can undoubtedly be attributed to plain and simple sfortuna (“bad luck” in Italian) that were clearly not under the full control of policymakers. Other aspects, however, are emblematic of the profound obstacles that leaders in Italy faced in recognizing the magnitude of the threat posed by Covid-19, organizing a systematic response to it, and learning from early implementation successes — and, most importantly, failures.
It is worth emphasizing that these obstacles emerged even after Covid-19 had already fully impacted in China and some alternative models for the containment of the virus (in China and elsewhere) had already been successfully implemented. What this suggests is a systematic failure to absorb and act upon existing information rapidly and effectively rather than a complete lack of knowledge of what ought to be done.
Here are explanations for that failure — which relate to the difficulties of making decisions in real time, when a crisis is unfolding — and ways to overcome them.
Recognize your cognitive biases. In its early stages, the Covid-19 crisis in Italy looked nothing like a crisis. The initial state-of-emergency declarations were met by skepticism by both the public and many in policy circles — even though several scientists had been warning of the potential for a catastrophe for weeks. Indeed, in late February some notable Italian politicians engaged in public handshaking in Milan to make the point that the economy should not panic and stop because of the virus. (A week later, one of these politicians was diagnosed with Covid-19.)
Similar reactions were repeated across many other countries besides Italy and exemplify what behavioral scientists call confirmation bias — a tendency to seize upon information that confirms our preferred position or initial hypothesis. Threats such as pandemics that evolve in a nonlinear fashion (i.e., they start small but exponentially intensify) are especially tricky to confront because of the challenges of rapidly interpreting what is happening in real time. The most effective time to take strong action is extremely early, when the threat appears to be small — or even before there are any cases. But if the intervention actually works, it will appear in retrospect as if the strong actions were an overreaction. This is a game many politicians don’t want to play.
The systematic inability to listen to experts highlights the trouble that leaders — and people in general — have figuring out how to act in dire, highly complex situations where there’s no easy solution. The desire to act causes leaders to rely on their gut feeling or the opinions of their inner circle. But in a time of uncertainty, it is essential to resist that temptation, and instead take the time to discover, organize, and absorb the partial knowledge that is dispersed across different pockets of expertise.
Avoid partial solutions. A second lesson that can be drawn from the Italian experience is the importance of systematic approaches and the perils of partial solutions. The Italian government dealt with the Covid-19 pandemic by issuing a series of decrees that gradually increased restrictions within lockdown areas (“red zones”), which were then expanded until they ultimately applied to the entire country.
In normal times, this approach would probably be considered prudent and perhaps even wise. In this situation, it backfired for two reasons. First, it was inconsistent with the rapid exponential spread of the virus. The “facts on the ground” at any point in time were simply not predictive of what the situation would be just a few days later. As a result, Italy followed the spread of the virus rather than prevented it. Second, the selective approach might have inadvertently facilitated the spread of the virus. Consider the decision to initially lock down some regions but not others. When the degree announcing the closing of northern Italy became public, it touched off a massive exodus to southern Italy, undoubtedly spreading the virus to regions where it had not been present.
This illustrates is what is now clear to many observers: An effective response to the virus needs to be orchestrated as a coherent system of actions taken simultaneously. The results of the approaches taken in China and South Korea underscore this point. While the public discussion of the policies followed in these countries often focuses on single elements of their models (such as extensive testing), what truly characterizes their effective responses is the multitude of actions that were taken at once. Testing is effective when it’s combined with rigorously contact tracing, and tracing is effective as long as it is combined with an effective communication system that collects and disseminates information on the movements of potentially infected people, and so forth.
These rules also apply to the organization of the health care system itself. Wholesale reorganizations are needed within hospitals (for example, the creation of Covid-19 and non Covid-19 streams of care). In addition, a shift is urgently needed from patient-centered models of care to a community-system approach that offers pandemic solutions for the entire population (with a specific emphasis on home care). The need for coordinated actions is especially acute right now in the United States.
Learning is critical. Finding the right implementation approach requires the ability to quickly learn from both successes and failures and the willingness to change actions accordingly. Certainly, there are valuable lessons to be learned from the approaches of China, South Korea, Taiwan, and Singapore, which were able to contain the contagion fairly early. But sometimes the best practices can be found just next door. Because the Italian health care system is highly decentralized, different regions tried different policy responses. The most notable example is the contrast between the approaches taken by Lombardy and Veneto, two neighboring regions with similar socioeconomic profiles.
Lombardy, one Europe’s wealthiest and most productive areas, has been disproportionately hit by Covid-19. As of March 26, it held the grim record of nearly 35,000 novel coronavirus cases and 5,000 deaths in a population of 10 million. Veneto, by contrast, fared significantly better, with 7,000 cases and 287 deaths in a population of 5 million, despite experiencing sustained community spread early on.
The trajectories of these two regions have been shaped by a multitude of factors outside the control of policymakers, including Lombardy’s greater population density and higher number of cases when the crisis erupted. But it’s becoming increasingly apparent that different public health choices made early in the cycle of the pandemic also had an impact.
Specifically, while Lombardy and Veneto applied similar approaches to social distancing and retail closures, Veneto took a much more proactive tack towards the containment of the virus. Veneto’s strategy was multi-pronged:
- Extensive testing of symptomatic and asymptomatic cases early on.
- Proactive tracing of potential positives. If someone tested positive, everyone in that patient’s home as well as their neighbors were tested. If testing kits were unavailable, they were self-quarantined.
- A strong emphasis on home diagnosis and care. Whenever possible, samples were collected directly from a patient’s home and then processed in regional and local university labs.
- Specific efforts to monitor and protect health care and other essential workers. They included medical professionals, those in contact with at-risk populations (e.g., caregivers in nursing homes), and workers exposed to the public (e.g., supermarket cashiers, pharmacists, and protective services staff).
Following the guidance from public health authorities in the central government, Lombardy opted instead for a more conservative approach to testing. On a per capita basis, it has so far conducted half of the tests conducted in Veneto and had a much stronger focus only on symptomatic cases — and has so far made limited investments in proactive tracing, home care and monitoring, and protection of health care workers.
The set of policies enacted in Veneto are thought to have considerably reduced the burden on hospitals and minimized the risk of Covid-19 spreading in medical facilities, a problem that has greatly impacted hospitals in Lombardy. The fact that different policies resulted in different outcomes across otherwise similar regions should have been recognized as a powerful learning opportunity from the start. The findings emerging from Veneto could have been used to revisit regional and central policies early on. Yet, it is only in recent days, a full month after the outbreak in Italy, that Lombardy and other regions are taking steps to emulate some of the aspects of the “Veneto approach,” which include pressuring the central government to help them boost their diagnostic capacity.
The difficulty in diffusing newly acquired knowledge is a well-known phenomenon in both private- and the public-sector organizations. But, in our view, accelerating the diffusion of knowledge that is emerging from different policy choices (in Italy and elsewhere) should be considered a top priority at a time when “every country is reinventing the wheel,” as several scientists told us. For that to happen, especially at this time of heightened uncertainty, it is essential to consider different policies as if they were “experiments,” rather than personal or political battles, and to adopt a mindset (as well as systems and processes) that facilitates learning from past and current experiences in dealing with Covid-19 as effectively and rapidly as possible.
It is especially important to understand what does not work. While successes easily surface thanks to leaders eager to publicize progress, problems often are hidden due to fear of retribution, or, when they do emerge, they are interpreted as individual — rather than systemic — failures. For example, it emerged that at the very early onset of the pandemic in Italy (February 25), the contagion in a specific area in Lombardy could have been accelerated through a local hospital, where a Covid-19 patient was not been properly diagnosed and isolated. In talking to the media, the Italian prime minister referred to this incident as evidence of managerial inadequacy at the specific hospital. However, a month later it became clearer that the episode might have been emblematic of a much deeper issue: that hospitals traditionally organized to deliver patient-centric care are ill-equipped to deliver the type of community-focused care needed during a pandemic.
Collecting and disseminating data is important. Italy seems to have suffered from two data-related problems. In the early onset of the pandemic, the problem was data paucity. More specifically, it has been suggested that the widespread and unnoticed diffusion of the virus in the early months of 2020 may have been facilitated by the lack of epidemiological capabilities and the inability to systematically record anomalous infection peaks in some hospitals.
More recently, the problem appears to be one of data precision. In particular, in spite of the remarkable effort that the Italian government has shown in regularly updating statistics relative to the pandemic on a publicly available website, some commentators have advanced the hypothesis that the striking discrepancy in mortality rates between Italy and other countries and within Italian regions may (at least in part) be driven by different testing approaches. These discrepancies complicate the management of the pandemic in significant ways, because in absence of truly comparable data (within and across countries) it is harder to allocate resources and understand what’s working where (for example, what’s inhibiting the effective tracing of the population).
In an ideal scenario, data documenting the spread and effects of the virus should be as standardized as possible across regions and countries and follow the progression of the virus and its containment at both a macro (state) and micro (hospital) level. The need for micro-level data cannot be underestimated. While the discussion of health care quality is often made in terms of macro entities (countries or states), it is well known that health care facilities vary dramatically in terms of the quality and quantity of the services they provide and their managerial capabilities, even within the same states and regions. Rather than hiding these underlying differences, we should be fully aware of them and plan the allocation of our limited resources accordingly. Only by having good data at the right level of analysis can policymakers and health care practitioners draw proper inferences about which approaches are working and which are not.
A Different Decision-Making Approach
There is still tremendous uncertainty on what exactly needs to be done to stop the virus. Several key aspects of the virus are still unknown and hotly debated, and are likely to remain so for a considerable amount of time. Furthermore, significant lags occur between the time of action (or, in many cases, inaction) and outcomes (both infections and mortality). We need to accept that an unequivocal understanding of what solutions work is likely to take several months, if not years.
However, two aspects of this crisis appear to be clear from the Italian experience.
- First, there is no time to waste, given the exponential progression of the virus. As the head of the Italian Protezione Civile (the Italian equivalent of FEMA) put it, “The virus is faster than our bureaucracy.”
- Second, an effective approach towards Covid-19 will require a war-like mobilization — both in terms of the entity of human and economic resources that will need to be deployed as well as the extreme coordination that will be required across different parts of the health care system (testing facilities, hospitals, primary care physicians, etc.), between different entities in both the public and the private sector, and society at large.
Together, the need for immediate action and for massive mobilization imply that an effective response to this crisis will require a decision-making approach that is far from business as usual. If policymakers want to win the war against Covid-19, it is essential to adopt one that is systemic, prioritizes learning, and is able to quickly scale successful experiments and identify and shut down the ineffective ones. Yes, this a tall order — especially in the midst of such an enormous crisis. But given the stakes, it has to be done.
A Coronavirus Great Awakening?
Sometimes the most important ingredient for spiritual renewal is a cataclysmic event.
Could a plague of biblical proportions be America’s best hope for religious revival? As the 75th anniversary of the end of World War II approaches, there is reason to think so.
Three-quarters of a century has dimmed the memory of that gruesome conflict and its terrible consequences: tens of millions killed, great cities bombed to rubble, Europe and Asia stricken by hunger and poverty. Those who survived the war had to grapple with the kinds of profound questions that only arise in the aftermath of calamity. Gazing at the ruins from his window at Cambridge University, British historian Herbert Butterfield chose to make sense of it by turning to the Hebrew Bible.
“The power of the Old Testament teaching on history—perhaps the point at which the ancient Jews were most original, breaking away from the religious thought of the other peoples around them—lay precisely in the region of truths which sprang from a reflection on catastrophe and cataclysm,” Butterfield wrote in “Christianity and History” (1949). “It is almost impossible properly to appreciate the higher developments in the historical reflection of the Old Testament except in another age which has experienced (or has found itself confronted with) colossal cataclysm.”
Americans, chastened by the horrors of war, turned to faith in search of truth and meaning. In the late 1940s, Gallup surveys showed more than three-quarters of Americans were members of a house of worship, compared with about half today. Congress added the words “under God” to the Pledge of Allegiance in 1954. Some would later call this a Third Great Awakening.
Today the world faces another moment of cataclysm. Though less devastating than World War II, the pandemic has remade everyday life and wrecked the global economy in a way that feels apocalyptic.
Who will save us now that the monster has broken free?
“Men may live to a great age in days of comparative quietness and peaceful progress, without ever having come to grips with the universe, without ever vividly realising the problems and the paradoxes with which human history so often confronts us,” Butterfield wrote. “We of the twentieth century have been particularly spoiled; for the men of the Old Testament, the ancient Greeks and all our ancestors down to the seventeenth century betray in their philosophy and their outlook a terrible awareness of the chanciness of human life, and the precarious nature of man’s existence in this risky universe.”
The past four years have been some of the most contentious and embarrassing in American history. Squabbling over trivialities has left the public frantic and divided, oblivious to the transcendent. But the pandemic has humbled the country and opened millions of eyes to this risky universe once more.
“Sheer grimness of suffering brings men sometimes into a profounder understanding of human destiny,” Butterfield wrote. Sometimes “it is only by a cataclysm,” he continued, “that man can make his escape from the net which he has taken so much trouble to weave around himself.”
For societies founded on the biblical tradition, cataclysms need not mark the end. They are a call for repentance and revival. As the coronavirus pandemic subjects U.S. hospitals to a fearsome test, Americans can find solace in the same place that Butterfield did. Great struggle can produce great clarity.
Could a rogue virus lead to a grand creative moment in America’s history? Will Americans, shaken by the reality of a risky universe, rediscover the God who proclaimed himself sovereign over every catastrophe?
Mr. Nicholson is president of the Philos Project.