Winning the Race to Open America After the Coronavirus Crisis Decision time is coming. by James Jay Carafano

The most consequential decision America must make is this: How do we safely open the country as quickly as possible? Our lives and livelihoods, our prosperity, security, freedom, and stature among nations hinge on getting this right.  

This debate has mushroomed far beyond the realm of science, data and expert opinion. Partisan politics, public protests, distrust, mistrust and uncertainty over what we still don’t know about this disease are in the mix as well. 

For all the squabbling, it is still possible to reach a responsible, bipartisan consensus about the way forward. There are already dozens of sound recommendations on how to open the country back up. The answer lies simply in asking Americans what they think about them.

Americans ought to have a say in how to get America’s businesses, churches, ballparks and schools open for all of us. My colleagues at the Heritage Foundation assembled an independent National Coronavirus Recovery Commission consisting of 17 wise men and women from the fields of medicine and public health, business and government, disaster response and relief, academia and education, and the faith community. 

The non-partisan commission’s goal is to inform the decision-making of the president, governors, county officials and mayors in real-time, highlighting the common-sense points of agreement and action that reflect what Americans want: to be protected from a deadly disease and get America back on its feet as soon as practical.

Americans recognize that our recovery can’t just be run out of Washington. We all have a voice, responsibilities and a role to play. To make sure that happens the administration rightly relies on the traditional federalist response for managing all kinds of disasters from earthquakes to pandemics. 

Under this system, local officials—mayors, county officials, and governors—lead, and the federal government backs up them up. Federal support comes in the form of guidance by the CDC, supplies from the national medical stockpile, military support to civilian authorities and more. 

This approach is not only consistent with American governance, it is also a proven model—one that has successfully managed recoveries from the Great San Francisco Earthquake to today. No response is perfect in times of crisis, but ours has served better than most to protect lives, recover prosperity and protect freedom.

This week, the commission released 47 specific recommendations to reopen America. The list overall should inspire confidence in the administration’s plan to lift the lockdown in coordination with the states.

The commission-endorsed the approach that aims to slow the spread of the coronavirus with expanded testing, reporting, and contact tracing. At the same time, the commission’s approach would continue building the science behind the response (increasing the availability and rapidity of new diagnostic tests, therapeutics and vaccines). Additionally, these recommendations show how to return to a more normal level of business activity, at the regional level, as local conditions allow. It found that we have adequate testing capacity now to better inform the decision-making of local public health officials and that the capacity for national testing will likely keep pace with plans to gradually open up the country while preventing the resurgence of a major outbreak.

The commission recommended that state and local authorities should reject calls to test every American before loosening social distancing requirements. It righty calls a universal testing requirement unnecessary and unreasonable. Rather, the commission advised: “The mechanics of reopening individual economies should be led by governors and proceed as expeditiously as possible according to data gathered by testing and contact tracing and deployed on the county or zip code level.”

As to the role of Washington, the commission has recommended:

“that the federal government serve in a critical role of supplying reliable information and guidance, reducing barriers to recovery, and providing a back-stop of resources where states need more supply. While there is no single national solution to the recovery process, the role of the federal government ought to be to support and complement governors in bringing their communities back to life. The federal government should assist state and local leaders in expeditiously reopening businesses and schools except in communities where an outbreak is occurring or believed to be imminent.”

This proposal is consistent with how the federal government has dealt with the outbreak from the start and should serve well going forward.

Other key suggestions address the role of Congress, the private sector and local governments. The full list of recommendations are on the commission’s website. 

The commission’s work is important, not just for its “how-to” recommendations, but because it demonstrates there is more of a national consensus to move forward than partisan sniping and an adversarial press suggest. 

America is not locked in bitter, paralyzing indecision. Americans are ready to take the practical and responsible next steps to take their country back.

Anthony Fauci’s Gen Z Cred The public-health expert has developed the kind of internet presence that many public figures, especially politicians, only dream of building. by CHRISTIAN PAZ

The memes came first.

A two-second grimace and a face-palm were all it took to launch Anthony Fauci into the internet’s collective conscience—his reaction to President Donald Trump’s criticism of the “Deep State Department” during a coronavirus task-force briefing in mid-March.

Immediately, the hashtag #FauciFacepalm started trending on Twitter; scores of TikTok videos (including one set to One Direction’s “What Makes You Beautiful”) flooded the platform; and, as my colleague Kaitlyn Tiffany has reported, lustful confessions of Fauci’s sex appeal popped up everywhere.

Then came the guest appearances by the director of the National Institute of Allergy and Infectious Diseases: a podcast interview with the sharp-tongued hosts from Barstool Sports, a chat with the NBA star Steph Curry on Instagram Live, a live-stream with Mark Zuckerberg on Facebook, and appearances on four popular YouTube channels.

Fauci has developed the kind of internet presence that many public figures, politicians especially, only dream of building. It’s partially the product of his gameness to go on unconventional digital platforms, but it’s organic too. The denizens of the internet have chosen to make him ubiquitous, a privilege reserved for those who demonstrate authenticity, relatability, and trustworthiness. In Fauci’s case, the 79-year-old immunologist has used this influence to inform Americans about the coronavirus and debunk myths, even as his status within the administration has become more precarious over time.

“There’s a weird thing where the internet, the meme culture, has to kind of approve and bring people in … You can’t force yourself into the culture. Fauci didn’t try,” said 19-year-old Kai Watson, who recently analyzed Fauci’s omnipresence in a YouTube video. “That’s why people love him.”

Using social-media platforms, influencers, and memes to spread issue awareness or political messages isn’t new. The 2020 election has already been branded “the year of the influencer,” after Democratic presidential hopefuls tried (and mostly failed) to leverage support from online stars to boost their popularity among young voters. Podcasts such as The Joe Rogan Experience, The Ben Shapiro Show, and Pod Save America are must-stops for some political figures.

What’s different about Fauci is his willingness to speak to young and diverse communities on the platforms they use most—and his ability to do it really well, says Mike Varshavski, a family-medicine physician and YouTuber who has partnered with Fauci.

“There’s no filter there,” Varshavski, who goes by Doctor Mike online, told me. “You end up realizing that this is a human sitting in front of you, not a political candidate. And the more we can humanize politicians, health-care experts, the more people are going to believe them and trust them—because they know how they think.”

Fauci’s approach stands in sharp contrast to, say, Michael Bloomberg’s: To get the former New York mayor’s name and message across, his presidential campaign tried to pay influencers to post about him. The effort fizzled shortly after it began. The strategy came across as cold, calculated, and disconnected from how young people use social media, Watson told me.

Watson and his high-school best friend, Chase Steele, both from Redmond, Washington, run a small YouTube channel where they recently discussed Fauci’s internet presence after seeing him pop up on the site’s homepage as a featured guest on the four popular shows. In each tight, 15-minute segment, Fauci fielded a range of questions about the coronavirus and COVID-19’s infectivity, the government’s response, and the Centers for Disease Control and Prevention’s social-distancing recommendations. (Fauci’s office did not respond to requests for comment on this story.)

The YouTube channels Fauci joined (hosted by Varshavski; the comedian Lilly Singh;  the news commentator Philip DeFranco; and Trevor Noah, whose Daily Show maintains a lively presence on the platform) have a combined audience of 33 million people. Many of them are young, diverse Americans who don’t usually tune in to cable or network news, but who need to be informed about the virus. Each Fauci video has racked up more than 4 million views; Varshavski’s has garnered more than 5.3 million since March 29.

“The fact that he can come on a show like mine, like Trevor Noah’s, like Philip DeFranco’s—he’s reaching millions of people that it’s gonna have a direct impact on,” the 30-year-old Varshavski told me. “They otherwise would have been unknowingly possibly spreading this virus, spreading misinformation, and it really just pulls them into our corner as advocates.” YouTube approached the White House task force after Fauci’s interview with Barstool Sports, a task-force official told me.

Since the beginning of the outbreak, public-health experts have been especially concerned with the increased risk of community spread of COVID-19 among younger Americans, who might contract the virus, not present symptoms, and go about their lives infecting others. Reports of Mardi Gras revelers and Florida spring-breakers fueled these concerns—and intergenerational strife. (After some older Americans placed the blame on Millennials, the latter group quickly clarified that most of the pandemic partiers were members of Gen Z.)

When their friends began to return from college and local high schools moved to holding classes remotely, Watson and Steele worried that young people would not take social-distancing guidelines seriously. Watson, who was traveling home from a trip to Europe around the time Italy announced its national lockdown, told me he saw his friends posting Snapchats about upcoming spring-break trips to Mexico, and others joking about how they would have to party at home if they couldn’t go abroad.

The Fauci face-palm changed things. Although Watson and Steele had heard the doctor’s name plenty of times on cable news since the outbreak began, they didn’t expect their friends to know him well. But Watson said he soon began to see friends repost and share Fauci memes that doubled as social-distancing recommendations. They noticed more of their friends staying home, especially if they had traveled recently. And they were surprised to see an uptick in engagement from younger viewers on their own YouTube discussion of Fauci’s interviews.

Many young Americans trust Fauci because of the memes, Steele suggested. They make him seem relatable, humorous, and human, in contrast to the other coronavirus task-force members, who seem more rigid. Memes are “our way of legitimizing somebody,” Varshavski said. “This happens sometimes in a bad way, obviously, but this is a prime example of it happening for a good reason.”

To younger audiences, Fauci’s persona feels familiar. He’s essentially the “Bill Nye of coronavirus,” Watson told me, referring to the well-known science educator and TV personality. And his no-nonsense personality evokes memories of an authoritative but compassionate college professor or high-school teacher, Watson said.

At the same time, Fauci’s online exposure has opened him up to the darker side of internet fame: He’s now the target of scorn from some of the president’s online supporters, and the right-wing memeosphere has developed multiple conspiracy theories about him, including one where Fauci is a Hillary Clinton plant working to undermine Trump.

But the attention and trust that Fauci has accumulated among his internet fans may bear lessons for politicians and government officials who hope to reach younger audiences. Politicians often fail to connect with these online communities, because they wait until the home stretch of a campaign season to ramp up their social-media strategy, or try to pay for an influencer army like Bloomberg did, or deploy celebrity endorsements in ways that don’t resonate with young people.

Fauci’s approach demonstrates respect for the users of social-media platforms, Brent J. Cohen, the executive director of Generation Progress, a youth-engagement group, told me.

“Engaging with young people authentically and consistently and on the platforms that young people prefer is just the best way to build the type of relationships that build the trust that then allow people to look at you as a credible source of information,” Cohen said. “That’s what Dr. Fauci is doing right now.”

Watson and Steele told me they hope other government experts catch on to this strategy. When the 2020 campaign kicks back up, they said, more politicians should go on the podcasts young people listen to, go live on their own Instagram accounts, and “seem like actual people.”

“They don’t have to wear the politics hat all the time,” Steele said.

The Real Reason to Wear a Mask Much of the confusion around masks stems from the conflation of two very different uses.by ZEYNEP TUFEKCI, JEREMY, HOWARD and TRISHA GREENHALGH

If you feel confused about whether people should wear masks and why and what kind, you’re not alone. COVID-19 is a novel disease and we’re learning new things about it every day. However, much of the confusion around masks stems from the conflation of two very different functions of masks.

Masks can be worn to protect the wearer from getting infected or masks can be worn to protect others from being infected by the wearer. Protecting the wearer is difficult: It requires medical-grade respirator masks, a proper fit, and careful putting on and taking off. But masks can also be worn to prevent transmission to others, and this is their most important use for society. If we lower the likelihood of one person infecting another, the impact is exponential, so even a small reduction in those odds results in a huge decrease in deaths. Luckily, blocking transmission outward at the source is much easier. It can be accomplished with something as simple as a cloth mask.

A key transmission route of COVID-19 is via droplets that fly out of our mouths—that includes when we speak, not just when we cough or sneeze. A portion of these droplets quickly evaporate, becoming tiny particles whose inhalation by those nearby is hard to prevent. This is especially relevant for doctors and nurses who work with sick people all day. Medical workers are also at risk from procedures such as intubation, which generate very tiny particles that can float around, possibly for hours. That’s why their gear is called “personal protective equipment,” or PPE, and has stringent requirements for fit in order to stop ingress—the term for the transmission of these outside particles to the wearer. Until now, most scientific research and discussion about masks has been directed at protecting medical workers from ingress.

But the opposite concern also exists: egress, or transmission of particles from the wearer to the outside world. Historically, much less research has been conducted on egress, but controlling it—also known as “source control”—is crucial to stopping the person-to-person spread of a disease. Obviously, society-wide source control becomes very important during a pandemic. Unfortunately, many articles in the lay press—and even some in the scientific press—don’t properly distinguish between ingress and egress, thereby adding to the confusion.

The good news is that preventing transmission to others through egress is relatively easy. It’s like stopping gushing water from a hose right at the source, by turning off the faucet, compared with the difficulty of trying to catch all the drops of water after we’ve pointed the hose up and they’ve flown all over the place. Research shows that even a cotton mask dramatically reduces the number of virus particles emitted from our mouths—by as much as 99 percent. This reduction provides two huge benefits. Fewer virus particles mean that people have a better chance of avoiding infection, and if they are infected, the lower viral exposure load may give them a better chance of contracting only a mild illness.

COVID-19 has been hard to control partly because people can infect others before they themselves display any symptoms—and even if they never develop any illness. Three recent studies show that nearly half of patients are infected by people who aren’t coughing or sneezing yet. Many people have no awareness of the risk they pose to others, because they don’t feel sick themselves, and many may never become overtly ill.

Think of the coronavirus pandemic as a fire ravaging our cities and towns that is spread by infected people breathing out invisible embers every time they speak, cough, or sneeze. Sneezing is the most dangerous—it spreads embers farthest—coughing second, and speaking least, though it still can spread these embers. These invisible sparks cause others to catch fire and in turn breathe out embers until we truly catch fire—and get sick. That’s when we call in the firefighters—our medical workers. The people who run into these raging blazes to put them out need special heat-resistant suits and gloves, helmets, and oxygen tanks so they can keep breathing in the fire—all that PPE, with proper fit too.

If we could just keep our embers from being sent out every time we spoke or coughed, many fewer people would catch fire. Masks help us do that. And because we don’t know for sure who’s sick, the only solution is for everyone to wear masks. This eventually benefits the wearer because fewer fires mean we’re all less likely to be burned. My mask protects you; your masks protect me. Plus, our firefighters would no longer be overwhelmed, and we could more easily go back to work and the rest of our public lives.

To better understand what level of mask-wearing we need in the population to get this pandemic under control, we assembled a transdisciplinary team of 19 experts and looked at a range of mathematical models and other research to learn what would happen if most people wore a mask in public. We wrote and submitted an academic paper as well as a layperson’s summary. Every infectious disease has a reproduction rate, called R. When it’s 1.0, that means the average infected person infects one other person. The 1918 pandemic flu had an R of 1.8—so one infected person infected, on average, almost two others. COVID-19’s rate, in the absence of measures such as social distancing and masks, is at least 2.4. A disease dies out if its R falls under 1.0. The lower the number, the faster it dies out.

The effectiveness of mask-wearing depends on three things: the basic reproduction number, R0, of the virus in a community; masks’ efficacy at blocking transmission; and the percentage of people wearing masks. The blue area of the graph below indicates an R0 below 1.0, the magic number needed to make the disease die out.

Models show that if 80 percent of people wear masks that are 60 percent effective, easily achievable with cloth, we can get to an effective R0 of less than one. That’s enough to halt the spread of the disease. Many countries already have more than 80 percent of their population wearing masks in public, including countries such as Hong Kong, where most stores deny entry to unmasked customers, and the more than 30 countries that legally require masks in public spaces, such as Israel, Singapore, and the Czech Republic. Mask use in combination with physical distancing is even more powerful.

While cloth masks are sufficient for protecting others, people who are immunocompromised or those who have a few left over from fire season or hobbies may be considering wearing N95s, to better  protect themselves. One note of caution: Many nonmedical N95s have exhalation valves (to make them less stuffy to wear) that let out unfiltered air, and thus they won’t  stop the wearer from infecting others—so they shouldn’t be worn around other people unless the valve is covered over with tape or cloth.

The community use of masks for source control is a “public good”: something we all contribute to that eventually benefits everyone—but only if almost everyone contributes, which can be a challenge to persuade people to do. It’s like emission filters in our car exhausts and chimneys: They need to be installed in all cars, factories, and houses to guarantee clean air for everyone. Usually, laws, regulations, mandates, or strong cultural norms ensure maximal participation. And once that happens, the result can be amazing.

For example, in Hong Kong, only four confirmed deaths due to COVID-19 have been recorded since the beginning of the pandemic, despite high density, mass transportation, and proximity to Wuhan. Hong Kong’s health authorities credit their citizens’ near-universal mask-wearing as a key factor (surveys show almost 100 percent voluntary compliance). Similarly, Taiwan ramped up mask production early on and distributed masks to the population, mandating their use in public transit and recommending their use in other public places—a recommendation that has been widely complied with. The country continues to function fully, and their schools have been open since the end of February, while their death total remains very low, at only six. In the Czech Republic, masks were not used during the initial outbreak, but after a grassroots campaign led to a government mandate on March 18, masks in public became ubiquitous. The results took a while to be reflected in the official statistics: The first five days of April still saw an average of 257 new cases and nine deaths per day, but the most recent five days of data show an average of 120 new cases and five deaths per day.  Of course, we can’t know for sure to what degree these success stories are due to masks, but we do know that in every region that has adopted widespread mask-wearing, case and death rates have been reduced within a few weeks.

We know a vaccine may take years, and in the meantime, we will need to find ways to make our societies function as safely as possible. Our governments can and should do much—make tests widely available, fund research, ensure medical workers have everything they need. But ordinary people are not helpless; in fact, we have more power than we realize. Along with keeping our distance whenever possible and maintaining good hygiene, all of us wearing just a cloth mask could help stop this pandemic in its tracks.

Why Some People Get Sicker Than Others COVID-19 is proving to be a disease of the immune system. This could, in theory, be controlled. by JAMES HAMBLIN

The COVID-19 crash comes suddenly. In early March, the 37-year-old writer F. T. Kola began to feel mildly ill, with a fever and body aches. To be safe, she isolated herself at home in San Francisco. Life continued apace for a week, until one day she tried to load her dishwasher and felt strangely exhausted.

Her doctor recommended that she go to Stanford University’s drive-through coronavirus testing site. “I remember waiting in my car, and the doctors in their intense [protective equipment] coming towards me like a scene out of Contagion,” she told me when we spoke for The Atlantic’s podcast Social Distance. “I felt like I was a biohazard—and I was.” The doctors stuck a long swab into the back of her nose and sent her home to await results.  

Lying in bed that night, she began to shake, overtaken by the most intense chills of her life. “My teeth were chattering so hard that I was really afraid they would break,” she said. Then she started to hallucinate. “I thought I was holding a very big spoon for some reason, and I kept thinking, Where am I going to put my spoon down?”

An ambulance raced her to the hospital, where she spent three days in the ICU, before being moved to a newly created coronavirus-only ward. Sometimes she barely felt sick at all, and other times she felt on the verge of death. But after two weeks in the hospital, she walked out. Now, as the death toll from the coronavirus has climbed to more than 150,000 people globally, Kola has flashes of guilt and disbelief: “Why did my lungs make it through this? Why did I go home? Why am I okay now?”

COVID-19 is, in many ways, proving to be a disease of uncertainty. According to a new study from Italy, some 43 percent of people with the virus have no symptoms. Among those who do develop symptoms, it is common to feel sick in uncomfortable but familiar ways—congestion, fever, aches, and general malaise. Many people start to feel a little bit better. Then, for many, comes a dramatic tipping point. “Some people really fall off the cliff, and we don’t have good predictors of who it’s going to happen to,” Stephen Thomas, the chair of infectious diseases at Upstate University Hospital, told me. Those people will become short of breath, their heart racing and mind detached from reality. They experience organ failure and spend weeks in the ICU, if they survive at all.

Meanwhile, many others simply keep feeling better and eventually totally recover. Kola’s friend Karan Mahajan, an author based in Providence, Rhode Island, contracted the virus at almost the same time she did. In stark contrast to Kola, he said, “My case ended up feeling like a mild flu that lasted for two weeks. And then it faded after that.”

“There’s a big difference in how people handle this virus,” says Robert Murphy, a professor of medicine and the director of the Center for Global Communicable Diseases at Northwestern University. “It’s very unusual. None of this variability really fits with any other diseases we’re used to dealing with.”

This degree of uncertainty has less to do with the virus itself than how our bodies respond to it. As Murphy puts it, when doctors see this sort of variation in disease severity, “that’s not the virus; that’s the host.” Since the beginning of the pandemic, people around the world have heard the message that older and chronically ill people are most likely to die from COVID-19. But that is far from a complete picture of who is at risk of life-threatening disease. Understanding exactly how and why some people get so sick while others feel almost nothing will be the key to treatment.

Hope has been put in drugs that attempt to slow the replication of the virus—those currently in clinical trials like remdesivir, ivermectin, and hydroxychloroquine. But with the flu and most other viral diseases, antiviral medications are often effective only early in the disease. Once the virus has spread widely within our body, our own immune system becomes the thing that more urgently threatens to kill us. That response cannot be fully controlled. But it can be modulated and improved.

One of the common, perplexing experiences of COVID-19 is the loss of smell—and, then, taste. “Eating pizza was like eating cardboard,” Mahajan told me. Any common cold that causes congestion can alter these sensations to some degree. But a near-total breakdown of taste and smell is happening with coronavirus infections even in the absence of other symptoms.

Jonathan Aviv, an ear, nose, and throat doctor based in New York, told me he has seen a surge in young people coming to him with a sudden inability to taste. He’s unsure what to tell them about what’s going on. “The non-scary scenario is that the inflammatory effect of the infection is temporarily altering the function of the olfactory nerve,” he said. “The scarier possibility is that the virus is attacking the nerve itself.” Viruses that attack nerves can cause long-term impairment, and could affect other parts of the nervous system. The coronavirus has already been reported to precipitate inflammation in the brain that leads to permanent damage.

Though SARS-CoV-2 (the new coronavirus) isn’t reported to invade the brain and spine directly, its predecessor SARS-CoV seems to have that capacity. If nerve cells are spared by the new virus, they would be among the few that are. When the coronavirus attaches to cells, it hooks on and breaks through, then starts to replicate. It does so especially well in the cells of the nasopharynx and down into the lungs, but is also known to act on the cells of the liver, bowels, and heart. The virus spreads around the body for days or weeks in a sort of stealth mode, taking over host cells while evading the immune response. It can take a week or two for the body to fully recognize the extent to which it has been overwhelmed. At this point, its reaction is often not calm and measured. The immune system goes into a hyperreactive state, pulling all available alarms to mobilize the body’s defense mechanisms. This is when people suddenly crash.

Bootsie Plunkett, a 61-year-old retiree in New Jersey with diabetes and lupus, described it to me as suffocating. We met in February, taping a TV show, and she was her typically ebullient self. A few weeks later, she developed a fever. It lasted for about two weeks, as did the body aches. She stayed at home with what she presumed was COVID-19. Then, as if out of nowhere, she was gasping for air. Her husband raced her to the hospital, and she began to slump over in the front seat. When they made it to the hospital, her blood-oxygen level was just 79 percent, well below the point when people typically require aggressive breathing support.

Such a quick decline—especially in the later stages of an infectious disease—seems to result from the immune response suddenly kicking into overdrive. The condition tends to be dire. Half of the patients with COVID-19 who end up in the intensive-care unit at New York–Presbyterian Hospital stay for 20 days, according to Pamela Sutton-Wallace, the regional chief operating officer. (In normal times, the national average is 3.3 days). Many of these patients arrive at the hospital in near-critical condition, with their blood tests showing soaring levels of inflammatory markers. One that seems to be especially predictive of a person’s fate is a protein known as D-dimer. Doctors in Wuhan, China, where the coronavirus outbreak was first reported, have found that a fourfold increase in D-dimer is a strong predictor of mortality, suggesting in a recent paper that the test “could be an early and helpful marker” of who is entering the dangerous phases.  

These and other markers are often signs of a highly fatal immune-system process known as a cytokine storm, explains Randy Cron, the director of rheumatology at Children’s of Alabama, in Birmingham. A cytokine is a short-lived signaling molecule that the body can release to activate inflammation in an attempt to contain and eradicate a virus. In a cytokine storm, the immune system floods the body with these molecules, essentially sounding a fire alarm that continues even after the firefighters and ambulances have arrived.

At this point, the priority for doctors shifts from hoping that a person’s immune system can fight off the virus to trying to tamp down the immune response so it doesn’t kill the person or cause permanent organ damage. As Cron puts it, “If you see a cytokine storm, you have to treat it.” But treating any infection by impeding the immune system is always treacherous. It is never ideal to let up on a virus that can directly kill our cells. The challenge is striking a balance where neither the cytokine storm nor the infection runs rampant.

Cron and other researchers believe such a balance is possible. Cytokine storms are not unique to COVID-19. The same basic process happens in response to other viruses, such as dengue and Ebola, as well as influenza and other coronaviruses. It is life-threatening and difficult to treat, but not beyond the potential for mitigation.

At Johns Hopkins University, the biomedical engineer Joshua Vogelstein and his colleagues have been trying to identify patterns among people who have survived cytokine storms and people who haven’t. One correlation the team noticed was that people taking the drug tamsulosin (sold as Flomax, to treat urinary retention) seemed to fare well. Vogelstein is unsure why. Cytokine storms do trigger the release of hormones such as dopamine and adrenaline, which tamsulosin can partially block. The team is launching a clinical trial to see if the approach is of any help.

One of the more promising approaches is blocking cytokines themselves—once they’ve already been released into the blood. A popular target is one type of cytokine known as interleukin-6 (IL-6), which is known to peak at the height of respiratory failure. Benjamin Lebwohl, director of research at Columbia University’s Celiac Disease Center, says that people with immune conditions like celiac and inflammatory bowel disease may be at higher risk of severe cases of COVID-19. But he’s hopeful that medications that inhibit IL-6 or other cytokines could pare back the unhelpful responses while leaving others intact. Other researchers have seen promising preliminary results, and clinical trials are ongoing.

If interleukin inhibitors end up playing a significant role in treating very sick people, though, we would run out. These medicines (which go by names such as tocilizumab and ruxolitinib, reading like a good draw in Scrabble) fall into a class known as “biologics.” They are traditionally used in rare cases and tend to be very expensive, sometimes costing people with immune conditions about $18,000 a year. Based on price and the short supply, Cron says, “my guess is we’re going to rely on corticosteroids at the end of the day. Because it’s what we have.”

That is a controversial opinion. Corticosteroids (colloquially known as “steroids,” though they are of the adrenal rather than reproductive sort), can act as an emergency brake on the immune system. Their broad, sweeping action means that steroids involve more side effects than targeting one specific cytokine. Typically, a person on steroids has a higher risk of contracting another dangerous infection, and early evidence on the utility of steroids in treating COVID-19, in studies from the outbreak in China, was mixed. But some doctors are now using them to good effect. Last week, the Infectious Diseases Society of America issued guidelines on steroids, recommending them in the context of a clinical trial when the disease reaches the level of acute respiratory distress. They may have helped Plunkett, the 61-year-old from New Jersey. After three days on corticosteroids, she left the ICU—without ever being intubated.

Deciding on the precise method of modulating the immune response—the exact drug, dose, and timing—is ideally informed by carefully monitoring patients before they are critically ill. People at risk of a storm could be monitored closely throughout their illness, and offered treatment immediately when signs begin to show. That could mean detecting the markers in a person’s blood before the process sends her into hallucinations—before her oxygen level fell at all.

In typical circumstances in the United States and other industrialized nations, patients would be urged to go to the hospital sooner rather than later. But right now, to avoid catastrophic strain on an already overburdened health-care system, people are told to avoid the hospital until they feel short of breath. For those who do become critically ill and arrive at the ER in respiratory failure, health-care workers are then behind the ball. Given those circumstances, the daily basics of maintaining overall health and the best possible immune response become especially important.

The official line from the White House Coronavirus Task Force has been that “high-risk” people are older and those with chronic medical conditions, such as obesity and diabetes. But that has proven to be a limited approximation of who will bear the burden of this disease most severely. Last week, the Centers for Disease Control and Prevention released its first official report on who has been hospitalized for COVID-19. It found that Latinos and African Americans have died at significantly higher rates than white Americans. In Chicago, more than half of the people who have tested positive, and nearly 60 percent of those who have died, were African American. They make up less than one-third of the city’s population. Similar patterns are playing out across the country: Rates of death and severe disease are several times higher among racial minorities and people of low socioeconomic status.

hese disparities are beginning to be acknowledged at high levels, but often as though they are just another one of the mysteries of the coronavirus. At a White House briefing last week, Vice President Mike Pence said his team was looking into “the unique impact that we’re seeing reported on African Americans from the coronavirus.” Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, has noted that “we are not going to solve the issues of health disparities this month or next month. This is something we should commit ourselves for years to do.”

While America’s deepest health disparities absolutely would require generations  to undo, the country still could address many gaps right now. Variation in immune responses between people is due to much more than age or chronic disease. The immune system is a function of the communities that brought us up and the environments with which we interact every day. Its foundation is laid by genetics and early-life exposure to the world around us—from the food we eat to the air we breathe. Its response varies on the basis of income, housing, jobs, and access to health care.

The people who get the most severely sick from COVID-19 will sometimes be unpredictable, but in many cases, they will not. They will be the same people who get sick from most every other cause. Cytokines like IL-6 can be elevated by a single night of bad sleep. Over the course of a lifetime, the effects of daily and hourly stressors accumulate. Ultimately, people who are unable to take time off of work when sick—or who don’t have a comfortable and quiet home, or who lack access to good food and clean air—are likely to bear the burden of severe disease.

Much is yet unknown about specific cytokines and their roles in disease. But the likelihood of disease in general is not so mysterious. Often, it’s a matter of what societies choose to tolerate. America has empty hotels while people sleep in parking lots. We are destroying food while people go hungry. We are allowing individuals to endure the physiological stresses of financial catastrophe while bailing out corporations. With the coronavirus, we do not have vulnerable populations so much as we have vulnerabilities as a population. Our immune system is not strong.

CORONAVIRUS: COVID-19 Indians Aren’t Buying China’s Narrative For a majority of Indians, Beijing isn’t part of the solution to the pandemic, but the problem. by YASMEEN SERHAN

For much of the world, the coming weeks and months (if not years) will be dedicated to curbing the spread of the coronavirus. In China, where the outbreak has purportedly been contained, another challenge is pressing: damage control.

Beijing has been mounting a diplomatic push to help the world contain the pandemic and, in the process, reposition itself not as the authoritarian power that was slow to sound the alarm on the impending health crisis, but as the global leader that stepped up when others didn’t. In some places, it appears to be working.

Not everywhere, though. In India, which this month marked 70 years of diplomatic relations with Beijing, anti-China sentiment has soared. Many Indians fault the country for allowing the virus’s spread, and references to the “Wuhan virus” and “China virus” have become commonplace.

India’s perception of China at this moment matters, if for no other reason than to signal how others might be viewing Beijing’s efforts. Like many countries, India doesn’t count China as a key ally, nor does it necessarily have much incentive to praise Beijing for its response to the pandemic so far. India is, however, also among the many countries that have become reliant on China—not just for trade and investment, which was the case before the pandemic, but, perhaps most crucially now, for the vital equipment required to curb the spread of the virus, including testing kits, face masks, and other personal protective gear. That dependence has proved enough to prevent India from openly criticizing China—at least in any official capacity. It hasn’t stopped the Indian public from turning on Beijing, though, nor is it likely to prevent other countries’ populations from doing the same.

If India proves impervious to its charitable efforts, China might wonder, who else will?

India has always had a complicated relationship with its larger neighbor. Though India was the first country in Asia outside the Communist bloc to establish diplomatic ties with the People’s Republic of China, in April 1950, their shared history has been riddled with tensions—not least a war (which China won) and an unresolved border dispute in Arunachal Pradesh, India’s northeasternmost state. Compounding these divisions are India’s tensions with its bitter rival Pakistan (an ally of China’s) and other long-standing issues such as the status of Kashmir, a disputed territory between India and Pakistan to which China also lays some territorial claim. But India and China also share a number of common interests, including a robust, if lopsided, trading relationship.

“The India-China relationship has had its ups and downs,” Gautam Bambawale, India’s ambassador to China from 2017 to 2018, told me. He noted that officials on both sides tend to describe the relationship as one “where there are elements of both cooperation as well as competition.” Others have described the two countries as “frenemies.”

The growing resentment toward China among Indians isn’t for any of those reasons, though—at least, not exclusively. According to a recent survey by the Bangalore-based Takshashila Institution, a majority of Indians fault Beijing for the global pandemic, citing China’s early mishandling of the outbreak and its failure to alert the world to the severity of the crisis fast enough. Such perceptions aren’t without merit: China stands accused of having suppressed information about the extent of the coronavirus outbreak after its detection in Wuhan late last year, reportedly costing the world precious days to contain it.

But China’s early errors aren’t the only thing that has swayed Indian public opinion against it. According to the same study, 65 percent of respondents distrust Beijing’s word on the scale of the crisis, including its claims that the outbreak within China has been contained. It’s a narrative that has been met with skepticism elsewhere, too, suggesting that the Chinese government’s efforts to present its own handling of the crisis as one to emulate will be challenging. In India, they appear to have backfired altogether.

“Many of the things that China does in terms of public diplomacy are actually counterproductive,” Tanvi Madan, the director of the Brookings Institution’s India Project, told me. She noted that Beijing’s attempts to highlight its own assistance—and, in some cases, deflect blame—have come across in India as condescending. “Maybe they think that is helpful, but in India, where people are going to resent this Chinese sense of superiority,” Madan said, “that actually builds resentment.”

This anti-China sentiment has manifested in a number of ways. The term “Wuhan virus”—popularized by President Donald Trump, and which critics say perpetuates already rampant racism and xenophobia surrounding the crisis—is regularly used in India, as are hashtags such as #ChinaLiedAndPeopleDied and #MakeChinaPay. A cartoon depicting the World Health Organization chief, Tedros Adhanom Ghebreyesus, blindfolded with a Chinese-flag face mask has been widely circulated online by Indians (including Bollywood star Amitabh Bachchan, who tweeted the image to his 41 million followers before eventually deleting it). “Whether it’s memes on Twitter or WhatsApp, or comedy sketches or prime-time news shows dedicated to highlighting how China’s influenced the WHO or how it’s keeping Taiwan out of the WHO,” Madan said, “criticism of China has gone mainstream.”

Casting about for someone to blame for the pandemic is not unique to India (where Indian Muslims, who bore the brunt of recent communal violence in the country, have faced an uptick in bigotry and attacks). In the United States, President Trump has found a multitude of targets, including the media, state governors, and the WHO. Still, for U.S. lawmakers, China has proved to be a rare source of consensus, scapegoated by both Republicans and Democrats alike. The same can’t be said for their Indian counterparts. Although many Indians, even some close to the government, have criticized Beijing’s handling of the pandemic, Prime Minister Narendra Modi’s government has been reluctant to do so.

“The government doesn’t want to go down the road of getting into a blame game,” Ashok Kantha, the Indian ambassador to China from 2014 to 2016 and now the director of the Institute of Chinese Studies in Delhi, told me. Part of the reason for this, Kantha said, is priorities: Delhi is more concerned with containing the virus than ascribing blame for it. Political pragmatism is also at play. India needs China, particularly when it comes to procuring medical equipment. Irrespective of Indian public opinion on China, “you will not see the Indian government outdo Trump on this,” Madan said.

While this widespread dependence on China could limit the degree of criticism Beijing gets in the short term, that does not mean it is impervious. Reports of faulty test kits and defective masks have already proved a blow to China’s diplomacy, as a number of countries are opting to reject Chinese-made equipment.

When I asked Madan whether the Chinese government cares about its perception among the Indian public, she said it’s unlikely. “They still think that their primary audience is the Indian government [because] that’s who they can get stuff done with,” she said.

This may be the case for now, but it could prove problematic for Beijing in the long term. After all, how India—and, indeed, the rest of the world—perceives China in this moment will likely impact its global perception long after the pandemic has passed. “Being oblivious to the sentiments of 1.3 billion people of a country whose median age is 27 is not a sign of wisdom,” Nitin Pai, a co-founder and the director of the Takshashila Institution, told me in an email, “for they will see you as an adversary for the rest of their long lives.”