Much of the focus on COVID-19 testing thus far into the pandemic has been on tests that can determine whether someone is actively infected with the novel coronavirus, or SARS-CoV-2. But, in his drive to open up America again, President Donald Trump has turned his attentionto blood-based antibody tests, which can show whether someone was previously infected with the virus.
This will help us assess the number of cases that have been asymptomatic or mildly symptomatic, and support our efforts to get Americans back to work by showing us who might have developed the wonderful, beautiful immunity, Trump said at anApril 17 press conference.
The tests do have the potential to relay valuable information about who might already have immunity and how widely COVID-19 has spread. But so far, the tests are not widely available and many of those that are available do not work as advertised.
The U.K., for instance, spent $20 million on antibody tests from China that the government subsequently found were not accurate enough to use. An emergency room in Laredo, Texas, also dropped half a million dollars on tests from China that were too unreliable to deploy.
Other tests are better but, like any test, will still miss some people who have antibodies or incorrectly tag others as having antibodies when they dont. And more fundamentally, experts told us too little is known about how the immune system responds to the new virus to know for sure whether antibodies actually protect a person from contracting the disease.
Well run through how the tests work and why its so hard to interpret what the results might mean.
What are antibodies and why is it useful to check for them?
Antibodies are specialized proteins that help clear the body of invading microbes. Made by immune cells known as B cells shortly after infection, antibodies specifically recognize pathogens, binding to the surfaces of viruses and stopping them from entering cells, for example, or marking them for destruction by other parts of the immune system.
The proteins dont exist until at least a few days into an acute infection, and often arent detectable until a week or more after symptoms appear, Rangarajan Sampath, the chief scientific officer of the nonprofit Foundation for Innovative New Diagnostics, told us.
But because some antibodies persist for months if not years after someone has recovered, they offer a glimpse into the past and can reveal whether someone was previously infected, potentially even if that person never had symptoms.
The earliest antibodies that B cells pump out known as immunoglobulin M, or IgM may overlap with infection, Sampath said. IgM antibodies bind a bit less well to pathogens, but are the first on the scene, peaking within several weeks or so andthen declining. The most common antibody, IgG, takes longer to ramp up, but is more finely tuned to recognize microbes and is longer-lasting. Other antibody types, including IgA, which is present in the respiratory tract, are also delayed.
Because of the time lag, antibody tests are not very good at determining whether someone is infected with SARS-CoV-2.
The antibody test by itself cannot tell you whether youre currently active with a live infection or not, said Sampath. You could be. You cannot rule it out. But its also possible that what you had was a past infection, as recently as a few days ago.
For this reason, the Food and Drug Administration says antibody tests should not be used as the sole basis to diagnose COVID-19. Molecular tests, which check for the presence of viral RNA, are needed to diagnose an infection.
Its worth mentioning that different antibodies have different functions, and most antibody tests cannot discriminate between those that may be able to bind to the virus, but arent able to prevent infection the way so-called neutralizing antibodies can.
These tests are just looking for the presence of antibodies that are able to recognize SARS-CoV-2, said Lisa Gralinski, a virologist who studies human coronaviruses at the University of North Carolina at Chapel Hill. Theyre not telling us anything about the quality of those antibodies, so we dont know if theyre neutralizing.
Usually we would expect that they are, but in the case of an ongoing pandemic, she added, we dont want to be providing people with false confidence or incorrect information.
This is one reason why health experts have been cautious about making sweeping claims that antibody tests can necessarily identify those who are immune, even if scientists think its highly likely that a person with antibodies will have at least partial immunity for some period of time.
In the context of the current pandemic, a persons antibodies may also be valuable as a possible COVID-19 treatment. Scientists are exploring delivering antibody-rich blood, or whats called convalescent plasma, from people who recovered from COVID-19 to help patients still struggling with the disease.
How do COVID-19 antibody tests work?
Precisely because antibodies are highly specific and bind to certain features of a pathogen for example, the spike protein that sticks out from the surface of the COVID-19 virus its possible to design tests that can fish them out and say whether a person has them in their blood. (Antibody tests are also known as serological tests, since antibodies are found in the serum portion of the blood.)
As Johns Hopkins Center for Health Security explains, this can be done in the lab with whats called an enzyme-linked immunosorbent assay, or ELISA. Scientists attach some SARS-CoV-2 surface protein to a plastic plate, then add a bit of patient serum. If there are antibodies in the serum that recognize the viruss surface protein, they will stick to the protein, which can then be seen by adding a lab antibody that recognizes human antibodies and has the ability to trigger a color change.
Other tests try to do something similar, but in a more user-friendly platform. Many rapid serology tests, for instance, look a bit like pregnancy tests, but instead of using a urine sample, require the user to add a small amount of blood. As the liquid moves through the test strip, SARS-CoV-2 antibodies, if present, encounter viral proteins, and can even be sorted according to whether they are IgM or IgG, with a positive result popping up as a colored band.
The rapid tests typically take 10-30 minutes per sample, whereas the lab-based ELISAs take several hours, but can test many samples at once.
How accurate are COVID-19 antibody tests?
Poor accuracy has plagued many of the first tests that companies developed. Sampath said the problems boil down to bad reagents, or the materials the tests use, and a general lack of validation to know whether the tests work.
Many of the tests that came out initially came out in a hurry, he said. And many of them were not tested widely. They were tested on a very small set of, lets say, highly positive patients that may have looked like this was really good. But now, when you start testing them on a broader population, you start finding that they didnt really have the performance that was needed.
One issue, Sampath said, is that some tests, especially the rapid ones, may be falsely detecting antibodies to other coronaviruses, including those that cause common colds. That could yield a high false positive rate, which could be dangerous if people are led to believe they might be immune. Tests, too, may not be sensitive enough to detect SARS-CoV-2 antibodies when they are present, producing false negatives.
Indeed, the two measures that dictate how reliable a test is are sensitivity, or how many people are correctly labeled as having antibodies, and specificity, or how many people are correctly told they lack them.
Many manufacturers report these figures based on small-scale, in-house tests, but those reports may not reflect reality on the ground, as some governments have found.
In one preliminary evaluation, posted as a preprint to medRxiv, nine commercially available rapid tests were found to miss as many as 35% to 45% of samples that were positive. The rapid tests generally produced fewer false positives 7% or less but even that performance may not be good enough, especially if the tests are used in a population in which few people have been infected.
This gets at a strange quirk of testing, in which test performance depends not just on the quality of the test, but also on the population its being tested in. A test thats 95% specific, for example, might sound pretty good, but if only 1% of people are infected, then 85% of the positive results could be wrong.
Sampaths organization, FIND, is working on independently evaluating a variety of antibody tests. The FDA is also partnering with the Centers for Disease Control and Prevention and the National Institutes of Health to assess serological tests. According to a CDC website, results are expected in late April.
Sampath, however, said he thought it would still be several months before there would be enough data on tests used for patient management. And until then, many bad tests are still out there. Many of those tests are still circulating, he said, and many of them continue to add to this noise and confusion.
Whats the status of COVID-19 antibody tests in the U.S.?
For most people, antibody tests are not yet available, although numerous companies are now making them, and some cities are beginning to roll out tests to determine how many people in the community have already been infected.
As of April 24, the FDA has given emergency use authorization, or EUA, to four antibody tests, including a point-of-care cartridge test from Cellex, a lab-based ELISA from Mount Sinai and a high-throughput test from Ortho Clinical Diagnostics.
Many more antibody tests are on the market, but have not received an EUA. The FDA permits this under a special emergency policy, as long as the test is validated by the manufacturer and test results do not claim the ability to diagnose COVID-19. At this time, the FDA does not allow any serological tests to be performed at home, so all tests must be conducted in clinical labs or by health care workers.
One such non-EUA test is from Abbott, which runs on existing machines in hospitals and reference labs, and has been mentioned by name by the president. The company has said it expects to be able to ship 4 million tests by the end of April and 20 million tests per month, starting in June.
Experts, however, are skeptical that companies will be able to meet the demand for serological tests anytime soon. Were really entering into this era of antibody testing, and were not anywhere close to where we need to be, said Michael Mina, an epidemiologist at Harvard Universitys T.H. Chan School of Public Health, in a press call. Its really going to make the demand for PCR testing look minimal, he added, referring to the molecular diagnostic tests for COVID-19.
Sampath also warned that none of the tests had been fully vetted yet. Even the EUA, its a really quick and dirty way of getting something in front of the FDA for an evaluation. Its not a true FDA-approved test that they would normally do.
And while some of the tests may work fine, Sampath said there was too little data to go on.
There are perhaps a handful of tests that may be on the border of being good enough, but we dont know, he said. And we dont know that because we only have the manufacturers claim.
Will someone be protected from being infected again if they have antibodies to the virus?
Its quite likely that someone with SARS-CoV-2 antibodies will have some degree of immunity to the virus because its a sign the body has seen and responded to the pathogen before and because its typical of most viruses that spark short-term infections.
Generally we know with infections like this, that at least for a reasonable period of time, youre going to have antibody levels that will be protective, said Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, in an April 8 interview with the Journal of the American Medical Association.
Scientists nevertheless caution that protection is not a given. UNCs Gralinski said immunity would be very likely, but because the virus is new and there isnt direct evidence yet it cant be known for certain.
Reports out of South Korea and other parts of Asia have raised concerns about reinfection or viral reactivation a term usually reserved for when viruses go dormant inside cells since some people who recovered from COVID-19 have tested positive again for the virus.
But many scientists are doubtful of those claims. Gralinski said coronaviruses dont reactivate, and rather than people becoming reinfected, its more likely that as patients eliminate the virus from their bodies, the amount of swabbed virus hovers around the diagnostic tests threshold of detection.
My suspicion is that were dealing with sensitivity issues, where people are kind of on the low edge of detectability with their infection as theyre clearing virus, she said. When theyre dancing around the detection limit for virus positivity, its easy to have things go down for a couple of days and then come back up.
Many other questions about potential COVID-19 immunity remain, including what antibody level might be needed to confer protection and whether people who were infected with SARS-CoV-2 but never developed symptoms are any less protected than those with more severe cases.
How long might someone be immune to COVID-19?
Scientists cant know with any certainty how long someone who contracted COVID-19 might be protected, but they can look to other human coronaviruses for clues.
In one experiment, volunteers were intentionally infected with a coronavirus that causes a common cold, and after a year, some participants were susceptible to infection again, although many did not develop noticeable symptoms.
Other studies of patients infected with severe acute respiratory syndrome, or SARS, in 2003 indicate antibodies begin to wane after about four months, but stick around in most people for two years. By year three, though, up to a quarter of patients no longer had detectable antibodies, and after six years,almost noone did.
If SARS-CoV-2 behaves like its predecessor, Gralinski said it might be possible to expect perhaps a couple of years of immunity, but not much more.
Reasonable guesses are that on the short end there might be partial protection for about a year or close to a year. And on the long end it might be longer it might be several years of good protection, said Marc Lipsitch, an epidemiologist and director of Harvards Center for Communicable Disease Dynamics, in a call with reporters. But its really speculative at this point.
Its worth noting that immune protection doesnt just stem from circulating antibodies, nor is it a simple on or off switch. As Vineet Menachery, a coronavirus researcher at the University of Texas, explained in a Twitter thread, there are other ways the body remembers the pathogens it has encountered. This includes so-called memory cells that can swing into action more quickly if a microbe returns. So, even if a person loses their neutralizing antibodies to SARS-CoV-2 and can become reinfected, theyre likely to at least be less sick the second time around.
What do antibody studies say so far about how much COVID-19 has spread?
In the U.S., a few so-called serosurvey or seroprevalence studies are beginning to be done that get at how many people in certain areas have already been infected.
Many of the results, however, are highly preliminary or lack sufficient detail for scientists to fully understand them.
New York state, for example, announced on April 23 that of its first phase of 3,000 antibody tests, 13.9% were positive, with a higher 21.2% positive rate in New York City.
A small survey of 200 people in Chelsea, Massachusetts, found that 64 people, or 32%, tested positive for SARS-CoV-2 antibodies.
Another study, in Santa Clara, California, estimated that 2.5% to 4.2% of all people in the county had been infected with COVID-19, and suggested that the number of COVID-19 cases could be some 50 to 85 times higher than the confirmed count.
The Santa Clara work, however, which has not yet been peer-reviewed and was posted to the preprint site medRxiv, has been heavily criticized for its data analysis and its methodology. Critics argue the population sample, which was recruited from Facebook, may have been biased, and that statistically, the researchers cant actually rule out that all of the positive antibody tests were false positives.
Experts say its important that these studies be done, but some are worried that they are not being done carefully enough. As A. Marm Kilpatrick, a professor at the University of California, Santa Cruz who studies infectious disease dynamics, said on Twitter of the Santa Clara study, We need these kinds of studies and data badly. Unfortunately this paper is badly misleading.
Part of the reason why its so important is because the information can be used to make a more accurate estimate of how dangerous COVID-19 is. If far more people have been infected than expected, that would lower estimates of how deadly COVID-19 is, which could influence public policy decisions about how important it is to keep instituting stringent physical distancing and other public health measures.
The other main reason to keep tabs on the figure is because it can say how close a community might be to achieving herd immunity, or the point at which people who are susceptible to the virus can still be protected because so many other people are already immune. This is based on how contagious a disease is, and since people with SARS-CoV-2 infect an average of two to three other people, youd need around 50% to 67% of the population to be immune to get herd immunity.
No results yet indicate any population is close to that. And in fact, most studies from around the world have suggested relatively few people have contracted COVID-19.
As the World Health Organization noted on April 20, many studies indicate only 2% to 3% of people have been infected.
We absolutely must remain vigilant because what were learning fromthese early serologic studies, even with all of their faults and all of the limitations, said WHO scientist Maria Van Kerkhove, is that a lower proportion of people are actually, it appears, are infected. And that means a large proportion of the public remains susceptible.
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A tip led police to more than a dozen bodies at the the Andover Subacute and Rehabilitation Center in Andover, N.J. The state is among those that grant temporary immunity from civil suits to nursing homes. Ted Shaffrey/AP hide caption
A tip led police to more than a dozen bodies at the the Andover Subacute and Rehabilitation Center in Andover, N.J. The state is among those that grant temporary immunity from civil suits to nursing homes.
The people most vulnerable to the coronavirus are older adults with underlying health conditions. And that perfectly describes the residents of nursing homes.
There are no authoritative numbers on fatalities, but estimates are in the thousands. A report by The Wall Street Journal this week said more than 10,000 nursing home residents have died of COVID-19. So, fearing a flood of lawsuits, nursing homes and other health care facilities have been seeking, and gaining, temporary immunity from potential civil suits in several states across the country.
"It's unprecedented times that we're dealing with," says Cory Kallheim, the vice president of Legal Affairs and Social Accountability for LeadingAge, an organization representing non-profit nursing homes and assisted living facilities. "So it puts (nursing homes) in a really, really difficult spot. They're doing the best they can in the difficult circumstances."
But those calls for immunity also raise questions about accountability and whether poorly run nursing homes are being given a pass.
"Providing blanket immunity to nursing homes for any kind of substandard care, abuse, or neglect is an extremely poor and dangerous idea anytime, and particularly so in regard to COVID-19," says Richard Mollot, executive director of the Long Term Care Community Coalition, which advocates for nursing home residents.
"Nursing homes are themselves more strained, more understaffed than they are on a usual basis," he says, leaving residents even more vulnerable to infection and neglect.
But Kallheim says that health care facilities need immunity from civil suits, in part, because of the shortage of testing and personal protective equipment (PPE). Nursing homes don't want to be held legally responsible for a bad outcome that was beyond their control to prevent.
Another reason these protections are necessary, Kallheim says, is that the guidance from the federal government, as well as the understanding of the virus itself, are constantly changing.
"We don't have an understanding of how this (virus) is spread," he says. "We're getting more information as we move forward each day, each week. And it's putting a real tax on what our providers are able to do."
Some of these legal immunity measures have been approved by executive order, others by legislation. The states include Connecticut, Illinois, Massachusetts, Michigan, New Jersey and New York.
In some states, Louisiana for example, legal immunity is already on the books in case of natural disasters, when health care facilities might be overwhelmed. The measures kick in as soon as the governor declares a state of emergency.
Health care trade organizations also have sent letters urging the adoption of legal immunity measures to governors in Pennsylvania, California, and Florida.
There are some differences between the existing measures. While most states focus on civil suits, New York also a protects health facilities and personnel from criminal complaints. But none of the immunity measures offer protection in cases of gross negligence or willful misconduct.
Nursing homes have been ground zero for COVID-19. The awareness of the grave dangers of the disease began with an outbreak at the Life Care Center nursing home in Kirkland, Wash. where at least 37 people have died.
Since then, the stories of the rapid spread of infection and death in nursing homes have been staggering: at the Andover Subacute and Rehab Center I and II in New Jersey, at least 70 residents died and police found 17 bodies piled up in a make shift morgue. In California, at least 33 staff and 69 residents have been infected and more than a dozen have died at the Gateway Rehabilitation and Care Center, based on news reports and state and local figures.
All of these nursing homes - and many others with major COVID-19 outbreaks - were cited during their most recent health inspections for failing to implement a plan for infection control, as required. Which is why advocate Richard Mollot thinks these legal immunity provisions increase the risks for nursing home residents.
The nursing homes are getting "total carte blanche to do as much or as little or whatever they want to do," he says. "For the most part, it'll be as little. And there'll be no repercussions for even significant abject neglect."
The immunity protections for health care providers and personnel will only last as long as the COVID-19 emergency lasts. But no one knows how long that will be.
Press release from the Humboldt County Joint Information Center:
Additional testing capability will be available to Humboldt County starting in a few short weeks.
A COVID-19 community testing site, provided by the State of California Testing Task Force in conjunction with OptumServe, is slated to open in Eureka and is estimated to be fully operational for the public in the next one to two weeks.
Humboldt County Health Officer Dr. Teresa Frankovich said this new testing site will be an incredible boost for the county as we move into the next phase of our response to COVID-19, with the site having the ability to test approximately 96 people per day,
Our goal is to be able to conduct broad testing and surveillance in our community so that we will have an on-going understanding of how much COVID transmission is occurring, Dr. Frankovich said. With this extra capacity we are going to be able to test mildly symptomatic people and eventually, even people without symptoms so that we can better identify early and very mild COVID infections so that we can contain them most effectively.
This has been a critical ongoing need and one that Humboldt County Public Health has been working to address together with our County Emergency Operations Center team since early in this pandemic, Dr. Frankovich said. This state-provided resource makes that goal possible and we are deeply appreciative for this opportunity.
The Eureka testing site is one of 80 planned sites across the state being set up to increase COVID-19 testing of Californians and is one of the first in our region. To determine where to locate new testing sites, the state looked at both rural and urban areas where Californians may have trouble accessing testing, due in part to distance and other factors. That information was then evaluated to ensure communities in most need of testing received needed resources regardless of socioeconomic status.
Once the community testing site is fully operational, Humboldt County residents will be able to schedule an appointment and receive a test. Test results will be available within 48 to 72 hours. More information regarding the location of the testing site and how to make an appointment will be announced in the coming weeks.
The Humboldt County Emergency Operations Center has been working on this request for a mobile test site for weeks. I am thankful that the state has chosen Humboldt County as one of the first sites to be established, Sheriff William Honsal said. By increasing testing, we will be positioned to meet one of the requirements of the Governors roadmap to lift the Shelter-in-Place.
For the most recent COVID-19 information, visitcdc.govorcdph.ca.gov. Local information is available athumboldtgov.orgor during business hours by contactingcovidinfo@co.humboldt.ca.usor calling 707-441-5000.
PIERRE, S.D. (KTIV) -- Public health officials are reporting 84 additional cases of COVID-19 in South Dakota, bringing the statewide total to 20,40.
According to South Dakota health officials, there has been one additional death reported due to COVID-19, there has been 10 deaths total in the state.
Currently, officials say 1,190 South Dakotans have recovered from the virus, Officials say there are 61 individuals currently hospitalized due to the virus.
Out of the 14,824 COVID-19 tests done in the state,12,784 of them have come back negative. That's about 86% of all tests done in South Dakota.
The South Dakota Department of Health says a vast majority of the state's cases are in Minnehaha County, where Sioux Falls is located.
Only 28% of the factories that make active ingredients for pharmaceuticals for the domestic market are located in the U.S., according to the Food and Drug Administration. Ariana Lindquist/Bloomberg via Getty Images hide caption
Only 28% of the factories that make active ingredients for pharmaceuticals for the domestic market are located in the U.S., according to the Food and Drug Administration.
The coronavirus pandemic has renewed concerns about the dependence of the United States on other countries for supplies of prescription drugs and ingredients.
The U.S. ignored the decline of domestic medical manufacturing and waited too long to seriously invest in the federal office designed to prepare for pandemics, Sen. Chris Coons, D-Del., said in an interview.
"We are now paying both in needless exposure by our front-line health workers and needless deaths for having not been better prepared for this," he says.
Nearly three-quarters of the active ingredient manufacturing facilities for medicines sold in the U.S. are located in other countries. Only 28% are domestic, according to Food and Drug Administration figures.
"Historically, the production of medicines for the U.S. population has been domestically based," Dr. Janet Woodcock, director of the FDA's Center for Drug Evaluation and Research, said in congressional testimony last October. "However, in recent decades, drug manufacturing has gradually moved out of the United States."
John McShane, a managing partner at the health care product consulting firm Validant, says he remembers when drug companies shifted much of their manufacturing overseas. "I was actually a victim of the move of APIs [active pharmaceutical ingredients] out of the country," he says.
He was a plant manager for Abbott Laboratories in the late '90s and returned to manufacturing in 2005 after a few years directing broader quality and validation programs at the company. But his return was short-lived.
"Abbott was shutting five plants, including the plant I used to work at, and outsourcing all of the production," he says. "The plant I used to run has been demolished. It's basically green space and asphalt now."
Abbott and AbbVie, a 2013 spinoff focused on pharmaceuticals, declined to comment.
Major companies have "mown down" the U.S. plants that made the key components of their drugs, McShane says. By his count, the last major API facility constructed in the U.S. was built almost 30 years ago.
He says companies moved manufacturing to locations with tax incentives, like Ireland, or countries that had cheaper labor and more lax environmental laws at the time, like India and China. Mergers and acquisitions in the pharmaceutical industry have also contributed to plant closures.
The danger of offshore supply chains
Coons says the United States should have been "concerned about the offshoring of most of the critical components of the supply chain that keeps us healthy and safe."
Today, the biggest suppliers of active pharmaceutical ingredients are India and China. The COVID-19 pandemic has spurred fears of shortages because of work interruptions and changes in export policies.
"If we have another global pandemic that leads the world to close borders and leads global supply chains to shatter or to break down, we are distinctly vulnerable because we are now so dependent upon globally integrated supply chains," Coons says, adding that these concerns also apply to other medical products, such as masks and ventilators.
Research shows a continuing decline in domestic drug manufacturing in recent years. The number of domestic API facilities registered with the FDA fell about 10% from 2013 through 2019, according to research by health economists Rena Conti and Ernst Berndt of Boston University and the Massachusetts Institute of Technology, respectively.
Rebuilding U.S. pharmaceutical manufacturing would take substantial investments and patience.
"To even get to 50% of our drugs being made in the U.S., it will take one to two decades and billions of dollars," McShane says. It would likely take government incentives to lure pharmaceutical giants back home.
Pharmaceutical Research and Manufacturers of America, the main trade group for the brand-name drug industry, "supports efforts to invest in" U.S. manufacturing, spokeswoman Holly Campbell said in statement. But, she said, there are advantages to having a globalized supply chain when emergencies strike because companies can shift their sourcing to unaffected facilities.
BARDA funding for research and development
The government has tools to spur the development and manufacturing of treatments and vaccines for COVID-19.
In March, Congress appropriated $3.5 billion for the Biomedical Advanced Research and Development Authority as part of legislation to respond to COVID-19. BARDA is part of the Department of Health and Human Services, and it was created in 2006 to speed up the nation's response to bioterrorism, emerging diseases and nuclear threats.
BARDA found itself in the spotlight this week, when Rick Bright, its director since 2016, said in a statement that he was removed from his post because he insisted that the government fund "safe and scientifically vetted solutions" to COVID-19 and not on "drugs, vaccines and other technologies that lack scientific merit." He said he pushed back against funding "potentially dangerous drugs promoted by those with political connections."
BARDA awards grants to fund research and development of experimental products in the hopes of eventually adding them to the National Strategic Stockpile. It also established a network of four domestic manufacturing facilities able "to address every day and emergency needs."
To combat COVID-19, BARDA announced it will support Johnson & Johnson and Moderna as they develop experimental vaccines against the virus, and will help Johnson & Johnson scale up manufacturing capabilities so it can make up to 300 million vaccine doses annually in the U.S.
What Congress gave BARDA last month as part of the CARES Act was more money than the office had been granted in the past. And Sen. Coons says past low funding levels are a problem.
"If you go back and look at the budgets of the last few years, we were not robustly investing in this work," Coons says. "And we should have been investing in things like the national stockpile, innovation in vaccines and in therapeutics and in ensuring our supply chain before there was a crisis."
Interest in preparing for a pandemic can be cyclical, says Dana Goldman, director of the Schaeffer Center for Health Policy & Economics at the University of Southern California.
"We're faced by a crisis," he says. "We realize we're unprepared. We are willing to spend a lot of money dealing with the situation. And then as the risks seem to wane and we change administrations, it's natural when you're trying to find other money for other priorities that you would see this type of cycle."
All these developments have taken place under pressure from Washington and Brussels. In hearings over the past few years, Congress has criticized the companiesnot always in consistent waysfor allowing harmful speech. In 2018, Congress amended the previously untouchable Section 230 of the Communications Decency Act to subject the platforms to the same liability that nondigital outlets face for enabling illegal sex trafficking. Additional amendments to Section 230 are now in the offing, as are various other threats to regulate digital speech. In March 2019, Zuckerberg invited the government to regulate harmful content on his platform. In a speech seven months later defending Americas First Amendment values, he boasted about his team of thousands of people and [artificial-intelligence] systems that monitors for fake accounts. Even Zuckerbergs defiant ideal of free expression is an extensively policed space.
Against this background, the tech firms downgrading and outright censorship of speech related to COVID-19 are not large steps. Facebook is using computer algorithms more aggressively, mainly because concerns about the privacy of users prevent human censors from working on these issues from home during forced isolation. As it has done with Russian misinformation, Facebook will notify users when articles that they have liked are later deemed to have included health-related misinformation.
But the basic approach to identifying and redressing speech judged to be misinformation or to present an imminent risk of physical harm hasnt changed, according to Monika Bickert, Facebooks head of global policy management. As in other contexts, Facebook relies on fact-checking organizations and authorities (from the World Health Organization to the governments of U.S. states) to ascertain which content to downgrade or remove.
Read: How to misinform yourself about the coronavirus
What is different about speech regulation related to COVID-19 is the context: The problem is huge and the stakes are very high. But when the crisis is gone, there is no unregulated normal to return to. We liveand for several years, we have been livingin a world of serious and growing harms resulting from digital speech. Governments will not stop worrying about these harms. And private platforms will continue to expand their definition of offensive content, and will use algorithms to regulate it ever more closely. The general trend toward more speech control will not abate.
Over the past decade, network surveillance has grown in roughly the same proportion as speech control. Indeed, on many platforms, ubiquitous surveillance is a prerequisite to speech control.
The public has been told over and over that the hundreds of computers we interact with dailysmartphones, laptops, desktops, automobiles, cameras, audio recorders, payment mechanisms, and morecollect, emit, and analyze data about us that are, in turn, packaged and exploited in various ways to influence and control our lives. We have also learned a lotbut surely not the whole pictureabout the extent to which governments exploit this gargantuan pool of data.
DES MOINES, Iowa (KCRG) - The Iowa Department of Public Health announced on Friday an additional 521 confirmed cases and 11 deaths in Iowa.
That brings the totals to 4,445 confirmed cases and 107 deaths in the state. In total, 31,973 people have been tested for the virus and 1,604 have recovered.
The new deaths occurred in Black Hawk, Bremer, Linn, Polk and Scott Counties.
A new outbreak was reported at Mitchell Village Care Center, a long-term care facility in Polk County. That brings the total of outbreaks at long-term care facilities up to 13.
There are 278 patients hospitalized with COVID-19 with 44 of them having been admitted in the last 24 hours. There are 104 patients in ICU, and 60 are on ventilators.
Regional Medical Coordination Centers (RMCC) Region 6, is no longer rated a 10. It is now a 9, along with region 1 and 5, which together covers most of the eastern and central portions of the state.
For more information, including a county by county breakdown of the numbers, click here.
The launchof the new collaborationis being co-hosted by WHO Director-General Dr Tedros Adhanom Ghebreyesus, Emmanuel Macron, President of the French Republic,Ursula von derLeyen, President ofthe European Commission,andn the Bill and Melinda Gates Foundation.n
Thevirtual eventwill includesenior United Nations, government andpublichealthand industryleaders from around the world.n
Part of the Pandemic Issue of The Highlight, our home for ambitious stories that explain our world.
Covid-19 has moved like wildfire at first seemingly far away, then unnervingly close as it has ripped across the world in a few months, leaving tens of thousands dead, economies flattened, and the futures of hundreds of millions of people in limbo.
As many of us shelter in place with no end in sight, its only human for us to imagine how life will resume, even if the unfamiliar and unpredictable behavior of the virus has made it difficult to know with any certainty.
The longer the global effort to stymie the pandemic through lockdown continues, however, the less likely well reemerge into a world we recognize. Already, some things are clear: Health care, stretched to horrifying extremes in afflicted cities, must change, and it will. The worlds Instagram-fueled love affair with travel will cool. Many will keep stashes of personal protective equipment at the ready; many more will lose faith in governments to assist us, much less protect us.
To begin to envision the legacy of this Covid-19, Vox asked experts in fields ranging from behavioral sciences to economics; restaurateurs; and big thinkers on democracy and public health to predict whats next. These, they say, are 11 ways the pandemic will transform our societies.
For many, the doldrums of quarantine are now giving way to post-isolation fantasies, as people pledge to spend more time with family and friends, or finally book that bucket-list trip. But even the smallest and sweetest of goals getting a haircut, giving a hug, or grabbing a drink could feel like climbing Mount Kilimanjaro when were free.
Were going to have to work through this quarantine state of mind even when the physical quarantine has lifted, says Sheva Rajaee, founder of the Center for Anxiety and OCD in Irvine, California.
The coronavirus has made intimacy feel treacherous, because the disease can sometimes move from person to person through the most mundane activities, like talking, kissing, even singing. That it can be transmitted asymptomatically has forced us to envision everyone as a potential threat. We are training people to see the world as a dangerous place. This invisible enemy could be anywhere, says David Spiegel, a professor of psychiatry and behavioral sciences at Stanford University. Interacting with your barber or bartender wont be easy if you view them as potential carriers. There will be a lot of damage to be undone as people try and rebuild some semblance of a normal life, Spiegel says, adding that avoidance makes phobias worse. Exposure will be an important part of recovery.
The temporary solution to the coronavirus self-quarantine, and potentially months of it not only delays this process, but also has psychological repercussions of its own. The true extent of the problem is not yet clear, and there are few analogues. But in Wuhan, China, where the virus originated, some people there now refuse to leave their homes and have developed agoraphobia, psychiatrist Steven Taylor told the Atlantic. FOMO has morphed into FOGO, or the fear of going out. Some peoples reticence to reengage with society may resolve on its own, Rajaee says, but for many, this is the beginning of a lifetime of management.
Eleanor Cummins
Cummins reports on the intersection of science and popular culture; she previously wrote about social-distancing scofflaws for the Highlight.
In the United States, masks are more readily associated with crime than public health. Were a nation of mask skeptics: Several states have enacted anti-mask laws throughout history as a means of quelling protest and stifling dissent. But the immediacy of the pandemic the horror stories of bodies stacked up in refrigerated trucks, the overwhelmed hospitals, and the atmosphere of fear and paranoia created in its wake will force Westerners to reconsider old stigmas associated with masks for the sake of public health.
The mask aversion is compounded by the longstanding epidemic of police violence against people of color, some of whom understandably fear the consequences of purchasing essential goods while cloaked in a prophylactic bandana. Even now, its easy for a mask to evoke dastardly connotations or be mistaken for a disguise.
Wearing a mask may be even stranger to us than wearing a Speedo at the beach, says Brandon Brown, an epidemiologist and associate professor at UC Riverside. Its just not the norm [in the US], so there is judgment, but there is nothing wrong with it.
In China and other nations, masks are now part of everyday life, Abrar Chughtai, an epidemiologist and researcher at the University of New South Wales in Sydney, Australia, says via email. Asian countries have faced such epidemics and pandemics more in the past, he says, including SARS outbreak of 2002-2004, which still looms large in the public imagination in China and Hong Kong.
These nations have long understood face coverings as a public health resource and a tool for cultivating national unity. Its routine, for example, to see people donning masks on the streets of Beijing, Seoul, or Taipei as they take to the streets or socialize with friends, because someone with a cough will likely be hesitant to put their neighbors in jeopardy.
It does seem that in general, thinking of and protecting others is more of a norm in some countries other than our own, Brown says.
But public sentiment on the issue of masks is evolving. Just as the US mobilizes to provide front-line workers with personal protective equipment amid mass shortages, brands are also swooping in to meet a surge in demand for masks that gel with modern consumer tastes. Cloth masks designed and marketed by Los Angeles Apparel and Christian Siriano are reflections of this broader shift in the cultural climate. Mega-influencers like Kim Kardashian and Bella Hadid have also endorsed them with pandemic-era selfies, lending masks a stamp of pop-culture-approved normalcy.
Though the science behind the effectiveness of masks is far from exact, living through the pandemic will undeniably alter Western attitudes about them, as well as government policy. And as the memory of Covid-19 becomes permanently enmeshed with the national psyche, masks are likely to become a fixture of our post-pandemic world.
Sam Blum
Blum is a writer and journalist based in New York.
It was one of the earliest and most visible effects of the coronavirus pandemic: First one, then several, then all 50 states shuttered schools. Many day care centers closed, too, and in the span of a few weeks in March and April, tens of millions of American parents, most of whom ordinarily work outside the home, suddenly became full-time child care workers.
For the relatively fortunate, that has meant trying to work from home while simultaneously caring for children without help from family members and caretakers they might ordinarily lean on and without the ability to entertain kids with trips or play dates.
For others, it has meant making a wrenching decision between taking care of family and getting a paycheck (the federal stimulus bill includes paid leave for some parents, but not all).
Either way, for many people around the country, parents and non-parents alike, the sheer work of taking care of children all day suddenly has become extremely obvious.
In the past, that work has often been invisible. Many parents feel the need to hide or minimize the evidence of their children at the office, economist Emily Oster has written, because they fear being sidelined. Meanwhile, about 80 percent of private sector employees and 93 percent of low-wage workers have zero paid parental leave.
Americas undervaluation of the work of child care is also evidenced in its treatment of child care workers, who make an average of $10.82 an hour and often lack health insurance and other benefits. Many are on some form of public assistance and live paycheck-to-paycheck even in the best of times. As child care provider Miren Algorri told Vox, Were overworked, were underpaid, and we dont even exist.
But now the work of child care suddenly isnt as invisible. Kids have started popping up in Zoom meetings. Parents who once might have been able to practice what Oster has called secret parenting have had to ask for flexibility, and some employers (though by no means all) have begun to grant it.
Cities have set up emergency child care centers, with officials understanding, perhaps for the first time, that nurses and bus drivers cant go to work if theres no one to care for their children. Even the federal government has set aside $3.5 billion for child care in its relief package for American workers.
For the first time in a long time, Americans have been forced to acknowledge that taking care of kids is difficult, necessary work.
As Algorri put it, We are the workforce behind the workforce.
Anna North
North covers gender issues, reproductive rights and more for Vox.
The effect of the coronavirus pandemic on our sense of economic confidence will have everything to do with how long we are stuck inside, how long we are out of work, and what safety nets fail us in the interim. Even if stay-at-home orders are mostly over by this summer, how many of us would risk our lives to frequent restaurants or go shopping? The virus, whenever its over, will affect our every financial, demographic, and lifestyle decision, from borrowing money to having children to living in crowded cities.
The US consumer confidence index has already dropped 30 percent since February. Millions of newly unemployed workers and small businesses already cant or arent paying their rent or mortgage.
And its all happening as about 30 percent of Americans have zero emergency savings, and only one-fifth have savings sufficient to last six months. No surprise our country has been overspending for decades. Our national saving rate has declined dramatically since the 1950s and 60s. If and when people emerge from their homes, theyll be cowed, not confident, economic actors.
Fewer Americans will start businesses, and those they start will be safely online; surviving businesses will hire and borrow less. People may prepay their mortgages instead of maxing out their 401(k)s or playing the market. Many people will start saving not for a rainy day but for a years-long deluge.
Just as families during the Great Depression relied on kitchen gardens and community thrift gardens to grow food rather than buy it, well return to growing our own food to the extent we have space or can move somewhere that does. Entertainment and social events will move to potlucks, board games, and other living room entertainment instead of movies or restaurants, just as it did during that period.
For those with the means, the first trip wont be to Gucci, if its there. It may be to Kansas to buy a small home, with ample land for planting and posting Keep Out signs.
Laurence Kotlikoff
Kotlikoff is a professor of economics at Boston University and a personal finance consultant.
Amid the coronavirus pandemic, incarcerated Americans the 2.3 million people often housed in overcrowded facilities, many people of color, many with undermanaged chronic health problems have emerged as one of the nations most vulnerable populations. Outbreaks have ripped through prisons and jails including New Yorks Rikers Island, Illinois facilities including Chicagos Cook County Jail and the Stateville Correctional Center, the Parnall Correctional Facility in Jackson, Michigan, and many others across the nation a scenario that was unnervingly predictable.
In response, some local governments are suspending jail time for technical violations, and reducing arrests for low-level offenses such as prostitution or minor drug crimes; the federal government is also identifying at-risk prisoners who could serve the rest of their sentences at home. Some older and otherwise vulnerable prisoners, pretrial detainees, and people serving misdemeanor sentences have already been released. For many, this is a permanent early release. For others, they are free until they have to return for trial.
These arent reforms. Theyre emergency tactics. But they could serve as a transformative moment, a glimpse at whether efforts to reduce the number of imprisoned should be permanent. We could end broken windows policing for minor street-level drug and quality-of-life offenses, which lead to too many low-level arrests. We could end cash bail, which perpetuates the cycle of poverty and incarceration. We could stop issuing unimaginably long prison sentences that keep the incarceration rate high. We could start releasing older prisoners by granting them parole.
This pandemic has illuminated a broader view of the inequities in the US, and can serve as more than an opportunity to test and observe more just policing and incarceration policies. It could lead to permanent reform of our criminal justice system.
Sylvia A. Harvey
Harvey is a journalist and the author of The Shadow System: Mass Incarceration and the American Family.
The US has tied health insurance to employment and then shuttered broad swaths of the economy to respond to a health crisis, during which millions of workers have been laid off, leaving them without health coverage. Our social safety net is in disrepair and overwhelmed when people need it most. Many of our essential workers are making the minimum wage. People of color are dying of the coronavirus at disproportionate rates.
The economic and social framework of America was already tenuous, and the pandemic has broken it.
We built an economy that is a very fine-tuned race car that can go very fast, and might occasionally win a few races, says Roosevelt Institute president Felicia Wong, but once it breaks down, its very difficult to fix, and there really is no underlying resilience.
Wong believes were at a crucial choice point, in which we either repair the system with a Band-Aid that still leaves us fragile or move toward a government with more guardrails for the economy and a bigger role in setting the direction of our health, social insurance, and economic systems.
Many Americans have long believed in a pull-yourself-up-by-your-bootstraps ideology the American dream, that if you work hard enough, you can make it. Its a country where the us is the people who made it, and the them often with a racial element are people who are viewed as lazy and inept. But rugged individualism and the free market cant fix many of our current problems, and, in fact, have rendered the country increasingly vulnerable and fragile for years. Amid the current devastation, will we begin to imagine the role of the federal government in our society and our economy as one that takes a more hands-on, proactive approach? Theres a chance though we will need leaders to drive us there, many of whom are being radicalized right now.
After moments of crises, the US government and its people historically have tended to want to go back to the way things were before, and its unclear that this time will be different, warns Jamila Michener, an assistant professor of government at Cornell University. But we also cant unsee what weve seen. The proximate problem is the virus, Michener says, but the deeper problem is the structure of our social, political, and economic systems.
Yet change isnt always easy to perceive. The Occupy Wall Street movement, born out of the Great Recession, was broadly deemed a failure, but it has animated much of the leftist politics and policies of the past decade. America is broken but it can be fixed.
Emily Stewart
Stewart covers business and politics for Vox.
The images of Wisconsins recent election the first in-person election held during the height of the Covid-19 US outbreak were dystopian. In Milwaukee, where the number of available polling places shrank from 180 to just five for a city of about 592,000 people, voters wearing surgical masks stood 6 feet apart in lines stretching around the block. One woman held up a large homemade sign emblazoned with the words This is ridiculous.
Wisconsin is a messy dress rehearsal for what will happen in November if we dont act, ACLU voting rights campaign strategist Molly McGrath recently told Vox.
The pandemic has temporarily upended US elections as some states push back their primaries to early June. But this time is giving lawmakers an opportunity to reimagine what our elections system could look like.
While electronic voting is still a faraway goal, given concerns about the possibility of hacking, ideas are already circulating for how states could get paper ballots into the hands of more voters and increase turnout. In the five states that already have universal vote-by-mail, studies have found voter turnout increases particularly among those less likely to vote in person. Exercising ones constitutional right to vote could be as easy as checking a box, sealing an envelope, and putting it in the mail. (Even if it is a process that might slow down vote counting.)
In the Senate, the effort is being led by Ron Wyden (D-OR) and Amy Klobuchar (D-MN), who introduced a bill in the wake of coronavirus that would expand both in-person early voting and no-excuse absentee vote by mail. It would require states to set up contingency plans in the event we are still social distancing by the November general election.
The bill would open up in-person polls 20 days before election day in each state to give people the opportunity to vote early, require all mail-in ballots submitted in the 21 days leading up to an election be counted, and make it so all voters can request an absentee ballot.
Similar processes are already in place in some other countries: In Switzerland, for example, all voters receive mail-in ballots that they can submit up to three weeks before the election, and in New Zealand, advance voting polls are set up 12 days before election day.
Theres increased agreement among Democratic and Republican governors and secretaries of states that something must be done to coronavirus-proof their elections. New Hampshires Republican Gov. Chris Sununu recently announced that the state could expand absentee voting if the virus persists into the fall, a measure he has previously opposed, and Republican officials in other states may do the same.
But getting all states ready will take time and a lot of federal money. And President Donald Trump and some congressional Republicans are balking at expanding vote-by-mail access, even though theres no evidence it favors Democrats, and some Republican states have long used it.
The pandemic, and Wisconsins election in the midst of it, could be a watershed moment to make the case for vote-by-mail reform.
Ella Nilsen
Nilsen covers Congress and Democrats for Vox.
Hoyos Kitchen isnt as busy as it used to be. The family-owned Somali restaurant in Columbus, Ohio, had to close its buffet brick-and-mortar location; only its stall in the citys North Market remains open. Mohammad Hassan, who owns the restaurant with his brother and their mother, says hes seen a dispiriting 50 percent drop in customers since the pandemic began, but says, I take solace in the fact that its not only us.
Hassans story resembles that of many immigrant restaurateurs who have long enriched Americas dining ecosystem. The pandemic has laid bare the restaurant industrys creaky foundations. Media coverage has focused on celebrity chefs with name recognition and lofty net worths, obscuring restaurants like Hassans that are disproportionately vulnerable to extinction.
Predictions late last month suggested that 75 percent of independent restaurants wont weather the pandemic, which has forced closures of untold thousands of eating and drinking establishments nationwide. Many independent restaurateurs doubt that the CARES Acts Paycheck Protection Program will provide sufficient loan coverage for their restaurants. Capital may flow more easily toward larger businesses, further marginalizing restaurants without investors or large social media followings: Danny Meyers Shake Shack, with more than 200 locations, for example, attracted widespread criticism when it applied for and received a small-business relief loan. (The company later announced that it would return the money.)
This means the pandemic could wipe out eateries that showcase immigrant fare. Some owners fear facing prejudices that their cuisines arent profitable enough to save because they arent continental European. Others havent applied for relief funds like the one offered by the James Beard Foundation suspended within hours of launching after a logjam of responses due to language barriers and lack of access to public relations firms that could help them navigate labyrinthine application processes. Hassan himself is reluctant to apply for these funds without fully understanding the fine print, fearing any misstep may leave his struggling business liable to pay things back.
But without such restaurants, a class of talented chefs (without material privileges to start) would be jobless and unable to display their talents. Diners would have to settle for a sterile culinary monoculture where corporate chains dot the country.
Toni Elkhouri of Cedars Cafe in Melbourne, Florida, applied but hasnt heard back from the Beard fund. Shes not holding her breath. Elkhouri and her mother, Marlene, have pivoted to curbside delivery and preselling their Mediterranean meals for holidays, helping them level an initial 83 percent loss in business. Otherwise we will die on the vine, she said. No one will come and save us.
Mayukh Sen
Sen is is a James Beard Award-winning writer and teaches food journalism at New York University.
Universal basic income (UBI) is the idea that the government should give every citizen a regular infusion of free money, no strings attached. Its moved from the fringes into the mainstream over the past few years, with several countries around the world running pilot programs to test it.
Now, the coronavirus and its economic ripple effects are bolstering the view that such payments are necessary during the pandemic, and even after it.
Spain has announced it will roll out a basic income as soon as possible to help its citizens cope. Crucially, Deputy Prime Minister Nadia Calvino said the government aims to make this something that stays forever, that becomes a structural instrument, a permanent instrument. In the UK, more than 170 members of Parliament have also urged the government to give citizens a UBI during the pandemic, though so far their calls have been rejected.
Scott Santens, a prominent UBI advocate, said he believes the pandemic will make a UBI in the US more likely as well.
Through no fault of their own, people are finding themselves in need of money, he told Vox. This profound feeling of insecurity may be quite new to people who felt they had job security, and they may gain an appreciation for permanent economic security through an income floor that would always be there, just in case.
Political figures such as Democratic Rep. Alexandria Ocasio-Cortez and former presidential candidate Andrew Yang also say the US should follow suit.
People who may even have symptoms are going to work in public places because they dont feel they have a choice, Yang told CNBC. A Universal Basic Income would enable these waitresses and parking attendants and [ride-hail] drivers to stay home.
Although some Americans are getting a one-time $1,200 coronavirus stimulus payment, those are not a true UBI; theyre an emergency stopgap measure rather than a permanent program. UBI gives people income stability so they can do long-term planning, which in turn can make them happier and healthier.
Many people are now encountering the inadequacy of the American safety net for the first time. Theyre finding it deeply frustrating to have to make dozens or even hundreds of attempts to file benefits claims while unemployment offices are overwhelmed by demand. It could be simpler and more humanizing for money to simply show up in their bank accounts.
As people get more frustrated with bureaucracy and conditions, Santens said, I think they will start thinking differently about a system that operates differently, one built on trust and dignity instead of distrust and degradation.
Sigal Samuel
Samuel is a writer for Voxs Future Perfect.
The shock of Covid-19 has already caused people to rethink norms as simple as shaking hand. As we try better to protect ourselves and our loved ones during this and future pandemics, we will create new taboos around personal hygiene and behaviors.
Terms such as personal protective equipment (PPE) have already entered common parlance, a phenomenon that could be extended to personal protective behaviors (call it PPB): actions such as never coughing or sneezing into the open air or onto ones hands, and avoiding touching ones eyes, nose, or mouth. People will wash their hands and avoid touching public objects much more, and greetings that do not involve hand-to-hand contact will be popular.
Historically, certain behaviors become taboo for what on the surface are religious or cultural reasons, but probably originate from an understanding of their health risks. Cultures that dont eat pork, for example, likely stopped because in warm climates the meat often carried dangerous parasites such as trichinella worms. Now, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases and the top US expert on the virus, has supported the idea that we should never shake hands again, and seeing people in films hugging, shaking hands, and kissing is already causing a frisson.
In the post Covid-19 world, the strengthening of taboos is inevitable. A cross-cultural shift will leave people less keen to engage in physical ways to show politeness or affection.
Susan Michie and Robert West
Michie and West are professors of health psychology at University College London.
Recently, just off Interstate 40 in a western part of North Carolina, a clergy member and 10 funeral guests stood several feet apart from one another around a casket as it was lowered. As the cars drove by, the mourners dispersed, heading back to their own places of isolation, unable to hug each other as the intimate, albeit distant service concluded.
When history looks back on this moment, one thing will be clear for religious and spiritual leaders: Gathering together matters most. Though many will bemoan the livestreaming efforts, the lack of in-person worship, or the fruition of online giving in the midst of the worst of the pandemic, and after, many religious leaders will claim virtual community-building as a means of survival and growth.
Many pastors are grappling with the complexity of encouraging older church members to use online services and giving; urban and suburban churches that minister to homeless populations are struggling to find those members if they dont have a physical address. Some might say these issues have always been there. While that may be true, the isolation and distancing and the desire for spiritual guidance right now makes these realities all the more complex.
As one pastor of a United Methodist Church in Los Angeles said, The pandemic crystallizes our mission. We have to focus on whats most essential for our respective communities. It also provides a clearer vision of a leaner but kinder church one capable of bending toward change. The recognition of love and truth-telling in a community setting should have been the mission of the church a long time ago, and for some clergy and congregations, it has been. But the takeaway is clear: People are in need of community, and though they cant gather like they wish, they still wish to gather.
Perhaps soon those mourners in North Carolina can give their loved one the send-off they deserved. Until the moments of gathering return, communities of faith will continue forward into the unfolding future creatively but only if they accept and embrace the possibility the innovation of this moment holds.
Rev. Rob Lee
At first, Linda Lam explained away the deep fatigue that left her feeling weak and worn out.
The 70-year-old from Richmond Hill had just returned on Feb. 20 from a two-week sightseeing cruise on the Nile River and it would take time, she reasoned, to shake the jet lag and recover her usual energy.
But a few days later, after she woke up with a constant cough that left her breathless, Lam began to worry she had COVID-19, even though Egypt had yet to become a hotspot for the virus.
Then, on March 2 one day after finding out she tested positive Lams cough worsened, and soon she was struggling to breathe. Her son, Kevin, rushed her to Mackenzie Richmond Hill Hospital, where she was quickly escorted to the intensive care unit.
That was it. I havent seen her since.
Lam spent more than seven weeks in the ICU before she was finally discharged Wednesday to a medical ward amid cheers and applause from hospital staff, who were among the first in the province to treat a critically ill patient with COVID-19 and who took extraordinary steps to keep their patient alive.
Doctors at Mackenzie Health believe Lam is one of the first patients in Ontario with COVID-19 to be intubated. She is also among the few people worldwide to have received an experimental drug, remdesivir, which is being tested as a potential treatment for COVID-19. And in this ICU, Lam is so far the only patient with COVID-19 to leave the unit alive.
It was the best day, the best day ever, said Samantha McLachlan, the ICUs patient care manager.
Our whole team, we were outside her room when she came to get picked up. We lined the hallway and we were clapping, and she was clapping along with us and smiling up at us. It was such a beautiful moment.
Lam came close to dying several times during the nearly five weeks she was sedated and connected to a ventilator. Her kidneys failed, her liver function was dangerously compromised and, at one point, the ventilator was pushing 100 per cent oxygen into her lungs.
On March 2 nine days before the NBA suspended its season due to the virus, and 15 days before Ontario declared a provincial emergency few critical care physicians in the province had cared for a patient with COVID-19. Like hospital staff across the country, physicians and nurses at Mackenzie Health had been preparing for the arrival of COVID-19 patients, they had just not expected to see one so soon.
When we intubated her, it was a frightening moment; Ive never before been frightened in my career, said Dr. Ali Ghafouri, a critical care physician at Mackenzie Health. But everything went smoothly, and we got her initiated on life support. Thats when the journey started.
Lam had counted down the days to her February trip to Egypt, never expecting COVID-19 would find her while she admired the views and visited historical sites along the Nile River.
In mid-February, according to the World Health Organization, there were about 50,000 lab-confirmed COVID-19 cases worldwide, with only about 500 cases outside China.
We were watching all the news reports and knew what was going on with the virus; she really thought shed be OK in Egypt, said Kevin, recalling how his mother reported feeling unusually tired after her return on Feb. 20. She told me I think Im too old for travel; this might be my last trip.
That seemed strange; shes always been a go-getter, very active and the centre of her social scene.
Six days later, when her fatigue hadnt lessened, Kevin took Lam to the emergency department at Mackenzie Richmond Hill Hospital, where doctors prescribed a new blood pressure medication, hoping that would boost her energy. Since Lam had, as yet, no other flu-like symptoms, hospital staff did not suspect COVID-19. On Feb. 26, there were only five lab-confirmed COVID-19 cases in Ontario.
But on Feb. 29, after Lam started to cough and feel pressure in her chest, she went back to the emergency department. This time, physicians tested for the virus and sent Lam home, where she lives alone, to self-isolate and monitor her symptoms. Kevin, who lives in the same neighbourhood as his mother, also went into self-isolation with his wife and two young children.
Thats when it began to feel real for us, he said. But we were always more worried for her.
The next day, Lam found out she had COVID-19. Still, she was hopeful she would recover on her own.
She kept telling me, it felt like a severe cold and that she didnt feel like she was in danger, Kevin said.
On Monday, symptoms worsening, Lam called Kevin, telling him she could barely breathe and asked to go back to Mackenzie Richmond Hill Hospital.
When I dropped her off, I wasnt thinking that far ahead I didnt know that would be the last time Id see her for a long time or maybe even never again.
Kevin and his family did not, to their knowledge, get the virus, though theyve remained in self-isolation since the beginning of March. Of the five friends who travelled with Lam to Egypt, three others tested positive for COVID-19, though none has needed hospital care.
McLachlan was in the ICU that Monday when the hospitals emergency department alerted the critical care team that a COVID-positive patient with respiratory concerns was being brought up to the ICU.
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I can remember standing outside her room, helping get her off the stretcher and watching her walk into her room, said McLachlan, also a registered nurse. She was scared. I also remember how scared everyone else was. It was all so new, this virus. It was just the beginning of COVID-19 in Toronto. But she walked into her room and thanked us and the glass door slid behind her.
For the first two days in the ICU, Lam was stable, able to call her family and browse the news on her phone. But then her breathing grew increasingly laboured, her blood oxygen levels dropped, and the ICU team prepared to intubate her.
She knew we were doing it, McLachlan said. We talked to her and reassured her. I remember her being scared. I remember her asking us to help her stay alive.
Dr. Danny Chen, physician lead in infection prevention and control at Mackenzie Health, knew almost immediately Lam could die of the virus. She was older with underlying health conditions, including high blood pressure and diabetes, and she quickly deteriorated during her first few days in hospital.
She had these strikes against her; thats what prompted us to see if there were any treatments out there in clinical trial, knowing nothing had yet been proven. She was our patient, getting worse in front of us. We wanted to see what we could do for her and her family.
Chen applied to Gilead Sciences for compassionate use of remdesivir, an antiviral drug developed as a potential treatment for Ebola. Though the drug failed for that deadly virus, its among the leading contenders for a potential COVID-19 treatment, and a number of clinical trials are underway worldwide.
Four days after contacting the drugmaker and two days after Lam was intubated Chen had the medication in hand and was speaking with her two sons about the potential benefits and risks of giving it to their mom.
We signed off on my mothers behalf, said Kevin. We felt like we didnt have any other choice; it sounded like she was going to die. What other chance did she have to get better?
The study, the results of which were published on April 10, described the outcomes of 61 patients from the United States, Europe, Canada and Japan. The study could not determine whether it is an effective treatment; those trials are ongoing.
Chen said Lam tolerated the drug well, but it is impossible to know whether it made a difference in her care.
We do know that the odds were stacked against her, said Chen, noting published data suggest that about 70 per cent of patients with COVID-19 who are intubated will not survive. From our hospital standpoint, what we feel is that we gave her every chance we could to get better.
Seven weeks into treating patients with COVID-19, Ghafouri and the ICU team have learned much about the complex disease. The fear is gone, though some of the uncertainty about how to care for patients remains.
Its very unpredictable, said Ghafouri, who has not hugged his children since March 2 the day Lam came to hospital for fear of transmitting the virus. Ive learned that if a patient survives the first seven or eight days, they could possibly survive longer. So far, most of my patients have passed away within the first week. And the ones who survive, it takes four, five or six weeks to heal.
In Lams case, Ghafouri and the ICU team drew on their previous critical care experience to manage the new disease even as they learned about its unpredictability.
We just kept at it. We tried to fix whatever was fixable, troubleshoot whatever we can, and fine-tune all the medications. We were supporting all her organs her kidneys, her liver, her heart until her body started the process of healing itself.
So far, Lam is doing well on the medical ward. She is sitting up and wearing her glasses and visiting with her two sons families by video conference.
She cant yet speak because a tracheotomy tube remains in her throat. But Lam can wave to her family from her hospital bed and nod along with her grandchildrens stories. Kevin said they all cant wait to give her a hug.
Chen said Lams recovery will be long, with many ups and downs, as her body heals after so many weeks in the ICU. Her muscles are weak, and shell need to practise walking, talking and other daily activities. But there appears to be no lasting organ damage, and Chen said her body is no longer fighting the virus. Though she is likely not infectious, Chen said Lam is not officially virus-free as she has not yet had two negative COVID-19 lab tests, taken 24 hours apart.
McLachlan knows there will be many more difficult days in the ICU. The COVID-19 pandemic is far from over.
But seeing Lam leave the ICU, smiling and waving at her care team, has given staff some hope that there will be more patients who survive the disease.
There is light at the end of this tunnel. With perseverance and with faith, we will see positive outcomes. And now that weve seen it, we will do everything in our power for our other patients because we want to have more of these moments.
