In this book, Pepe says “I think it’s worth a try.” In this simple sentence lies the bridge toward new behaviors. Pepe steps out of his comfort zone by changing his diet, managing his feelings, and walking with his family. He takes one step at a time in forging a path toward improved health. From these changes come more opportunities, as Pepe plants the seed for his future self.
Whether you are a child who has some challenges with your health or are interested in learning some skills that can strengthen a feeling of wellness, Pepe Find His Way provides tools that are sure to be useful. Please be sure to enter your email on the right to become a member of Your Health Forum for access to more books, carefully researched articles and virtual and physical community events.
What a great way to use eggplant in place of dough for snacks that are healthy AND tasty!
Actually considered a fruit, the eggplant was originally from China and made its way East. It is popularly used in Middle Eastern and Greek dishes. At one point from the 14th century to the 1700’s in Italy, eggplant was not regularly eaten. A member of the nightshade family, it was believed to be a cause of fever, epilepsy and insanity. Not to mention it has a very unappealing, bitter taste that requires soaking prior to cooking.
Eggplant has a lot of fiber and is packed with vitamins and minerals like potassium, Vitamin B6, Vitamin A, magnesium and folic acid. It is a versatile food and is a great staple for a plant-based diet.
In this recipe provided by Lucia of Lalu, Inc, the eggplant slices become the small snacks in the form of pizza. If you are a fan of Eggplant Parmesan, you’ll like this preparation! This could even be the kids go-to snack. It might be fun to have the children design their own mini-pizzas with their favorite pizza toppings.
Hope you enjoy it! Don’t forget to check out the website of Lalu, Inc. for recipes and nutrition information in Spanish and English.
I had an annoying, dry cough in the beginning of February. Then the cough roared like a hungry beast. No fever. Just the cough, with shortness of breath and fatigue that escalated quickly over a two-week period. Was it COVID-19, I asked myself repeatedly? I don’t know now, and maybe I wouldn’t ever know, unless the testing starts very shortly to all people, rich or poor, healthy (for the asymptomatics amongst us) or sick, despite what Jared Kushner, as a spokesman for President Trump, says about enough tests now. I haven’t had one at the peak of coughing/shortness of breath/fatigue. Have you? Just to make sure?
But with Trump in charge, forget that option. “Coming up shortly,” or “Within the next two weeks,” or, my favorite, “Soon” is Trump-speak, when most people, after the passage of time, forget he made those promises in the first place. But I remember. You can count on that.
WIRED had an article written by Megan Molteni who says that scientists are running like crazy to comprehend why some patients also develop neurological ailments like confusion, stroke, seizure, or loss of smell. Stories of other, stranger symptoms like headaches, confusion, seizures, tingling and numbness, the loss of smell or taste have been going on for weeks.
“The medicines we use to treat any infection have very different penetrations into the central nervous system,” says S. Andrew Josephson, chair of the neurology department at the University of California, San Francisco. He is saying that most drugs can’t pass through the blood-brain barrier, a living wall around the brain. He also says if the coronavirus is penetrating the barrier and infecting neurons, that could make it more difficult to find appropriate treatments.
When the virus first started in Wuhan, China, health records indicate that 214 patients admitted to the Union Hospital of Huazhong University of Science and Technology, 36.4 percent of the patients showed signs of nervous-system-related issues, including headaches, dizziness, confusion, strokes, prolonged seizure, and a slowly disappearing sense of smell, some before the fever and cough were apparent.
“We’ve been telling people that the major complications of this new disease are pulmonary, but it appears there are a fair number of neurologic complications that patients and their physicians should be aware of,” says Josephson.
Without that information, datasets in particular, there’s no way to know how to interpret reports on patients, and “single cases are tantalizing, but they can be fraught with coincidence,” says Josephson.
COVID-19’s horrendous death toll, 61, 656 as of this writing, is other-worldly, science fiction-like worthy, and not many autopsies are being done. Only some pictures of the lungs, but a good chance that there’s some viral invasion of the brain.
A paper in the New England Journal of Medicine examining 58 patients in Strasbourg, France, found that more than half were confused or agitated, with brain imaging suggesting inflammation.
“You’ve been hearing that this is a breathing problem, but it also affects what we most care about, the brain,” says Josephson. “If you become confused, if you’re having problems thinking, those are reasons to seek medical attention,” he added.
Viruses affect the brain, explained Michel Toledano, a neurologist at Mayo Clinic in Minnesota. The brain is protected by something called the blood-brain-barrier, something that Josephson says, too, which blocks foreign substances but could be penetrated if compromised.
Since loss of smell is one of the symptoms of COVID-19, some have hypothesized the nose might be the pathway to the brain. But in the case of the novel coronavirus, doctors hold on to current evidence that the neurological impacts are more likely the result of overactive immune response rather than brain invasion.
Jennifer Frontera, who is also a professor at NYU School of Medicine, explains documenting notable cases including seizures in COVID-19 patients with no prior history of the episodes, and new patterns of small brain hemorrhages.
“We’re seeing a lot of consults of patients presenting in confusional states,” said Rohan Arora, a neurologist at the Long Island Jewish Forest Hills hospital, adding that more than 40 percent of recovered virus patients. “Returning to normal,” added Arora, “appears to be taking longer than for people who suffer heart failure or stroke.” [Apparently, Dr. Arora hasn’t worked extensively with stroke patients. After 11 years, I’m still recovering. Just sayin’.]
Anyway, good advice if you have any of those symptoms–headaches, dizziness, confusion, prolonged seizure, and a disappearing sense of smell–go to the doctor. Many doctors are seeing patients through tele-conference now. If you had a stroke as a result of COVID-19, you probably have already gone to the hospital where there are tests but not too many of them.
One more thing. How about Trump supporters try injecting or swallowing disinfectants to see if they work or this headline: Online demand for hydroxychloroquine surged 1,000% after Trump backed it, study finds. I say that statement with sarcasm, but unlike Trump, he said it confidently when he recommended Lysol, Clorox, and hydroxychloroquine, despite his walkback when people were alarmed and others broke into peals of laughter. It’s on tape, Mr. President.
It is our first month into social distancing measures. We have had a few months to see and read about how the pandemic affected some countries, challenging the health systems of Italy and China. We now witness the effect of the pandemic in New York City, while the case loads increase in other cities. Hospitals have struggled to find beds, personal protective equipment, and ventilators. Healthcare workers are being stretched to their breaking point to care for sick patients.
As of April 15, of the 644,089 cases in the United States, 28,529 people have died from COVID-19. It is a sad reality that more people will succumb to this infection.
We grapple with the paradox, that some will develop severe disease, while the majority of people will have only mild disease. A closer look at the risk factors of those most affected by COVID-19 does allay some fears. As with all infections, advanced age (>65 years, especially >75 year of age) is the greatest risk factor. Nevertheless, we are more than chronologic age. Underlying conditions often increase with age, including obesity, hypertension, diabetes, lung disease, and immunocompromising conditions are important underlying risk factors.
What explains these exceptional cases, e.g. a thirty year old female with no other health problems who dies from COVID-19 after having a severe presentation? The news media covers these cases, because they are mysterious and show that this process can be severe. We learn about the way the body interact with the virus, and we begin to realize that a person with “who was otherwise healthy” was a person who has risk factors that haven’t been determined. Recent studies have brought light to genetic susceptibility for more severe infections, such as single gene polymorphisms and HLA variance.
Unfortunately, news reports can stoke further fears. We as humans are wired to consider these exceptional cases over what is more likely, a cognitive distortion known as catastrophizing. Our minds weigh risks and predict ways we should react to this unseen, approaching threat. It is as if our brain fixates on these negative outcomes to trigger an action. A result of this is to go into “fight, flight or freeze mode,” and, since we can’t fight an invisible enemy, it often manifests as “waiting out the pandemic.” Enter some new routine like netflix binge watching, eat your cravings, nod off and repeat.” These behaviors put us as risk for becoming unhealthy.
There are some active ways that we can become more resilient through this and protect ourselves from severe disease. Although we are not able to change our age, inherited chromosomes, and there is no fountain of youth. Nevertheless, we can protect ourselves from severe infections through daily healthy decisions. The burgeoning field of epigenetics shows that diet, stress and sleep affect genetic expression and our immune systems.
What follows are some strategies to protect one from more severe COVID-19 disease during the pandemic:
Get plenty of sleep.
Keep physically active.
Keep stress levels low.
Keep a healthy weight.
Eat a nutritious diet.
Avoid or limit medications that can affect the immune system.
No smoking or use of alcohol, marijuana and other drugs.
1. Get plenty of sleep. “Sleep helps healing”
The quarantine has altered, sometimes drastically, our normal routines. As we adjust, some people working from home may compromise a healthy duration of sleep to get more work done in the evening. Others may look at the schedule change as a vacation and become more lax with their routine.
Sleep deprivation can lead to impairment of immune activation, of both innate and adaptive immunity. There are likely hormonal factors (e.g elevated cortisol) that contribute to these changes. Decreased sleep leads to impaired activation of the immune system and increased inflammation. In one study, pro-inflammatory cytokines IL-6 and TNF-alpha receptor 1 were increased after four days of sleep deprivation.
A good night’s rest improves the body’s adaptive immune response, which allows T cells to work better at going to infected sites and lymph nodes. Adequate sleep ensures that cytokines, which are cell signaling agents, function adequately to interact with T-helper cells.
Sleep disorders such as sleep apnea or primary insomnia can decrease efficiency of sleep and lead to health risks. It is important to discuss with your doctor if you have frequent sleeping problems, whether it is getting to sleep or staying asleep. Other signs can include decreased restful sleep, feeling tired early in the day, “caffeinating” possibly more than 2-3 cups reaching for alcohol or sleeping pills at night. Other signs include lower extremity swelling, frequent nighttime urination, dry mouth in the night, night sweats and morning headaches.
Action: As for the quarantine, ensure that you are sleeping a consistent duration at consistent times. Refer to the prior articles on sleep for more details (The Scoop on Sleep, Sleep Disorders Patient Education).
2. Keep physically active
Regular exercise strengthens and conditions the body and provides richly oxygenated blood to all of its cells.. Physical activity leads to a reduction of the stress reaction and enhances sleep. Rapid increases in Natural Killer (NK) cells were found after exercise secondary to norepinephrine release. Exercise essentially lowers systemic inflammation.
Regular activity requires increased effort during this time of quarantine, as devout gym-goers have lost their routine. A consequence of closing the gyms and other exercise centers during this time of social distancing could be an increase in physical deconditioning, falls, and weight gain. These could exacerbate chronic health conditions in some people. It is therefore important to attempt to maintain the intensity of your exercise regimen while at home. Kenneth Powell et. al. have published a general guide to exercise, which supports that “some activity is better than none and more is better than less.”
Action: Set aside some time each day to walk or job outside, to stretch your back and legs, and to do some mat exercises with light weights at home. There are multiple online options and apps, if your looking for some motivation.
3. Keep levels of Stress Low
Stress hormones, such as cortisol, epinephrine and norepinephrine, are released in a fight or flight perceived or real situation or with sleep deprivation. These hormones can lead to T-cell dysfunction and leukocyte adhesions molecules which allow T-cell to traffic to sites of infection. Exercise and meditation will likely reduce one’s reaction to stress and lead to decreased cortisol secretions.
Stress attenuates the immune system. In studies of medical students undergoing a short-term 3-day period of examinations (J. Glaser and R. Glaser), there were levels of decreased natural killer cells, a part of innate immunity, during the times of the exams. The researchers found less gamma interferon activity and T-cell response in test tubes. Even with chronic mild stress or depression, there may be an impact on the lymphoctye-T cell response to mitogens (things that normally activate the immune system directly).
What can we gather from this information? The immune system reacts to hormones that are produced in the stress state, inlcuding cortisol, norepinephrine and epinephrine. Immune cells possess receptors that interact with these hormones. Self-management of stress with resilience practices such as physical exercise and meditation reduces the severity of this impact and keeps the immune system functioning at its maximum.
4. Maintain a healthy weight.
Healthy Weight is a Full System Benefit. Obesity is a chronic disease.
A healthy weight allows that body to function optimally and prevent multiple insults, including infections. It allows for an effective immune system to neutralize infectious particles and reduce the severity of disease process. As one becomes more overweight, the body becomes taxed by its attempt to compensate. This impacts the way the immune system functions as well. There was an association with high Body Mass Index results (BMI>35) and increase need for being hospitalized in the ICU or even death during the swine flu outbreak in 2010.
In a recent publication (Petrilli et al.) that evaluated the risks in 4,103 patients with COVID-19 disease in New York City, a body mass index (BMI) of greater than 40 correlated with a six-fold higher risk of severe disease (OR 6.2, 95% CI, 4.2-9.3). The only other risk factors that were higher was age >= 75 (OR 66.8) and age 65-74 (OR 10.9).
Let the message be clear: obesity is a chronic disease. Obesity can lead to acute and chronic inflammation. Occasionally, as an infectious diseases doctor, I have been asked to see someone for a chronically elevated white blood cell count. One common link is that the majority of these patients were significantly obese. Increased adipose tissue leads to a build-up of inflammatory hormones (adipokines), such as leptic, IL-6, tumor necrosis factor and resistin. Macrophages are recruited into adipose tissue and continue the response and inflammation. There may be some localized oxygen delivery issues into fatty tissue as well, known as hypoxia. There are impacts in both innate and celluliar immunity. An already taxed body cannot develop a robust immune response.
We cannot talk about the parts without talking about the whole. Obesity leads to multiple systemic decompensations as the body attempts to compensate.
1) Increase adipose tissue leads to tissue hypoxia, macrophage infiltration and a pro-inflammatory state, as discussed.
2) Sleep deprivation from obstructive sleep apnea leads to cortisol hypersecretion, which is a potent immunosuppressant.
3) chronic hypoventilation of the lungs increases the risk of pneumonia.
4) aspiration of gastroesophageal reflux leads to an increased risk of pneumonia.
5) Long-term obesity can lead to liver and spleen disease, which impairs the immune system substantially.
6) Impaired glucose metabolism can lead to deficiencies in innate (antimicrobial peptides, natural killer cell activity) and acquired immunity (T-cell and B-cell immunity).
5. Eat a nutritious diet.
A healthy diet provides the ingredients through which a robust immune system is established. Every food that enters our digestive system requires the body to incorporate it through metabolic pathways. Ultimately, the metabolites of the food reach our vascular system, a network that connects to every cell in the body. Our immune system operates from this pathway
Certain foods can rev up our inflammatory response, which might disable as strong of an immune response to infection. Examples of these foods include ultra-processed high carbohydrate foods, refined flour, snack foods, French fries, fried foods, sodas, and red meats. Studies have shown increased levels of known markers of increased inflammation, including IL-6, IL-7, and TNF-alpha. A host of chronic medical conditions, including autoimmune disorders, irritable bowel syndrome, psoriasis and other dermatitis, diabetes, cardiovascular disease, degenerative joint disease, Alzheimer’s disease, and even anxiety and depression have been associated with inflammation.
A whole foods, plant-based diet is protective of inflammation and can “boost” the immune system. Vegetables are replete with vitamins and fiber that protect the body and optimize its functional state. As a general rule of thumb, mix up your diet with a rainbow of colors, vegetables, healthy grain fibers, nuts and fruits. Keep well hydrated with water. A healthy, well-balanced diet would include all of the nutrients, vitamins, and anti-oxidants to keep the immune system functioning at its best.
Vitamins and Nutrients
Although nutrient supplementation has not been studied rigorously in trials, there is support for vitamin D supplementation in infections. Vitamin D has a known role in the innate immunity including its role in inducing cathelcidins and defensins. Vitamin D is also involved in adaptive immunity and affets expression of T helper cells. During the winter in northern hemisphere countries, relative insufficiency of vitamin D results from decreased sunlight. So, it might be reasonable to take a vitamin D supplement available over-the-counter.
Zinc may be associated with inhibiting replicase (RNA-dependent RNA polymerase), an enzyme associated with viral replication of COVID-19, in an in vitro study. Studies have shown that chloroquine (and likely a related drug, hydroxychloroquine) may allow the zinc to enter into a cellular membrane (known as an ionophore). Whether this equates to some benefit as a supplement is not clear.
Vitamin C has an important role in the immune and vascular systems. A deficiency in vitamin C, a common occurrence in the age of maritime exploration, can lead to collagen defects that increased vascular fragility, delayed wound healing, bleeding, and even atherogenesis. Vitamin C has multiple effects on both the innate and adaptive immune system, including antioxidant properties, leukocyte (White blood cell) signaling (that improve wound healing), T-cell maturation and antibody generation. While vitamin C deficiency is exceedingly rare in modern times, fad diets and extremely limited diets seen in economic hardships, marginalized populations, and homelessness require its consideration. Interestingly infections could precipitate scury in already at-risk populations. Vitamin C stores are not long-lasting, so a diet replete with plenty of citrus foods will ensure that you are protected.
Action: Incorporate a palatte of plant-based foods in your diet, such as vegetables, unprocessed grains, and fruits. These foods will provide an abundance of nutrients, vitamins and fiber. Supplementation with a multivitamin may be useful, but let it not replace the source. The food will fuel your system and lead to vascular health and a robust immune system.
6. Avoid or limit medications that can affect the immune system.
We live in a pill-taking society. More than a third of patients ages 62 to 85 take at least five prescription medications. What the pharmaceutical industry is studying for a “desired effect” or drug indication is an effect that causes some degree of destabilization in an already taxed system. Although, in the short run, these drugs may mitigate risks of a chronic disease, a pathway toward optimizing one’s health has the strongest benefit.
Medications can have direct or indirect effects on the immune system. Medications such as prednisone, cellcept (mycophenolate), imuran (azathioprine) can have a direct effect on the both innate and adaptive immune system, by impairing both B-cell (think antibodies) and T-cell (think killer T-cells) function.
Newer medications, known as monoclonal antibodies are directed toward T cell receptor (CD-3) and IL-2a and are associated with some degree of immunodeficiency. There may be an increased risk of activating TB in someone who has latent TB infection as well as Staph aureus infections possibly and other fungal infections. Whether an agent (Actemra, an IL-6 inhibitor) that is effective for rheumatoid arthritis may benefit those with severe COVID-19 is the subject of one study.
With the COVID-19 pandemic, several medication concerns have been raised. Some researchers hypothesized, that since SARS-CoV-2 enters Type 2 pneumocytes using ACE2 receptors (also found in the vascular system), medications that may lead to more expression of these receptors could cause a more severe presentation of COVID-19. These medications include ibuprofen, a type of diabetic medication (thiazolidinedione class) and ACE inhibitors, a type of blood pressure medication. Although more research is necessary to clarify this risk, the conditions themselves (high blood pressure, diabetes and heart disease) treated with these medications are risk factors for SEVERE COVID-19 disease. As for now, I would not advise someone to stop a medication to treat the condition that, if not treated, could increase the risk of severe disease. As for ibuprofen, infrequent use is probably with limited risk, but I wouldn’t recommend using this medication regularly anyways.
Action: Medications are a short-term measures that cause decompensation (ie. side effects) to get a desired effect. When one has a diseased condition, there is a state of decompensation that often affects multiple systems. The pathway toward disease mitigation (and health optimization) requires a healthy lifestyle.
7. No smoking and marijuana and limit excessive alcohol intake
If you are a smoker, NOW is the best time to quit. COVID-19 is a respiratory tract virus. In an recent article, a greater association of death and severe disease in smokers was found in multiple studies out of Wuhan, China. Zhang et al., found a 2 fold risk (Odds ration 2.23) of severe disease in smokers in a total of 140 patients, 58 patients had severe disease and 82 had non-severe disease. With severe: 3.4% were current smokers and 6.9% were former smokers; With non-severe: 0% current smokers and 3.7% former smokers. Liu et al. found a high proportion of smokers with smoking history (27.3%) who had a adverse outcome compared with 3% smoking history in those with improvement.
A smoker also has a three-fold higher risk of bacterial pneumonia than a non-smoker, and a two-fold higher risk of getting influenza. Tobacco paralyzes respiratory cilia (tiny hairs) movement, limiting the body’s natural ability to clear bacteria and other particles away from the lower respiratory tract.
It appears that therecommendations for alcohol 60% or stronger alcohol-based hand sanitizers were misconstrued as a way to treat the virus directly in the throat. As the COVID-19 cases surged in Iran, 44 people died from methanol poisoning after false rumors of its benefit as a “miracle cure” in treating the disease emerged. Keep the alcohol use for the hands, not for the system. There is likely no completley safe level of alcohol, with increasing toxicity with dose.
The immune system is affected from alcohol beginning with the gut microbiome and the gut barrier. As a result of this disruption, the liver becomes inflammed with increased fat deposition, or “fatty liver.” There is an increased risk of pneumonia, by increasing the risk of aspiration, altering ciliary function (an innate protective mechanism in the lungs), and altering the function of immune cells in the respiratory tract. The bone marrow can be injured at higher levels.
Action: Every substance that you put in your body has to be metabolized by the body to protect it from harm. Known toxins like smoking, alcohol and drugs impair the immune system as it impairs all aspects of a healthy body. Abstinence from these substances will provide optimal protection from a severe COVID-19 infection.
If you already have a chronic condition, there are ways to improve the situation…
Oftentimes, multiple chronic conditions emerge in the diseased state. Whether you have hypertension or diabetes, there are often some other emerging problems. Many times, a healthy weight can provide protection from these conditions. If your weight is not optimal, even beginning toward this direction can provide great benefits.
When we think of weight loss, we have to think of all of the systems in play. In many ways, a healthy is like being in an orbit. It is generated by largely a plant-based diet, an active lifestyle with daily exercise, and a low stress state and resilient mind. Action towards improving one of these areas generally begins to extend to the other areas to lead to a balanced state.
Action: Begin by adding plant-based foods in your diet. Think of the natural source of food (rather than various stages of processing). Developing a new routine is not always easy, but it always starts with a decision to take it one day at a time, one moment at a time, and one bite at a time. The impact on your diseased state can be dramatic and liberating.
People who do not have someone to put drops in their eyes four times a day need help. Task modification helped me succeed after my recent cataract surgery. It is easy to drop and difficult to squeeze the stiff sides of a tiny 5 ml bottle. I am glad I found the Autosqueeze Eye Drop Bottle. The big wings are easy to hold and require only a gentle squeeze.
Before I lie down on my bed I gather two bottles of eye drops and a Kleenex tissue. I put a pillow on my chest (not stomach) and put my sound elbow on the pillow. This support makes my hand remain steady instead of bobbing around as I hold the bottle in the air. To stop myself from blinking I distract myself by looking through the opening formed by my thumb and index finger instead of the bottle. I try to get the drop in the inner corner of my eye.
When I put the cap back on I need to stop my hand from bobbing up and down and accidentally touching the tip of the bottle. I keep my hand still by pressing my elbow firmly against the pillow. homeafterstroke.blogspot.com
Summary: The COVID-19 Pandemic is an unprecedented event that requires a rift in the societal fabric in order to stop its spread. This forced isolation, along with the threats on financial and health security, can create pressures on those already with a history of depression and anxiety and lead to challenges in those that don’t.
Here are seven tips to nurture your mental wellness and create resilience during this uncertain time of social distancing. Not only will these strategies help you to maintain some normalcy through these times, they just might help you excel.
The COVID-19 pandemic has been responsible for widespread upheaval. Literally overnight, we have been asked to change our behaviors, stay at home other than essential trips out, and wait for this pandemic to pass. Trips, social events, religious gatherings, and restaurants have been canceled or closed. We have been asked to work from home and hold teleconferences instead of physical meetings. For many of us, these are the very ways that we define our social and support network.
Constant reporting of new case numbers and new virus-related deaths has been both emotionally distressing and overwhelming throughout the world. When paired with shelter-in-place orders and the inevitable time spent confined at home, this unprecedented global event has placed tremendous stress on some of the population’s most vulnerable. Current events are making it harder for everyone to protect and promote mental health. Absent of key resources and often unable to receive the same support and social engagement that’s typical of their daily lives, those with diagnosed and chronic mental health issues are finding themselves in an increasingly dangerous space. The good news is that even in times like these, there are still multiple ways to create the conditions for resilient mental health.
Who’s At Greatest Risk Of Experiencing Mental Health Issues During The COVID-19 Pandemic?
Right now and for the foreseeable future, everyone is at risk of experiencing deep depression, anxiety, and stress. So much of what’s going on in the world is impossible for people to control. This sense of helplessness invariably fosters feelings of hopelessness, even in many who have formerly enjoyed consistently good mental health, general mood balance, and overall high life qualities.
However, there is also a very large number of people who are especially prone to mental distress at this time. This includes people who by choice or by circumstance were already spending significant amounts of time alone and in virtual isolation such as: elderly adults with age-related mobility issues, those with agoraphobia or fear of leaving the home, and disabled individuals who largely live in confinement. Those at greater risk for mental and emotional distress at this time additionally include people who are presently battling drug or alcohol addiction, those who have dealt with substance abuse or addiction in the past, recent divorcees, widowers, those grieving close friends, and those with a history of trauma and who may also be living with post-traumatic stress disorder.
Stressors to Mental Health During Quarantine:
A recent review article from Lancet by Samantha Brooks et al. entitled The psychological impacts of quarantine and how to reduce it discussed several risk factors that provoked a greater risk of mental health issues. It is with hopes that identifying the triggers to depression and anxiety can help us to construct ways to mitigate these risks.
Longer duration quarantine (>10 days) or duration uncertain: Associated with poorer mental health, e.g. PTSD, avoidance behavior and anger.
Fears of Infection. In one review, those who were concerned tended to be parents with young children or pregnant women.
Frustration and Boredom. A change in usual behavior even routine things like shopping or social networking can create a sense of boredom and isolation.
Inadequate Supplies Concerns. This includes the ability to get regular medical care and prescriptions.
Inadequate Information. In studies, participants raised the greatest concerns when there was unclear messaging from public health authorities or a concern for lack of transparency. Some concern with adhering with quarantine protocols was a predictor of post-traumatic stress disorder in one study.
Financial Factors. Many people have been asked to modify their work routines such as working from home and, in certain cases, have even lost their jobs. Those with a lower financial safety net, such as those with high debt to income burden, are particularly at risk.
The seven simple strategies that follow can benefit anyone who’s feeling the pressure of world and economic events, and who’s struggling to maintain mental health in the face of prolonged and mandated social distancing and social isolation.
Get Outside And Get Moving
Most shelter-in-place orders that are presently being enforced are not intended to prevent people from going outside entirely. Instead, these orders have been designed to limit gatherings and activities that bring large numbers of people together. Moreover, in addition to not restricting solitary outside activities, or outside activities involving two people or fewer, many of these orders have been issued by municipal bodies that are actively encouraging people to get outside and exercise. The general understanding is that too much time spent indoors and leading a highly sedentary lifestyle is not beneficial for anyone at any time.
Pick a time each day to get outside and get moving. This can be as simple as taking a short walk around your neighborhood or going for a ride on your bike during the early morning hours or late afternoon. Although there are fewer recreational areas still open for enjoyment, there is also far less traffic on the streets. You can use this as an opportunity to better appreciate your neighborhood without the hustle and bustle of moving vehicles and busy consumers.
A short walk or bike ride will lift your spirits and give you the opportunity to re-center your thoughts. It can also make you feel more connected to the world around you. Outside exercise can even be as simple as taking your yoga mat out into the yard or onto a patio or balcony. It might be a good time to get outside to a local park and practice the calming art of Shinrin-yoku, or forest bathing. In addition to benefiting from conscious and structured movement, you’ll have the benefit of fresh air, sunlight, and a restored sense of normalcy.
Continue Interacting With Others Via Social Media And Other Online Platforms
Now is a great time to start making use of social networking platforms. If you haven’t leveraged them before, these are great spaces for reconnecting with distant family members, childhood friends that you’ve lost contact with, and loved ones that you normally communicate with in other ways. Video chat platforms such as Skype can give you the benefit of both speaking to and seeing the people who normally fill your life, and who provide you with the social stimulation and engagement that’s absolutely essential for maintaining good mental health.
Brighten Each Day With Exploration, New Learning, And Other Enriching Activities
For many, the COVID-19 pandemic has provided a very bittersweet silver-lining; massive amounts of free time. For those who are no longer working or having to physically commute long distances to their jobs, as well as those who are no longer attending in-person classes at school, this event offers countless opportunities to engage in new forms of learning and exploration. If you’ve ever wanted to make your own sourdough starter, crochet a blanket for a brand new or aging family member, teach yourself a new language, or pick up the cello, piano, or guitar, now is a great time to do it. These activities are personally enriching. More importantly, efforts to promote personal growth often give people greater hope for the future.
Engage In Art Therapy
Now is also a time to break out your adult coloring books, or, better yet, start with a tabula rasa mentality and create your own work. Art is one of the most therapeutic activities that you can engage in. It’s immersive, cathartic, and relaxing. When you’re focused on drawing or coloring in the lines, choosing complementary colors, and achieving a very specific aesthetic, you cannot simultaneously dwell on all the outside problems that are beyond your realm of control. Creating art in any form can be both meditative and restorative. This is additionally a good time for art appreciation. Take advantage of online museum tours, free or discounted art or cooking classes, and other arts-related resources. Use online videos to start practicing and exploring martial arts, or start reading and writing poetry. Keeping a journal is also a great way to begin organizing your thoughts, analyzing your own emotions, and venting about your personal discomfort among other things. If you ever dreamed of writing your memoirs, the present moment is offering the perfect opportunity.
For those of you interested in using this form of expression and participating in an ongoing exhibition of art inspired by these current times, see the art that is posted on Instagram Hashtag #Cov19_art. I would like to compile the art, poetry, photography and writing into book that documents the psyche of these times and celebrates our perseverance.
Unplug And Unwind
For all the resources, information, and assistance that the Internet is able to provide during this crisis, it can be just as harmful as it is beneficial. This is especially true when people spend too much time on the web, and when they spend too much time immersing themselves in activities and ideas that foster stress. While staying informed is vital, you must limit the amount of news that you’re reading. Nothing is currently so dire that it requires minute-by-minute updates. Set a special time for logging in and gathering essential information from trusted news sources. Then, set a special time for turning your phone off, logging off your computer, and turning off your TV. Whether you have diagnosed mental health issues or believe yourself to be in excellent mental health, too much information can lead to overload and can leave you feeling deflated, detached, depressed, or excessively anxious.
Make Sure That You’re Getting Enough Quality Sleep
Getting poor-quality or insufficient sleep at this time is a bad idea. Not only will this undermine your efforts to maintain good mental health, but it can also lead to a flagging immune system. If you had a nighttime ritual before, try to stick to it. Moreover, don’t try to mute your emotions or lull yourself to sleep with increased indulgence in alcohol. Some areas under quarantine are reporting as much as a 40 percent increase in alcohol consumption since the institution of stay-at-home orders. Rather than promoting good sleep, alcohol actually reduces overall sleep quality, and shortens the amount of time that people are able to remain asleep.
Try reading a book or meditating before going to bed, taking a warm shower, and turning off all electronics and Internet-connected devices. If necessary, sip a warm cup of chamomile tea or a large mug of warm milk and honey. Making deep and restful sleep a top-priority is one the best things that you can do to promote physical and mental health at this time.
Practice Mindfulness And Conscious Directing Of Your Thoughts
No other world event has highlighted the value and importance of mindfulness than the COVID-19 pandemic. With so much going on around you, it can be difficult to not let feelings of anxiety and panic set in. There is enough fear and stress in the present movement to exhaust anyone’s ability to mentally process current world circumstances. As such, there is no need, reason, or benefits in worrying about possible problems that might lie far ahead in the future. Practice focusing on the moment. Enjoy what you have you right now and work on fostering a mindset of gratitude. If you’re tired of being stuck alone at home, remind yourself that there are some people who have no homes to take shelter in. Give yourself permission to only worry about and deal with the problems that you’re immediately facing. Practicing mindfulness can help alleviate negative emotions about past events, while also limiting anxiety about what the future might hold.
The state of your mental health should be a key concern right now. Actively promoting good mental health and proactively protecting your general sense of well-being is critical. With greater mood balance, proper stress management techniques, and a focus on enriching and expanding yourself, you can successfully survive the mental and emotional ravages of this global pandemic, and any other unexpected life events.
I believe you all had this experience at least once in your lifetime, where you make some purchase and bring it home and the color is wrong, or the taste is horrid, or you’ve just spent money foolishly and regret your purchase, and then you have to deal with the store owner in returning it or the corporate and unseen signs on day 8 that say “No returns after 7 days.” Oryou get some unjust bill and, after calling customer service, you can’t adjust it and you pay it out of sheer desperation.
Let me tell you my story. At 14-years-old, I started to return things for my mother because she couldn’t think fast on her feet with her anxiety. She waited in the car and trusted that the return would go smoothly. When I came out of the store, I saw her quizzical look turn into a grin as I nodded my head that all had gone well. Back in the 1960s, nobody wanted to say no.
She went on sending me into the stores, plus a new thing developed. She trusted me at 16 to pretend that I was her, calling about an unjust bill. Everybody had a boss, I learned from my father, and I went right to the top, bypassing customer service. If the operator didn’t say who was in charge, I hung up and called an hour later, falsely saying that I wanted to speak to the “person in charge” because so-and-so treated me “extraordinarily well.” Then the operator had zero reluctance to connect me and, once she did, I let that CEO or Assistant or VP have it with utter animosity that the bill was wrong.
“How did you get my number?” the person in charge sometimes said.
“Heh, heh,” I said to myself.
I told that same person that I was going to report the company to the Better Business Bureau (back when the BBB meant something) and 9 out of 10 times the issue was resolved. When I threatened legal action, even though our family didn’t even have a lawyer, the 10th one came through, too.
All through college I did the same thing for my mother, and when I was married at 21, and had a job right out of college as an English teacher, I went into the quiet nurse’s office from 12 o’clock on from time to time (she was gone by noon every day), closed the door, and did the identical thing.
So I was totally prepared to accept the position at the Philadelphia Daily News as a Consumer Columnist at 31, except now I had the power of the press behind me. As I got letters from Philadelphia and environs with people having trouble with the supervisor, and sometimes the head honcho, all the cases were settled, with the businesses scrambling to adjust or eradicate the bill that was charged to my reader.
All except one, years later, because the CEO threatened to withdraw his $500,000 advertising every week from the Philadelphia Daily News and, as a result, I was fired, out of the job I loved. But even so, the same techniques worked! Using an authoritative voice like I used to do, every case was resolved.
Fast forward 30 years and I received an unjust bill, but the techniques that I developed weren’t working anymore. I had a stroke at sixty, a very significant one, that affected the right side of my body and affected my speech early on, that sometimes, particularly if I was tired, people wouldn’t understand my slurred speech. Often times, the person who answered didn’t connect me to the person in charge, much less to the CEO’s office. Or they would just hang up on me.
I stopped calling places and let my caregivers do it but, invariably (except Joyce #2 and Clare), they put a finger up for me to be still while they were saying the wrong thing. It was a mess. But as my speech improved over time, I made the calls myself. And then I got a bill that the was so unjust, I had to call again.
I fell off the chair in the Fall of 2018, which was stupid enough, and the bill was from the ambulance company for $1450 and was for a ride to the hospital, which I didn’t pay, resulting in my credit score going down over a hundred points.
After the hospital checked me out and the ER doctor said all was intact, the hospital’s ER nurse, unbeknownst to me, called for a ride back to return home. (She called, not me!) Medicare said the ambulance company didn’t cover my ride going to the hospital, but they covered my ride back. That logic was unacceptable, so I appealed.
But Medicare didn’t receive the pile of papers that I sent them (and I appealed their decision, rejecting me once again) even though I sent them certified, including the the primary doctor’s letter that I couldn’t walk, and all the correspondence that I had collected over more than a year since then. I also sent the stack to the local ambulance company in Portland, the headquarters in California, the appeals officer–again, and to the CEO of the hospital.
I spoke with the Assistant to the CEO and she kept transferring me to the Business Office.
Before she transferred me one recent time, she said, “You know, the CEO is so busy with COVID-19 and….”
I shot back and interrupted her, “This issue has been going on a year and a half, and COVID-19 wasn’t even in the picture yet,” in a clear voice that even surprised me. And her, I’d like to think!
In short, I was getting nowhere. A representative from the Business Office said that information was wrong, a year and a half later. Medicare covered the ride to the hospital, but they didn’t cover the ride back.
So my successful technique that I had years before wasn’t working now. So out of pure desperation, I decided to contact the hospital once, and at times, twice a week for two months, and the old expression, the squeaky wheel gets the oil, came into play. I pestered them, and thought soon they would cave because of my annoying calls.
(By the way, says the Quote Investigator, “The earliest appearance of this expression located by QI occurred in a collection of stories published in 1903. Cal Stewart the author constructed a colorful raconteur character that he called Uncle Josh Weathersby. The saying under investigation was contained in an epigraph that was ascribed to this character:
“I don’t believe in kickin’,
It aint apt to bring one peace;
But the wheel what squeaks the loudest
is the one what gets the grease.”
—Josh Weathersby.”)
Anyway, as result of doing that very annoying strategy for two months, the Assistant to the CEO and I spoke, tired and annoyed to get a call from me every week, and she said the hospital would pay the bill, adding, “It’s not our fault.”
Yeah, right.
In the case of the unjust bill, what do you do? Just what I did. Do it all!
1. Call to the top tier of an organization first and maybe threaten to call your lawyer even if you don’t have one.
2. Send an email after every call to tell them what occurred, even if you know they remember. If you don’t have their email address, use the same method I did, by calling back in an hour and saying you want to give good news directly to the person in charge who helped you in an extraordinarily way.
3. Call the heck to the top tier (a la squeaky wheel and oil) They want you to forget, just to pay the damn bill.
Or write to me. I’d be happy to combat those shop owners or corporate monsters. But not now. So many people are out of work. I wouldn’t want to pile on. But when the virus isn’t a problem anymore, you know where to find me–hcwriter@gmail.com.
One more thing–this method that I used since I was a teenager works, and it did in my most recent case as well to have the hospital pay the bill, and I was especially happy, sheltered in place for now in these troubling times, that it happened on my birthday!
Can I get a viral infection after handling a package from someone who was infectious or that was delivered from a country where there is a high caseload?
What are the signs of symptoms of viruses, including COVID-19?
3. How does SARS-CoV-2 cause infection in human pneumocytes
4. What are the contributing factors to more severe disease.
The United States prepares itself for the impact of COVID-19 that will likely be unprecedented. Although we can say that most people who become infected will have a milder disease, we cannot always predict who is at greater risk for a severe outcome. Particular attention goes to healthcare workers, lower-income communities, and people with advanced age and chronic health conditions. To those unfortunate ones who develop severe disease and require hospitalization, the US health system faces shortages of ventilators, personal protective equipment (PPE), bedspace and the even the healthcare workers to attend to them. Worst-case scenarios project hospitals to become flooded with those who have severe disease, particularly if cases were to occur with the same momentum as Italy or China. The hope is that through the social distancing measures recently implemented, we may be able to blunt the outbreak peak and prevent overburdening our healthcare system.
The general audience has had access to many resources on COVID-19, such as the CDC, WHO, health blogs, video posts, and primary literature. As we face this outbreak, never before has the nation’s working knowledge of viral infections been greater. Since the outbreak was declared in December, we have had three months to learn more about this virus.
This post will go one step further into understanding the contributing factors to a viral emergence and how this likely is not the last outbreak we will have in the coming years. What happens when a virus infects our bodies? What occurs inside that leads to a certain presentation of a disease state? Although COVID-19 is shrouded in mystery, it adheres to natural rules, many of which we still need to define. The mechanism by which a pathogen causes an infection is a clue to how it can be defeated.
Viruses are Host and Cell-specific, until they cross species.
Viruses are intracellular pathogens that are species- and cell-specific. This means that they are usually only capable of infecting one animal. Though there may be some fluidity to this concept. A virus can reside in an animal, whether it is actively infecting the animal or not. An animal virusis called a zoonotic virus, and the animal carrying it is a reservoir. In viral zoonotic spread, mammals (e.g. bats, primates, etc) are the most common reservoir followed by birds. When the conditions are right and several barriers are able to be breached, viruses can jump species, infecting other animals including humans. The process by which a virus jumps species and causes human infection is termed a spillover, an example of which is our current COVID-19 pandemic.
Over 75% of new or emerging diseases originate from animals. From 1940 to 2004,Jones et al. (2008) determined that there were a total of 335 emerged diseases, 60% originating from animals. In most outbreaks, human behaviors shaped the conditions that made it possible. The principal factor relates to human encroachment into animal habitats. It is no coincidence that an acceleration of outbreak has occurred in the last sixty years (fourfold increase) in the setting of a massive population boom. Eerily, a Times article describing spillovers written in May 2017 was entitled The World is Not Ready for the Next Pandemic.
“We cut the trees; we kill the animals or cage them and send them to markets. We disrupt ecosystems, and we shake viruses loose from their natural hosts. When that happens, they need a new host. Often, we are it.” David Quammen, author of Spillover: Animal Infections and the Next Pandemic writing in New York Times.
From the 1800’s, it took approximately 127 years for the population to increase by one billion, i.e. from one to two billion, an achievement that only took thirteen year intervals over the last several decades to achieve 7 billion. The population growth may be a driving force for disputes over settlements, habitat invasion, the use of exotic animals as a food source in the setting of growing food insecurity, or the trade and introduction of exotic animals to be used as products or pets. Certain features directly related to the virus, including mutations, deletions and recombination, enable the virus to survive and then flourish within an introduced animal.
Although outbreaks are infrequent events, current conditions may allow for an increased risk. For a virus to jump species from an animal reservoir to to human to human spread, usually several conditions would need to be met. First, animals infected with a virus need to be stable and have persistent shedding of virus, while not succumbing to it. Second, the animals would need to be in close proximity to humans. Next, an exchange of infected fluids, such as saliva, mucus, feces or blood, or the ingestion of an animal allows for a sufficient amount of virus to be introduced into the new animal by its usual infection route. While inside the human, some of the virus must possess a specific (enough) receptor mutation to allow for avidity (or connection) of the virus to a host receptor to gain entry into the specific cell. Finally, it must be able to propagate and infect other cells, without being identified and neutralized by the host’s innate immunity. Once it is able to survive and replicate within the human host, it must be able to be transmitted from one human to another. If any of these conditions are not sustained, a spillover does not occur.
From the “Street Light Diagram,” yellow (level 2) is intended to connote caution. Red (level 3) indicates higher risk of pandemic potential, but certain viral and non-viral kinetics (e.g. population density, behaviors) prevent easy transmission. These factors influence the basic reproductive number (Ro), with an Ro of greater than one to allow for risk of exponential growth. The black (level 4) designation is related to epidemic spread. For a detailed list of RNA viruses that are recognized as causing infections in humans and their respective levels, refer to Woolhouse M. et al (list).
Of particular concern are the 180 and counting (2 newly identified per year) RNA viruses capable of infecting humans, the majority (89%) of which are zoonotic. Examples of recent RNA viruses that have emerged include HIV, influenza virus, NIPAH virus and the Coronaviruses SARS, MERS and SARS-CoV-2. RNA viruses may more easily jump species, because of their tendency to mutate and adapt more easily when introduced. Not all RNA pathogens that cause infection in humans from animals are capable of being spread from human to humans. The majority of zoonotic RNA viruses are restricted to level 2 (approx 107 out of 180 species). An example of this would be avian influenza (H5, N2 or H9, N2), which does readily not cause human-to-human transmission. It may be related to the cell type infected, the sialic acid receptor, which is in the upper respiratory tract of poultry and lower in humans. This is fortunate because it has an estimated case fatality rate of 14-30%. Level 3 spread is seen only in about 73 species and spread is limited in 26 of these RNA viruses. The remainder (47 Level 4 RNA viruses) can spread human to human, causing epidemics..
Very rarely,a virus may already be able to adapt to a human and lead to an outbreak, termed “off-the-shelf” viruses. More likely, viruses eventually adapt from repeated animal to human transmission and evolve to be more transmissable between humans (Level 3 to Level 4). HIV probably crossed over from chimpanzees to humans in what is now the Democratic Republic of the Congo in the 1920’s, possibly from hunters who ate “bush meat” or had cuts and wounds contaminated with chimpanzee blood infected with Simian immunodeficiency virus (SIV), a milder disease which does not alter the lifespan of the infected animal. The ability of HIV to cause a prolonged infection and be transmitted via various routes including bloodborne and sexually enabled it to become a level 4 pathogen and reach global transmission.
The SARS-CoV-2 emerged likely from bats with the possiblity of a secondary animal reservoir the pangolin. Bats are known carriers of coronaviruses and have been determined to be the likely reservois for SARS and MERS. Andersen et al. published a recent correspondence entitled the proximal origin of SARS-CoV-2. The authors discusss several possible and contributing scenarios. On account of a 96% identical genome with a sampled bat coronavirus, bats were likely the original reservoir of SARS-CoV-2. However, SARS-CoV-2 may have evolved the protein stucture of the S-spike to allow for better binding to human ACE2 receptors from pangolin through natural selection. It is possible that a polybasic cleavage site (necessary for cell-cell fusion) may have evolved after being introduced into humans.
From Spillover to Infection and Disease
When COVID-19 emerged from an animal source and was capable of human to human transmission, humans had no prior memory of this virus. The immune system was caught off-guard with minimal defense. As a virus infects cells and increases its numbers in the host, the disease develops, a time when a person presents with signs and symptoms. Even in the setting of a novel virus, most of the way a disease manifests is due to the host inflammatory response and not because of a distinct genetics, appearances (e.g. receptor sites) and other characteristics of a virus.
Cell infection
A virus is an obligatory intracellular pathogen, meaning it can only thrive within cells. A specific virus infects a specific type of cell. Hepatitis C virus infects hepatocytes; BK virus infects the transitional cells of the bladder; influenza virus and coronaviruses infect type I and type II pneumocytes in the respiratory tract; HIV infects CD4 lymphocytes and Langhans cells. The specificity of cell-type is not accidental and relates to a lock-and-key mechanism that a virus has with the cell it infects. Think of it as a parasite requiring the mechanics of the host to build more copies of itself. It enters the lining of the respiratory tract and attaches onto cells by means of a receptor interaction. Specifically, this is between an outer membrane receptor of the virus (Spike glycoprotein (S)) and a receptor(s) on the host cell. The virus then enters the cell by a process known as endocytosis.
Upon entry, the virus hijacks the cell’s ability to read nucleic acids and produce proteins. COVID-19 is a positive strand RNA virus, with the viral RNA serving as a messenger RNA, leading to the production of hundreds of copies of virus RNA and proteins in a single cell (known as replication). These copies self-assemble and form multiple viruses, or progeny. This results in stress on the cell and cause changes in the cell membrane (membrane rearrangements), damages the infected cell, and go on to infect other cells.
The extent to which a virus can infect cells in known as its pathogenicity. The speed at which a virus can spread through the body and infect other cells is known as the virus lifecycle. In the case of viruses, typically thousands of copies can be generated in a period of a day and lead to significant inflammatory changes in the body as a response to infection.
ACE2 as a SARS-CoV-2 receptor
The S receptor on the SARS-CoV-2 binds to a specific receptor that lines the cells of the lung tissue, as well as heart kidney, endothelium (the inner lining of blood vessels) and the intestines, known as the Angiotensin-converting enzyme 2 (ACE2) receptor. This interaction is a required step for viral entry into the cell. Using a mouse model, an increased expression of the ACE2 receptor allowed for more viral entry into the cells and resulted in greater disease severity. Further studies will have to sort out the speculation that medications such as ACE inhibitors, Angiotensin receptor blockers (ARBs), ibuprofen, or thiazolidinediones, all of which upregulate ACE2 receptors would potentially worsen COVID-19 disease. As for now, it does not appear to be the case. In the realm of vaccine and therapy options, it remains to be seen if blocking these receptors, for instance through antibody therapies, or providing a vaccine that triggers antibodies to the S receptor would alter pathogenesis of the virus.
How does our immune system recognize these invaders?
The evolution of the immune system occurred in the face of the continuous onslaught of microbes from the environment.The human immune system consists of innate and adaptive immunity.
Innate Immune System
The innate immune system is the first branch to respond to a viral assault. The components of the innate immune system include cells, such as natural killer cells, dendritic cells, monocytes and neutrophils, and complement proteins. The innate system senses changes that occur to the cell from viral products and cell damage (Pattern Recognition Receptors). This triggers the release of interferons (IFN), which promote inflammation (activate molecules known as cytokines) and reduce virus replication. The cytokines signal special cells, known as natural killer and dendritic cells, which destroy infected host cells to reduce the spread of the viral infection. The PRRs also trigger a process known as autophagy, in which an infected cell degrades itself to reduce (or the intent to reduce) further infection.
The complement system consists of several proteins that form a complex, leading to cell breakdown (lysis). They can also signal certain cells such as activated macrophages to engulf infected cells, a process known as opsonization.
Adaptive Immune System
Adaptive immunity requires antibody production and cell-mediated mechanisms. Some natural antibodies may already be circulating for a given virus that can provide some initial immunity (known as IgM class antibodies). These are generated by antibody-producing white blood cells known as B cells. Otherwise specific cells known as Activated macrophages can engulf cells to produce antigen that express more pathogen-specific antibodies by B cells. The dominant antibody types in humans are IgM, IgD, IgG, IgA, and IgE, each of which has specific roles in the immune response. The IgG is involved in the memory responses and form to neutralize a virus.
Another white blood cell line, known as T lymphocytes (T cells), are produced in a small gland known as the thymus, which is inside the front part of the chest (behind the sternum and in between the lungs). These T cells provide cell-mediated immunity. Specific cells are produced that have receptors for a given pathogen and can neutralize them.
From Infection to Disease
When a person becomes infected with a virus or bacteria, there is a period of time at which s/he is symptomatic. The term that is used from onset of the infection and expression of the disease is known as incubation period. Various viral infections have different incubation periods. For instance, influenza’s incubation period is one to four days; COVID-19 may take one to fourteen days (average of 6) to show symptoms. During the prodromal phase, the person develops early symptoms of a viral disease. This could be the beginning of nasal congestion, sore throat, cough and tiredness. After a threshold is reached and enough cells become infected, a more sizable inflammatory response is generated. It is at this time, the person becomes symptomatic.
During the invasive phase, the number of circulating virus intensifies, while the body responds to the infection with a maelstrom of inflammatory markers. The severity of the presentation correlates to the intensity of infection and the inflammatory response. Eventually, the inflammation subsides as neutralization of the virus as a result of the immune system. It is at this point that a person’s symptoms gradually resolve.
Viral Disease: It’s all about inflammation
In approximately 80-85% of those infected with SARS-CoV-2, only a mild disease is seen. In the remaining, a severe infection can lead to hypoxia (low oxygen levels) and need for mechanical ventilation. Owing to increased cellular damage, the subsequent inflammatory response may pose a threat on life.
Risk Factors: In a study of clinical course and risk factors for mortality in COVID-19, risk factors were identified in almost half of the patients, with hypertension, diabetes and coronary heart disease. Smoking likely leads to a two-fold risk of more severe disease than a non-smoker. Advanced age is also a significant mortality risk. From the Wuhan epicenter data: 80+ years, 14.8%; 70-79 years, 8%; 60-69 years, 3.6%; 50-59 years 1.3%. This is likely on account of dysfunctional innate immunity, IL-2 signaling (not down-regulating) and T-cell mediated immune system with aging. What still remains unknown for COVID-19 infection is whether there exist genetic determinants (as seen in other viral diseases) that lead to a greater risk of a more severe infections. This could explain why we are hearing reports of severe disease in the “otherwise healthy” youth.
Pathogenecity and Inflammation Contribute to Disease Manifestations. The extent to which someone presents with more severe disease relates to an interaction of amount of cell destruction from viral burden and host response. Below is a depiction of the contributing effects of Viral Pathogenicity and Host Inflammatory Response in disease. Increased viral infection burden is likely an important contributor to a greater immune response. It may be that type 2 pneumocyte infection in the lower respiratory tract may cause a greater cytokine release than infection in upper respiratory cells.
Disease Presentation
The most common symptoms on admission were fever and cough, sometimes with sputum production and fatigue. Interestingly, the average time of presentation of respiratory complaints, such as shortness of breath, is approximately 7 days and need for invasive ventilation is 14.5 days (range 12-19 days), suggesting that the latter part of infection may be when greater inflammation develops “cytokine storm”. The most frequently observed complication was sepsis, followed by respiratory failure, ARDS, heart failure and septic shock.
**The shortness of breath (“Dyspnea” in blue) started around day 7 in both groups**
Laboratory Findings for Hospital Management
There is a significant inflammatory response in more severe infections of COVID-19. Patients may develop ARDS, which is the leading cause of mortality. Several findings of the disease support a hypercytokine, hyperinflammatory response that contribute to a more severe presentation. These patients have a persistent fever, low white blood cell count, elevated cytokines (IL-2, IL-7, IL-6, GM-CSF, Interferon gamma and others), an elevated ferritin, and an elevated D-dimer.
Future Therapy
In an unprecedented move, the FDA has granted emergency authorization for the use of hydroxychloroquine along with azithromycin based on early clinical data that there may be a benefit of hydroxychloroquine in reducing viral load and inflammatory state. We await further progress in other therapeutics and vaccine trials, many of which are now underway.
Summary
The COVID-19 outbreak was a spillover event of a novel coronavirus from an animal reservoir that led human to human transmission. Further research is required to understanding the way the infection can lead to various disease manifestations, including who may be susceptible to more severe presentations. Hydroxychloroquine along with azithromycin may provide some benefit in treating those with severe disease. As for now, we await for the results on the treatment and vaccination fronts.
I would be remiss in these uncertain times if I didn’t share this brilliant article with you from The Atlantic, written by the talented Ed Yong, a staff writer. It’s a long article but definitely worth it.
The pandemic is different from anything we–who are alive– have seen. Every time I think of one more group who will be affected, I come up with three or four more. So having abandoned that idea of writing an article “of who’s affected,” I came across Yong’s article that needed to be read by you, my dear readers.
Caution: He makes dire predictions, but somehow given our current leadership, being what it frightening is, deems it believable.
A global pandemic of this scale was inevitable. In recent years, hundreds of health experts have written books, white papers, and op-eds warning of the possibility. Bill Gates has been telling anyone who would listen, including the 18 million viewers of his TED Talk. In 2018, I wrote a story for The Atlantic arguing that America was not ready for the pandemic that would eventually come. In October, the Johns Hopkins Center for Health Security war-gamed what might happen if a new coronavirus swept the globe. And then one did. Hypotheticals became reality. “What if?” became “Now what?”
So, now what? In the late hours of last Wednesday, which now feels like the distant past, I was talking about the pandemic with a pregnant friend who was days away from her due date. We realized that her child might be one of the first of a new cohort who are born into a society profoundly altered by COVID-19. We decided to call them Generation C.
As we’ll see, Gen C’s lives will be shaped by the choices made in the coming weeks, and by the losses we suffer as a result. But first, a brief reckoning. On the Global Health Security Index, a report card that grades every country on its pandemic preparedness, the United States has a score of 83.5—the world’s highest. Rich, strong, developed, America is supposed to be the readiest of nations. That illusion has been shattered. Despite months of advance warning as the virus spread in other countries, when America was finally tested by COVID-19, it failed.
“No matter what, a virus [like SARS-CoV-2] was going to test the resilience of even the most well-equipped health systems,” says Nahid Bhadelia, an infectious-diseases physician at the Boston University School of Medicine. More transmissible and fatal than seasonal influenza, the new coronavirus is also stealthier, spreading from one host to another for several days before triggering obvious symptoms. To contain such a pathogen, nations must develop a test and use it to identify infected people, isolate them, and trace those they’ve had contact with. That is what South Korea, Singapore, and Hong Kong did to tremendous effect. It is what the United States did not.
As my colleagues Alexis Madrigal and Robinson Meyer have reported, the Centers for Disease Control and Prevention developed and distributed a faulty test in February. Independent labs created alternatives, but were mired in bureaucracy from the FDA. In a crucial month when the American caseload shot into the tens of thousands, only hundreds of people were tested. That a biomedical powerhouse like the U.S. should so thoroughly fail to create a very simple diagnostic test was, quite literally, unimaginable. “I’m not aware of any simulations that I or others have run where we [considered] a failure of testing,” says Alexandra Phelan of Georgetown University, who works on legal and policy issues related to infectious diseases.
The testing fiasco was the original sin of America’s pandemic failure, the single flaw that undermined every other countermeasure. If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases. None of that happened. Instead, a health-care system that already runs close to full capacity, and that was already challenged by a severe flu season, was suddenly faced with a virus that had been left to spread, untracked, through communities around the country. Overstretched hospitals became overwhelmed. Basic protective equipment, such as masks, gowns, and gloves, began to run out. Beds will soon follow, as will the ventilators that provide oxygen to patients whose lungs are besieged by the virus.
With little room to surge during a crisis, America’s health-care system operates on the assumption that unaffected states can help beleaguered ones in an emergency. That ethic works for localized disasters such as hurricanes or wildfires, but not for a pandemic that is now in all 50 states. Cooperation has given way to competition; some worried hospitals have bought out large quantities of supplies, in the way that panicked consumers have bought out toilet paper.
Partly, that’s because the White House is a ghost town of scientific expertise. A pandemic-preparedness office that was part of the National Security Council was dissolved in 2018. On January 28, Luciana Borio, who was part of that team, urged the government to “act now to prevent an American epidemic,” and specifically to work with the private sector to develop fast, easy diagnostic tests. But with the office shuttered, those warnings were published in The Wall Street Journal, rather than spoken into the president’s ear. Instead of springing into action, America sat idle.
Rudderless, blindsided, lethargic, and uncoordinated, America has mishandled the COVID-19 crisis to a substantially worse degree than what every health expert I’ve spoken with had feared. “Much worse,” said Ron Klain, who coordinated the U.S. response to the West African Ebola outbreak in 2014. “Beyond any expectations we had,” said Lauren Sauer, who works on disaster preparedness at Johns Hopkins Medicine. “As an American, I’m horrified,” said Seth Berkley, who heads Gavi, the Vaccine Alliance. “The U.S. may end up with the worst outbreak in the industrialized world.”
I. The Next Months
Having fallen behind, it will be difficult—but not impossible—for the United States to catch up. To an extent, the near-term future is set because COVID-19 is a slow and long illness. People who were infected several days ago will only start showing symptoms now, even if they isolated themselves in the meantime. Some of those people will enter intensive-care units in early April. As of last weekend, the nation had 17,000 confirmed cases, but the actual number was probably somewhere between 60,000 and 245,000. Numbers are now starting to rise exponentially: As of Wednesday morning, the official case count was 54,000, and the actual case count is unknown. Health-care workers are already seeing worrying signs: dwindling equipment, growing numbers of patients, and doctors and nurses who are themselves becoming infected.
Italy and Spain offer grim warnings about the future. Hospitals are out of room, supplies, and staff. Unable to treat or save everyone, doctors have been forced into the unthinkable: rationing care to patients who are most likely to survive, while letting others die. The U.S. has fewer hospital beds per capita than Italy. A study released by a team at Imperial College London concluded that if the pandemic is left unchecked, those beds will all be full by late April. By the end of June, for every available critical-care bed, there will be roughly 15 COVID-19 patients in need of one. By the end of the summer, the pandemic will have directly killed 2.2 million Americans, notwithstanding those who will indirectly die as hospitals are unable to care for the usual slew of heart attacks, strokes, and car accidents. This is the worst-case scenario. To avert it, four things need to happen—and quickly.
In the U.S., the Strategic National Stockpile—a national larder of medical equipment—is already being deployed, especially to the hardest-hit states. The stockpile is not inexhaustible, but it can buy some time. Donald Trump could use that time to invoke the Defense Production Act, launching a wartime effort in which American manufacturers switch to making medical equipment. But after invoking the act last Wednesday, Trump has failed to actually use it, reportedly due to lobbying from the U.S. Chamber of Commerce and heads of major corporations.
Some manufacturers are already rising to the challenge, but their efforts are piecemeal and unevenly distributed. “One day, we’ll wake up to a story of doctors in City X who are operating with bandanas, and a closet in City Y with masks piled into it,” says Ali Khan, the dean of public health at the University of Nebraska Medical Center. A “massive logistics and supply-chain operation [is] now needed across the country,” says Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health. That can’t be managed by small and inexperienced teams scattered throughout the White House. The solution, he says, is to tag in the Defense Logistics Agency—a 26,000-person group that prepares the U.S. military for overseas operations and that has assisted in past public-health crises, including the 2014 Ebola outbreak.
This agency can also coordinate the second pressing need: a massive rollout of COVID-19 tests. Those tests have been slow to arrive because of five separate shortages: of masks to protect people administering the tests; of nasopharyngeal swabs for collecting viral samples; of extraction kits for pulling the virus’s genetic material out of the samples; of chemical reagents that are part of those kits; and of trained people who can give the tests. Many of these shortages are, again, due to strained supply chains. The U.S. relies on three manufacturers for extraction reagents, providing redundancy in case any of them fails—but all of them failed in the face of unprecedented global demand. Meanwhile, Lombardy, Italy, the hardest-hit place in Europe, houses one of the largest manufacturers of nasopharyngeal swabs.
Some shortages are being addressed. The FDA is now moving quickly to approve tests developed by private labs. At least one can deliver results in less than an hour, potentially allowing doctors to know if the patient in front of them has COVID-19. The country “is adding capacity on a daily basis,” says Kelly Wroblewski of the Association of Public Health Laboratories.
On March 6, Trump said that “anyone who wants a test can get a test.” That was (and still is) untrue, and his own officials were quick to correct him. Regardless, anxious people still flooded into hospitals, seeking tests that did not exist. “People wanted to be tested even if they weren’t symptomatic, or if they sat next to someone with a cough,” says Saskia Popescu of George Mason University, who works to prepare hospitals for pandemics. Others just had colds, but doctors still had to use masks to examine them, burning through their already dwindling supplies. “It really stressed the health-care system,” Popescu says. Even now, as capacity expands, tests must be used carefully. The first priority, says Marc Lipsitch of Harvard, is to test health-care workers and hospitalized patients, allowing hospitals to quell any ongoing fires. Only later, once the immediate crisis is slowing, should tests be deployed in a more widespread way. “This isn’t just going to be: Let’s get the tests out there!” Inglesby says.
These measures will take time, during which the pandemic will either accelerate beyond the capacity of the health system or slow to containable levels. Its course—and the nation’s fate—now depends on the third need, which is social distancing. Think of it this way: There are now only two groups of Americans. Group A includes everyone involved in the medical response, whether that’s treating patients, running tests, or manufacturing supplies. Group B includes everyone else, and their job is to buy Group A more time. Group B must now “flatten the curve” by physically isolating themselves from other people to cut off chains of transmission. Given the slow fuse of COVID-19, to forestall the future collapse of the health-care system, these seemingly drastic steps must be taken immediately, before they feel proportionate, and they must continue for several weeks.
In these moments, when the good of all hinges on the sacrifices of many, clear coordination matters—the fourth urgent need. The importance of social distancing must be impressed upon a public who must also be reassured and informed. Instead, Trump has repeatedly played down the problem, telling America that “we have it very well under control” when we do not, and that cases were “going to be down to close to zero” when they were rising. In some cases, as with his claims about ubiquitous testing, his misleading gaffes have deepened the crisis. He has even touted unproven medications.
Away from the White House press room, Trump has apparently been listening to Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases. Fauci has advised every president since Ronald Reagan on new epidemics, and now sits on the COVID-19 task force that meets with Trump roughly every other day. “He’s got his own style, let’s leave it at that,” Fauci told me, “but any kind of recommendation that I have made thus far, the substance of it, he has listened to everything.”
But Trump already seems to be wavering. In recent days, he has signaled that he is prepared to backtrack on social-distancing policies in a bid to protect the economy. Pundits and business leaders have used similar rhetoric, arguing that high-risk people, such as the elderly, could be protected while lower-risk people are allowed to go back to work. Such thinking is seductive, but flawed. It overestimates our ability to assess a person’s risk, and to somehow wall off the ‘high-risk’ people from the rest of society. It underestimates how badly the virus can hit ‘low-risk’ groups, and how thoroughly hospitals will be overwhelmed if even just younger demographics are falling sick.
A recent analysis from the University of Pennsylvania estimated that even if social-distancing measures can reduce infection rates by 95 percent, 960,000 Americans will still need intensive care. There are only about 180,000 ventilators in the U.S. and, more pertinently, only enough respiratory therapists and critical-care staff to safely look after 100,000 ventilated patients. Abandoning social distancing would be foolish. Abandoning it now, when tests and protective equipment are still scarce, would be catastrophic.
If Trump stays the course, if Americans adhere to social distancing, if testing can be rolled out, and if enough masks can be produced, there is a chance that the country can still avert the worst predictions about COVID-19, and at least temporarily bring the pandemic under control. No one knows how long that will take, but it won’t be quick. “It could be anywhere from four to six weeks to up to three months,” Fauci said, “but I don’t have great confidence in that range.”
II. The Endgame
Even a perfect response won’t end the pandemic. As long as the virus persists somewhere, there’s a chance that one infected traveler will reignite fresh sparks in countries that have already extinguished their fires. This is already happening in China, Singapore, and other Asian countries that briefly seemed to have the virus under control. Under these conditions, there are three possible endgames: one that’s very unlikely, one that’s very dangerous, and one that’s very long.
The first is that every nation manages to simultaneously bring the virus to heel, as with the original SARS in 2003. Given how widespread the coronavirus pandemic is, and how badly many countries are faring, the odds of worldwide synchronous control seem vanishingly small.
The second is that the virus does what past flu pandemics have done: It burns through the world and leaves behind enough immune survivors that it eventually struggles to find viable hosts. This “herd immunity” scenario would be quick, and thus tempting. But it would also come at a terrible cost: SARS-CoV-2 is more transmissible and fatal than the flu, and it would likely leave behind many millions of corpses and a trail of devastated health systems. The United Kingdom initially seemed to consider this herd-immunity strategy, before backtracking when models revealed the dire consequences. The U.S. now seems to be considering it too.
The third scenario is that the world plays a protracted game of whack-a-mole with the virus, stamping out outbreaks here and there until a vaccine can be produced. This is the best option, but also the longest and most complicated.
It depends, for a start, on making a vaccine. If this were a flu pandemic, that would be easier. The world is experienced at making flu vaccines and does so every year. But there are no existing vaccines for coronaviruses—until now, these viruses seemed to cause diseases that were mild or rare—so researchers must start from scratch. The first steps have been impressively quick. Last Monday, a possible vaccine created by Moderna and the National Institutes of Health went into early clinical testing. That marks a 63-day gap between scientists sequencing the virus’s genes for the first time and doctors injecting a vaccine candidate into a person’s arm. “It’s overwhelmingly the world record,” Fauci said.
But it’s also the fastest step among many subsequent slow ones. The initial trial will simply tell researchers if the vaccine seems safe, and if it can actually mobilize the immune system. Researchers will then need to check that it actually prevents infection from SARS-CoV-2. They’ll need to do animal tests and large-scale trials to ensure that the vaccine doesn’t cause severe side effects. They’ll need to work out what dose is required, how many shots people need, if the vaccine works in elderly people, and if it requires other chemicals to boost its effectiveness.
“Even if it works, they don’t have an easy way to manufacture it at a massive scale,” said Seth Berkley of Gavi. That’s because Moderna is using a new approach to vaccination. Existing vaccines work by providing the body with inactivated or fragmented viruses, allowing the immune system to prep its defenses ahead of time. By contrast, Moderna’s vaccine comprises a sliver of SARS-CoV-2’s genetic material—its RNA. The idea is that the body can use this sliver to build its own viral fragments, which would then form the basis of the immune system’s preparations. This approach works in animals, but is unproven in humans. By contrast, French scientists are trying to modify the existing measles vaccine using fragments of the new coronavirus. “The advantage of that is that if we needed hundreds of doses tomorrow, a lot of plants in the world know how to do it,” Berkley said. No matter which strategy is faster, Berkley and others estimate that it will take 12 to 18 months to develop a proven vaccine, and then longer still to make it, ship it, and inject it into people’s arms.
It’s likely, then, that the new coronavirus will be a lingering part of American life for at least a year, if not much longer. If the current round of social-distancing measures works, the pandemic may ebb enough for things to return to a semblance of normalcy. Offices could fill and bars could bustle. Schools could reopen and friends could reunite. But as the status quo returns, so too will the virus. This doesn’t mean that society must be on continuous lockdown until 2022. But “we need to be prepared to do multiple periods of social distancing,” says Stephen Kissler of Harvard.
Much about the coming years, including the frequency, duration, and timing of social upheavals, depends on two properties of the virus, both of which are currently unknown. First: seasonality. Coronaviruses tend to be winter infections that wane or disappear in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect. “Much of the world is waiting anxiously to see what—if anything—the summer does to transmission in the Northern Hemisphere,” says Maia Majumder of Harvard Medical School and Boston Children’s Hospital.
Second: duration of immunity. When people are infected by the milder human coronaviruses that cause cold-like symptoms, they remain immune for less than a year. By contrast, the few who were infected by the original SARS virus, which was far more severe, stayed immune for much longer. Assuming that SARS-CoV-2 lies somewhere in the middle, people who recover from their encounters might be protected for a couple of years. To confirm that, scientists will need to develop accurate serological tests, which look for the antibodies that confer immunity. They’ll also need to confirm that such antibodies actually stop people from catching or spreading the virus. If so, immune citizens can return to work, care for the vulnerable, and anchor the economy during bouts of social distancing.
Scientists can use the periods between those bouts to develop antiviral drugs—although such drugs are rarely panaceas, and come with possible side effects and the risk of resistance. Hospitals can stockpile the necessary supplies. Testing kits can be widely distributed to catch the virus’s return as quickly as possible. There’s no reason that the U.S. should let SARS-CoV-2 catch it unawares again, and thus no reason that social-distancing measures need to be deployed as broadly and heavy-handedly as they now must be. As Aaron E. Carroll and Ashish Jha recently wrote, “We can keep schools and businesses open as much as possible, closing them quickly when suppression fails, then opening them back up again once the infected are identified and isolated. Instead of playing defense, we could play more offense.”
Whether through accumulating herd immunity or the long-awaited arrival of a vaccine, the virus will find spreading explosively more and more difficult. It’s unlikely to disappear entirely. The vaccine may need to be updated as the virus changes, and people may need to get revaccinated on a regular basis, as they currently do for the flu. Models suggest that the virus might simmer around the world, triggering epidemics every few years or so. “But my hope and expectation is that the severity would decline, and there would be less societal upheaval,” Kissler says. In this future, COVID-19 may become like the flu is today—a recurring scourge of winter. Perhaps it will eventually become so mundane that even though a vaccine exists, large swaths of Gen C won’t bother getting it, forgetting how dramatically their world was molded by its absence.
III. The Aftermath
The cost of reaching that point, with as few deaths as possible, will be enormous. As my colleague Annie Lowrey wrote, the economy is experiencing a shock “more sudden and severe than anyone alive has ever experienced.” About one in five people in the United States have lost working hours or jobs. Hotels are empty. Airlines are grounding flights. Restaurants and other small businesses are closing. Inequalities will widen: People with low incomes will be hardest-hit by social-distancing measures, and most likely to have the chronic health conditions that increase their risk of severe infections. Diseases have destabilized cities and societies many times over, “but it hasn’t happened in this country in a very long time, or to quite the extent that we’re seeing now,” says Elena Conis, a historian of medicine at UC Berkeley. “We’re far more urban and metropolitan. We have more people traveling great distances and living far from family and work.”
After infections begin ebbing, a secondary pandemic of mental-health problems will follow. At a moment of profound dread and uncertainty, people are being cut off from soothing human contact. Hugs, handshakes, and other social rituals are now tinged with danger. People with anxiety or obsessive-compulsive disorder are struggling. Elderly people, who are already excluded from much of public life, are being asked to distance themselves even further, deepening their loneliness. Asian people are suffering racist insults, fueled by a president who insists on labeling the new coronavirus the “Chinese virus.” Incidents of domestic violence and child abuse are likely to spike as people are forced to stay in unsafe homes. Children, whose bodies are mostly spared by the virus, may endure mental trauma that stays with them into adulthood.
After the pandemic, people who recover from COVID-19 might be shunned and stigmatized, as were survivors of Ebola, SARS, and HIV. Health-care workers will take time to heal: One to two years after SARS hit Toronto, people who dealt with the outbreak were still less productive and more likely to be experiencing burnout and post-traumatic stress. People who went through long bouts of quarantine will carry the scars of their experience. “My colleagues in Wuhan note that some people there now refuse to leave their homes and have developed agoraphobia,” says Steven Taylor of the University of British Columbia, who wrote The Psychology of Pandemics.
But “there is also the potential for a much better world after we get through this trauma,” says Richard Danzig of the Center for a New American Security. Already, communities are finding new ways of coming together, even as they must stay apart. Attitudes to health may also change for the better. The rise of HIV and AIDS “completely changed sexual behavior among young people who were coming into sexual maturity at the height of the epidemic,” Conis says. “The use of condoms became normalized. Testing for STDs became mainstream.” Similarly, washing your hands for 20 seconds, a habit that has historically been hard to enshrine even in hospitals, “may be one of those behaviors that we become so accustomed to in the course of this outbreak that we don’t think about them,” Conis adds.
Pandemics can also catalyze social change. People, businesses, and institutions have been remarkably quick to adopt or call for practices that they might once have dragged their heels on, including working from home, conference-calling to accommodate people with disabilities, proper sick leave, and flexible child-care arrangements. “This is the first time in my lifetime that I’ve heard someone say, ‘Oh, if you’re sick, stay home,’” says Adia Benton, an anthropologist at Northwestern University. Perhaps the nation will learn that preparedness isn’t just about masks, vaccines, and tests, but also about fair labor policies and a stable and equal health-care system. Perhaps it will appreciate that health-care workers and public-health specialists compose America’s social immune system, and that this system has been suppressed.
Aspects of America’s identity may need rethinking after COVID-19. Many of the country’s values have seemed to work against it during the pandemic. Its individualism, exceptionalism, and tendency to equate doing whatever you want with an act of resistance meant that when it came time to save lives and stay indoors, some people flocked to bars and clubs. Having internalized years of anti-terrorism messaging following 9/11, Americans resolved to not live in fear. But SARS-CoV-2 has no interest in their terror, only their cells.
Years of isolationist rhetoric had consequences too. Citizens who saw China as a distant, different place, where bats are edible and authoritarianism is acceptable, failed to consider that they would be next or that they wouldn’t be ready. (China’s response to this crisis had its own problems, but that’s for another time.) “People believed the rhetoric that containment would work,” says Wendy Parmet, who studies law and public health at Northeastern University. “We keep them out, and we’ll be okay. When you have a body politic that buys into these ideas of isolationism and ethnonationalism, you’re especially vulnerable when a pandemic hits.”
Veterans of past epidemics have long warned that American society is trapped in a cycle of panic and neglect. After every crisis—anthrax, SARS, flu, Ebola—attention is paid and investments are made. But after short periods of peacetime, memories fade and budgets dwindle. This trend transcends red and blue administrations. When a new normal sets in, the abnormal once again becomes unimaginable. But there is reason to think that COVID-19 might be a disaster that leads to more radical and lasting change.
The other major epidemics of recent decades either barely affected the U.S. (SARS, MERS, Ebola), were milder than expected (H1N1 flu in 2009), or were mostly limited to specific groups of people (Zika, HIV). The COVID-19 pandemic, by contrast, is affecting everyone directly, changing the nature of their everyday life. That distinguishes it not only from other diseases, but also from the other systemic challenges of our time. When an administration prevaricates on climate change, the effects won’t be felt for years, and even then will be hard to parse. It’s different when a president says that everyone can get a test, and one day later, everyone cannot. Pandemics are democratizing experiences. People whose privilege and power would normally shield them from a crisis are facing quarantines, testing positive, and losing loved ones. Senators are falling sick. The consequences of defunding public-health agencies, losing expertise, and stretching hospitals are no longer manifesting as angry opinion pieces, but as faltering lungs.
After 9/11, the world focused on counterterrorism. After COVID-19, attention may shift to public health. Expect to see a spike in funding for virology and vaccinology, a surge in students applying to public-health programs, and more domestic production of medical supplies. Expect pandemics to top the agenda at the United Nations General Assembly. Anthony Fauci is now a household name. “Regular people who think easily about what a policewoman or firefighter does finally get what an epidemiologist does,” says Monica Schoch-Spana, a medical anthropologist at the Johns Hopkins Center for Health Security.
Such changes, in themselves, might protect the world from the next inevitable disease. “The countries that had lived through SARS had a public consciousness about this that allowed them to leap into action,” said Ron Klain, the former Ebola czar. “The most commonly uttered sentence in America at the moment is, ‘I’ve never seen something like this before.’ That wasn’t a sentence anyone in Hong Kong uttered.” For the U.S., and for the world, it’s abundantly, viscerally clear what a pandemic can do.
The lessons that America draws from this experience are hard to predict, especially at a time when online algorithms and partisan broadcasters only serve news that aligns with their audience’s preconceptions. Such dynamics will be pivotal in the coming months, says Ilan Goldenberg, a foreign-policy expert at the Center for a New American Security. “The transitions after World War II or 9/11 were not about a bunch of new ideas,” he says. “The ideas are out there, but the debates will be more acute over the next few months because of the fluidity of the moment and willingness of the American public to accept big, massive changes.”
One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trump’s approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero. During the second term of his presidency, the U.S. turns further inward and pulls out of NATO and other international alliances, builds actual and figurative walls, and disinvests in other nations. As Gen C grows up, foreign plagues replace communists and terrorists as the new generational threat.
One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of “America first” politics. The nation pivots, as it did after World War II, from isolationism to international cooperation. Buoyed by steady investments and an influx of the brightest minds, the health-care workforce surges. Gen C kids write school essays about growing up to be epidemiologists. Public health becomes the centerpiece of foreign policy. The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.
In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.
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What more do you need to know, yes? As or me, I will absolutely tolerate, having compromising albeit controlled asthma and senior citizenship, being inside with very occasional strolls around the block, because the alternative scares the crap out of me–that is, getting coronavirus and dying. My sons and I are starting video calls via the computer. It isn’t enough, but for the interim, it will be fine, I slowly repeat to myself a couple of times every day.