I asked eight chatbots if I had Covid-19. The answers varied widely – STAT

Can blood from coronavirus survivors help other people fight the illness?

Doctors in New York will soon be testing the idea in hospitalized patients who are seriously ill.

Blood from people who have recovered can be a rich source of antibodies, proteins made by the immune system to attack the virus. The part of the blood that contains antibodies, so-called convalescent plasma, has been used for decades to treat infectious diseases, including Ebola and influenza.

Its kind of difficult scientifically to know how valuable it is in any disease until you try, said Dr. David L. Reich, president and chief operating officer of the Mount Sinai Hospital, which will be using the treatment. Its not exactly a shot in the dark, but its not tried and true.

Dr. Reich said it would be tried as a treatment for hospitalized patients who had a moderate form of the disease and had trouble breathing, but not for those who are in advanced stages of the disease.

The idea is to get to the right patients at the right time, he said. But its experimental.

Researchers at Mount Sinai were among the first in the United States to develop a test that can detect antibodies in recovering patients, an essential part of this treatment strategy.

On Tuesday, the Food and Drug Administration gave permission for the plasma to be used experimentally on an emergency basis to treat coronavirus patients, and hospitals in New York quickly began asking to participate, said Dr. Bruce Sachais, chief medical officer of the New York Blood Center, which will collect, test and distribute the plasma.

Our main focus is, how do we implement this quickly to help the hospitals get product to their patients, Dr. Sachais said. We have blood centers in New England, Delaware and the Midwest, so we can do the same thing in other regions. Were working with other blood centers and hospitals that may collect their own blood and want to do this. We may not be able to collect enough plasma in New York to help the entire country, so we want to share with other centers to help them.

Dr. Reich said that an email asking Mount Sinai staff members who had recovered to consider donating plasma went a little viral, and quickly drew 2,000 responses.

But volunteers will have to be carefully screened to meet strict criteria. The donors will include people who tested positive for the virus when they were ill, recovered, have had no symptoms for 14 days, now test negative and have high levels, also called titers, of antibodies that fight the virus. Dr. Reich said that because there were delays and shortages in testing, the number of people who qualify may be low at first.

Our expectation, based on reports from the Chinese experience, is that most people who get better have high-titer antibodies, Dr. Sachais said. Most patients who recover will have good antibodies in a month.

People who qualify will then be sent to blood centers to donate plasma. The procedure, called apheresis, is similar to giving blood, except that the blood drawn from the patient is run through a machine to extract the plasma, and the red and white cells are then returned to the donor. Needles go into both arms: Blood flows out of one arm, passes through the machine and goes back into the other arm. The process usually takes 60 to 90 minutes, and can yield enough plasma to treat three patients, Dr. Sachais said.

People who have recovered have antibodies to spare, and removing some will not endanger the donors or diminish their own resistance to the virus, Dr. Sachais said. We may get rid of 20 percent of their antibodies, and a couple days later theyll be back.

The plasma will be tested to make sure it is not carrying infections like hepatitis or H.I.V., or certain proteins that could set off immune reactions in the recipient. If it passes the tests, it can then be frozen, or used right away. Each patient to be treated will receive one unit, about a cup, which will be dripped in like a blood transfusion. As with blood transfusions, plasma donors and recipients must have matching types, but the rules are not the same as those for transfusions.

We think this is going to be an effective treatment for at least some patients, but we dont really know yet, Dr. Sachais said. Hopefully, well get some data in the next few weeks from the first patients, to see if were on the right track.

In other coronavirus epidemics I dont think we have strong evidence, he said. We dont have controlled data. There were reports from SARS and MERS that patients improved.

He said the decision to try this approach was based in part on reports from China that it seemed to help patients. But the reports are not based on controlled studies or definitive data.

Dr. Sachais said an article in a journal that was not peer-reviewed described treating 10 patients in China with one unit each of convalescent plasma, and said it appeared safe and seemed to quickly lower their virus levels.

Its anecdotal, he said.

A researcher not associated with the new treatment plans said there was evidence to support using plasma from survivors.

Four to six or eight weeks after infection, their blood should be full of antibodies that will neutralize the virus and that will theoretically limit the infection, said Vineet Menachery, a virologist at the University of Texas Medical Branch.

In studies in mice, he said, If you can drive the virus replication down tenfold to hundredfold, that can be the difference between life and death.

He described the use of convalescent plasma as a classic approach that is a really effective way to treat if there are enough donors with enough of the right antibodies.

A potential risk, he said, is that the patients immune system could react against something in the plasma, and cause additional illness.

Although hospitals will gather information about the patients being treated, the procedure is not being done as part of a clinical trial. There will not be a placebo group or the other measures needed to determine whether a treatment works.

People are so desperately ill now, it isnt the right time, Dr. Reich said. Theyre in the hospital, theyre sick, in intensive care, on ventilators. Some get sick so quickly, and its such a severe illness in some people, we feel its not the right moment.

He said the doctors were relying on science and evidence as much as possible.

But he added: You see this steamroller coming at you, and you dont want to sit there passively and let it roll over you. So you put together everything you have to try to fight it. This has the potential to help and also the potential to harm, but we just wont know until its later in the process of the disease and people have had an opportunity to try different things.

Survivors seem eager to help.

Were getting a lot of requests, Dr. Sachais said. One center sent a survey to patients who are getting better, and there were hundreds of responses saying they were interested in being donors. This is going to bring people together. People whove survived will want to do something for their fellow New Yorkers.

In the third week of February, as the COVID-19 epidemic was still flaring in China, I arrived in Kolkata, India. I woke up to a sweltering morningthe black kites outside my hotel room were circling upward, lifted by the warming currents of airand I went to visit a shrine to the goddess Shitala. Her name means the cool one; as the myth has it, she arose from the cold ashes of a sacrificial fire. The heat that she is supposed to diffuse is not just the fury of summer that hits the city in mid-June but also the inner heat of inflammation. She is meant to protect children from smallpox, heal the pain of those who contract it, and dampen the fury of a pox epidemic.

The shrine was a small structure within a temple a few blocks from Kolkata Medical College. Inside, there was a figurine of the goddess, sitting on a donkey and carrying her jar of cooling liquidthe way she has been depicted for a millennium. The temple was two hundred and fifty years old, the attendant informed me. That would date it to around the time when accounts first appeared of a mysterious sect of Brahmans wandering up and down the Gangetic plain to popularize the practice of tika, an early effort at inoculation. This involved taking matter from a smallpox patients pustulea snake pit of live virusand applying it to the pricked skin of an uninfected person, then covering the spot with a linen rag.

The Indian practitioners of tika had likely learned it from Arabic physicians, who had learned it from the Chinese. As early as 1100, medical healers in China had realized that those who survived smallpox did not catch the illness again (survivors of the disease were enlisted to take care of new victims), and inferred that the exposure of the body to an illness protected it from future instances of that illness. Chinese doctors would grind smallpox scabs into a powder and insufflate it into a childs nostril with a long silver pipe.

Vaccination with live virus was a tightrope walk: if the amount of viral inoculum in the powder was too great, the child would succumb to a full-fledged version of the diseasea disaster that occurred perhaps one in a hundred times. If all went well, the child would have a mild experience of the disease, and be immunized for life. By the seventeen-hundreds, the practice had spread throughout the Arab world. In the seventeen-sixties, women in Sudan practiced tishteree el jidderee (buying the pox): one mother haggling with another over how many of a sick childs ripe pustules she would buy for her own son or daughter. It was an exquisitely measured art: the most astute traditional healers recognized the lesions that were likely to yield just enough viral material, but not too much. The European name for the disease, variola, comes from the Latin for spotted or pimpled. The process of immunizing against the pox was called variolation.

Lady Mary Wortley Montagu, the wife of the British Ambassador to Constantinople, had herself been stricken by the disease, in 1715, leaving her perfect skin pitted with scars. Later, in the Turkish countryside, she witnessed the practice of variolation, and wrote to her friends in wonder, describing the work of one specialist: The old woman comes with a nut-shell full of the matter of the best sort of small-pox, and asks what vein you please to have opened, whereupon she puts into the vein as much matter as can lie upon the head of her needle. Patients retired to bed for a couple of days with a fever, and, Lady Montagu noted, emerged remarkably unscathed. They have very rarely above twenty or thirty in their faces, which never mark; and in eight days time they are as well as before their illness. She reported that thousands safely underwent the operation every year, and that the disease had largely been contained in the region. You may believe I am well satisfied of the safety of this experiment, she added, since I intend to try it on my dear little son. Her son never got the pox.

In the centuries since Lady Montagu marvelled at the efficacy of inoculation, weve made unimaginable discoveries in the biology and epidemiology of infectious disease, and yet the COVID-19 pandemic poses no shortage of puzzles. Why did it spread like wildfire in Italy, thousands of miles from its initial epicenter, in Wuhan, while India appears so far to have largely been spared? What animal species transmitted the original infection to humans?

But three questions deserve particular attention, because their answers could change the way we isolate, treat, and manage patients. First, what can we learn about the dose-response curve for the initial infectionthat is, can we quantify the increase in the risk of infection as people are exposed to higher doses of the virus? Second, is there a relationship between that initial dose of virus and the severity of the diseasethat is, does more exposure result in graver illness? And, third, are there quantitative measures of how the virus behaves in infected patients (e.g., the peak of your bodys viral load, the patterns of its rise and fall) that predict the severity of their illness and how infectious they are to others? So far, in the early phases of the COVID-19 pandemic, we have been measuring the spread of the virus across people. As the pace of the pandemic escalates, we also need to start measuring the virus within people.

Most epidemiologists, given the paucity of data, have been forced to model the spread of the new coronavirus as if it were a binary phenomenon: individuals are either exposed or unexposed, infected or uninfected, symptomatic patients or asymptomatic carriers. Recently, the Washington Post published a particularly striking online simulation, in which people in a city were depicted as dots moving freely in spaceuninfected ones in gray, infected ones in red (then shifting to pink, as immunity was acquired). Each time a red dot touched a gray dot, the infection was transmitted. With no intervention, the whole field of dots steadily turned from gray to red. Social distancing and isolation kept the dots from knocking into one another, and slowed the spread of red across the screen.

This was a birds-eye view of a virus radiating through a population, seen as an on-off phenomenon. The doctor and medical researcher in meas a graduate student, I was trained in viral immunologywanted to know what was going on within the dots. How much virus was in that red dot? How fast was it replicating in this dot? How was the exposurethe touch timerelated to the chance of transmission? How long did a red dot remain redthat is, how did an individuals infectiousness change over time? And what was the severity of disease in each case?

What weve learned about other virusesincluding the ones that cause AIDS, SARS, and smallpoxsuggests a more complex view of the disease, its rate of progression, and strategies for containment. In the nineteen-nineties, as researchers learned to measure how much H.I.V. was in a patients blood, a distinct pattern emerged. After an infection, the virus count in the blood would rise to a zenith, known as peak viremia, and patients with the highest peak viremia typically became sicker sooner; they were least able to resist the virus. Even more predictive than the peak viral load was the so-called set pointthe level at which someones virus count settled after its initial peak. It represented a dynamic equilibrium that was reached between the virus and its human host. People with a high set point tended to progress more rapidly to AIDS; people with a low set point frequently proved to be slow progressors. The viral loada continuum, not a binary valuehelped predict the nature, course, and transmissibility of the disease. To be sure, every virus has its own personality, and H.I.V. has traits that make viral load especially revealing: it causes a chronic infection, and one that specifically targets cells of the immune system. Yet similar patterns have been observed with other viruses.

PARIS One of the worlds best health care systems is facing its severest test ever, and whether it succeeds will say much about the ultimate adequacy of a well-funded, well-equipped and broadly accessible national treatment plan.

If Frances experiment in confining its citizens less rigorous than the Chinese, more precocious than the Italian, far more organized than the American yields the hoped-for flattening of the curve, it would be vindication not just for the underlying system, but for a Western democracys organized effort to combat the coronavirus. The verdict is still weeks away.

President Emmanuel Macron has told the French, over and over, that the country is at war. On the surface, it is going into battle well prepared.

France spends more on health than most of its developed-world peers, offers world-beating access to doctors at less cost, and encourages all its citizens, through universal government-funded coverage, to keep track of their conditions. It has twice the number of intensive care beds that Italy has.

Mr. Macron has not been shy about touting the virtues of that system, especially in comparison with the United States.

What this pandemic is showing, right now, is that free health care, without regard to income, career, or profession, our welfare state, these are not costs or burdens, but precious assets when fate strikes, Mr. Macron said in a televised address to the country two weeks ago.

What the pandemic shows is that there are goods and services which must be protected from the laws of the market, he added.

But with coronavirus cases doubling every four days, even Frances relatively luxurious system is creaking and straining. A week into Frances total lockdown little stirs on the echoing streets of Paris and the normally traffic-bound Place de la Concorde is now an empty windswept plaza there are no signs of a letup in the intensity of the epidemic.

For France, this is a crash test of our system, said Franois Bricaire, an infectious disease specialist at the National Academy of Medicine. It is small comfort to the French that the coronavirus numbers in their country are well below those in Italy and Spain, for the moment. By Thursday, 1,696 had died in the hospitals in Italy, deaths were at 6,077 more than 3,000 were in critical condition, and there were more than 29,000 known infections.

Our centralized system is perhaps better adapted than the Italian to an epidemic, Mr. Bricaire said, adding, The decisions made in Paris are immediately circulated around the country.

But the authorities may be significantly underestimating the number of dead in France.

The hospital deaths represent only a small portion of the mortality, the French national health director Jrme Salomon told journalists Tuesday night. In particular, more and more deaths in nursing homes, not counted so far in the official tallies, are coming to light, particularly in eastern France 16 in Haute-Marne, seven in Haute-Savoie, 20 in Vosges.

Another 16 died in a Paris nursing home, according to French news reports.

The epidemic was worsening rapidly, Mr. Salomon said Tuesday night, calling it intense and severe.

Overstretched hospitals in Alsace, the hardest-hit region by far, have had to send out patients by military planes to less affected regions, and even in a medicalized train. A conference of 2,000 evangelical Christians at Mulhouse in February, where an unknown but significant number of those there were infected, has had the effect of a coronavirus bomb, first on Alsace, and then on all of France, as the participants spread throughout the country.

Were at the limit of our capacities, Jean Sibilia, dean of the medical faculty at Strasbourg University, said. As long as were doubling cases every four days, you can just imagine the load, he said.

Hospitals in Alsace are so full the French Army has had to scramble to set up a field hospital.

What were living through here is completely exceptional, said Jean-Franois Cerfon, an emergency room doctor in the eastern town of Colmar. A massive influx of patients, over a short period, and theyre in for the long haul. Lets just hope that by July were out of this nightmare.

Now, amid the same bitter debates taking place in other countries opposition politicians are asking whether officials were prepared, why stocks of masks were not higher, and whether Mr. Macron moved fast enough the government is holding its breath about whether the robust French system can hold. The debates have been muted though, because public anxiety has so far outweighed the countrys strong attachment to individual liberties.

There are no guarantees. No system can hold indefinitely, said Philippe Juvin, head of the emergency room at Hpital Europen Georges-Pompidou in Paris. Theres always a moment when the wave is too big, he said.

Its going to be a test of organization, and a human test, he added, noting that the wave of patients arriving at hospitals in critical condition was growing. Will we have the capacity to hold up?

Weeks of protests by hospital personnel, before the crisis, over too-long hours and overstretched personnel underscored the health systems low morale.

Others are trying to put on a brave face. The teams are holding up well, said Martin Hirsch, the director of Paris hospitals. They have extraordinary capabilities.

Yet the capital is hovering near its critical-care bed limit of 1,200, and Mr. Hirsch told French news media on Wednesday that he could only see three days ahead.

Mr. Hirsch, a veteran health official, also has acknowledged the giant unknown. How can you talk about facing up to something that we have never even known before? he said in a telephone interview.

For weeks, France thought it could escape Italys fate even as it kept a wary eye on its neighbor. The initial measures were limited closing schools in the rural Paris exurbs and in the northwestern region of Brittany, where some cases had been noted, and banning gatherings of more than 1,000.

On March 6, with nine dead already, Mr. Macron went to the theater, partly to show the French that normal life could continue. But five days later, he closed the schools, and two days after that, bars, restaurants and nonessential businesses.

Still, he allowed the first round of Pariss mayoral election to go ahead on March 15. On that sunny Sunday, thousands of French crowded the citys parks and cafes.

Mr. Macron ordered them to remain in their homes the next day.

With this action, France put itself in a more favorable position than Italy. The confinement order began when just 148 were dead. The Italian government, by contrast, waited until the death toll was over 800 before ordering a national lockdown.

Sick patients who could have been saved were not, because the Italian health system was saturated, said William Dab, a former French national health director. He added, In France, we are still able to save patients who are in intensive care.

There has been resistance to the confinement in the immigrant suburbs, where restless residents are crammed into inhospitable tower blocks. Police officers have already handed out tens of thousands of fines.

The authorities say they have no choice but to continue. The stakes are too high.

The measures that have been adopted, they are our last chance to overcome this crisis democratically, Mr. Dab said. To show we can overcome this without authoritarianism, without dictatorship, that a democracy can overcome a crisis like this.

For me, he added, thats what this is all about.

Constant Mheut and Eva Mbengue contributed reporting from Paris.

Dr. Deborah Birx, who coordinates the White House Coronavirus Task Force, criticized a test "where 50% or 47% are false positives" at a briefing on March 17. Kevin Dietsch/UPI/Bloomberg via Getty Images hide caption

Dr. Deborah Birx, who coordinates the White House Coronavirus Task Force, criticized a test "where 50% or 47% are false positives" at a briefing on March 17.

When asked why the United States didn't import coronavirus tests when the Centers for Disease Control and Prevention ran into difficulty developing its own, government officials have frequently questioned the quality of the foreign-made alternatives.

But NPR has learned that the key study they point to was retracted just days after it was published online in early March.

Top officials in the Trump administration have alluded to this study, including Dr. Deborah Birx, who coordinates the White House coronavirus task force. "It doesn't help to put out a test where 50% or 47% are false positives," she said at a White House briefing on March 17, explaining why health officials didn't accept tests from other countries.

Food and Drug Commissioner Stephen Hahn cited the figure as well during an interview on Morning Edition on Friday.

"It's really important to understand, getting an accurate and reliable test on the market's important," he told host David Greene. "Our team can provide you with an abstract that was recently published in the literature about a test that was performed in another country that demonstrated a 47% false positive rate. Now, think about that, David. What that means is that if you had a positive test, it was pretty close to a flip of a coin as to whether it was real or not."

We followed up and got the abstract, which is a summary of the scientific paper.

The abstract is in English, though the paper itself is in Chinese, and describes a test developed in China. That provenance in itself is notable, because the factoid about flawed tests has come up in response to questions about why the administration didn't ask to import tests the World Health Organization distributes, when it became evident the CDC was struggling to scale up its own test.

The WHO has relied heavily on a test produced in Germany not China.

The figure 47% does indeed appear in the abstract of the Chinese paper, but it doesn't refer to the overall quality of this viral test. Instead, it refers to one particular slice of the population: people who have no symptoms of COVID-19 but have had close contact with those who had been diagnosed with the disease.

The abstract concludes that close contacts are often labeled as being infected when they apparently are not. The abstract makes no mention of the overall performance of the test.

When we tried to retrieve the actual paper from the Chinese journal, we got a dead link. A graduate student at Stanford University School of Medicine who is fluent in Chinese volunteered to help us track down the paper.

In a phone call with the journal Chinese Journal of Epidemiology, sponsored by the Chinese Medical Association, she learned that the paper had been accepted after peer-review and published online on March 5, but it was retracted within a few days. A representative from the journal told the graduate student there was a problem with the paper but did not know the details.

However, during the brief period the paper was available from the Chinese journal, it was indexed by the U.S. National Library of Medicine's PubMed service, which posted the English-language abstract. It is not marked retracted, though the link to the underlying paper leads to an error message.

The senior author of the study, Prof. Guihua Zhuang, who is the dean of the school of public health at Xi'an Jiaotong University, informed the graduate student via email that there was some issue with the paper and confirmed it had been retracted. The professor did not explain the problem, but said it was a sensitive matter.

Without access to the paper, nobody can assess the value of the work or determine whether it suffers from a scientific flaw. It's also unknown if the paper was retracted for political reasons. That's a possibility, though it was retracted well before U.S. officials started citing it in public in a way that disparaged the Chinese coronavirus test.

Whatever the case, the expectation in science is that conclusions in papers that have been retracted should not be relied upon.

"Scientists shouldn't be depending on the results of as scientific paper when the authors are saying through the retraction that they do not have confidence in the results," says Dr. Steven Goodman, professor of epidemiology and population health at Stanford.

NPR asked FDA Commissioner Hahn for a comment. His press office pointed to the abstract that is still posted on PubMed, but did not say whether anyone at FDA had read the full paper during the few days it was considered a legitimate entry in the scientific literature.

You can reach NPR Science Correspondent Richard Harris at rharris@npr.org.

Medical professionals sanitize their facemasks prior to storing them away on March 23, 2020. They were preparing to collect specimens for coronavirus testing at the Mississippi State Fairgrounds in Jackson, Miss. Rogelio V. Solis/AP hide caption

Medical professionals sanitize their facemasks prior to storing them away on March 23, 2020. They were preparing to collect specimens for coronavirus testing at the Mississippi State Fairgrounds in Jackson, Miss.

Updated 2:46 p.m. ET

Louisiana has emerged as a hot spot for the spread of coronavirus, with nearly 2,305 cases of COVID-19 and 83 reported deaths.

"Our rate of growth is faster than any state in the country," Democratic Gov. John Bel Edwards said during a televised address this week.

He warns the crisis has overwhelmed Louisiana's ability to combat the spread of the disease, and care for the sick. And in contrast to neighboring states, Louisiana is imposing tight restrictions on movement and economic activity.

"I know this is completely the opposite of what we're used to and how we live in Louisiana," Edwards said. "It's a major adjustment, but it is necessary. Stay home; stop the spread; save lives."

His message is in sharp contrast to neighboring Mississippi.

"We're not gonna make rash decisions simply because some other states decide to do things," said Mississippi Gov. Tate Reeves, who has been in self-isolation in the governor's mansion since returning from a trip to Spain on March 13. He's been answering coronavirus questions submitted via live chats on Facebook.

"Eric Worth says 'China did a lockdown and it was good for them. Why can't Mississippi?' Well Eric I'm going to tell you that Mississippi is never going to be China," Reeves responded.

A conservative free-market Republican, Reeves says he didn't want to take actions that would do more harm than good. He closed public schools, and this week issued an executive order limiting nonessential gatherings to 10 people, suspending in-restaurant dining, and curtailing visits to nursing homes and hospitals. Other directives remain voluntary.

"You must stay home as much as you can," Reeves urged. "Do not go out if you can possibly avoid it."

That's not enough for some Mississippi cities. Oxford and Tupelo, for instance, have ordered residents to stay home, and limited nonessential business.

"We're trying to save lives," says Tupelo Mayor Jason Shelton, a Democrat.

He says there's been an unfortunate political debate around social distancing practices.

"Some people in leadership, some people in media, unfortunately, called this a hoax and encouraged people not to take it seriously," Shelton says. "That's still lingering."

Mississippi State Health Officer Thomas Dobbs acknowledges too many people are disregarding calls for social distancing.

"We have reports of people still congregating in mass around weddings, around funerals and going to church," Dobbs said. "If you're piled up outside of a retail store trying to get supplies, that's not social distancing. Please do everything you can to stay out of congregated groups."

In a region where people often work across state lines, or have family in a neighboring state, medical experts say the different messages can confound efforts to mitigate the impact of the coronavirus.

Still governors have been reluctant to order statewide lockdowns.

Florida Gov. Ron DeSantis, a Republican, has called for "surgical" approaches tailored to different regions of his diverse state.

"These blunt measures, you wouldn't want to do them on a community where the virus hasn't spread through the community," DeSantis said, citing the potential negative economic impact.

"People are gonna go out of business; people are gonna lose their jobs; there's gonna be upheavals in their lives," DeSantis said. "That is something that we should not do flippantly."

Officials in Birmingham, Ala., have issued a shelter-in place order, but Republican Gov. Kay Ivey says a statewide lockdown is not coming.

"The safety and well-being of Alabamians is paramount," Ivey said. "However, I agree with President Trump, who thinks that a healthy and vital economy is just as essential to our quality of life."

"It would be very shortsighted of us to get back to economic recovery, and people start getting sick again," says Alabama physician and former U.S. Surgeon General Regina Benjamin. "We'd be back in the same place that we are."

She says borders don't really matter with the coronavirus, and has an analogy the Gulf states should understand.

"It's like having a Category 4 hurricane that has entered into the Gulf of Mexico," Benjamin says. "We don't prepare by geography. We don't prepare by county or by city or even by state. We prepare for the whole region because we know that storm's going to hit."

She says it's not a matter of if it will make landfall, but when, and how strong.

If you think you dont have a huge role to play in how the coronavirus outbreak plays out, think again. You have the potential to make this pandemic so much worse.

Thats because the coronavirus is both more contagious and more deadly than the common flu. One person can easily transmit it to other people without knowing it, and those people would then transmit it to even more people, creating a terrifying snowball effect.

The good news is, just as you can easily transmit the virus to other people, you can easily avoid transmitting it if youre willing to stay home. Thats right: Simply by sitting on your couch, you can potentially save lives.

To see why, check out the visualization below. It shows how one person with the coronavirus, who passes on the virus to three other people (some experts say three is the average, though others estimate the infectiousness is a bit lower), can very quickly spawn a public health nightmare that afflicts thousands of people. But it also shows how one person can mitigate that effect through social distancing. By avoiding the office, the barbecue, the airport, and so on, an individual can deprive the virus of the opportunity to infect more people.

One striking real-world example of this phenomenon is the woman known as Patient 31. South Korea had only 30 cases of Covid-19 until, in February, she became infected and started inadvertently spreading the virus. Despite having a fever, she had lunch with a friend at a hotel and attended church services, coming into physical contact with many of the worshippers. In a matter of days, hundreds of people from the church and its environs tested positive for Covid-19.

You do not want to be Patient 31.

This is why even if youre young and healthy and falsely believe the virus cant kill you (it can), youd do well to stay home in order to protect others especially older and immunocompromised people who are at greater risk of dying if they contract Covid-19, as well as the health care workers who have to expose themselves to the risk every day.

Believe it or not, through the simple act of staying home, you can save many people even many thousands of people from contracting the virus.

Hugh Montgomery, director of the Institute for Human Health and Performance at University College London, broke down the math in an incredibly clear and simple video.

To figure out just how infectious a disease is, experts use the basic reproduction number, called the R0 (pronounced R naught). That refers to how many other people one sick person will infect on average in a group that doesnt already have immunity. The higher the R0, the higher the likelihood that many people will get sick.

The R0 for the common flu is 1.3. So, if you get the flu, you will, on average, pass that on to 1.3 people. Montgomery calculates that if each of those 1.3 people pass it on to another 1.3 people, and that keeps on happening 10 times, then by the 10th time, 14 people will have the flu.

(Thats because 1.3 to the power of 10 is 13.786. Hes rounding up a bit.)

The coronavirus, however, is more contagious than the common flu. Experts are still trying to figure out the R0, and in any case its not something thats precisely fixed, since diseases behave differently in different environments and some people (known as super-spreaders) are more contagious than others. But the World Health Organization says most estimates of the coronaviruss R0 are around 2 or 2.5, while some estimates put it as high as 3.11. Montgomery uses an R0 of 3 to make his calculations.

So every person passes to it three now that doesnt sound like much of a difference, but if each of those three pass it to three and that happens in 10 layers, I have been responsible for infecting 59,000 people, he says.

(Thats because 3 to the power of ten is 59,049. Hes rounding down a bit.)

Montgomerys back-of-the-envelope math simplifies reality a little; for example, he assumes that all the people in all 10 layers of transmission will be susceptible to contracting the virus, whereas some might already have immunity to it. But his basic point holds up.

And the conclusion he draws at the end is crucial: If you are irresponsible enough to think that you dont mind if you get the flu, remember its not about you its about everybody else.

Although it can be genuinely hard to act altruistically when the beneficiaries are so invisible after all, you wont be able to see the grandfather or nurse youve kept from getting sick please know that the benefits are real nonetheless.

Every day that you practice social distancing during the pandemic, youre doing someone else (maybe hundreds or even thousands of someone elses) a great kindness. So if you can, stay home. Its the easiest act of heroism youll ever do.

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On weekday evenings, sisters Lesley Laine and Lisa Ingle stage online happy hours from the Southern California home they share. It's something they've been enjoying with local and faraway friends during this period of social distancing and self-isolation. And on a recent evening, I shared a toast with them.

We laughed and had fun during our half-hour Facetime meetup. But unlike our pre-pandemic visits, we now worried out loud about a lot of things like our millennial-aged kids: their health and jobs. And what about the fragile elders, the economy? Will life ever return to "normal?"

"It feels like a free-fall," says Francis Weller, a Santa Rosa, Calif., psychotherapist. "What we once held as solid is no longer something we can rely upon."

The coronavirus pandemic sweeping the globe has not only left many anxious about life and death issues, it's also left people struggling with a host of less obvious, existential losses as they heed stay-home warnings and wonder how bad all of this is going to get.

To weather these uncertain times, it's important to acknowledge and grieve lost routines, social connections, family structures and our sense of security and then create new ways to move forward says interfaith chaplain and trauma counselor, Terri Daniel.

"We need to recognize that mixed in with all the feelings we're having of anger, disappointment, perhaps rage, blame and powerlessness is grief," says Daniel, who works with the dying and bereaved.

Left unrecognized and unattended, grief can negatively impact "every aspect of our being physically, cognitively, emotionally spiritually," says Sonya Lott, a Philadelphia-based psychologist specializing in grief counseling.

Yet with our national focus on the daily turn of events as the coronavirus spreads and with the chaos it's brought, these underlying or secondary losses may escape us. People who are physically well may not feel entitled to their emotional upset over the disruption of normal life. Yet, Lott argues, it's important to honor our own losses even if those losses seem small compared to others.

"We can't heal what we don't have an awareness of," says Lott.

Whether we've named them are not, these are some of the community-wide losses many of us are grieving. Consider how you feel when you think of these.

Social connections Perhaps the most impactful of the immediate losses as we hunker down at home is the separation from close friends and family. "Children aren't able to play together. There's no in-person social engagement, no hugging, no touching which is disruptive to our emotional well-being," says Daniel.

Separation from our colleagues and office-mates also creates significant loss. Says Lott: "Our work environment is like a second family. Even if we don't love all the people we work with, we still depend on each other."

Habits and habitat With the world outside our homes no longer safe to inhabit the way we once did, Daniel says we've lost our "habits and habitats," as we can no longer engage in our usual routines and rituals. And no matter how mundane they may have seemed - whether grabbing a morning coffee at the local caf, driving to work, or picking up the kids from school routines help define your sense of self in the world. Losing them, Daniel says, "shocks your system."

Assumptions and security We go to sleep assuming we'll wake up the next morning, "that the sun will be there and your friends will all be alive and you'll be healthy," Weller says. But the spread of the virus has shaken nearly every assumption we once counted on. "And so we're losing our sense of safety in the world and our assumptions about ourselves," he says.

Trust in our systems When government leaders, government agencies, medical systems, religious bodies, the stock market and corporations fail to meet public expectations, it can leave citizens feeling betrayed and emotionally unmoored. "We are all grieving this loss," Daniel says.

Sympathetic loss for others Even if you're not directly affected by a particular loss, you may be feeling the grief of others, including those of displaced workers, of health care workers on the frontlines, of people barred from visiting elderly relatives in nursing homes, of those who have already lost friends and family to the virus and to those who will.

Once you identify the losses you're feeling, look for ways to honor the grief surrounding you, grief experts urge.

Bear witness and communicate

Sharing our stories is an essential step, Daniel says.

"If you can't talk about what's happened to you and you can't share it, you can't really start working on it," Daniel says. "So, communicate with your friends and family about your experience."

It can be as simple as picking up the phone and calling a friend or family member, says Weller. He suggests simply asking for and offering a space in which to share your feelings without either of you offering advice or trying to fix anything for the other.

"Grief is not a problem to be solved," he says. "It's a presence in the psyche awaiting, witnessing."

For those with robust social networks, Daniel suggests gathering a group of friends virtually to share these losses together. Using apps, such as Zoom, Skype, Facetime or Facebook Live, virtual meetups are easy to set up on a daily or weekly basis.

Write, create, express

Whether you're an extrovert or introvert, keeping a written or recorded journal of these days offers another way to express, to identify and to acknowledge loss and grief.

And then there's art therapy, which can be especially helpful for children unable to express well with words, for teens and even for many adults.

"Make a sculpture, draw a picture or create a ceremonial object," says Daniel, who often incorporates shamanic ceremonies into grief workshops she conducts.

Another exercise she often uses in grief workshops is a simple one in which participants use their breath to blow their sadness, fear and anger into a rock that they then throw away.

"What this does is takes all that intense, painful energy out of your body and into an inanimate object that they symbolically throw far away from themselves," Daniel says.

Meditate

Regular meditation and just taking time to slow down and take several deep, calming breaths throughout the day also works to lower stress and is available to everyone, Lott says. For beginners who want guidance she suggests downloading a meditation app onto your smart phone or computer.

Be open to joy

And finally, Lott urges, make sure to let joy and gratitude into your life during these challenging times. Whether it's a virtual happy hour, tea time or dance party, reach out to others, she says.

"If we can find gratitude in the creative ways that we connect with each other and help somebody," she says, "then we can hold our grief better and move through it with less difficulty and more grace."

This story was produced in partnership with Kaiser Health News.

Russian medical experts prepare to check passengers arriving from Italy at Moscows Sheremetyevo International Airport this month.

By Richard StoneMar. 26, 2020 , 10:35 AM

For weeks, Russia seemed to have dodged a bullet. As coronavirus disease 2019 (COVID-19) raged just across the border in China, Russia was virtually untouched, reporting just seven confirmed infections as recently as 10 March. Since then, the number has risen fast: Russia has now reported 840 infections, about two-thirds of them in the Moscow region.

Some health care providers have questioned whether Russia truly kept the novel coronavirus at bay. Anastasia Vasilyeva, head of Russias Alliance of Doctors trade union, haspointed outthat pneumonia cases in Moscow spiked in Januarythey were 37% higher than in January 2019, according to Rosstat, Russias statistics agency. She asserts that COVID-19 must have accounted for at least part of the increase. Others attribute the increase to a greater number of pneumonia patients, anxious about the new coronavirus, seeking treatment.

With COVID-19 cases nowindisputably on the risein Russia, authorities are moving fast to ramp up detection and hospital bed capacity. Russias federal coronavirus coordination council says 193,000 testsbased on the polymerase chain reaction(PCR) have been done to date. Swabs initially had to be shipped to Siberia for analysis at the State Research Center of Virology and Biotechnology VECTOR. Russias Federal Service for the Oversight of Consumer Protection and Welfare (Rospotrebnadzor)the countrys analog of the U.S. Centers for Disease Control and Preventionhas just expanded testing to its regional laboratories and the Anti-Plague Research Institute.

The agency says it has created a reserve of 700,000 test kits that it will regularly replenish. And the coronavirus council announced yesterday it is allotting 1.4 billion rubles ($17.7 million) to VECTOR, the antiplague facility, and several Rospotrebnadzor labs to spur vaccine and drug development.

To cope with a rising tide of patients, Russias federal government is building a new hospital on Moscows outskirts. Authorities have called on Moscow residents over age 65 to self-isolate at homean admonishment that Russian President Vladimir Putin, 67, exempted himself from. But Putin on 24 March donned protective gear while visiting a hospital treating COVID-19 patients, and yesterday he ordered all nonessential workplaces to close from 28 March to 5 April, declaring that the safest thing is to be at home now. Today, the government suspended international travel into and out of Russiastarting tomorrowexcept for charter flights for bringing expatriates home.

As Russia contends with the mounting COVID-19 threat,Sciencecaught up with SergeyAlkhovsky, a virologist who studies emerging and zoonotic viral infections at the Russian Ministry of Healths D.I. Ivanovsky Institute of Virology. This interview has been edited for brevity and clarity.

Q: How do you explain the success of Russias containment efforts while cases in China were skyrocketing starting in late January?

A:The border with China was closed at the end of January. The border is long, but in total there are only 16 [legal] crossings. All of them were closed, and only one still worked for evacuation of Russians from China. The railway from China was stopped, and all charter flights were canceled. Only a few airlines remained in operation, arriving at one terminal in Moscow with medical supervision of all arrivals and recording of their residence and contacts. By the way, the first two cases in Russia were found on 31 January in two Chinese tourists.

Q: Yet infectious disease wards in the Moscow region are already reaching capacity.

A:Sick people who had contact with foreigners have been isolated in hospitals starting in early February. So, starting last month, hospitals were full of suspected patients, and their relatives were warned about the danger of infection. [Russiascoronavirus commission yesterday said 112,000 people are in self-isolation in their homes.]

Q: Where are all these patients coming from?

A: There is some community transmission, but the majority of patients who tested positive arrived from Europe. Unfortunately, measures to restrict air travel with Europe were introduced too late, when outbreaks had already occurred in Italy and other countries. [The first genome of the novel coronavirus sequenced from a Russian patienta woman in St. Petersburgplaced it in a clade circulating in Europe.]

Q: Initially, Russia allowed work on the novel coronavirus in biosafety level 3 (BSL-3) labs. Last week, it relaxed the regulation to allow research in BSL-2 facilities. Why the change?

A: It had become clear that the virus is not so dangerous.

Q: What do you mean?

A: The initial decision of the authorities was to allow work with the virus only at VECTOR. This decision seemed excessive, as it meant many research groups could not get the virus for development and testing of vaccines and antiviral drugs. Now we know more about the virus and these strict requirements are canceled. This will allow for PCR testing in more BSL-2laboratories and will allow scientists from other institutions to get involved in the work on the virus.

Q: In vaccine and drug R&D?

A: Russia has developed vaccines against tick-borne encephalitis, polio, smallpox, influenza, and other infections. Groups from scientific institutions at Rospotrebnadzor, the Ministry of Health, and the Federal Biomedical Agency have declared they will conduct early vaccine trials in the near future. Within several months, we expect to have two to three vaccine options. But the development of anticoronavirus drugs is still at the very initial stages.

WASHINGTON President Trump said Thursday that he planned to label different areas of the country as at a high risk, medium risk or low risk to the spread of the coronavirus, as part of new federal guidelines to help states decide whether to relax or enhance their quarantine and social distancing measures.

Our expanded testing capabilities will quickly enable us to publish criteria, developed in close coordination with the nations public health officials and scientists, to help classify counties with respect to continued risks posed by the virus, Mr. Trump said in a letter to the nations governors.

In it, the president thanked Republican and Democratic governors alike for stepping up to help America confront this unprecedented global pandemic.

But in a video teleconference with governors to discuss the response to the virus, and in a television appearance late Thursday night, Mr. Trump struck a less conciliatory tone, criticizing some of them instead for taking from the federal government.

In the call, he rebuffed a plea from Gov. Jay Inslee of Washington for a more forceful response to the outbreak, according to two officials familiar with the conversation. Later, during an interview with the Fox News host Sean Hannity, the president singled out Mr. Inslee as well as Gov. Gretchen Whitmer of Michigan for requesting federal aid at all.

We have people like Governor Inslee, he should be doing more, Mr. Trump said. He shouldnt be relying on the federal government. The president called Mr. Inslee a failed presidential candidate who was always complaining.

As for Ms. Whitmer, who has sent Mr. Trump a request for a major disaster declaration for her state, he did not refer to her by name.

We had a big problem with a woman governor you know who Im talking about from Michigan, the president said. All she does is sit there and blame the federal government, she doesnt get it done and we send her a lot. He said he did not like dealing with governors who take and then they complain and described Ms. Whitmer as a new governor who has not been pleasant.

He also reiterated his desire to start opening up some parts of the country in the near future. I think we can start by opening up certain parts of the country, the farm belt, certain parts of the Midwest, other places, he said.

Mr. Trump previewed the new set of federal guidelines in his letter as the death toll from the virus in the United States passed 1,000, and in hot spots like New York, 100 people had died because of the virus in one day. Gov. Andrew M. Cuomo of New York said on Thursday that the worst days and weeks of the crisis were still ahead.

But Mr. Trump, in his letter, said the goal of the new rules was to look toward the day when Americans could resume their normal economic, social and religious lives.

Earlier in the week, he said he wanted to reopen the country for business by Easter, on April 12, despite widespread warnings from health officials that the worst effects of the virus were still weeks away and prematurely lifting social distancing guidelines would result in unnecessary deaths.

At the time, Dr. Anthony S. Fauci, a leading health expert on the administrations coronavirus task force, said the additional testing now available gave the administration some flexibility in different areas to do so.

People might get the misinterpretation youre just going to lift everything up, Dr. Fauci said, explaining Mr. Trumps impatience to jump-start the economy and tell Americans they could resume everyday life. Thats not going to happen, Dr. Fauci said. Its going to be looking at the data in regions of the country where there was not an obvious outbreak of the virus.

As a practical matter, however, Mr. Trump does not have the power to decide whether the country can reopen. He can issue federal guidelines, but the decision of whether to return to business as usual is up to each state.

States are understood to have a general power to legislate for the health, welfare, safety and morals for the people of their state, said Andrew Kent, who teaches constitutional law at Fordham Universitys School of Law.

The administration released its first set of federal guidelines to slow the spread of the coronavirus on March 16. The 15-day plan included closing schools and telling people to avoid groups of more than 10 as well as bars, restaurants, food courts and discretionary travel.

Mr. Trump has been eager to send a message to the business community and to the markets that there is an end date to the economic standstill caused by the coronavirus and the response to it.

But public health experts warned that there needed to be a nationwide approach to fighting the spread of a virus that could easily move around the country just as it has done around the globe. And many expressed horror at the idea of pulling back on mitigation efforts too early.

Since his declaration of an Easter timeline, his aides have made clear that it was meant less as an edict and more as an ambition. Kellyanne Conway, the counselor to the president, said Thursday that the administration would follow the facts of the data in the new guidelines it issued.

Stephanie Grisham, the White House press secretary, said in an interview with Fox & Friends that the president wants to have a message of hope to the American people.

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

Three months ago, no one knew that SARS-CoV-2 existed. Now the virus has spread to almost every country, infecting at least 446,000 people whom we know about, and many more whom we do not. It has crashed economies and broken health-care systems, filled hospitals and emptied public spaces. It has separated people from their workplaces and their friends. It has disrupted modern society on a scale that most living people have never witnessed. Soon, most everyone in the United States will know someone who has been infected. Like World War II or the 9/11 attacks, this pandemic has already imprinted itself upon the nations psyche.

A global pandemic of this scale was inevitable. In recent years, hundreds of health experts have written books, white papers, and op-eds warning of the possibility. Bill Gates has been telling anyone who would listen, including the 18 million viewers of his TED Talk. In 2018, I wrote a story for The Atlantic arguing that America was not ready for the pandemic that would eventually come. In October, the Johns Hopkins Center for Health Security war-gamed what might happen if a new coronavirus swept the globe. And then one did. Hypotheticals became reality. What if? became Now what?

So, now what? In the late hours of last Wednesday, which now feels like the distant past, I was talking about the pandemic with a pregnant friend who was days away from her due date. We realized that her child might be one of the first of a new cohort who are born into a society profoundly altered by COVID-19. We decided to call them Generation C.

As well see, Gen Cs lives will be shaped by the choices made in the coming weeks, and by the losses we suffer as a result. But first, a brief reckoning. On the Global Health Security Index, a report card that grades every country on its pandemic preparedness, the United States has a score of 83.5the worlds highest. Rich, strong, developed, America is supposed to be the readiest of nations. That illusion has been shattered. Despite months of advance warning as the virus spread in other countries, when America was finally tested by COVID-19, it failed.

Anne Applebaum: The coronavirus called Americas bluff

No matter what, a virus [like SARS-CoV-2] was going to test the resilience of even the most well-equipped health systems, says Nahid Bhadelia, an infectious-diseases physician at the Boston University School of Medicine. More transmissible and fatal than seasonal influenza, the new coronavirus is also stealthier, spreading from one host to another for several days before triggering obvious symptoms. To contain such a pathogen, nations must develop a test and use it to identify infected people, isolate them, and trace those theyve had contact with. That is what South Korea, Singapore, and Hong Kong did to tremendous effect. It is what the United States did not.

As my colleagues Alexis Madrigal and Robinson Meyer have reported, the Centers for Disease Control and Prevention developed and distributed a faulty test in February. Independent labs created alternatives, but were mired in bureaucracy from the FDA. In a crucial month when the American caseload shot into the tens of thousands, only hundreds of people were tested. That a biomedical powerhouse like the U.S. should so thoroughly fail to create a very simple diagnostic test was, quite literally, unimaginable. Im not aware of any simulations that I or others have run where we [considered] a failure of testing, says Alexandra Phelan of Georgetown University, who works on legal and policy issues related to infectious diseases.

The testing fiasco was the original sin of Americas pandemic failure, the single flaw that undermined every other countermeasure. If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases. None of that happened. Instead, a health-care system that already runs close to full capacity, and that was already challenged by a severe flu season, was suddenly faced with a virus that had been left to spread, untracked, through communities around the country. Overstretched hospitals became overwhelmed. Basic protective equipment, such as masks, gowns, and gloves, began to run out. Beds will soon follow, as will the ventilators that provide oxygen to patients whose lungs are besieged by the virus.

Read: The people ignoring social distancing

With little room to surge during a crisis, Americas health-care system operates on the assumption that unaffected states can help beleaguered ones in an emergency. That ethic works for localized disasters such as hurricanes or wildfires, but not for a pandemic that is now in all 50 states. Cooperation has given way to competition; some worried hospitals have bought out large quantities of supplies, in the way that panicked consumers have bought out toilet paper.

Partly, thats because the White House is a ghost town of scientific expertise. A pandemic-preparedness office that was part of the National Security Council was dissolved in 2018. On January 28, Luciana Borio, who was part of that team, urged the government to act now to prevent an American epidemic, and specifically to work with the private sector to develop fast, easy diagnostic tests. But with the office shuttered, those warnings were published in The Wall Street Journal, rather than spoken into the presidents ear. Instead of springing into action, America sat idle.

Derek Thompson: America is acting like a failed state

Rudderless, blindsided, lethargic, and uncoordinated, America has mishandled the COVID-19 crisis to a substantially worse degree than what every health expert Ive spoken with had feared. Much worse, said Ron Klain, who coordinated the U.S. response to the West African Ebola outbreak in 2014. Beyond any expectations we had, said Lauren Sauer, who works on disaster preparedness at Johns Hopkins Medicine. As an American, Im horrified, said Seth Berkley, who heads Gavi, the Vaccine Alliance. The U.S. may end up with the worst outbreak in the industrialized world.

Having fallen behind, it will be difficultbut not impossiblefor the United States to catch up. To an extent, the near-term future is set because COVID-19 is a slow and long illness. People who were infected several days ago will only start showing symptoms now, even if they isolated themselves in the meantime. Some of those people will enter intensive-care units in early April. As of last weekend, the nation had 17,000 confirmed cases, but the actual number was probably somewhere between 60,000 and 245,000. Numbers are now starting to rise exponentially: As of Wednesday morning, the official case count was 54,000, and the actual case count is unknown. Health-care workers are already seeing worrying signs: dwindling equipment, growing numbers of patients, and doctors and nurses who are themselves becoming infected.

Italy and Spain offer grim warnings about the future. Hospitals are out of room, supplies, and staff. Unable to treat or save everyone, doctors have been forced into the unthinkable: rationing care to patients who are most likely to survive, while letting others die. The U.S. has fewer hospital beds per capita than Italy. A study released by a team at Imperial College London concluded that if the pandemic is left unchecked, those beds will all be full by late April. By the end of June, for every available critical-care bed, there will be roughly 15 COVID-19 patients in need of one. By the end of the summer, the pandemic will have directly killed 2.2 million Americans, notwithstanding those who will indirectly die as hospitals are unable to care for the usual slew of heart attacks, strokes, and car accidents. This is the worst-case scenario. To avert it, four things need to happenand quickly.

Read: All the presidents lies about the coronavirus

The first and most important is to rapidly produce masks, gloves, and other personal protective equipment. If health-care workers cant stay healthy, the rest of the response will collapse. In some places, stockpiles are already so low that doctors are reusing masks between patients, calling for donations from the public, or sewing their own homemade alternatives. These shortages are happening because medical supplies are made-to-order and depend on byzantine international supply chains that are currently straining and snapping. Hubei province in China, the epicenter of the pandemic, was also a manufacturing center of medical masks.

In the U.S., the Strategic National Stockpilea national larder of medical equipmentis already being deployed, especially to the hardest-hit states. The stockpile is not inexhaustible, but it can buy some time. Donald Trump could use that time to invoke the Defense Production Act, launching a wartime effort in which American manufacturers switch to making medical equipment. But after invoking the act last Wednesday, Trump has failed to actually use it, reportedly due to lobbying from the U.S. Chamber of Commerce and heads of major corporations.

Some manufacturers are already rising to the challenge, but their efforts are piecemeal and unevenly distributed. One day, well wake up to a story of doctors in City X who are operating with bandanas, and a closet in City Y with masks piled into it, says Ali Khan, the dean of public health at the University of Nebraska Medical Center. A massive logistics and supply-chain operation [is] now needed across the country, says Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health. That cant be managed by small and inexperienced teams scattered throughout the White House. The solution, he says, is to tag in the Defense Logistics Agencya 26,000-person group that prepares the U.S. military for overseas operations and that has assisted in past public-health crises, including the 2014 Ebola outbreak.

This agency can also coordinate the second pressing need: a massive rollout of COVID-19 tests. Those tests have been slow to arrive because of five separate shortages: of masks to protect people administering the tests; of nasopharyngeal swabs for collecting viral samples; of extraction kits for pulling the viruss genetic material out of the samples; of chemical reagents that are part of those kits; and of trained people who can give the tests. Many of these shortages are, again, due to strained supply chains. The U.S. relies on three manufacturers for extraction reagents, providing redundancy in case any of them failsbut all of them failed in the face of unprecedented global demand. Meanwhile, Lombardy, Italy, the hardest-hit place in Europe, houses one of the largest manufacturers of nasopharyngeal swabs.

Read: Why the coronavirus has been so successful

Some shortages are being addressed. The FDA is now moving quickly to approve tests developed by private labs. At least one can deliver results in less than an hour, potentially allowing doctors to know if the patient in front of them has COVID-19. The country is adding capacity on a daily basis, says Kelly Wroblewski of the Association of Public Health Laboratories.

On March 6, Trump said that anyone who wants a test can get a test. That was (and still is) untrue, and his own officials were quick to correct him. Regardless, anxious people still flooded into hospitals, seeking tests that did not exist. People wanted to be tested even if they werent symptomatic, or if they sat next to someone with a cough, says Saskia Popescu of George Mason University, who works to prepare hospitals for pandemics. Others just had colds, but doctors still had to use masks to examine them, burning through their already dwindling supplies. It really stressed the health-care system, Popescu says. Even now, as capacity expands, tests must be used carefully. The first priority, says Marc Lipsitch of Harvard, is to test health-care workers and hospitalized patients, allowing hospitals to quell any ongoing fires. Only later, once the immediate crisis is slowing, should tests be deployed in a more widespread way. This isnt just going to be: Lets get the tests out there! Inglesby says.

These measures will take time, during which the pandemic will either accelerate beyond the capacity of the health system or slow to containable levels. Its courseand the nations fatenow depends on the third need, which is social distancing. Think of it this way: There are now only two groups of Americans. Group A includes everyone involved in the medical response, whether thats treating patients, running tests, or manufacturing supplies. Group B includes everyone else, and their job is to buy Group A more time. Group B must now flatten the curve by physically isolating themselves from other people to cut off chains of transmission. Given the slow fuse of COVID-19, to forestall the future collapse of the health-care system, these seemingly drastic steps must be taken immediately, before they feel proportionate, and they must continue for several weeks.

Juliette Kayyem: The crisis could last 18 months. Be prepared.

Persuading a country to voluntarily stay at home is not easy, and without clear guidelines from the White House, mayors, governors, and business owners have been forced to take their own steps. Some states have banned large gatherings or closed schools and restaurants. At least 21 have now instituted some form of mandatory quarantine, compelling people to stay at home. And yet many citizens continue to crowd into public spaces.

In these moments, when the good of all hinges on the sacrifices of many, clear coordination mattersthe fourth urgent need. The importance of social distancing must be impressed upon a public who must also be reassured and informed. Instead, Trump has repeatedly played down the problem, telling America that we have it very well under control when we do not, and that cases were going to be down to close to zero when they were rising. In some cases, as with his claims about ubiquitous testing, his misleading gaffes have deepened the crisis. He has even touted unproven medications.

Away from the White House press room, Trump has apparently been listening to Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases. Fauci has advised every president since Ronald Reagan on new epidemics, and now sits on the COVID-19 task force that meets with Trump roughly every other day. Hes got his own style, lets leave it at that, Fauci told me, but any kind of recommendation that I have made thus far, the substance of it, he has listened to everything.

Read: Grocery stores are the coronavirus tipping point

But Trump already seems to be wavering. In recent days, he has signaled that he is prepared to backtrack on social-distancing policies in a bid to protect the economy. Pundits and business leaders have used similar rhetoric, arguing that high-risk people, such as the elderly, could be protected while lower-risk people are allowed to go back to work. Such thinking is seductive, but flawed. It overestimates our ability to assess a persons risk, and to somehow wall off the high-risk people from the rest of society. It underestimates how badly the virus can hit low-risk groups, and how thoroughly hospitals will be overwhelmed if even just younger demographics are falling sick.

A recent analysis from the University of Pennsylvania estimated that even if social-distancing measures can reduce infection rates by 95 percent, 960,000 Americans will still need intensive care. There are only about 180,000 ventilators in the U.S. and, more pertinently, only enough respiratory therapists and critical-care staff to safely look after 100,000 ventilated patients. Abandoning social distancing would be foolish. Abandoning it now, when tests and protective equipment are still scarce, would be catastrophic.

Read: Americas hospitals have never experienced anything like this

If Trump stays the course, if Americans adhere to social distancing, if testing can be rolled out, and if enough masks can be produced, there is a chance that the country can still avert the worst predictions about COVID-19, and at least temporarily bring the pandemic under control. No one knows how long that will take, but it wont be quick. It could be anywhere from four to six weeks to up to three months, Fauci said, but I dont have great confidence in that range.

Even a perfect response wont end the pandemic. As long as the virus persists somewhere, theres a chance that one infected traveler will reignite fresh sparks in countries that have already extinguished their fires. This is already happening in China, Singapore, and other Asian countries that briefly seemed to have the virus under control. Under these conditions, there are three possible endgames: one thats very unlikely, one thats very dangerous, and one thats very long.

The first is that every nation manages to simultaneously bring the virus to heel, as with the original SARS in 2003. Given how widespread the coronavirus pandemic is, and how badly many countries are faring, the odds of worldwide synchronous control seem vanishingly small.

The second is that the virus does what past flu pandemics have done: It burns through the world and leaves behind enough immune survivors that it eventually struggles to find viable hosts. This herd immunity scenario would be quick, and thus tempting. But it would also come at a terrible cost: SARS-CoV-2 is more transmissible and fatal than the flu, and it would likely leave behind many millions of corpses and a trail of devastated health systems. The United Kingdom initially seemed to consider this herd-immunity strategy, before backtracking when models revealed the dire consequences. The U.S. now seems to be considering it too.

Read: What will you do if you start coughing?

The third scenario is that the world plays a protracted game of whack-a-mole with the virus, stamping out outbreaks here and there until a vaccine can be produced. This is the best option, but also the longest and most complicated.

It depends, for a start, on making a vaccine. If this were a flu pandemic, that would be easier. The world is experienced at making flu vaccines and does so every year. But there are no existing vaccines for coronavirusesuntil now, these viruses seemed to cause diseases that were mild or rareso researchers must start from scratch. The first steps have been impressively quick. Last Monday, a possible vaccine created by Moderna and the National Institutes of Health went into early clinical testing. That marks a 63-day gap between scientists sequencing the viruss genes for the first time and doctors injecting a vaccine candidate into a persons arm. Its overwhelmingly the world record, Fauci said.

But its also the fastest step among many subsequent slow ones. The initial trial will simply tell researchers if the vaccine seems safe, and if it can actually mobilize the immune system. Researchers will then need to check that it actually prevents infection from SARS-CoV-2. Theyll need to do animal tests and large-scale trials to ensure that the vaccine doesnt cause severe side effects. Theyll need to work out what dose is required, how many shots people need, if the vaccine works in elderly people, and if it requires other chemicals to boost its effectiveness.

Even if it works, they dont have an easy way to manufacture it at a massive scale, said Seth Berkley of Gavi. Thats because Moderna is using a new approach to vaccination. Existing vaccines work by providing the body with inactivated or fragmented viruses, allowing the immune system to prep its defenses ahead of time. By contrast, Modernas vaccine comprises a sliver of SARS-CoV-2s genetic materialits RNA. The idea is that the body can use this sliver to build its own viral fragments, which would then form the basis of the immune systems preparations. This approach works in animals, but is unproven in humans. By contrast, French scientists are trying to modify the existing measles vaccine using fragments of the new coronavirus. The advantage of that is that if we needed hundreds of doses tomorrow, a lot of plants in the world know how to do it, Berkley said. No matter which strategy is faster, Berkley and others estimate that it will take 12 to 18 months to develop a proven vaccine, and then longer still to make it, ship it, and inject it into peoples arms.

Read: COVID-19 vaccines are coming, but theyre not what you think

Its likely, then, that the new coronavirus will be a lingering part of American life for at least a year, if not much longer. If the current round of social-distancing measures works, the pandemic may ebb enough for things to return to a semblance of normalcy. Offices could fill and bars could bustle. Schools could reopen and friends could reunite. But as the status quo returns, so too will the virus. This doesnt mean that society must be on continuous lockdown until 2022. But we need to be prepared to do multiple periods of social distancing, says Stephen Kissler of Harvard.

Much about the coming years, including the frequency, duration, and timing of social upheavals, depends on two properties of the virus, both of which are currently unknown. First: seasonality. Coronaviruses tend to be winter infections that wane or disappear in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect. Much of the world is waiting anxiously to see whatif anythingthe summer does to transmission in the Northern Hemisphere, says Maia Majumder of Harvard Medical School and Boston Childrens Hospital.

Second: duration of immunity. When people are infected by the milder human coronaviruses that cause cold-like symptoms, they remain immune for less than a year. By contrast, the few who were infected by the original SARS virus, which was far more severe, stayed immune for much longer. Assuming that SARS-CoV-2 lies somewhere in the middle, people who recover from their encounters might be protected for a couple of years. To confirm that, scientists will need to develop accurate serological tests, which look for the antibodies that confer immunity. Theyll also need to confirm that such antibodies actually stop people from catching or spreading the virus. If so, immune citizens can return to work, care for the vulnerable, and anchor the economy during bouts of social distancing.

Scientists can use the periods between those bouts to develop antiviral drugsalthough such drugs are rarely panaceas, and come with possible side effects and the risk of resistance. Hospitals can stockpile the necessary supplies. Testing kits can be widely distributed to catch the viruss return as quickly as possible. Theres no reason that the U.S. should let SARS-CoV-2 catch it unawares again, and thus no reason that social-distancing measures need to be deployed as broadly and heavy-handedly as they now must be. As Aaron E. Carroll and Ashish Jha recently wrote, We can keep schools and businesses open as much as possible, closing them quickly when suppression fails, then opening them back up again once the infected are identified and isolated. Instead of playing defense, we could play more offense.

Whether through accumulating herd immunity or the long-awaited arrival of a vaccine, the virus will find spreading explosively more and more difficult. Its unlikely to disappear entirely. The vaccine may need to be updated as the virus changes, and people may need to get revaccinated on a regular basis, as they currently do for the flu. Models suggest that the virus might simmer around the world, triggering epidemics every few years or so. But my hope and expectation is that the severity would decline, and there would be less societal upheaval, Kissler says. In this future, COVID-19 may become like the flu is todaya recurring scourge of winter. Perhaps it will eventually become so mundane that even though a vaccine exists, large swaths of Gen C wont bother getting it, forgetting how dramatically their world was molded by its absence.

The cost of reaching that point, with as few deaths as possible, will be enormous. As my colleague Annie Lowrey wrote, the economy is experiencing a shock more sudden and severe than anyone alive has ever experienced. About one in five people in the United States have lost working hours or jobs. Hotels are empty. Airlines are grounding flights. Restaurants and other small businesses are closing. Inequalities will widen: People with low incomes will be hardest-hit by social-distancing measures, and most likely to have the chronic health conditions that increase their risk of severe infections. Diseases have destabilized cities and societies many times over, but it hasnt happened in this country in a very long time, or to quite the extent that were seeing now, says Elena Conis, a historian of medicine at UC Berkeley. Were far more urban and metropolitan. We have more people traveling great distances and living far from family and work.

After infections begin ebbing, a secondary pandemic of mental-health problems will follow. At a moment of profound dread and uncertainty, people are being cut off from soothing human contact. Hugs, handshakes, and other social rituals are now tinged with danger. People with anxiety or obsessive-compulsive disorder are struggling. Elderly people, who are already excluded from much of public life, are being asked to distance themselves even further, deepening their loneliness. Asian people are suffering racist insults, fueled by a president who insists on labeling the new coronavirus the Chinese virus. Incidents of domestic violence and child abuse are likely to spike as people are forced to stay in unsafe homes. Children, whose bodies are mostly spared by the virus, may endure mental trauma that stays with them into adulthood.

Read: The kids arent all right

After the pandemic, people who recover from COVID-19 might be shunned and stigmatized, as were survivors of Ebola, SARS, and HIV. Health-care workers will take time to heal: One to two years after SARS hit Toronto, people who dealt with the outbreak were still less productive and more likely to be experiencing burnout and post-traumatic stress. People who went through long bouts of quarantine will carry the scars of their experience. My colleagues in Wuhan note that some people there now refuse to leave their homes and have developed agoraphobia, says Steven Taylor of the University of British Columbia, who wrote The Psychology of Pandemics.

But there is also the potential for a much better world after we get through this trauma, says Richard Danzig of the Center for a New American Security. Already, communities are finding new ways of coming together, even as they must stay apart. Attitudes to health may also change for the better. The rise of HIV and AIDS completely changed sexual behavior among young people who were coming into sexual maturity at the height of the epidemic, Conis says. The use of condoms became normalized. Testing for STDs became mainstream. Similarly, washing your hands for 20 seconds, a habit that has historically been hard to enshrine even in hospitals, may be one of those behaviors that we become so accustomed to in the course of this outbreak that we dont think about them, Conis adds.

Pandemics can also catalyze social change. People, businesses, and institutions have been remarkably quick to adopt or call for practices that they might once have dragged their heels on, including working from home, conference-calling to accommodate people with disabilities, proper sick leave, and flexible child-care arrangements. This is the first time in my lifetime that Ive heard someone say, Oh, if youre sick, stay home, says Adia Benton, an anthropologist at Northwestern University. Perhaps the nation will learn that preparedness isnt just about masks, vaccines, and tests, but also about fair labor policies and a stable and equal health-care system. Perhaps it will appreciate that health-care workers and public-health specialists compose Americas social immune system, and that this system has been suppressed.

Aspects of Americas identity may need rethinking after COVID-19. Many of the countrys values have seemed to work against it during the pandemic. Its individualism, exceptionalism, and tendency to equate doing whatever you want with an act of resistance meant that when it came time to save lives and stay indoors, some people flocked to bars and clubs. Having internalized years of anti-terrorism messaging following 9/11, Americans resolved to not live in fear. But SARS-CoV-2 has no interest in their terror, only their cells.

Years of isolationist rhetoric had consequences too. Citizens who saw China as a distant, different place, where bats are edible and authoritarianism is acceptable, failed to consider that they would be next or that they wouldnt be ready. (Chinas response to this crisis had its own problems, but thats for another time.) People believed the rhetoric that containment would work, says Wendy Parmet, who studies law and public health at Northeastern University. We keep them out, and well be okay. When you have a body politic that buys into these ideas of isolationism and ethnonationalism, youre especially vulnerable when a pandemic hits.

Graeme Wood: The Chinese virus is a test. Dont fail it.

Veterans of past epidemics have long warned that American society is trapped in a cycle of panic and neglect. After every crisisanthrax, SARS, flu, Ebolaattention is paid and investments are made. But after short periods of peacetime, memories fade and budgets dwindle. This trend transcends red and blue administrations. When a new normal sets in, the abnormal once again becomes unimaginable. But there is reason to think that COVID-19 might be a disaster that leads to more radical and lasting change.

The other major epidemics of recent decades either barely affected the U.S. (SARS, MERS, Ebola), were milder than expected (H1N1 flu in 2009), or were mostly limited to specific groups of people (Zika, HIV). The COVID-19 pandemic, by contrast, is affecting everyone directly, changing the nature of their everyday life. That distinguishes it not only from other diseases, but also from the other systemic challenges of our time. When an administration prevaricates on climate change, the effects wont be felt for years, and even then will be hard to parse. Its different when a president says that everyone can get a test, and one day later, everyone cannot. Pandemics are democratizing experiences. People whose privilege and power would normally shield them from a crisis are facing quarantines, testing positive, and losing loved ones. Senators are falling sick. The consequences of defunding public-health agencies, losing expertise, and stretching hospitals are no longer manifesting as angry opinion pieces, but as faltering lungs.

After 9/11, the world focused on counterterrorism. After COVID-19, attention may shift to public health. Expect to see a spike in funding for virology and vaccinology, a surge in students applying to public-health programs, and more domestic production of medical supplies. Expect pandemics to top the agenda at the United Nations General Assembly. Anthony Fauci is now a household name. Regular people who think easily about what a policewoman or firefighter does finally get what an epidemiologist does, says Monica Schoch-Spana, a medical anthropologist at the Johns Hopkins Center for Health Security.

Such changes, in themselves, might protect the world from the next inevitable disease. The countries that had lived through SARS had a public consciousness about this that allowed them to leap into action, said Ron Klain, the former Ebola czar. The most commonly uttered sentence in America at the moment is, Ive never seen something like this before. That wasnt a sentence anyone in Hong Kong uttered. For the U.S., and for the world, its abundantly, viscerally clear what a pandemic can do.

The lessons that America draws from this experience are hard to predict, especially at a time when online algorithms and partisan broadcasters only serve news that aligns with their audiences preconceptions. Such dynamics will be pivotal in the coming months, says Ilan Goldenberg, a foreign-policy expert at the Center for a New American Security. The transitions after World War II or 9/11 were not about a bunch of new ideas, he says. The ideas are out there, but the debates will be more acute over the next few months because of the fluidity of the moment and willingness of the American public to accept big, massive changes.

One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trumps approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero. During the second term of his presidency, the U.S. turns further inward and pulls out of NATO and other international alliances, builds actual and figurative walls, and disinvests in other nations. As Gen C grows up, foreign plagues replace communists and terrorists as the new generational threat.

One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of America first politics. The nation pivots, as it did after World War II, from isolationism to international cooperation. Buoyed by steady investments and an influx of the brightest minds, the health-care workforce surges. Gen C kids write school essays about growing up to be epidemiologists. Public health becomes the centerpiece of foreign policy. The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.

In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.

Listen to Ed Yong discuss this story on an episode of Social Distance, The Atlantics podcast about living through a pandemic:

Subscribe to Social Distance on Apple Podcasts or Spotify (How to Listen)