Pfizer aims to create coronavirus vaccine by end of 2020 – MLive.com

Shoppers may see more shortages of unexpected products, including laptops, toilet paper and medicines. Some companies could find themselves lacking raw materials and components, a recipe for further financial trouble.

So far this year, most of the disruptions have stemmed from factory shutdowns in China, a manufacturing hub for products like electronics and industrial machinery. Laptop exports from China to the United States have plummeted, for instance, just as demand is surging as companies switch to remote work and students are thrust into distance learning.

But like the virus, which spread from China to the rest of the world, so too will the economic disruptions, which are likely to intensify in months to come. For companies and consumers who have come to rely on being able to ship goods rapidly and seamlessly around the world, the disruptions could come as a shock.

China has shown us how extreme the downturn in industrial activity can be, said Chris Rogers, a global trade and logistics analyst at Panjiva.

Across the United States and Europe, major manufacturers like Volkswagen and Ford have shuttered, in turn reducing demand for steel, electronics and other components.

So far, many of the product shortages in the United States and Europe dont stem from an actual lack of goods, but rather surging demand from consumers, who are stockpiling bleach, toilet paper, diapers and dried beans, unsure what the months to come will hold.

Other shortages are occurring as producers of toilet paper, food and other products try to figure out how to rework supply chains that are set up to provide bulk shipments to restaurants and schools to instead meet household demand.

Photo: Chip Somodevilla/Getty Images

Were committed to keeping our readers informed.Weve removed our paywall from essential coronavirus news stories. Become a subscriber to support our journalists. Subscribe now.

Over the past few days, some glimmers of relative hope have flickered down the end of what had seemed until recently a possibly endless tunnel. The COVID-19 news since the weekend isnt all good; in a pandemic it rarely is, and yesterday marked the highest number of new deaths in the United States reported yet: 1,941, almost 50 percent higher than the previous peak, which came just on Saturday. In New York, the epicenter, 800 patients died yesterday of COVID-19, twice as many as on any day before, and now, in addition to those deaths registered by hospitals, 200 New Yorkers are dying at home each day, uncounted in the official statistics, perhaps ten times as many as died during a typical day before the pandemic arrived.

But also over the past few days, the number of new hospitalizations in New York has probably begun to flatten. San Francisco has started to think about what follows shelter in place. And, in perhaps the most significant development, revisions to the pandemic model developed by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington suggested that the country would ultimately need fewer beds, fewer ICU beds, fewer ventilators and doctors and nurses and PPE in short, fewer hospital resources of all kinds than was expected. More strikingly, it revised its most recent estimates for the ultimate coronavirus death toll downward by 11,765, or roughly 15 percent: from 93,531 to 81,766. A couple of days later, it revised them even more dramatically, from 81,766 to 60,415, or roughly 25 percent more.

These revisions may be eye-opening, in addition to being encouraging, because as recently as a week or two ago, the projections discussed by most public-health officials were much, much higher. When Donald Trump unveiled his flatten the curve chart, months after public-health experts began advocating that approach to the disease, he was working off the IMHE model, and suggesting that between 100,000 and 240,000 Americans would die. A model developed by the CDC projected a range between 200,000 and 1.7 million. The Imperial College model famously predicted 2.2 million deaths in the U.S. in a do-nothing scenario, and more than 1 million even if quite aggressive mitigation measures were adopted. As of April 2, a survey of public-health officials summarized by FiveThirtyEight found a median projection of around 263,000 deaths. The new IHME model suggests an ultimate toll less than one-quarter that number, about one-20th the figure projected in the Imperial Colleges mitigation scenario, and less than one-30th what was projected in their do nothing scenario.

As Zeynep Tufekci has brilliantly written for the Atlantic, models like these are not meant to be crystal balls, producing projections we can all take to the bank, but a survey of possible futures that depend on what choices are made and what policies are engineered and implemented in response to the pandemic threat. Nevertheless, the gap between what experts projected a few weeks ago and what they are projecting now is absolutely astounding, and it is primarily a reflection of just how much has been done, and how quickly, to defend against and respond to the coronavirus. In many cases, we have achieved so much more than modelers even imagined possible that the range of outcomes we are now looking at did not even appear at the very low end of initial forecasts. The models werent wrong, exactly, they seemingly just underestimated how widespread, thorough, and steadily maintained social-distancing measures could be. How could they not? It can be easy to forget, a few weeks into something like a hemisphere-wide lockdown, just how absolutely unprecedented this public-health mobilization truly is: nearly every American in every state embracing punishing, restrictive quarantine-like isolation for the sake of the country as a whole. We are doing so willingly, with hardly any meaningful resistance to shelter-in-place guidance, even though the statistical profile of the disease, while brutal, would allow most Americans to think it was a much more significant threat to others (the case fatality rate here now estimated between 2 and 3 percent). This is solidarity I simply didnt believe was possible in this country anymore and under any circumstances, and it has arrived in the space of just weeks, in the midst of national political chaos with tribal partisanship still boiling at a feverish peak. It is breathtaking.

The phenomenon is bigger than the U.S., of course, as are most aspects of this disease; as horrifying as Americans may find the lack of leadership in Washington, the U.S. response falls roughly in the middle of a range of governmental incompetence exhibited by the nations of Western Europe. But while governments in those countries were much slower than they could have been, they also moved quickly and in unison when they did bringing them into line with aggressive actions taken by Asian countries to produce an unprecedented global response to the kind of collective-action problem we used to assume was almost unsolvable at the international level. The terrifying projections of economic impacts are, of course, a sign of how much the world as a whole has elected to cut back, as are the hard-to-believe recoveries of environments that were, until quite recently, toxically polluted. In Los Angeles, thanks to reduced car traffic, the air quality is now best in the world, and in Delhi, the air-quality index has fallen from 999 (the very top of the scale, and about three times the dangerous level of pollution) to 45 (which counts as almost unthinkably pristine). To cite just one additional figure, estimates now suggest more than 1.5 billion schoolchildren have already been taken out of school to protect against COVID-19. These interruptions may prove problematic in ways sociologists will study decades from now, since even beyond the possible traumas of a pandemic, childhood breaks in school tend to exacerbate educational inequities. And it may be the case that this collective, coordinated global bunkering is as much, or more, a reflection of personal fear and pandemic anxiety that it is of a truly universal and humanitarian sense of shared fate and collective purpose. Nevertheless, we have never seen anything like this globally, and in our lifetimes, we probably never will again. We need a plan for the next phase, urgently. But in the meantime, this moment of solidarity is truly something to behold.

How long that solidarity and those lockdowns continue is an open, and perhaps unanswerable question none of us have been through this before, and its hard to predict at what point the commitment to collective safety might break, and break to what degree, opening up which share of the population to potentially lethal exposure. But how long our lockdowns last probably isnt the most operative question when it comes to sorting out and planning for a medium-term COVID-19 future. Nor is it how many have died, how quickly those death rates are growing, or how long they have stayed flat. It also isnt the number of hospitalizations, or confirmed cases, or total tests taken. All of these tell us about the state of the disease at various points in the recent past: cases reflecting infections one to two weeks ago, hospitalizations two to three weeks ago, and deaths three to four weeks ago. Of course, they also represent a baseline from which to project the future trajectory of that disease.

But in sketching that trajectory from that baseline, in forecasting the ultimate severity and shape of this pandemic, the most important data point is how many people are, or were, infected without anybody noticing. And our best hope, on that point, is that the disease is actually much more infectious than weve thought. That wouldnt change how many are now sick or dying, but it would change, perhaps significantly, how many more wed expect to fall sick, to require hospitalization, to require ventilators, and ultimately how many wed expect to die.

Each of those deaths is a tragedy, and a horror. It is also a numerator, or part of one. The denominator is made up of how many people out there contracted the disease. And the fraction tells you, in theory, roughly how bad the outlook will be when the disease has finally passed through the entire population (which, barring the arrival of a vaccine, may take longer than the achieving of herd immunity, which is our clearest path back to normal life). The bigger that denominator, the less severe the disease at the population level: If roughly 13,000 Americans have died out of a total number of infected of 400,000 (the current confirmed case number), that is a pandemic nightmare of a certain scale; if 13,000 Americans have died out of a total number of infected of 4,000,000, that implies a final toll of a different, considerably lesser scale; and if the total number of infected is 40,000,000, even more so, with hospitalization and case fatality rates much, much lower as a result. It would also suggest that we are much further along the timeline of the pandemic and much closer to its conclusion. The bigger that denominator, the more people caught the coronavirus without realizing it, and the more people that caught the coronavirus without realizing it, the less severe the disease looks, and the faster well likely get through its brutality and emerge into a strange-seeming post-pandemic future.

So, how big is that denominator number? Unfortunately, we dont know. Worse, in the U.S., it is at this point, and for the very foreseeable future, unknowable. A second-order outrage about the pathetic, outrageous lack of test kits, and the backlog processing even the tests we do have, is that in addition to limiting our ability to treat those patients we know are ill and to take public-health measures to protect the vulnerable parts of our population, we have very little sense of the scale of the outbreak we are dealing with. When we cant even test all those patients who show up at hospitals complaining of symptoms, we are miles from a clear sense of how many other people might be carrying the disease around infecting others, of course, but also changing the size of that denominator. This is one of the reasons there has been so much recent enthusiasm for the possibility of whats called serological testing, which can tell anyone, even the asymptomatic, if theyve already acquired immunity. Until we do institute large-scale serological and community testing of that kind, we will be living in darkness.

Into that darkness have crept the amateur prognostications and armchair epidemiology of a loose confederation of contrarian writers, thinkers, and internet provocateurs Ive started to think of as the corona dark web. Like the intellectual dark web before it, the corona dark web lives a bit to the right of the social-media commentariat generally (which is anchored somewhere on the center-left), is powered by a desire to prove conventional wisdom wrong, and is made up of almost entirely of men, mostly speaking outside of or beyond their areas of expertise. Perhaps the most notable avatar was Aaron Ginn, the Silicon Valley product manager whose Medium post COVID-19: Evidence Over Hysteria was a viral sensation on the right at the same time the president was downplaying the pandemic threat, and then was unpublished by Medium in an effort to remove disinformation from its site. (The post was later republished by RealClearPolitics and can be read here.) On its most respectable fringe, the corona dark web has included, at various points, Obamas favorite legal scholar, Cass Sunstein; on its crazier fringe, libertarianisms favorite legal scholar, Richard Epstein. It has also included Elon Musk and the head of the IMF, and Jair Bolsonaro, the president of Brazil, who despite his office falls clearly onto the crazy side of the ledger. And it surely includes Alex Berenson, a former New York Times reporter and the author of a recent controversial book asserting the mental-health risks of marijuana use are much higher than widely believed, who has become a sort of Twitter iconoclast offering some amount of probably valuable perspective and skepticism, mixed with a kind of hysterical outrage that makes his analysis a bit harder to trust, especially for those who found their way to his contrarianism hoping for comforting news about the coronavirus (which, as Sean Trende has rightly pointed out, there seems to be a reluctance among credentialed, centrist social media to embrace any positive news). Berenson was recently praised by, among others, Brit Hume: If youre skeptical of the experts and suspicious of the computer modeling on Covid 19, the person to follow is former NY Timesman @AlexBerenson, he wrote on Twitter. He is doing the same sort of data analysis that the late Michael Crichton did on climate alarmism.

The Crichton comparison is damning, and there are many good reasons to be skeptical about Berensons skepticism, too. But it remains the case that to a degree most Americans do not appreciate, there is an enormous amount we simply do not understand at this point about this disease. We do not know how lethal it is. We do not know the effect of seasonality and climate on its spread. We do not understand the age skew of health outcomes, since the disparities between elderly patients and young ones vary wildly country to country. We do not know, for sure, whether those who have survived it have long-lasting immunity, short-lasting immunity, or why, in a few cases, at least, survivors seem to have no antibodies to the disease at all. We do not know how to treat it, at least not very well, with some doctors suggesting in recent days that the conventional use of ventilators on end-stage COVID-19 patients may be ineffective at best, and possibly even damaging.

On all of these questions, and indeed many others, we are flying mostly blind. But, in the face of a pandemic, we probably need to stop ourselves from deciding to stop flying as Amitha Kalaichandran argued as far back as February 26 in Scientific American, an argument echoed by Maggie Koerth April 6 in FiveThirtyEight and by Siobhan Roberts in her April 7 essay Embrace the Uncertainty in the New York Times. At the end of the day, Koerth wrote, experts told me, when evidence is lacking, individuals and public health officials alike have to make a call based on what we do know, our personal experiences and our own understanding of risk and risk management meaning, in other words, accepting that, sometimes, well just have to do the best we can without a clear set of instructions. Thats because, as the World Health Organizations executive director of Health Emergencies, Michael Ryan, put it during a presentation about the global coronavirus response back on February 13, uncertainty cant be an excuse for inaction. When it comes to pandemics, he said, you must react quickly. You must interrupt the chains of transmission. Speed trumps perfection. The greatest error is not to move. Be fast and have no regrets.

On many of these questions, the voices of the corona dark web are cultivating further uncertainty which is to say, some mix of complacency and delay. The more irresponsible members are advocating worse indifference to human suffering at a terrible scale. But embedded in the skeptical discourse is the highly important query about that total case-number denominator. On Stat News last month, the contrarian Stanford professor of epidemiology and public health, John P.A. Ioannidis, suggested that the quarantined Diamond Princess cruise ship represented the best contained, controlled environment in which to measure both infectiousness and fatality and based on that data, infectiousness was higher and fatality lower than most conventional models suggest. More recently, the investor Bill Ackman, a few weeks ago a coronavirus bear, announced that he was growing more optimistic, even in the medium term, because he saw reason to believe the asymptomatic infection rate could be as much as 50X higher than expected.

To me, the most compelling of these analyses came from Christopher Balding, a business professor in Vietnam specializing in China compelling in part because he refrained from offering concrete projections of his own, instead merely demonstrating that both small changes to our understanding of the diseases infectiousness would amount to significant changes of our understanding of its severity, and that we had pretty good reason to believe that estimates of its infectiousness were, by and large, too low: namely, small-scale community-testing efforts that revealed higher-than-expected infection levels in the general population (and therefore a lower share of severe cases). An Economist analysis looked at the unusual spike of doctor visits arising from flu-like symptoms atypical for this time of year and suggested that COVID-19 may have spread as much as 200 times as fast as widely understood. This would amount to a total rewriting of our understanding of the disease; as the authors suggest, it would mean the disease was only about as lethal as the flu, though very much easier to catch.

Are these analyses hard-nosed assessments or a form of contrarian wishful thinking? It is too early to say for sure, but we are now beginning to get glimmers of an answer, and, though they are just glimmers, they are not uniformly encouraging. The WHO has long maintained that asymptomatic carriers of the disease represent about a quarter of all infected which would suggest that, in a perfect and universal testing environment, wed find a third more carriers of the disease than wed find just by testing those presenting with symptoms. This would be a significant increase of the infected population, but not one that radically changes our picture of the severity of the disease. In Iceland, such a system as been instituted, and though only one percent of those tested were found positive, the number for asymptomatic carriers is higher: 50 percent of infected Icelanders dont know they are carrying COVID-19. This is twice as high as the WHO figure, as so, by this logic, relatively good news. But even a doubling of the denominator does not change our picture of the disease that dramatically it is not Bill Ackmans 50X, in other words, let alone the Economists 200X. It is also in line with a new CDC renanalysis suggesting that the infectiousness of the disease might be twice as high as conventional wisdom recently held a striking revision for those who remember the concern-trolling around those raising earlier alarms about elevated infectiousness rates, though not one that amounts to a basic reconceptualization of the nature of the disease or what we can expect from it. A new, small-sample serological survey in Germany holds more promising results: 14 percent of those tested carried coronavirus antibodies, meaning theyd already been exposed the disease, orders of magnitude more than is suggested by their confirmed case count of less than one-tenth of one percent of their population.

It is not easy to know how to interpret this range of findings each reflecting different testing protocols and measuring the state of the disease in different populations. And of course, the broader lesson of pandemic modeling and its encounter with public health and public knowledge over the past few months is: Models and statistical analysis are surely helpful, indeed the best we can do when operating in a state of testing ignorance, but they are not as helpful as tests. Which is why we need much more testing here in the U.S., but everywhere else as well. We are still, presumably, months away from a testing regimen here that could tell us the full scope of the disease. In the meantime, we should all be hoping that when those tests do begin to return results, they show more of us, not less, got sick. Indeed, we should be hoping that many more of us are sick right now.

Daily news about the politics, business, and technology shaping our world.

Last week, we asked for your questions about sex and the coronavirus. You had many.

Common queries involved the levels of precautions that one could theoretically take to reduce exposure during sex. But dont worry: Its hard to imagine well all have to have sex in decontamination suits with appropriate cutouts going forward.

Several people wondered if avoiding kissing or wearing a mask during sex may lower the risk of coronavirus transmission. We dont know. What we do know is risk starts when you get within six feet. If one person is infectious, the air and the bed or any surface on which you have sex or sleep will be contaminated with droplet nuclei.

But, wait! some of you have said, what if we dont sleep in the same room, and we manage sex standing up, not facing each other and neither of us needs to steady themselves against a surface? While I salute your core strength, you are still in the same room, breathing the same air and breathing heavily on each other and thus you have assumed risk.

What if I use an N95 mask? a few of you asked. Please dont. Health care workers are putting themselves at risk to provide medical care because they dont have enough of this equipment. If you have a stash of N95s, the sexiest thing to do is to donate them to your local hospital.

Now, on to your other questions.

What is the likelihood of a Covid-19 baby boom around Christmas? Just curious. Nick, 76, Charleston, S.C.

Highly unlikely.

Weve all heard about so-called blizzard babies and furlough fertility. The belief is when were stuck inside with another person, people quickly turn to sex. And if you are heterosexual, fertile and not using contraception, the result is a baby boom nine months later.

Except, cooped-up conceptions are a myth.

The fable may have originated from the New York City blackout of November 1965, where there were observations of labor and delivery units being deluged nine months later. However, once the data was analyzed, there was actually no baby boom.

But, you may say, what were experiencing is different from a single night or two of being homebound because of a blackout or blizzard.

The best comparison is likely from the influenza pandemic of 1918. Afterward, there was a decrease in birthrate of 5 percent to 15 percent in the United States and in three Scandinavian countries.

There are believed to be two causes (keep in mind there may be other factors that have been missed considering we are looking at data from a hundred years ago): first, an increased risk of first trimester miscarriages because of illness during the pandemic (we have no information to tell us there is an increased risk of miscarriage with Covid-19, so please dont extrapolate and panic).

Second is something we may see again: less sex as a result of stress economic uncertainty, illness, you name it and the reduced availability of sexual partners. That one may sound familiar, and thus, a baby boom toward the end of 2020 or in early 2021 seems unlikely.

Ive read that the protease inhibitor in PrEP protects against coronavirus. Does that mean people on PrEP (or H.I.V.-positive people using the same medications as part of their treatment) can continue to have sex without being as worried? Nate, 39, London

No.

There is no evidence to suggest the medications in PrEP are useful in protecting against coronavirus.

PrEP, otherwise known as the pre-exposure prophylaxis (PrEP) for H.I.V., involves taking two medications tenofovir and emtricitabine every day to protect against H.I.V. exposure from sexual activity. Truvada and Descovy are the two FDA-approved names for this combination of medications.

These two medications may also be taken as part of a treatment regimen for people living with H.I.V. Tenofovir and emtricitabine inhibit the enzyme reverse transcriptase, which is used by H.I.V. to make more copies of itself but is not used by coronaviruses.

Just as not all antibiotics work for all bacteria, not all antiviral medications work for all viruses.

The confusion is understandable considering that two other medications used for H.I.V. lopinavir and ritonavir, which act on the enzyme protease have been investigated as treatment for Covid-19. The first publication did not show benefit, but other research in continuing.

In the meantime, I would assume nothing but distance and hand-washing can protect us against Covid-19, while masks may help us protect others.

What are your thoughts on trying to get pregnant now? Doug, 33, Somerville, Mass.

Based on limited data, pregnant people dont seem to be at increased risk for serious illness from coronavirus. However, pregnancy increases the risk of serious outcomes for other respiratory viruses, like influenza, so pregnant people are currently considered an at-risk population for Covid-19. The risk of a preterm birth may also increase if you get sick with Covid-19.

With so many unknowns about what to expect when you are expecting during a pandemic, here are some considerations:

Pregnancy increases interactions with the health care system blood tests, ultrasounds, blood pressure checks and interactions with the health care system increase your risk of exposure to coronavirus.

Many medical centers are trying to limit routine in-person visits for the safety of their patients and workers, and are instead conducting some appointments virtually; many are also asking that partners not accompany women to these appointments.

If you have an underlying medical condition, like diabetes or high blood pressure, or had a complication, such as preterm delivery, in a prior pregnancy, then you are at higher risk for complications in your next pregnancy and will probably need more access to the heath care system.

If you have an unforeseen pregnancy complication, you may need an emergency department. In addition to potentially increasing your risk of exposure, if the hospital is at capacity with coronavirus patients or has no supply of personal protective equipment, there may be an impact on your care.

While most people have uncomplicated pregnancies, I would consider those factors. Many of us have taken for granted the ability to get the medical care we need in a true emergency. We cant do that anymore.

Ive seen a lot of articles on sex and the coronavirus, and yet none include guidelines for those of us who are extremely high-risk for complications because of pre-existing conditions. Is sex OK for these groups? Is it better to avoid altogether? I have very severe asthma, some autoimmune issues and a recent history of recurrent, severe pneumonia. What should someone like me know about intimacy during corona times? Phoebe, 26, Berkeley, Calif.

Unfortunately, we dont have good recommendations based on specific medical risk factors. Its not because we havent considered these groups its because we currently have substantial knowledge gaps, Im sorry to say.

As with everyone else those in low- or high-risk categories I would recommend no sex with anyone outside your household and no sex with anyone inside your household if they have symptoms (like a dry cough or fever) or if they have a known exposure and are quarantined and/or waiting for testing results.

In your case, if you live with your partner and they are not symptomatic, I would consider their exposure risk: Are they leaving the house? If so, is it to work in a situation with a higher exposure risk? Or if its simply to grocery shop, do they take steps to mitigate exposure, like social distancing and practicing good hand hygiene?

And, of course, remember that they could be asymptomatic and still infected.

Furthermore, sex is not the only household activity that could expose you. Unfortunately we dont know where to rank it, in terms of risk, compared with other activities that happen under the same roof.

What about sharing a meal, considering many of us likely spray droplets when we eat? What about sitting on the same couch watching a funny movie and laughing, which also sprays droplets?

If you are at higher risk because of pre-existing conditions, I would consider these factors and then discuss them with your doctor so you can decide what makes the most sense for you given your health conditions and your living situation. Everyone should pay extra attention to house hygiene cleaning surfaces after use as well as hand hygiene, as these actions may help reduce transmission between members of the household.

The more hygiene and distancing measures you can put in place, the lower your risk of transmission.

I heard this advice regarding social distancing and the hygiene measures and it stuck with me: If you feel as if you are doing too much, then you are probably doing it correctly. Its hard when no one has the answers, but its important to acknowledge that uncertainty.

Dr. Jen Gunter is an obstetrician and gynecologist in California. She is the author of the The Vagina Bible and writes The Cycle, a column on womens health that appears regularly in Styles.

Editors Note: The Atlantic is making vital coverage of the coronavirus available to all readers. Find the collection here.

Viruses arent picky. They tear through neighborhoods and nations, infecting whomever they can, and the new coronavirus is no exception: The pain of the present pandemic will be feltis already being feltby just about everyone in the United States and all over the world, in one way or another. After the pandemic has run its course, no one will be wholly untouched.

At the same time, there will be stark disparities in how certain segments of the American population experience this crisis. Some of these disparities will be the result of luck or coincidencea matter of where someone happened to travel, what line of work they chose, or what city they live in. But in a country that was highly unequal in so many ways well before it had a confirmed case of COVID-19, other disparities will be sadly predictable, falling along racial and class lines, as well as other fateful divides.

In the coming months and years, there will really be two pandemics in America. One will be disruptive and frightening to its victims, but thanks to their existing advantages and lucky near misses with the virus, they will likely emerge from it relatively stablephysically, psychologically, and financially. The other pandemic, though, will devastate those who survive it, leaving lasting scars and altering life courses.

Which of these two pandemics any given American will experience will be determined by a morbid mix of a sort of demographic predestinationshaped strongly by inequalityand purely random chance.

When someone dies, there are three ways to think about what caused it, according to Scott Frank, a professor at Case Western Reserve Universitys School of Medicine. The first is the straightforward, medical cause of deathdiagnosable things like heart disease or cancer. The second is the actual cause of deaththat is, the habits and behaviors that over time contributed to the medical cause of death, such as smoking cigarettes or being physically inactive. The third is what Frank refers to as the actual actual cause of deaththe bigger, society-wide forces that shaped those habits and behaviors.

In one analysis of deaths in the U.S. resulting from social factors (Franks actual actual causes), the top culprits were poverty, low levels of education, and racial segregation. Each of these has been demonstrated to have independent effects on chronic-disease mortality and morbidity, Frank said. (Morbidity refers to whether someone has a certain disease.) He expects that the same patterns will hold for COVID-19.

Read: The four timelines for life returning to normal

To begin with, the physical effects of COVID-19 are far worse for some people than others. There are two traits that seem to matter most.

The first is age. Older people are at greater risk of experiencing the more devastating version of the pandemic, in part because the immune system weakens with age. Early data from the Centers for Disease Control and Prevention indicate that, in the U.S., the risk of dying from the disease begins to climb at around age 55, and is especially acute for those 85 and older. I think the pattern were going to see clearly is an age-related pattern of mortality, Andrew Noymer, a public-health professor at UC Irvine, said. (Younger people arent invulnerable to the disease, though; the CDC found in mid-March that 20-to-54-year-olds had accounted for almost 40 percent of hospitalizations known to have been caused by the disease.)

The second trait that puts someone at increased risk is having a serious health condition such as diabetes, heart disease, or lung disease. These conditions seem to make cases of COVID-19 more likely to be severe or fatal, and the risks rise considerably for older adults who have any of these conditions, Frank told me.

But while everyone ages, rich and poor alike, these health conditions are not evenly distributed throughout the population. Theyre more common among people with less education, less money, and less access to health care. We know these social and economic conditions have a profound effect on chronic disease, Frank said, and then chronic disease has a profound effect on the mortality related to COVID.

When we someday tally up all the casualties of the coronavirus, the high number of older Americans among the dead will reflect the sad, universal fact of physical decline. But for many of those who had underlying health conditions, inequality will be the actual actual cause of death.

Since some minority groups have a higher prevalence of certain health conditions, like diabetes or high blood pressure, COVID-19 will likely affect them more intensely. We may not see it now, but when we look back at who was the sickest, who had the most complications, where there were excess deaths, its likely that we might see those coming down along racial lines, Hedwig Lee, a sociologist at Washington University in St. Louis, told me in mid-March.

This pattern is already starting to emerge in early data from places that include information about race in their reports on the local impact of the virus. In Chicago, where less than one-third of the population is black, more than two-thirds of the 86 people killed by COVID-19 as of last weekend were blackand four in five of those black patients had high blood pressure and/or diabetes. The state of Michigan and the Wisconsin county that contains Milwaukee have also had a disproportionate number of black residents die from the disease. A similar pattern was borne out in a recent CDC cross-country snapshot of hospitalizations in parts of 14 states during the month of March; black people accounted for 33 percent of hospitalizations for which racial data was available, despite making up only 18 percent of the population in the areas surveyed.

Read: What the racial data show

Lower-income people, in addition to any other risk factors they may have, are also at increased risk because their finances might change the way they seek treatment for the disease if they come down with it. When lower-income people get sick, they oftentimes delay going to the doctor, not because they dont want to get well, but because they simply dont have the money, Rashawn Ray, a fellow at the Brookings Institution, said. They wait until the last minute to go get help, like when they are literally about to die or when something catastrophic is happening. And forgoing a doctors guidance until the late stages of an illnessCOVID-19 or notcould be especially dangerous during a pandemic.

Americans health varies along racial and economic lines in the best of times. That will probably make the outcomes just as uneven, if not more, in the worst of times.

Two important predictors of an Americans well-being right now, other than whether that person has COVID-19, are the answers they and others in their household would give to two questions: Are you still able to work? And if so, can you work without risking exposure to the virus?

For a rapidly growing portion of the country, the answer to the first question is no. Three weeks ago, some 3.3 million Americans filed for unemployment benefits in a single week, a record-breaking total that was nearly five times as large as the previous recorded high. The following week, the number of new claims was twice as high6.9 million. Still another 6.6 million claims were filed last week, bringing the recent three-week total to nearly 17 millionan enormous figure that likely still understates how many Americans are actually out of work right now.

While few sectors of the economy have been spared by the pandemic, the businesses that have so far been hit particularly hard are the ones premised on physical presence and face-to-face interactions, such as retail stores, restaurants and bars, and hotels. If we think about those industries, they have a lot of low-wage and part-time workers, many of whom live paycheck to paycheck, said Susan Houseman, the director of research for the nonprofit Upjohn Institute for Employment Research. We worry about them in every single recession, and here theyre just being slammed.

Read: Americas restaurants will need a miracle

In this realm, too, racial minorities tend to be more vulnerable. Houseman noted that African American and Hispanic workers are usually disproportionately likely to lose their job during downturns. That was true during the Great Recession, and so far appears to be true of this economic crisis: According to the Pew Research Center, as of late March, 29 percent of white Americans said someone in their household was out of work or had received a pay cut because of the pandemic, while 36 percent of black Americans and 49 percent of Hispanic Americans said the same. (Separately, a recent study also suggested that women may be more likely to lose their job than men.)

Of course, still having a job is not an unalloyed good; for much of Americas current workforce, earning a paycheck means exposing oneself to the virus. There is a portion of the population, though, who are able to safely work without going outside and risking infection. For them, this period is generally more bearable. The Bureau of Labor Statistics estimates that less than 30 percent of American workers are able to do their jobs from home, and finds that this is much more likely to be the case for people who have at least a bachelors degree. Remote workers relative safety may persist even once life starts returning to normal, if people who are able to work from home choose to continue to do so, out of caution.

But because of the nature of the pandemic, the danger of a job doesnt map entirely neatly onto income and education levels. Yes, its the case that many truck drivers, grocery-store workers, and delivery people are still out in the world and risking exposure to the virus, but so are doctors, nurses, and pharmacists. The industry in which one happens to work is another point at which class and chance intersect.

During milder economic downturns, people who lose their job may be able to find work in another industry. But because such a wide range of businesses have scaled back or shut down operations, job hopping is harder to pull off now, Houseman said. It's also riskier: Grocery stores and delivery companies are hiring ambitiously, but for jobs that will put workers in greater danger of viral exposure.

Read: Denmarks idea could help the world avoid a Great Depression

The answers to each of these two questionswhether someone still has a job, and whether they can do it safelystrongly predict how any given American household is faring right now. To illustrate this, Rashawn Ray, the Brookings fellow, talked me through the probable realities of people who can do their job from home and people who are currently out of work.

The former group is likely to be salaried, and can limit their trips outside the house. They may have children to look after and stress over, but, barring any health concerns, theyre doing fine. Their job is safe, their salary and wages are safe, their mortgage and house is safe and theyre able to go to the grocery store and load up on a whole bunch of groceries, Ray said. Maybe they even choose to have the groceries delivered.

The latter group is living a completely different life right now, Ray told me. Perhaps they were already living paycheck to paycheck, but now that theyve been laid off or furloughed, theyre not sure how theyll be able to pay their usual expenses, let alone stock up on food and supplies. A lot of people who dont have money coming into the household are worried about losing their apartment or house, theyre worried about the fact that they cant get access easily to the food they need, and now theyre sitting at home with families, with children, trying to figure out whats happening, Ray said.

Andrew Noymer, the public-health professor, put it more concisely: Someone is at home wondering how hes going to make rent and feed his family, he said. And someone else is wondering if they can binge-watch the first season of The Sopranos or whatever.

The uncertain duration of this period makes getting through it even more difficult. I think that even a month of this could have devastating effects for many of our most vulnerable people, said Beth Mattingly, an assistant vice president in regional and community outreach at the Federal Reserve Bank of Boston. The longer it goes, the more concerned I am, and probably my concern grows exponentially, not linearly.

Whenever it does end, Rays first group will likely have a relatively smooth transition back into the office: Theyll throw their laptops into their bags, drop their kids off at school or daycare, and resume whatever projects they were working on the previous day from home.

But the second group probably wont be able to get back to work so quickly. Houseman likened the post-pandemic bout of rehiring to a game of musical chairs, because many businesses could go under between now and then. Some will start hiring again, but there will be more workers for the jobs they have than they can hire, she said. The longer [closures] persist, the more businesses are likely to go bankrupt, and the slower the recovery will be.

One thing that can provide a buffer from labor-market turbulence is having savings to draw on. No amount of cash can grant someone immunity from the virus itself, but wealth can prevent the pandemic from leaving deep financial scars. If you think about the possibility that people have to declare bankruptcy or foreclose on their house or lose their car, that takes a long time to recover from, said Vida Maralani, a sociologist at Cornell University who studies inequality. If you have to use up all your wealth, thats really different than Gee, I lost the money [I put down] on a summer Airbnb and now I cant vacation.

Life in America is always hard without cash reserves, but its especially hard now. One 33-year-old woman in a small town in Texas told a New York Times reporter, Im not going to let my kids go hungry. If I have to just eat once a day, thats what I have to do. Shes disabled and doesnt work, and her husband, a carpenter, has had fewer jobs lately.

Read: The best hopes for a coronavirus drug

According to the Federal Reserve, just under 40 percent of American adults wouldnt have enough cash on hand to cover an unexpected $400 expense, and that was before the pandemic cut off so many workers earnings. Having even a few thousand dollars saved up can make this time less stressful, Maralani said. It can be the difference between being able to cover a couple months expenses, like rent or car payments, and wondering where the money for them will possibly come from.

The federal government is attempting to address household-budget shortfalls. Late last month, Congress passed and President Donald Trump signed a $2.2 trillion economic relief package that included $300 billion to go directly to American households. Most adults will get $1,200 each, plus $500 per child (though they may not receive it until weeks or months from now). Beth Mattingly, of the Boston Fed, told me she thinks the relief package will provide significant help, though those who become unemployed or see their work hours reduced may still need more assistance.

Even if Americans receive help from the government, Rashawn Ray foresees lasting financial consequences for people who arent able to pay their bills now. If they are in a position where they have taken on a sizable amount of debt, [maybe] through payday loans, now they have added economic stressors that theyll have to deal with, he said. Additionally, even if landlords or lenders allow people to delay their rent or mortgage payments, that doesnt mean those people wont have to make those payments eventually. If this lasts 90 days, thats three months of rent they have to make up, Ray said.

Read: How you should get food during the pandemic

And in households across the country, regardless of wealth and income, COVID-19 will kill now-unknown numbers of people who support their families financially, Houseman noted. Their deaths will be painful personal losses for their families, who will also suffer economic consequences.

But in keeping with the often dystopian nature of American inequality, some households may, amid the tragedy, come out ahead. I think there are also going to be some people who are saving money in this, Mattingly said. Their income hasnt changed, but they arent going out to eat, theyre not driving, theyre not going to work in the office. They may not emerge from the pandemic completely unscathed, but they will have a much easier time transitioning back to normal once the crisis wanes.

As health-care workers confront the coronavirus on the front lines of hospitals, the home front of this pandemic is literally the home. Thats where many Americans are dutifully spending their days, and the conditions and location of ones housing have significant bearing on how one weathers a pandemic. Living in a cramped apartment with lots of relatives is risky on top of being uncomfortable; sharing a spacious, well-appointed house with few other people makes it safer and easier to ride out a lockdown.

In fact, some people may be thinking to themselves, as they hunker down with their work laptops, Netflix queues, and lack of social commitments, that pandemics arent so bad. Those people likely dont have serious health conditions or jobs that require them to leave home. They probably also dont have small children. For parents with kids at home, you suddenly have a very different act to juggle than you had before, Vida Maralani, the Cornell sociologist, said. Many parents who are able to work from home, especially mothers, are stretched as they try to do their jobs while looking after their children all day. Meanwhile, many parents who are struggling to make ends meet have those same child-care responsibilities on top of the stress of continuing to work outside of the house, out of necessity.

Read: The coronavirus is a disaster for feminism

Kids themselves will experience the pains of the pandemic unevenly, as keeping children out of school for several weeks or months may widen existing educational disparities. Many students from lower-income households simply arent logging on for their schools online classes to begin with, sometimes because they dont have a good internet connection at home. Maralani speculates that children whose parents have more time and resources may receive more and better home instruction than their peers, which may produce short-term or possibly even long-term learning gaps. Those are likely the same children who, even in the absence of their schools usual art or music programs, are still attending their violin lessons or karate classes over videochat.

The stress of managing a home can increase when older relatives are present. According to the latest data from the Pew Research Center, 20 percent of Americans live in households with two or more adult generations or with grandparents and grandchildren; Asian, Hispanic, and black Americans are more likely to live in multigenerational households than white ones.

This household arrangement is especially fraught in a pandemic, when every present body is another potential distributor, or recipient, of the virus. In February, a research team led by the World Health Organization estimated that transmission between people living in the same household was responsible for 78 to 85 percent of some 350 clusters of infections in two provinces in China. This is concerning for larger households around the world, and additionally so when they include older relatives, who tend to be at higher risk.

American families, whether big or small, are riding out this pandemic with varying degrees of comfort. As my colleague Megan Garber recently noted, the unpleasantness of staying indoors is related to how much room you have, how many rooms you have, whether you have a dishwasher or a washing machine or internet, whether you have an area in which to exercise or be alone or be together or cook or get fresh air. The distinguishing features of a living space, Garber argued, take on magnified importance when its occupants are there more or less around the clock.

Read: It pays to be rich during a pandemic

The physical spaces where people are enduring lockdown capture the full range of American inequality. Some affluent urbanites, finding their primary residences dissatisfactory, have retreated to their vacation homes; at least one billionaire has been sheltering in place in the Caribbean on his yacht. Meanwhile, some people without a place to live recently gathered in a makeshift shelter in a parking lot in Las Vegas without walls or a roof; across the country, groups that provide support to people without a home are scaling back or shutting down their operations, for fear of spreading the disease. I do worry about them, Andrew Noymer said of homeless people, noting that the virus could spread quickly among those who live in close proximity to one another. Prisons and jails, too, seem to be tragically conducive to the spread of disease.

Beyond the four walls (or no walls) of any particular living space, some neighborhoods will probably be more vulnerable to the virus than others. Communities of color, areas that are highly segregated in terms of race or income, are going to be the places where we would see, in all likelihood, clusters of illness, Scott Frank, the Case Western professor, said. In neighborhoods like these, people may have larger households and smaller living spaces, and may not be able to afford to stay home, putting themselves at risk each day while continuing to work.

Franks grim prediction, made when I spoke with him in mid-March, is already coming true. According to recent data from health officials in New York City, several neighborhoods with the lowest median household incomes were among those with the highest number of confirmed cases of COVID-19. This is terrible for the residents of those neighborhoods, but it may also be bad for everyone: One study in Delhi, India, found that outbreaks of influenza in the poorest parts of the city propelled the spread of the disease more widely.

Moreover, the long-standing, intractable problems in many lower-income areas, whether urban or rural, wont be put on hold during a pandemic. A lot of communities are already dealing with things like being over-policed, police violence, excess pollution exposure, and unemployment, Hedwig Lee, the sociologist, said. There are other [things] that have been impacting communities in a large-scale, wholesale waysome currently and some for many generationsand that makes this even scarier in terms of what it will look like once we get through this storm.

Read: America is acting like a failed state

Among these large-scale problems is the unevenness of internet access in some areas. As of 2017, something like 30 percent of American households didnt have a broadband internet connection, and millions of people only connect to the internet through their phones, frequently with meager data plans. With this particular pandemic, the guidelines are changing so quickly that immediate access to good information is absolutely required and absolutely at risk with access issues and not being online permanently, Mark Cameron, a medical professor at Case Western, said.

The fates of different places are not predetermined, thoughcity- or statewide public-health orders matter a lot. One telling example comes from autumn 1918, when American cities responded to the flu pandemic with many of the same social-distancing measures that are now in place across the U.S. Infamously, Philadelphia hosted a patriotic wartime parade with some 200,000 attendees (more than a tenth of the citys population) a week and a half after confirming its first case of influenza, and didnt close down schools or forbid public gatherings until another five days after the event. St. Louis, meanwhile, canceled most public gatherings and had flu patients isolate themselves just two days after detecting its first case. During the four-month stretch of the pandemic at the end of the year, Philadelphians were, by one studys accounting, roughly twice as likely as St. Louisans to die from it. A separate 2007 study looking at 43 cities pandemic-fighting strategies 100 years ago found that early, sustained, and layered application of measures such as social distancing and public-event bans was associated with reducing the impact of the outbreak.

As Ronald Brownstein has written in The Atlantic, many state governments responses to the present crisis have differed along political lines, with liberal leaders generally taking swifter action than conservative ones. At least partly as a result of local leaders directives, there was a pronounced difference in how many Americans in different states stayed home in the month of March. And that may go on to play a role in the toll the pandemic takes in different areas.

The many divides in American society that will shape peoples experience of the pandemic dont exist in isolation. Instead, they compound and overlap, increasing the risk that certain people will endure the more devastating of the two pandemics.

Some of that interplay may be a matter of bad luck. Perhaps youre more vulnerable to COVID-19 because you have asthma, and your partner happens to work at a hospital and might bring the virus back home. But some of these patterns are not a product of chance. People with less money are likelier to have chronic health conditions, and also to live near one another, making residents of many lower-income neighborhoods doubly vulnerable. In this way, American inequality produces clusters of disadvantage, not unlike a disease.

The coronavirus will be indiscriminate, harming some Americans unpredictably, regardless of race or class or any other category. But at the same time, much of the harm it bringsfar too muchwill be predictable.

We are not yet at the halfway point of our drama. We have barely made it to the end of the first act, when we slowly awaken to the threat coming our way and realize we must take some kind of action. That action, for now, is simply doing what we must to fight off Covid-19 and survive as a country, weakened but alive.

The halfway point comes only when the hero meets a worthy opponent not one who is weak or marginal or different, but someone or something that is truly monstrous. Covid-19, however terrible, is only a movie villain. Our real enemy does not come from the outside, but from within. Our real enemy is not the virus but our response to the virus a response that has been degraded and deformed by the structural inequalities of our society.

America has a history of settler colonization and capitalism that ruthlessly exploited natural resources and people, typically the poor, the migratory, the black and the brown. That history manifests today in our impulse to hoard, knowing that we live in an economy of self-reliance and scarcity; in our dependence on the cheap labor of women and racial minorities; and in our lack of sufficient systems of health care, welfare, universal basic income and education to take care of the neediest among us.

What this crisis has revealed is that, while almost all of us can become vulnerable even corporations and the wealthy our government prioritizes the protection of the least vulnerable.

If this was a classic Hollywood narrative, the exceptionally American superhero, reluctant and wavering in the first act, would make the right choice at this turning point. The evil Covid-19 would be conquered, and order would be restored to a society that would look just as it did before the villain emerged.

But if our society looks the same after the defeat of Covid-19, it will be a Pyrrhic victory. We can expect a sequel, and not just one sequel, but many, until we reach the finale: climate catastrophe. If our fumbling of the coronavirus is a preview of how the United States will handle that disaster, then we are doomed.

But amid the bumbling, there are signs of hope and courage: laborers striking over their exploitation; people donating masks, money and time; medical workers and patients expressing outrage over our gutted health care system; a Navy captain sacrificing his career to protect his sailors; even strangers saying hello to other strangers on the street, which in my city, Los Angeles, constitutes a nearly radical act of solidarity.

Albert Chambers, who will turn 100 in July, is due to arrive back home on Friday after recovering from the virus at Tickhill Road Hospital in Doncaster, northern England.

Chambers was admitted to the hospital three weeks ago after injuring his wrist in a fall. While there, he began to show symptoms of Covid-19 and tested positive for the virus.

But, despite the fears of his family, he recovered, and nurses at the hospital saw him off with a guard of honor -- a moment that was captured on video and shared on social media by the NHS Northeast and Yorkshire health trust.

"Thank you very much, I appreciate every bit you've done for me. It couldn't have been better," Chambers, who has lived alone since his wife's death almost two decades ago, tells one of the nurses in the video.

After the war, he protected London's royal palaces as a soldier in the Coldstream Guards.

"It's nice to have some positive news in the midst of what is a difficult time for everybody," Gater told CNN.

"When we heard the news we feared the worst but he's pulled through and it's amazing -- the staff there are incredible and we owe them a huge amount of gratitude. We were clapping very ferociously last night at 8 o'clock along with everyone else.

"It's testament to the care he was getting and his positive attitude and his fortitude."

One thing Chambers will have missed, Gater said, was his "guilty secret" -- a daily trifle bought from the supermarket Marks & Spencer.

"I'm just driving up and I've literally just stopped at a service station and bought him a load -- so hopefully that'll put a smile on his face," he said.

SUGARCREEK, Ohio On April 1, John Miller, a manufacturer here with deep connections to the close-knit Amish community of Central Ohio, got a call from Cleveland Clinic. The hospital system was struggling to find protective face masks for its 55,000 employees, plus visitors. Could his team sew 12,000 masks in two days?

He appealed to Abe Troyer with Keim, a local lumber mill and home goods business and a leader in the Amish community: Abe, make a sewing frolic. A frolic, Mr. Miller explained, is a colloquial term here that means, Get a bunch of people. Throw a bunch of people at this.

A day later, Mr. Troyer had signed up 60 Amish home seamstresses, and the Cleveland Clinic sewing frolic was on.

For centuries, the Amish community has been famously isolated from the hustle of the outside world. Homes still lack telephones or computers. Travel is by horse and buggy. Home-sewn clothing remains the norm. And even now, as the coronavirus rages in the country at large, there is resistance from people sustained by communal life to the dictates of social distancing that have brought the economy to a halt in Amish country as everywhere else.

But as the virus creeps ever closer, the Amish community is joining the fight.

If there is a need, people just show up, said Mr. Troyer, a man in his 40s with a gray-streaked beard and a mild German accent.

The Amish are not immune from the coronaviruss rampage. As of Thursday, Holmes County, where the nations largest Amish community resides, had only three confirmed coronavirus cases, but the pandemic has idled hundreds of Amish seamstresses, craftsmen and artisans, and Amish people do not apply for federal unemployment benefits.

It conflicts with our faith and our commitment to the government, said Atlee Raber, who founded Berlin Gardens, an area garden furniture maker that now makes protective face shields.

Almost overnight, a group of local industry, community and church leaders has mobilized to sustain Amish households by pivoting to work crafting thousands of face masks and shields, surgical gowns and protective garments from medical-grade materials. When those run scarce, they switch to using gaily printed quilting fabric and waterproof Tyvek house wrap.

We consider this a privilege that we can come in here and do something for somebody else whos in need and do it right at home here, and do it safely, Mr. Raber said, instead of taking handouts.

Mr. Miller, who is president of both Superb Industries, a manufacturer in Sugarcreek with medical, automotive and commercial clients, and Stitches USA, a commercial sewing operation, calls March 16 Black Monday. Thats when social distancing guidelines laid waste to Holmes Countys economy. Its also the day he convened a conference call with Developing Excellence, an area business group, to discuss the damage. Member businesses employ about 6,000 people, the majority of them Amish. Three days later, Mr. Miller created Operation Stop Covid-19.

I thought if we could pool resources and leverage the much needed technical skill of sewing that is literally lying latent in this community, we could do a lot, Mr. Miller said.

With area businesses, he set up a website and enlisted emergency workers from Sugarcreek Fire & Rescue to model prototypes of N95 mask covers, fluid-resistant gowns sewn of tarp material from Zincks Fabric Outlet in Sugarcreek, and boot covers made of Tyvek from Keim, in nearby Charm, Ohio.

Keims Amish millworkers built hardwood dividers for field hospitals in New York, the meticulous workmanship belying their temporary purpose. Berlin Gardens, which normally makes garden furniture from recycled plastic milk jugs, completed their first order of 20,000 plastic face shields for Yale New Haven Hospital last month.

Were close to 100,000 a day, Sam Yoder, the current owner of Berlin Gardens, said last Friday. It almost covers our payroll. Not quite.

While they work, the Amish employees are largely observing social distancing guidelines, but face masks are less popular.

The Cleveland Clinic order in particular holds special significance. The medical systems Union Hospital is just 11 miles from Sugarcreek.

Cleveland Clinic has been here for us, Mr. Miller said. They saved my moms life many times.

When the request from Cleveland came on April 1, Keim pledged its help, including with order and delivery logistics. The next morning, Mike Spence, who leads Superbs marketing operation, met Sarah Stamp, the general manager for innovations at Cleveland Clinic, on the side of Interstate 77, halfway between Cleveland and Sugarcreek. He brought a prototype mask with him.

They said roll, Mr. Miller recalled, and the sewing frolic began.

Abe Troyer went home that night carrying three heavy spools of wire. After dinner, he gave the wire, scissors and a yardstick to four of his five daughters Suetta, Mabel, Joanne, and Linda and told them to cut seven-inch lengths for the masks nose clips. Then Mr. Troyer, Keims sales director, used his work cell a flip phone whose ringtone plays Amazing Grace to relay to others in the community that the hospital in Cleveland needed thousands of masks immediately.

By evenings end, Mr. Troyers daughters had slid the three wire spools onto a broomstick wedged between two ladderback chairs and cut 20,000 nose clips.

Mr. Miller arrived around 9 p.m. at the Troyers home with more supplies. Entering their tidy kitchen with its beadboard wainscoting and a painting of a solitary tree on one wall, Mr. Miller was perplexed. Abe had told me hes got six people in his home that can sew. And I said, Have you sewn any?

Rosie Troyer, Mr. Troyers wife, told Mr. Miller, Were not going to sew any, because my husband still works. Were giving these to people who dont have a job. Mr. Troyer, who does not drive, jumped into Mr. Millers car. The pandemic had financially wounded Amish families to such an extent that, within one two-mile stretch, they dropped off mask-making kits at eight homes.

Each kit contains materials for 500 masks and a warning that says The Surgeon General of the United States has said that you have to wear a mask when youre making these, Mr. Miller said. So the first thing you do is sew one to wear.

Simrit Sandhu, the chief supply chain officer for the Cleveland Clinic, said the traditional channels for health care supplies had dried up amid the pandemic.

The need to find local solutions has become more important than ever before, she said. This was timing and relationships coming together as our need went up exponentially.

With raw materials difficult to secure, Amish seamstresses came up with a more efficient mask design. Mr. Miller met a clinic manager at the nearby Akron-Canton Airport, laying samples of the new mask on the hood of her Mazda for approval.

Cleveland Clinic has since increased its order to 10,000 masks a day, Ms. Sandhu said, and has also ordered protective gowns.

Amish leaders are aware that the coronavirus poses a threat to their deeply communal way of life. How to change those traditions is another matter.

More people are becoming aware of it, seeing a risk, but maybe not as fast as the outside world, said Leroy Yoder, an Amish bishop. People think that compared to other people, its nothing to worry about. But if we have to add names to the numbers, then its going to become real, but then its going to be too late.

On March 16, Ohio public health officials advised against gatherings of 10 people or more, and four days later, Ohios Amish steering committee advised all church districts to pay heed. The committee recommended stopping church services and urged Amish Ohioans to cancel or postpone weddings, youth and family gatherings until further notice.

But last Friday, black horse-drawn buggies clustered around a building in Holmes County. Inside, about 100 people gathered for a post-funeral meal. A church elder emerged and explained that he was spacing mourners four to an eight-foot table, and normally, 400 or 500 people would attend an Amish funeral.

The Budget, a local weekly newspaper, has devoted more than 50 pages to dispatches from Amish communities across the country struggling to reconcile social distancing with a way of life that survives through communal work and worship, with services held in homes and barns.

Coronavirus flu is probably the main talk worldwide. Lets remember to pray for the leaders of the world, read a missive from Mount Hope, Ohio, after describing a church service attended by more than a dozen families and some young folks.

The Cleveland project is a constant reminder of the disease, but the Amish still grapple with its implications. David Kline, an author and Amish bishop who still lives on the farm in Holmes County where he was born, recalled one of his children telling him that someone invited a youth group of 200 to assemble the face masks and then someone else remembered the guidelines.

I think its a time to pause and do some inventory on ourselves, he said. Sometimes its good to find out that we arent in control of everything.

From her sunny sewing room outside Charm, Gladys Beachy will coordinate nine women, including her widowed mother, who will sew 500 masks each. She cant help thinking that holding a quilting would make the repetitive job more interesting for all of them.

Various upcoming events Easter services, spring church communion service, her neighbors wedding are all canceled or delayed. Even my familys cutting back, she said. Were 16 right now and we cant all get together at once. So thatll be different well, for the next couple of weeks, hopefully.

Anyone who gets sick cannot work on the project. Jim Smucker, president of Keim, said the company has tucked warnings about Covid-19 into the paycheck envelopes of his 500 employees, including a New York Times story about a funeral that spread the disease in Albany, Ga.

Were a very individualistic society and the Amish have a lot to teach us about community, said Mr. Smucker, who was raised in a Mennonite household. Amid a pandemic, I think the shift has got to go from I, to we.

Philip Martin Rosoff, an emeritus professor at Duke University School of Medicine who headed the hospital ethics committee there, said that hospitals had become more corporate over the decades and that their executives consequently had the same impulses as other executives to control the narrative. However, he said, hospital officials have other reasons to be wary of doctors and nurses who take matters into their own hands, such as patient safety. He cited the refusal of some surgeons to treat H.I.V.-positive patients at the height of the AIDS epidemic.

Perhaps nowhere is the friction between health workers and management more palpable than in the New York area.

A doctor at Lincoln Medical and Mental Health Center in the Bronx, Deena Elkafrawi, was reprimanded after the British publication Metro quoted her as saying, I am scared that going to work could kill me, according to the Committee of Interns and Residents, a national association that represented her. Lincoln did not respond to a request for comment for this article.

Other health systems, including Northwell Health, NewYork-Presbyterian Hospital and Montefiore Medical Center, have barred workers from speaking to reporters, though not always with the explicit threat of termination.

Do not respond or speak to any reporters, as well as current or former employees, regarding a pending news story, wrote David A. Feinberg, the chief marketing and communications officer at the Mount Sinai Health System, in an email to all faculty and students on March 26. Mount Sinai has more than 40,000 employees.

There has been internal dissent as well. Tasha Smith, a Mount Sinai nurse, said she had been fired after complaining to her boss that she was uncomfortable treating coronavirus patients without proper equipment, and said she had brought a doctors note attesting to her anxiety. Mount Sinai said in a statement that Ms. Smith had been fired because without any notice, she walked off the job. It also said it always provided its medical staff with the equipment needed to safely do their job.

Ms. Smith, who had worked at the hospital for three years, said the abrupt firing frightened fellow nurses. Theyre afraid to speak up, she said. I was made an example of.

With its small population and isolated location, Iceland has earned praise and headlines for its plan to test as many people as possible for exposure to the new coronavirus. Why, some wondered, couldnt other countries be like Iceland?

But critics inside the country have called this rosy picture misleading.

They say the tiny Nordic island country of 360,000 people has not done enough to suppress new cases of Covid-19, the disease caused by the virus. Primary schools and day-care centers remain open, as do some restaurants with limited seating. Tourists are still allowed to arrive and travel without quarantine. The authorities at first limited gatherings to 100 people, then changed that to 20, long after other countries were imposing greater social isolation.

Icelands goal of testing everyone faces the same logistical hurdles that all countries face, the critics point out. It does not have enough medical personnel, supplies or hours in the day to test hundreds of thousands of people in a few weeks or months. They have warned of false optimism that will ultimately lead to more infections and death.

But Kjartan Hreinn Njalsson, the assistant to Icelands director of health, touted what he called a landmark moment on Wednesday: More people are now getting better than getting infected. In fact, he said, government officials believe cases may have peaked. We are not over the hill, but close to it.

Mr. Njalsson also said the country is well stocked with testing swabs and other necessary materials. We know that we will eventually need more viral swabs, he added, and that every country in the world is trying to secure stocks.

But so far Iceland has been steadily testing people with and without symptoms, with the help of deCODE genetics, a company that has long operated in the country and is a subsidiary of Amgen. The country has one of the highest proportion of tests performed by any country for the coronavirus, according to government officials. They have tracked the origins of different infections, traced contacts and even looked at the viruss different strains.

As of Wednesday, at least 30,000 samples had been tested, according to officials, and the country had at least 1,600 confirmed Covid-19 cases. Iceland confirmed its first case on Feb. 28. Six people have died.

To get tested at a hospital or clinic, individuals must meet certain criteria, such as having symptoms like a fever or being a member of a high-risk group. Health care workers, people who have traveled from high-risk areas, and those in quarantine are also able to get tested at a hospital or clinic.

Nearly everyone else can sign up to be tested by deCODE.

Dr. Kari Stefansson, the chief executive of deCODE, said the testing and sequencing that his company had provided indicates that, with a cohesive screening approach, you can slow the spread of the virus, you can make it manageable for society. The company has called for testing asymptomatic people as a way of finding undetected cases and stopping the spread of the disease.

Dagur B. Eggertsson, the mayor of Reykjavik, credited the countrys large-scale testing and daily briefings about the results with getting average citizens engaged with preparations. We cant use force, the mayor said. We have to use arguments and voice of reason to get people to work together.

But a few dissenters have said extreme restrictions were exactly what Iceland needed to stop the outbreak entirely. They warned, for example, that keeping schools open could contribute to the virus spreading.

Its true that many people got tested, said Frosti Sigurjonsson, a former member of Parliament who has been critical of the government response. Its more than in most countries, lets say that, but it is certainly not true that everybody can get tested. Its not feasible.

Mr. Sigurjonsson and another veteran parliamentarian had written an open letter calling on the government to be more aggressive. For example, he had suggested that Iceland close to tourism and isolate infected people from their families in the empty hotel rooms. If you can save a life, save it, he said. Dont think about the cost.

But on Wednesday he said he had been made hopeful by the latest statistics. The growth has certainly slowed and new cases are now becoming fewer every day, he said. So yes. It could have reached its peak. He suggested that the government had taken his criticism to heart.

But another critic of the government strategy, Chris McClure, an entrepreneur and trained social-behavioral epidemiologist who has worked on epidemic efforts in Connecticut and Florida in the past, said he believed the government should still take tougher steps, such as closing primary schools and day-care centers. He noted that children can be asymptomatic carriers, adding that Iceland now has confirmed cases in children.

He did acknowledge that new cases have reached a plateau. But this does not mean it will decrease, he said.

The evidence has shown that closing schools in other countries worked, Mr. McClure wrote in a Medium post. And while Iceland is testing about 1,000 people a day, he said, testing everyone would still take at least the rest of the year.

Iceland started off out of the gate doing quite well, he said during a phone interview, but as you see occurring everywhere in the world, there is an absolute scarcity of everything. Tests, respirators, everything.

Thorolfur Gudnason, the chief epidemiologist in Iceland, said the country was using both mitigation and suppression efforts. We are using extreme measures with rapid detection, he said, noting that the majority of new cases found have come from people already in quarantine. The stricter ban on gatherings took effect on March 24, and it was extended to include swimming pools, gyms, pubs and museums, which were closed. People have also been instructed to stay six feet apart.

He said primary schools and day care centers could remain open with limited class sizes and social distancing by teachers because studies have shown infection in children is rare. But in fact the most recent research shows children do get Covid-19 and some have died, according to preliminary report by the U.S. Centers for Disease Control and Prevention. Their symptoms tend to be milder but that means they could be spreading the virus to others in their families and communities.

Iceland has not prohibited tourists or placed them into quarantine, Dr. Gudnason said, because we think theyre not mixing that much with the population. They stay with their own groups and leave after a few days, he said.

You would cause a lot of problems to the functions in society, and I dont know if people would accept that for months and month, he said. Its going to be interesting to see whats happening in countries using extreme measures.

Did New Yorkers Who Fled to Second Homes Bring the Coronavirus?  The New York Times