Coronavirus In Italy: Lessons From the Frontlines It was the first European country to impose a lockdown. How is it doing now? by Martin J. Bull

Italy has been on the front line of the coronavirus pandemic since it exploded there in late February, and it was the first European country to impose lockdown on its citizens. 

Now the peak of the pandemic has passed, with the total number of positive coronavirus cases in decline since April 21. The “R0” figure (infection rate) has been brought down to below 1. Intensive care beds are being freed up, and 50,000-60,000 coronavirus tests carried out per day.

Prime Minister Giuseppe Conte, moreover, is coming out of the crisis with his reputation enhanced. Despite Italy having the third highest number of coronavirus cases in the world; the highest number of deaths save for the United States; a significant loss of medical personnel; and a veritable capacity crisis early on, Conte’s personal approval ratings are at an unprecedented 71%.

The far-right opposition League, although still the largest party in opinion polls, is disoriented. It has been left shouting largely redundant anti-immigration and anti-EU messages from the sidelines while its ratings decline.

Yet Conte’s real problems could be just about to begin. The economic impact of the continued lockdown is on a scale that has no precedents outside wartime. The projected figures for 2020 of the ministry of the economy, largely in line with those of the IMF, forecast big trouble ahead. GDP is projected to contract by 8% (against a pre-COVID predicted rise of 0.6%), the public deficit to rise from 2.2% to 10.4%, public debt to GDP to rise to an astronomical 155.7% (from a pre-COVID forecast of 135.2%) and the rate of unemployment to 11.6%. Forecasters estimate that 10 million Italians, a fifth of the total number of adults, will be thrown into poverty, unable to meet essential expenditure on food, medicines and a roof over their heads.

The south of the country is predicted to be especially hard hit, which is ironic since the pandemic has hit mainly the north and especially the industrial heartlands of Lombardy. Cases have been far fewer in the south, yet regional leaders there are aware that it is the lockdown that has kept those numbers low and their fragile health systems intact. The northern regions, spurred on by the Confederation of Italian Industry, are leading calls to reopen the economy. The challenge for Conte is how to achieve this without provoking further spikes in COVID-19 cases.

Phase 2

Exiting “phase 1” (lockdown) and going into “phase 2” (living with the virus) will be gradual. Although some industries such as automobiles, components, clothing may be given special permission to start early, May 4 will mark the reopening of the manufacturing sector, including textiles, construction and wholesale commerce.

From May 4 people will be free to travel beyond their municipality for limited reasons and with a self-certification document, but not their region unless visiting a second home. Parks and gardens will reopen. Exercise with other people will be possible, but not team sports, recreational activities or sunbathing.

Bars and restaurants will be permitted to sell takeaways, if ordered online. Funerals will restart but will be limited to a maximum of 15 people. The wearing of masks will be compulsory inside public places, on public transport or wherever social distancing cannot be guaranteed. Public transport will be adjusted to carrying fewer people at any one time.

On May 18, it will be the turn of retail shopping, museums, libraries and cultural centres to reopen; and on June 1 bars, restaurants, hairdressers and wellness centres, as long as they all meet stringent requirements regarding regular disinfecting and social distancing.

Excluded from the list for now are schools, which are not expected to reopen before September; religious services (to the open fury of the Catholic church), cinemas, theatres and nightclubs.

Phase 2 will be accompanied by extensive testing and contact tracing of the virus, and restrictions will be quickly reimposed on a zonal basis if necessary.

The formulation of phase 2 has, inevitably, been a severe test for Conte. His government has been split between those advocating extreme caution in line with the scientific advice, and those wanting a more rapid reopening of the economy. There has been criticism of the lack of clarity in several of the measures.

Surprising Survey in Sweden: Elderly More Likely To Support Government's Herd Immunity Strategy While 40% of 15-29 year olds state that the Swedish response has been sufficient, the corresponding figure is 61% for those above 70. by Erik Wengström

Sweden’s approach to managing the coronavirus outbreak has received considerable attention. In contrast to other countries, Sweden has relied on recommendations about social distancing rather than restricting people’s movements, trusting citizens to follow the official advice. 

While other countries have closed businesses, much remains up and running in Sweden, including cafes and bars. People are advised to limit their movements but not required to stay at home.

Within Sweden, the strategy has spurred a heated debate in the scientific community and drawn scepticism for being high risk.

Critics say making social distancing optional preserves the freedom of the young at the expense of the old, who are more seriously affected by COVID-19. But our new study shows that older people are more supportive of the approach taken by the government than their younger counterparts.

In a survey of more than 1,600 Swedes, opinions were certainly divided, with 31% of respondents rating the nation’s response to the outbreak as not forceful enough. Another 18% were neutral and the remaining 51% considered the response forceful enough. But, despite the argument that the strategy comes at the expense of the old, actually increased with age. Those aged 50 and above – those with elevated risk for severe complications from an infection – are most supportive of the Swedish response. While 40% of 15-29 year olds state that the Swedish response has been sufficient, the corresponding figure is 61% for those above 70.

The age gap in the approval rate of the Swedish strategy persists even after accounting for a range of other background variables – including income and education – that could potentially explain the observed pattern. Importantly, the higher approval rating among the elderly is not a mere reflection of higher trust in the government among this group. So, the striking generational divide does indeed seem to be real and reflect age differences in the perception of the government’s coronavirus strategy.

Another concern raised about the relaxed approach in Sweden is that it puts the economy ahead of the health of citizens.

It’s perhaps therefore not surprising that people who worry about the virus outbreak’s effects on the economy are more satisfied with the Swedish response than those who worry about the impact on the public health system.

This also suggests that even though many experts now reject the idea that a forceful response must be seen as a trade-off between economic and health concerns, the pattern clearly lives on in the minds of the public.

Another critical driver of the perception is a person’s own taste for taking health risks. Respondents with high health-risk tolerance are more likely to approve of Sweden’s response to the pandemic. This indicates that those who can tolerate the risks are more likely to be satisfied with the current – comparatively soft – policy adopted in Sweden.

An international example?

As countries scale down or consider scaling down restrictions, a natural question to ask is how governments should proceed and whether Sweden’s strategy provides a way forward. But there is an important matter to consider here. Trust stands out as a fundamental driver when it comes to whether people approve of the Swedish response. And since Sweden has among the highest levels of trust in the world, the strong relationship between trust and approval of the strategy might suggest its approach would be less successful elsewhere.

To measure trust, respondents had to state to what degree they agreed to the statement: “I assume that people have only the best intentions.” Among those with the lowest level of trust, only around 30% feel that the Swedish reaction has been sufficient. But for those with the highest level of trust, the corresponding figure is above 70%.

Coronavirus Can Affect the Heart of Those Without a Heart Disease People with existing heart disease are worse affected by COVID-19, but the virus can also affect the heart in people without heart disease. by David C Gaze

People with the most severe forms of COVID-19 are often older and have existing health problems. About 10% of COVID-19 patients have heart disease, diabetes and high blood pressure. Yet surprisingly, people with lung disease, such as asthma and chronic obstructive pulmonary disease (COPD) account for only 6% of severe COVID-19 cases. These statistics are similar in patient reports from China, Italy,the UK and the US. 

People with existing heart disease are worse affected by COVID-19, but the virus can also affect the heart in people without heart disease.

In both cases, when there is a severe COVID-19 infection, the heart undergoes a massive inflammatory response called myocarditis. The virus infects the cells of the heart causing the muscle tissue (myocardium) to undergo severe inflammation. This can alter the electrical conduction in the heart, affecting its ability to pump blood around the body. The result of which is less oxygen getting to organs, including the lungs. How this happens is unclear, but there are several possible mechanisms.

First, heart damage may be associated with the way the virus enters the cells. A spike-shaped protein on the surface of the virus locks on to a receptor on the cell surface called ACE2. In patients with underlying heart disease, there are a greater number of ACE2 receptors on the cell surface, which may result in a greater number of virus particles entering the cell causing significantly more inflammation than in people without heart disease.

Second, as with any infection, the body mounts a war against the invading pathogen. This requires more energy and an increased metabolism to fight a systemic viral infection, which is why our temperature goes up during an infection.

The immune system in a relatively healthy person is able to mount an adequate response to the infection and produce antibodies to combat the virus. People with much weaker immune systems, such as the elderly or those with underlying health problems, cannot sufficiently mount this response and fight the viral infection. The infection rages in the body and attacks vital organs especially the lungs and the heart.

Doctors are able to monitor the severity of the myocarditis using a blood test called troponin. This protein is usually found in the heart. It is released into the bloodstream when there is significant heart injury, such as during a heart attack.

Patients in Wuhan who were severely ill were more likely to have a greater concentration of troponin in their bloodstream than those less severely infected. This is also repeated in data from the Italian outbreak.

Cytokine storm

Some COVID-19 patients experience a sudden and severe onset of myocarditis known as fulminant myocarditis. It has been described in dead COVID-19 patients at post mortem (autopsy) or in living patients by a small surgical biopsy of the heart tissue (enodmyocardial biopsy).

The rapid inflammatory response to the virus in fulminant myocarditis is thought to be due to chemical signal burst called a cytokine storm. Cytokines are chemical messengers that are released from immune cells. They attract a great number of the inflammatory cells called T-helper cells to the site of infection.

When patients undergo a cytokine storm there is an unregulated response causing excessive inflammation, which can kill the patient. These patients not only have increased troponin but also increased concentrations of inflammatory markers showing signs of significant viral infection. Drugs to help control the immune system may be of use in controlling the sudden inflammatory response and trials are underway in COVID-19 patients.

Many viral diseases put such a huge strain on the body that the heart often cannot cope so more people die from heart problems than they do from the lung disease. COVID-19 is, in fact, similar to other respiratory pandemics. In 2009 there was a flu pandemic caused by the H1N1 virus – the so-called swine flu pandemic. Patients infected with H1N1 had a greater number of heart-related complications than is normally seen in typical seasonal flu infections with 62% demonstrating fulminant myocarditis.

The good news is that the vast majority of people (98%) with COVID-19 recover with no significant health problems.

The ‘Terrible Moral Choice’ of Reopening European leaders have set out plans for restarting their societies. But the choice isn’t theirs; it belongs to individual citizens. by RACHEL DONADIO

Ever since Emmanuel Macron declared France “at war” with the coronavirus, the entire country has been under home confinement, with residents allowed outside only for urgent needs. So when the government announced a gradual reopening of some businesses and schools starting in May, a deep confusion set in.

Le Monde, the country’s leading daily newspaper, captured some of the anxieties in a live blog taking a flood of reader questions. My neighbors invited people for a barbecue and they’re totally disregarding the confinement measures; what should I do? one asked. If I don’t want to send my children back to school, will I face sanctions? another said. (The answer to the second question is no—a major development in a country where schools are a pillar of the republic and essential to reopening the economy.)

Ever since they imposed lockdowns weeks ago, governments across Europe have taken away individual liberties and kept citizens in their homes to save lives. Now a subtle shift is happening, in which confinement orders are giving way to a reopening that ultimately places more responsibility on individuals. Governments will still communicate public-health directives and decide how and when to reopen businesses and schools, but millions of people will have to make millions of small and large decisions about how to go about their daily life—balancing their own risk tolerance, mental health, and need for income.

Negotiating between lives and livelihoods is not only a political and economic issue; it’s a philosophical one, with consequences that will resonate for years to come. “It’s really a terrible moral choice,” Boris Cyrulnik, a French psychologist and neurologist, told me. “Freedom will lead to death, while constriction and denying people their freedom will stave off death but will bring economic ruin.”

Cyrulnik, who survived the Second World War as an enfant caché—one of thousands of Jewish children sent away by their families to be hidden with foster parents—is an expert in the field of psychological resilience. He views the coronavirus pandemic in a broad context. Pandemics have been with us since the Neolithic period, he said, but the coronavirus interrupts an unprecedented period of peace and prosperity in the West since World War II.

How will we navigate this moment, when we will have to have confidence in ourselves, our governments, and our fellow citizens as we begin to emerge from our homes? Already, levels of trust in leadership vary across Europe and certainly across the United States. Compounding that, we’re reaching the stage in the crisis when our impending freedom can produce even greater anxiety, because the impetus will now be on us as individuals, not just the state, to do the right thing.

Some people—and sometimes I place myself in this category—are grappling with a kind of Stockholm syndrome, in which we’ve grown accustomed to the safe confines of home. But there’s a more vexing element to this new freedom too. For those who have been holed up at home for so long that they’re wary of venturing outside, strangers become threats. How can we trust that others are staying home if they’re sick? How can we know for sure that the person next to us on public transportation isn’t going to infect us? How can we be certain that local businesses are disinfecting surfaces often enough? How can large offices practice social distancing?

In Paris, where I live, some friends tell me they are going crazy working and homeschooling, and are eager to send their children back to school. Others are wary and would rather keep their kids at home. Some I’ve spoken with believe they shouldn’t in good conscience get on a plane this summer; others are eager to jet off to the Mediterranean for summer holidays they planned before the world changed. Coming to terms with the new normal is hard. Our actions will reshape relationships, as we’ll no doubt be more inclined toward quick judgments if we think our friends and relations are acting out of self-interest rather than the greater good. We’re all living in a science experiment—and a political and social-science experiment as well.

Much of Europe is ahead of the United States on the infection curve and offers lessons from the near future. (The state of Georgia is something of an exception, ahead of the rest of the country in reopening some businesses.) Some areas of Europe have been affected more than others, and the bloc is not at all unified in its response to the pandemic. In France, where more than 23,000 people have died of COVID-19, businesses and schools (but not universities) will begin reopening on May 11—if the infection rate stays low enough—but class sizes will be limited, social distancing will be required, and so will wearing masks on transport and in school. Only later will the government decide when cafés and restaurants might reopen.

In Italy, where more than 26,000 people have died of COVID-19, and which went on total lockdown before France, some businesses will begin reopening on May 4 and people will be able to see their family members, but group gatherings will remain banned. Restaurants and hair salons aren’t expected to reopen until June, and then only with social-distancing measures in place. Schools won’t reopen until the fall—a decision intended to protect older people, many of whom live in close proximity to their grandchildren (though in a country where grandparents are more often than not the primary source of child care for working parents, this raises the question of who exactly will look after kids if parents have to go back to work).

Elsewhere in Europe, Austria shut down quickly and has now allowed many businesses to resume, with plans to send students back to school next month with alternating classes. Denmark has already reopened its schools. Sweden never fully went on lockdown, resulting in less economic distress but a significantly higher death toll than those of its Scandinavian neighbors. In Germany, though schools remain closed, some businesses have been operating throughout the confinement period—putting intense pressure on their competitors in countries such as Italy where nonessential industry has been stopped for weeks.

Across the continent, people are unsure of what’s next. “Phase one was a lockdown. Everybody bought it. Now we’re opening up but no one really knows how and when,” says Jana Puglierin, a senior policy fellow at the European Council on Foreign Relations, who lives in Berlin. “What should be the priority? Kids going to school or day care? Or should it be shops opening?”

Governments did not impose lockdowns during the 1918 influenza pandemic, but that crisis still offers lessons. “When there’s a kind of external threat, people band together because they come to redefine the self, in a sense,” says Laura Spinney, the author of Pale Rider: The Spanish Flu of 1918 and How It Changed the World. “It’s still selfish behavior, but the self is defined as the group that’s victimized by the threat. The idea is, we’re all in this together.” But, she told me, “when the threat starts to recede, the collective self starts to fragment. That’s when you see what we might call bad behavior, more selfish behavior in the traditional sense, rather than in the new sense created by the pandemic.”

During the 1918 pandemic in the United States, people were compliant with health directives at first, but as time went on, “you saw the vaccines weren’t working, the doctors weren’t necessarily in control of the situation, trust kind of seeped away, and people’s compliance fell away,” Spinney said. Respecting measures that will prevent the spread of infection is “not a given by any means,” she said, “and governments have to work hard with their messaging and so on to keep it up.” Again, the shift here is one from government-mandated rules to a greater sense of individual responsibility.

Europe, a patchwork of countries with different time frames for reopening, is facing some of the same challenges as the United States. The European Union, though not a federal entity, has 27 member states whose citizens can, in theory, move freely across borders from one country to another. What one government decides will have implications for its neighbors—as with states in the U.S.—just as each of our individual decisions will affect our communities. European leaders can attempt to issue edicts from on high, but decisions will be made by politicians, and individuals, at the national and local levels. (The EU, for its part, has issued a road map to member countries, but it has no power to set policy across the bloc.)

Cyrulnik said that even if we regain the ability to make important decisions in our daily lives, the pandemic is a reminder of the limits of our liberty. “We have degrees of freedom, which are very important, but I think that we are much more constrained by our environments than we believe,” he said. For the foreseeable future, we will have to make “lots of little decisions—to go to school or not, to go on a trip or not.” Our choices will affect infection rates and government policies. How we navigate between trust and fear will reshape us not only as citizens, but as friends, families, and neighbors.

States Are Using the Pandemic to Roll Back Americans’ Rights Some state governments are criminalizing and censoring lawful speech under the guise of protecting public health. by Ronald J. Krotoszynski, Jr.

The coronavirus pandemic has led governments around the world to adopt draconian measures. Some of these, such as social-distancing mandates, are, quite obviously, bona fide and necessary efforts to control the rate of virus spread. Others, however, pretty clearly constitute a form of pandemic political opportunism, such as in Hungary, where the national Parliament dissolved itself after granting Prime Minister Viktor Orbán the power to rule (indefinitely) directly and by decree.
To date, U.S. President Donald Trump has not used the crisis to seize power and establish autocracy in the United States. To be sure, Trump is doing plenty to undermine American institutions—repeatedly attacking the press and individual journalists, actively weakening essential forms of oversight and accountability (even as the federal government has committed more than $2 trillion in direct spending to combat the pandemic), and firing or reassigning government employees, including scientists who publicly contradict his error-laden daily talking points—but the president has not (yet) attempted to use law to directly stifle voices that criticize him and his administration’s policies.

Unfortunately, that we do not see efforts to censor speech coming from the White House does not mean that such efforts are not actually happening in America. One need merely look to the statehouses for examples of this public-health crisis being used to implement measures that criminalize or impose civil liability on otherwise lawful forms of public dissent. A cynical political aphorism posits that one should “never let a good crisis go to waste,” and some state governments appear to be taking this maxim to heart. Invoking the need to protect “essential” or “critical” fossil-fuel infrastructure, several states recently have adopted laws that threaten environmental-protest organizers with various forms of vicarious civil and criminal liability.

Last month, Kentucky, South Dakota, and West Virginia all adopted statutes that criminalize protests of fossil-fuel development and also enable energy companies to seek damages from protest organizers. The newly enacted laws designate “natural gas or petroleum pipelines” as “key infrastructure assets” and criminalize “tampering with, impeding, or inhibiting operations of a key infrastructure asset.” The Kentucky law, passed by a GOP-controlled legislature and signed into law by the state’s Democratic governor, Andy Beshear, provides both criminal and civil penalties for anyone who damages property or for any person or organization that “directs or causes a person to violate” the law.

West Virginia’s new law is substantially similar. The West Virginia Critical Infrastructure Protection Act threatens environmental protesters with both fines and criminal sanctions. At a state legislative committee’s public hearing on the bill, Reverend Jim Lewis, an Episcopal minister, correctly observed, “This bill is designed to chill protesters.” Like Kentucky’s new law, the West Virginia statute makes “conspiring” to cause or inciting trespass or damage to fossil-fuel facilities a legal basis for imposing civil and criminal liability on protest organizers (including mainstream public-interest organizations). Accordingly, this law, like Kentucky’s, will have a profound chilling effect on perfectly lawful speech.

South Dakota enacted two laws: S.B. 151, which mirrors the Kentucky and West Virginia laws by declaring oil and natural-gas facilities to be “critical infrastructure,” and H.B. 1117, which creates civil and criminal penalties for incitement to riot as well as civil liability for both “riot” and “riot boosting” (which applies when a person “does not personally participate in any riot but directs, advises, encourages, or solicits other persons” to riot). H.B. 1117 does provide that the law should not be used “to prevent the peaceable assembly of persons for lawful purposes of protest or petition” or “to include the oral or written advocacy of ideas or expression of belief that does not urge the commission of an act or conduct of imminent force or violence.” However, if a speaker at a protest issues a general call “to stop this pipeline project now!,” and someone attending the rally subsequently trespasses on a pipeline work site, the terms of the South Dakota laws are sufficiently open-ended regarding joint and several liability that the pipeline company might be able to pursue a civil claim against the rally organizers for either “riot boosting” or conspiracy.

All three of these laws could easily be used to create vicarious liability for environmental groups that organize otherwise-lawful protests of carbon-based fuels. Going forward, speakers at completely peaceful environmental protests will need to choose their words with great care—lest they find themselves hauled into court to answer for criminal mischief committed by someone who happened to attend one of the organization’s events.

For example, if someone who attends a protest rally later commits an unlawful act that affects a natural-gas or oil facility, the protest organizer could face liability for “directing” or “causing” the damage. An organization such as Greenpeace, which advocates for renewable sources of energy and opposes continued reliance on fossil fuels, could be charged criminally or face a civil action if one of its members trespasses on or otherwise causes damage to an energy production site. Under criminal law, environmental organizations would face the risk of conspiracy charges; under civil law, energy companies could seek potentially bankrupting compensatory and punitive damages from such organizations. (The Fifth Circuit recently sustained exactly this kind of ersatz respondeat superior liability on a civil-rights protest organizer, despite the fact that taking this approach will have an astonishingly broad chilling effect on collective-protest activities; the decision is currently on appeal to the Supreme Court.)

These state laws are simply part of a broad, ongoing effort to squelch public forms of dissent in the United States. Since the Warren and Burger Courts, the speech rights of ordinary Americans have been shrinking. Salient examples include the National Park Service closing off access to government property that is perfectly suitable for public-protest activity (including the Jefferson Memorial and virtually all of the St. Louis Arch and Gateway Arch park); federal, state, and local government employers alike retaliating against whistleblowers (including demoting or even firing them); and the Department of State issuing total bans on transborder speech and free association by U.S. citizens with persons or organizations located abroad. In all three of these examples, the federal courts have upheld the government’s censorial actions against First Amendment challenges.

The country has seen the kind of government opportunism now on display in Kentucky, South Dakota, and West Virginia before. Just over 100 years ago, during the First World War, President Woodrow Wilson set about banning any and all public criticism of the federal government and the war effort. Congress passed laws such as the Espionage Act of 1917 and the Sedition Act of 1918, which effectively criminalized public expressions of dissent, and many states adopted “criminal syndicalism” acts that criminalized the expression of certain political and ideological opinions. The Supreme Court sustained these enactments and permitted U.S. citizens to be imprisoned for their public opposition to the war (perhaps the most famous being the labor leader Eugene Debs).

America must not permit its past to serve as prologue. Americans must not permit a public-health crisis to be turned into a crisis of democracy as well.

It is possible to promote public health without squelching dissent. Michigan Governor Gretchen Whitmer’s measured response to anti-lockdown protests in the state capital earlier this month provides a worthy example in this regard. Part of the protest, named “Operation Gridlock” by its sponsors, the Michigan Conservative Coalition and the Michigan Freedom Fund, complied with social-distancing orders: Drivers came to the state capitol in their vehicles to petition the government for an end to the restrictions. Other aspects of the protest, however, involved open civil disobedience of those orders‚ including in-person collective protest at the state capitol building that created a nontrivial risk of virus spread.

Whitmer did not move to arrest the protesters or end the in-person rally (although doing so would have been perfectly constitutional). Instead, she wisely used the event as a teaching moment for Michigan residents. The governor characterized “Operation Gridlock” as a “a political rally” that “endanger[ed] people’s lives, because this is precisely how COVID-19 spreads.” She added that the protesters were “not just endangering their own lives” but also “all of our first responders and our ability to meet the needs of the people of the state who are all trying to do the right thing.” Whitmer’s measured, calibrated response reflects both admirable restraint and obvious respect for the First Amendment. Arresting the protesters would have wasted scarce public-safety resources, endangered the health of the arresting officers and jail staff, and could easily have backfired by inciting others to engage in mass public protests without observing social-distancing rules.

A deliberative democracy that uses elections to hold the government accountable simply cannot function in the absence of free and open debate. As George Washington explained in his farewell address, “in proportion as the structure of a government gives force to public opinion, it is essential that public opinion should be enlightened." Public discourse and engagement are essential means of ensuring that the electorate has the information required to render prudent electoral verdicts.

Some years ago, Vincent Blasi, a professor at Columbia Law School, wrote a seminal law-review article entitled “The Pathological Perspective and the First Amendment.” In it, Blasi calls on federal and state courts to vigilantly protect the process of democratic deliberation in times of national stress and tumult—in times like the present. Blasi explains, “The overriding objective at all times should be to equip the first amendment to do maximum service in those historical periods when intolerance of unorthodox ideas is most prevalent and when governments are most able and most likely to stifle dissent systematically.” Why? Because such times are precisely when the process of democratic deliberation is most needed to ensure that the government adopts and enforces wise policies and, paradoxically, also when the government will be most tempted to censor speech critical of its actions. Accordingly, and as Blasi argues, the First Amendment “should be targeted for the worst of times”—which is to say: now.

Efficiency Is Biting Back Decades of streamlining everything made the U.S. more vulnerable. by Edward Tenner

The global quarantine, an optimist might argue, is pushing us toward a more web-mediated world. Millions of people who had seldom, if ever, used videoconferencing before March are now doing their jobs without a long commute, taking classes without getting on a school bus, or consulting a doctor without first sitting in a waiting room full of sick people. These changes are, by some standards, a form of efficiency. Yet the pandemic has forced them on us even as their benefits have yet to be firmly established. Who can predict not just test scores but long-term outcomes of remote learning? And who can say whether a physician’s physical presence and touch are truly irrelevant to protecting a patient’s health?
If the coronavirus pandemic does ultimately make our lives more efficient, it will be ironic. For decades, even before Silicon Valley championed the “disruptive technologies” of the web, leaders in business and government alike have declared war on allegedly wasteful spending. Overlooked is the fact that too much zeal for lean operation has pitfalls of its own. In practice, the pursuit of efficiency has often resulted in the consolidation of smaller companies and facilities into larger ones; in greater congestion as more people are packed into smaller spaces, whether in office towers or aboard commercial airliners; and in the tight coupling of deliveries and other business processes in ways that, at least when all goes well, speed up production and reduce warehouse inventories. But consolidation, congestion, and tight coupling may also make our economy less efficient in the long run—and our society more vulnerable to outside shocks such as the coronavirus. Efficiency, in fact, can be hazardous to our well-being, and a strategic amount of inefficiency is crucial in keeping society healthy.

Consolidation has long been a feature of American economic life, and corporate mergers and acquisitions are routinely justified as saving money and creating other efficiencies. Unsurprisingly, mergers have reshaped even nonprofit health care, as formerly independent hospitals have joined into larger systems. Writing in The New York Times in February 2019, the health-care economist Austin Frakt disputed hospital chains’ claims that consolidation had lowered costs and improved health outcomes.

As costs of health care have escalated, doing more with less has become a universal goal. Over the past two decades, the state of New York pressed for the elimination of 20,000 hospital beds. The pursuit of efficiency in the state’s health system was a bipartisan effort, originating in a 2006 report from a commission convened by Republican Governor George Pataki and continued by his Democratic successors, including Andrew Cuomo. The commission urged an occupancy rate of 85 percent, up from an allegedly wasteful 65 percent in 2004. Many of the hospitals closed during this wave of consolidation served the most economically troubled neighborhoods of New York City—neighborhoods that, in March and April, were disproportionately struck by the pandemic. Once COVID-19 threatened to overwhelm the New York hospital system, Cuomo was pleading with Washington, D.C., for additional beds.

Fortunately, because of public compliance with social-distancing measures, the need for hospital beds has proved less dire than authorities feared. But New York’s experience illustrates the difficulty of adding useful hospital space from scratch at moments of crisis; the Navy hospital ship USNS Comfort, which came to New York’s assistance, was ill-equipped for treating coronavirus cases and was of little help in absorbing patients with other ailments. The ship is now slated to depart.

In theory, efforts to make American health systems more efficient could have made them nimbler. In New York, the expansion of preventive and primary care was supposed to accompany the closure of hospitals. But that did not occur in many poor areas. Meanwhile, cutbacks in hospitalization nationwide have simply pushed unwell people into other forms of care. “Nursing home facilities,” The New York Times reported earlier this month, “have borne the brunt of a structural shift: Hospitals, seeking to keep costs down, send more vulnerable patients into a growing industry of nursing homes.” About a fifth of COVID-19 fatalities in the United States, the Times noted, have been linked to nursing-home and long-term care facilities.

The pandemic also exposed weaknesses not just in the extension of human life but in the provision of food that sustains it—specifically in the giant slaughterhouses and meat-packing plants of rural America. According to a 2000 report from the U.S. Department of Agriculture, new technology in the previous 20 years had revolutionized meat processing, increasing production in fewer plants through economies of scale. This evolution, which benefited shareholders far more than workers, produced today’s highly consolidated industry. While the early-20th-century horrors depicted in Upton Sinclair’s novel The Jungle are gone, meat cutting remains one of the most hazardous jobs, with workers often crowded together. Viral infections can spread at small plants, but at larger ones they can strike far more people more quickly. While the risk to consumers may be relatively small, a single asymptomatic infected worker could transmit the virus from the community to hundreds of fellow workers, or vice versa. At a Smithfield Foods plant in Sioux Falls, South Dakota, more than 700 workers have tested positive for the coronavirus. That plant alone handles up to 5 percent of the entire nation’s pork production, and its shutdown forced the closure of other Smithfield plants that use raw materials from Sioux Falls. The closure of a single plant can devastate the meat supply and agriculture of an entire region. The Tyson Foods plant in Pasco, Washington, that closed on Thursday for COVID-19 testing processes 2,300 head of cattle a day, reportedly supplying enough beef to feed 4 million people. The Trump administration announced yesterday it would designate meat plants as essential infrastructure and require them to remain open. This short-term move will not reverse the trends that brought about the current problem.

Concentration of industries does not necessarily imply that the physical facilities they operate will be jam-packed with people. Yet organizations small and large—in manufacturing, in white-collar industries, and in the transportation world—have been methodically congesting more people in fewer square feet as a way of cutting costs. Until governments decreed social distancing, executives and investment analysts spent years praising tighter occupancy as rational and efficient. Grumbling away, passengers on commercial airlines chose cheaper fares over legroom. Seat pitches—the distances between rows on jets—have contracted. Empty middle seats have grown rare. From 2002 to 2018, occupancy on U.S. domestic flights grew from about 68 percent to 86 percent. While modern planes filter microbes and pollutants effectively from circulating cabin air, crowded flights increase opportunities for infection from the breath of nearby passengers. As far into the pandemic as April 23, the New York Post reported, an American Airlines flight from Miami to New York was almost full, with only half of the passengers wearing face coverings. (The airline has since announced measures to reduce density.)

Travelers can sometimes pay extra to mitigate overcrowding. Office workers, like meatpackers, generally cannot. The open-plan office is a paradise for microbes, not people. Mark Zuckerberg described Facebook’s planned new headquarters in 2012 as “the perfect engineering space: one giant room that fits thousands of people, all close enough to collaborate together.” Yet studies of Swedish open-plan offices from several years earlier had found that density correlated with more frequent sick leave. Repeated moves of seats and laptops allow viruses to linger for hours on surfaces; much-vaunted snack bars in common spaces may encourage more hand-to-mouth contact. Nonetheless, in a single year, 2018 to 2019, per capita office space declined by more than 14 percent, to 195.6 square feet, according to a report by the real-estate brokerage JLL cited by The Wall Street Journal. Reporting on Amazon’s office leases in Bellevue, Washington, near Seattle, the Puget Sound Business Journal noted last year that 150 square feet of office space per worker was the standard in the area, and that some technology companies provided as little as 100. The troubled co-working giant WeWork tried to present itself as a tech company, but perhaps a more significant innovation was this: “It jams more people into its spaces,” Bloomberg News reported last year, “than just about any other commercial landlord.” The company offers about 55 square feet per workstation on average, and one London branch offers only 44, Bloomberg calculated. (Other analysts have cited similar estimates.) So far, no cases of COVID-19 have been conclusively tied to office environments like these, but the danger of community spread is obvious.   

A further consequence of the relentless drive for efficiency is what Charles Perrow, a sociologist of technological risk, has described as “tight coupling.” It happens when a system is so dependent on a series of linkages that the collapse of one of them can lead to a cascade of failure. This occurs most notoriously in conventional nuclear-power plants, but Perrow’s warning applies to other situations. Global networks of vendors, coordinated by the web and tapping overnight air-freight services, have long replaced the early-20th-century ideal of Henry Ford’s River Rouge, Michigan, plant, which united as much production as possible from raw materials on-site. From the now-forgotten Japanese productivity scare of the 1980s—during which many in the United States feared that the island nation’s hyperefficient manufacturing industries would crush our economy—American business learned just-in-time production, reducing inventories and storage costs. But in the absence of excess capacity, even around-the-clock operation has not produced enough masks and disinfecting wipes for health-care workers, let alone average citizens. Efficient in normal conditions, just-in-time techniques have been disastrous in the global fight against COVID-19, pitting nations—and even U.S. states—against one another.

The pain, grief, and economic ruin brought by the pandemic should teach us that efficiency—though still a worthy goal—must be tempered by what can only be called “strategic inefficiency.” We must make room for an optimum amount of waste. Strategic inefficiency does not mean simply going back to old ways. It does mean recognizing and paying for redundancy and flexibility—larger stocks of essential materials, spaces designed to be reconfigured as hospital rooms, just as the SS United States was designed to be readily converted to a troop ship in wartime. Likewise, calculations about the minimum square footage that office workers need will have to take into account the threat of contagion. We have all seen signs warning about occupancy levels that are “dangerous and unlawful.” We need to rethink office plans and co-working spaces; higher rents can be less expensive than insurance bills and sick days. We also need to look more skeptically at industry trends that may make society more vulnerable by concentrating production in a small number of giant plants.

But I fear that the many economic and social upheavals caused by the pandemic will lead not to greater caution, but to a redoubled search for efficiency through the same old methods of consolidation, congestion (at least once the urgency of social distancing fades), and tight coupling—along with more recent trends such as distance learning, telecommuting, and telemedicine. These internet-driven ideas, at least, may prove to have considerable merits.

But one caveat is worth keeping in mind: Arrangements that initially appear beneficial may turn out to have hidden flaws that reveal themselves only slowly. Even when experts conscientiously vet a proposed intervention for unwanted side effects, they cannot always find them. The medical field offers a cautionary example: The screening of new medicines by the FDA is time-consuming and costly, and that process sets a world standard of rigor. Yet according to the Harvard Health Blog, a study of all drugs the agency approved from 2001 to 2010 revealed that the FDA had issued alerts, warnings, or even recalls for a third of them.

A technological wonder such as free teleconferencing can gain widespread adoption without undergoing any such scrutiny. During the pandemic, the drawbacks of life on Zoom have become obvious in real time. One might think that showing the facial expressions of all participants in a meeting at once would promote better communication. In fact, these videoconferences force everyone to work harder in processing nonverbal cues. “Our minds are together when our bodies feel we’re not,” Gianpiero Petriglieri, a professor at the business school INSEAD, told the BBC. “That dissonance, which causes people to have conflicting feelings, is exhausting. You cannot relax into the conversation naturally.” In other words, videoconferencing is less efficient than a regular meeting.

Even failed experiments can be good for efficiency in the long run—if society can learn from them. The basic lesson is that innovations should be correctable and even reversible with experience. But whichever paths we choose, we need to remember that the greater fragility of society is too high a price to pay to save a little money and time.

Why the Coronavirus Is So Confusing. A guide to making sense of a problem that is now too big for any one person to fully comprehend. by Ed Yong

On march 27, as the U.S. topped 100,000 confirmed cases of COVID-19, Donald Trump stood at the lectern of the White House press-briefing room and was asked what he’d say about the pandemic to a child. Amid a meandering answer, Trump remarked, “You can call it a germ, you can call it a flu, you can call it a virus. You know, you can call it many different names. I’m not sure anybody even knows what it is.”

That was neither the most consequential statement from the White House, nor the most egregious. But it was perhaps the most ironic. In a pandemic characterized by extreme uncertainty, one of the few things experts know for sure is the identity of the pathogen responsible: a virus called SARS-CoV-2 that is closely related to the original SARS virus. Both are members of the coronavirus family, which is entirely distinct from the family that includes influenza viruses. Scientists know the shape of proteins on the new coronavirus’s surface down to the position of individual atoms. Give me two hours, and I can do a dramatic reading of its entire genome.

But much else about the pandemic is still maddeningly unclear. Why do some people get really sick, but others do not? Are the models too optimistic or too pessimistic? Exactly how transmissible and deadly is the virus? How many people have actually been infected? How long must social restrictions go on for? Why are so many questions still unanswered?

The confusion partly arises from the pandemic’s scale and pace. Worldwide, at least 3.1 million people have been infected in less than four months. Economies have nose-dived. Societies have paused. In most people’s living memory, no crisis has caused so much upheaval so broadly and so quickly. “We’ve never faced a pandemic like this before, so we don’t know what is likely to happen or what would have happened,” says Zoë McLaren, a health-policy professor at the University of Maryland at Baltimore County. “That makes it even more difficult in terms of the uncertainty.”

But beyond its vast scope and sui generis nature, there are other reasons the pandemic continues to be so befuddling—a slew of forces scientific and societal, epidemiological and epistemological. What follows is an analysis of those forces, and a guide to making sense of a problem that is now too big for any one person to fully comprehend.

I. The Virus

Because coronavirus wasn’t part of the popular lexicon until SARS-CoV-2 ran amok this year, earlier instances of the term are readily misconstrued. When people learned about a meeting in which global leaders role-played through a fictional coronavirus pandemic, some wrongly argued that the actual pandemic had been planned. When people noticed mentions of “human coronavirus” on old cleaning products, some wrongly assumed that manufacturers had somehow received advance warning.

There isn’t just one coronavirus. Besides SARS-CoV-2, six others are known to infect humans—four are mild and common, causing a third of colds, while two are rare but severe, causing MERS and the original SARS. But scientists have also identified about 500 other coronaviruses among China’s many bat species. “There will be many more—I think it’s safe to say tens of thousands,” says Peter Daszak of the EcoHealth Alliance, who has led that work. Laboratory experiments show that some of these new viruses could potentially infect humans. SARS-CoV-2 likely came from a bat, too.

It seems unlikely that a random bat virus should somehow jump into a susceptible human. But when you consider millions of people, in regular contact with millions of bats, which carry tens of thousands of new viruses, vanishingly improbable events become probable ones. In 2015, Daszak’s team found that 3 percent of people from four Chinese villages that are close to bat caves had antibodies that indicated a previous encounter with SARS-like coronaviruses. “Bats fly out every night over their houses. Some of them shelter from rain in caves, or collect guano for fertilizer,” Daszak says. “If you extrapolate up to the rural population, across the region where the bats that carry these viruses live, you’re talking 1 [million] to 7 million people a year exposed.” Most of these infections likely go nowhere. It takes just one to trigger an epidemic.

Once that happens, uncertainties abound as scientists race to characterize the new pathogen. That task is always hard, but especially so when the pathogen is a coronavirus. “They’re very hard to work with; they don’t grow very well in cell cultures; and it’s been hard to get funding,” says Vineet Menachery of the University of Texas Medical Branch. He is one of just a few dozen virologists in the world who specialize in coronaviruses, which have attracted comparatively little attention compared with more prominent threats like flu. The field swelled slightly after the SARS epidemic of 2003, but then shrunk as interest and funding dwindled. “It wasn’t ’til MERS came along [in 2012] that I even thought I could have an academic career on coronaviruses,” Menachery says.

The tight group of coronavirologists is now racing to make up for years of absent research—a tall order in the middle of a pandemic. “We’re working as hard as possible,” says Lisa Gralinski, a virologist at the University of North Carolina. “Our space is so intermingled that we can’t socially distance among ourselves much.”

One small mercy, she notes, is that SARS-CoV-2 isn’t changing dramatically. Scientists are tracking its evolution in real time, and despite some hype about the existence of different strains, the virologists I’ve spoken with largely feel that the virus is changing at a steady and predictable pace. There are no signs of “an alarming mutation we need to be worried about,” Gralinski says. For now, the world is facing just one threat. But that threat can manifest in many ways.

II. The Disease

SARS-CoV-2 is the virus. COVID-19 is the disease that it causes. The two aren’t the same. The disease arises from a combination of the virus and the person it infects, and the society that person belongs to. Some people who become infected never show any symptoms; others become so ill that they need ventilators. Early Chinese data suggested that severe and fatal illness occurs mostly in the elderly, but in the U.S. (and especially in the South), many middle-aged adults have been hospitalized, perhaps because they are more likely to have other chronic illnesses. The virus might vary little around the world, but the disease varies a lot.

This explains why some of the most important stats about the coronavirus have been hard to pin down. Estimates of its case-fatality rate (CFR)—the proportion of diagnosed people who die—have ranged from 0.1 to 15 percent. It’s frustrating to not have a firm number, but also unrealistic to expect one. “Folks are talking about CFR as this unchangeable quantity, and that is not how it works,” says Maia Majumder, an epidemiologist at Harvard Medical School and Boston Children’s Hospital.

The CFR’s denominator—total cases—depends on how thoroughly a country tests its population. Its numerator—total deaths—depends on the spread of ages within that population, the prevalence of preexisting illnesses, how far people live from hospitals, and how well staffed or well equipped those hospitals are. These factors vary among countries, states, and cities, and the CFR will, too. (Majumder and her colleagues are now building tools for predicting regional CFRs, so local leaders can determine which regions are most vulnerable.)

The variability of COVID-19 is also perplexing doctors. The disease seems to wreak havoc not only on lungs and airways, but also on hearts, blood vessels, kidneys, guts, and nervous systems. It’s not clear if the virus is directly attacking these organs, if the damage stems from a bodywide overreaction of the immune system, if other organs are suffering from the side effects of treatments, or if they are failing due to prolonged stays on ventilators.

Past coronavirus epidemics offer limited clues because they were so contained: Worldwide, only 10,600 or so people were ever diagnosed with SARS or MERS combined, which is less than the number of COVID-19 cases from Staten Island. “For new diseases, we don’t see 100 to 200 patients a week; it usually takes a whole career,” says Megan Coffee, an infectious-disease doctor at NYU Langone Health. And “if you see enough cases of other diseases, you’ll see unusual things.” During the flu pandemic of 2009, for example, doctors also documented heart, kidney, and neurological problems. “Is COVID-19 fundamentally different to other diseases, or is it just that you have a lot of cases at once?” asks Vinay Prasad, a hematologist and an oncologist at Oregon Health and Science University.

Prasad’s concern is that COVID-19 has developed a clinical mystique—a perception that it is so unusual, it demands radically new approaches. “Human beings are notorious for our desire to see patterns,” he says. “Put that in a situation of fear, uncertainty, and hype, and it’s not surprising that there’s almost a folk medicine emerging.” Already, there are intense debates about giving patients blood thinners because so many seem to experience blood clots, or whether ventilators might do more harm than good. These issues may be important, and when facing new diseases, doctors must be responsive and creative. But they must also be rigorous. “Clinicians are under tremendous stress, which affects our ability to process information,” McLaren says. “‘Is this actually working, or does it seem to be working because I want it to work and I feel powerless?’”

Consider hydroxychloroquine—the antimalarial drug that’s been repeatedly touted by the White House and conservative pundits as a COVID-19 “game changer.” The French studies that first suggested that the drug could treat COVID-19 were severely flawed, abandoning standard elements of solid science like randomly assigning patients to receive treatments or placebos, or including a control group to confirm if the drug offers benefits above normal medical care. The lead scientist behind those studies has railed against the “dictatorship of the methodologists,” as if randomization or controls were inconveniences that one should rebel against, rather than the backbone of effective medicine.

Larger (but still preliminary) studies from the U.S., France, and China have cast doubt on hydroxychloroquine’s effectiveness, and because it can cause heart problems, the National Institutes of Health has recommended against using it outside clinical trials. Those trials will offer clearer answers by the summer, and the drug may yet prove beneficial. For now, doctors are routinely prescribing it without knowing if it works or, crucially, if it does more harm than good. Meanwhile, people with lupus and rheumatoid arthritis, who actually need hydroxychloroquine, can’t get it. It is not the case that every new study contributes to our understanding of COVID-19. Sloppy ones are a net negative, adding to the already considerable uncertainty by offering the illusion of confidence where none exists.

III. The Research

Since the pandemic began, scientists have published more than 7,500 papers on COVID-19. But despite this deluge, “we haven’t seen a lot of huge plot twists,” says Carl Bergstrom, an epidemiologist and a sociologist of science at the University of Washington. The most important, he says, was the realization that people can spread the virus before showing symptoms. But even that insight was slow to dawn. A flawed German study hinted at it in early February, but scientific opinion shifted only after many lines of evidence emerged, including case reports, models showing that most infections are undocumented, and studies indicating that viral levels peak as symptoms appear.  

This is how science actually works. It’s less the parade of decisive blockbuster discoveries that the press often portrays, and more a slow, erratic stumble toward ever less uncertainty. “Our understanding oscillates at first, but converges on an answer,” says Natalie Dean, a statistician at the University of Florida. “That’s the normal scientific process, but it looks jarring to people who aren’t used to it.”

For example, Stanford University researchers recently made headlines after testing 3,330 volunteers from Santa Clara County for antibodies against the new coronavirus. The team concluded that 2.5 to 4.2 percent of people have already been infected—a proportion much higher than the official count suggests. This, the authors claimed, means that the virus is less deadly than suspected, and that severe lockdowns may be overreactions—views they had previously espoused in opinion pieces. But other scientists, including statisticians, virologists, and disease ecologists, have criticized the study’s methods and the team’s conclusions.

One could write a long article assessing the Santa Clara study alone, but that would defeat the point: that individual pieces of research are extremely unlikely to single-handedly upend what we know about COVID-19. About 30 similar “serosurveys” have now been released. These and others to come could collectively reveal how many Americans have been infected. Even then, they would have to be weighed against other evidence, including accounts from doctors and nurses in New York or Lombardy, Italy, which clearly show that SARS-CoV-2 can crush health-care systems. The precise magnitude of the virus’s fatality rate is a matter of academic debate. The reality of what it can do to hospitals is not.

The scientific discussion of the Santa Clara study might seem ferocious to an outsider, but it is fairly typical for academia. Yet such debates might once have played out over months. Now they are occurring over days—and in full public view. Epidemiologists who are used to interacting with only their peers are racking up followers on Twitter. They have suddenly been thrust into political disputes. “People from partisan media outlets find this stuff and use a single study as a cudgel to beat the other side,” Bergstrom says. “The climate-change people are used to it, but we epidemiologists are not.”

In an earlier era, issues with the Santa Clara study would have been addressed during peer review—the process in which scientific work is assessed by other researchers before being published in a journal. But like many COVID-19 studies, this one was uploaded as a preprint—a paper that hasn’t yet run the peer-review gauntlet. Preprints allow scientists to share data quickly, and speed is vital in a pandemic: Several important studies were uploaded and discussed a full month before being published.

Preprints also allow questionable work to directly enter public discourse, but that problem is not unique to them. The first flawed paper on hydroxychloroquine and COVID-19 was published in a peer-reviewed journal, whose editor in chief is one of the study’s co-authors. Another journal published a paper claiming that the new coronavirus probably originated in pangolins, after most virologists had considered and dismissed that idea.

Meanwhile, scientists are poring over preprints in open online spaces: The Santa Clara study may not have been formally peer-reviewed, but it has very much been reviewed by peers. It is easier than ever for journalists to assess how new research is being received, but only some are presenting these debates to their audience. Others are not. Some are even reporting on press-released research that hasn’t been uploaded as a preprint. “The rules for reporting on preprints shouldn’t be any different from reporting on journal articles,” the journalist Ivan Oransky told the media watchdog Health News Review. “Everything needs to be scrutinized beyond belief.”

Such scrutiny will become ever more necessary as the pandemic wears on. Julie Pfeiffer of UT Southwestern, who is an editor at the Journal of Virology, says that she and her colleagues have been flooded with submitted papers, most of which are so obviously poor that they haven’t even been sent out for review. “They shouldn’t be published anywhere,” she says, “and then they end up [on a preprint site].” Some come from nonscientists who have cobbled together a poor mathematical model; others come from actual virologists who have suddenly pivoted to studying coronaviruses and “are submitting work they never normally would in a rush to be first,” Pfeiffer says. “Some people are genuinely trying to help, but there’s also a huge amount of opportunism.”

IV. The Experts

Last month, the legal scholar Richard Epstein claimed that “the current organized panic in the United States does not seem justified” and that as the pandemic continued, “good news is more likely than bad.” His piece was widely circulated in conservative circles and the Trump administration. When asked about his lack of epidemiological training in an interview with The New Yorker’s Isaac Chotiner, Epstein responded, “One of the things you get as a lawyer is a skill of cross-examination. I spent an enormous amount of time over my career teaching medical people about some of this stuff.” His essay initially speculated that 500 Americans would die from COVID-19. He later updated that estimate to 5,000. So far, the death toll stands at 58,000, and is still rising.

Many other non-epidemiologists seem to have similarly accrued expertise in the field. The military historian Victor Davis Hanson proffered the widely shared idea that the coronavirus has been spreading in California since last fall—a claim disproved by genetic studies showing that the earliest U.S. case likely arrived in January. During a White House meeting, the economist Peter Navarro reportedly pointed to a pile of hydroxychloroquine studies and said, “That’s science, not anecdote” to Anthony Fauci, who has worked in public health for five decades and directs the National Institute of Allergy and Infectious Diseases. The Silicon Valley technologist Aaron Ginn self-published an article on Medium called “Evidence Over Hysteria—COVID-19” that was viewed millions of times before being debunked by Bergstrom and taken down.

Expertise is not just about knowledge, but also about the capacity to spot errors. Ginn couldn’t see them in his own work; Bergstrom could. The rest of us are more likely to fall in the former group than the latter. We hunger for information, but lack the know-how to evaluate it or the sources that provide it. “This is the epistemological crisis of the moment: There’s a lot of expertise around, but fewer tools than ever to distinguish it from everything else,” says Zeynep Tufekci, a sociologist at the University of North Carolina and an Atlantic contributing writer. “Pure credentialism doesn’t always work. People have self-published a lot of terrible pieces on Medium, but some of the best early ones that explained stuff to laypeople were from tech guys.”

Bergstrom agrees that experts shouldn’t be dismissive gatekeepers. “There’s a lot of talent out there, and we need all hands on deck,” he says. For example, David Yu, a hockey analyst, created a tool that shows how predictions from the most influential COVID-19 model in the U.S. have changed over time. “Looking at that thing for, like, an hour helped me see things I hadn’t seen for three weeks,” Bergstrom says.

A lack of expertise becomes problematic when it’s combined with extreme overconfidence, and with society’s tendency to reward projected confidence over humility. “When scientists offer caveats instead of absolutes,” Gralinski says, “that uncertainty we’re trained to acknowledge makes it sound like no one knows what’s going on, and creates opportunities for people who present as skeptics.” Science itself isn’t free from that dynamic, either. Through flawed mechanisms like the Nobel Prize, the scientific world elevates individuals for work that is usually done by teams, and perpetuates the myth of the lone genius. Through attention, the media reward voices that are outspoken but not necessarily correct. Those voices are disproportionately male.

The idea that there are no experts is overly glib. The issue is that modern expertise tends to be deep, but narrow. Even within epidemiology, someone who studies infectious diseases knows more about epidemics than, say, someone who studies nutrition. But pandemics demand both depth and breadth of expertise. To work out if widespread testing is crucial for controlling the pandemic, listen to public-health experts; to work out if widespread testing is possible, listen to supply-chain experts. To determine if antibody tests can tell people if they’re immune to the coronavirus, listen to immunologists; to determine if such testing is actually a good idea, listen to ethicists, anthropologists, and historians of science. No one knows it all, and those who claim to should not be trusted.

In a pandemic, the strongest attractor of trust shouldn’t be confidence, but the recognition of one’s limits, the tendency to point at expertise beyond one’s own, and the willingness to work as part of a whole. “One signature a lot of these armchair epidemiologists have is a grand solution to everything,” Bergstrom says. “Usually we only see that coming from enormous research teams from the best schools, or someone’s basement.”

V. The Messaging

In the early months of the pandemic, while the coronavirus blazed through China, even veteran disease experts seemed to misjudge the odds that the epidemic would become a full-blown pandemic. On January 26, Fauci himself said the virus posed a “very, very low risk to the United States” and was a concern for public-health officials, but not the public. Many journalists offered similar reassurances, and frequently compared the coronavirus threat with the allegedly greater danger of flu.

Some officials may have been motivated to avoid disproportionate panic, of the kind that gripped the U.S. during the Ebola outbreak of 2014. The instinct to be calm and measured is laudable—until it isn’t. “Alarmism is equated with misinformation, and a lot of it is misinformation. But when you do have something coming, no one feels empowered to say: ‘This one isn’t alarmism,’” Tufekci, the sociologist, says. “There’s a cultural script that we play, and when the script changes, it takes time to shift to a new one.”

The narrative that experts underplayed the risks isn’t fully correct, though. On January 26, Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health tweeted, “We should be planning for the possibility that [the coronavirus] cannot be contained.” He followed with a list of recommendations, several of which—more diagnostics, more protective equipment, transparent communication—the U.S. is still struggling to meet. Four days later, Scott Gottlieb, the former FDA commissioner, and Luciana Borio, who was part of the National Security Council’s now-dissolved pandemic-preparedness office, similarly urged the government to “act now” to prevent an American epidemic. “I hope the lesson people take from this is not ‘Experts were wrong,’” Tufekci says. “If you followed the right people, they were overwhelmingly right. We just didn’t put them in the right place so we could hear them.”

The World Health Organization has also come under fire for hewing too closely to China’s position in January, and being too slow to confirm that the coronavirus was spreading among people, or to finally describe the situation as a pandemic. These issues should not detract from all that the WHO has done to contain the crisis. Nor should they provide cover for leaders who still failed to prepare their countries after the risks became clearer, and after being exhorted to act “aggressively” and “swiftly” by, well, the WHO. But the agency’s missteps do offer lessons for communicating in an emergency. In mid-January, it sent a now-infamous tweet describing “no clear evidence of human-to-human transmission of the novel #coronavirus” without clearly discussing other important details, such as a new case in Thailand and warnings from Taiwan and Hong Kong. “They didn’t give the world the tells,” Tufekci says.

The same could be said of the White House and other U.S. officials who repeatedly assured Americans in January, February, and even March that their risk was low. That might have initially been true, Inglesby says, but officials should have noted that the true extent of the disease was unknown; that there wasn’t a way of measuring it, because tests weren’t in place; that the virus had already spread globally; and that control measures such as airport screening and travel bans have historically been unsuccessful. “The fuller statements take longer to explain, but that’s how it is in outbreaks.” Inglesby says. “There’s a lot of uncertainty, and we shouldn’t try to tidy it up.”

In late February, Nancy Messonnier, the respiratory-disease chief of the Centers for Disease Control and Prevention, broke ranks and told Americans that community spread of the virus within the U.S. was a question of when, not if. Messonnier urged the nation to prepare for possible school closures, loss of work, “disruption to everyday life that may be severe,” and “the expectation that this could be bad.” The next day, Trump asserted that cases were “going to be down to close to zero.” The day after, CDC Director Robert Redfield reiterated that “the risk is low,” and said that Messonnier could have been more articulate. Shortly after, Redfield said, “The American public needs to go on with their normal lives.” Of late, CDC officials, who were constant authoritative voices during past epidemics, have been mostly silent.

The impulse to be reassuring is understandable, but “the most important thing is to be as accurate as possible,” Inglesby says. “We should give people information so they can do what they think is right. We should tell people what we don’t know and when we’ll know more.” (The WHO is learning: On April 25, after wrongly tweeting that “there is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from infection,” they offered a longer and more accurate explanation.)

If officials—and journalists—are clear about uncertainties from the start, the public can better hang new information onto an existing framework, and understand when shifting evidence leads to new policy. Otherwise, updates feel confusing. When the CDC suddenly reverses its position on wearing masks, without having previously clarified why the issue was so divisive, it seems like an arbitrary flip-flop. “That’s a dangerous way to communicate,” says Kate Starbird at the University of Washington, who studies how information flows during a crisis. “It contributes to diminishing trust in organizations. And when people don’t have a place they can go for trusted information, it makes them vulnerable to disinformation.”

VI. The Information

During news events like Trump’s impeachment trial, people mostly share information to signal their beliefs, says Renée DiResta of Stanford, who studies how narratives spread online. But in a disaster, people tend to share information “to be useful to their community,” she says. Sharing offers agency. It allows people to collectively make sense of a situation riddled by anxiety and uncertainty. “But when an earthquake happens, you talk to your neighbors and in a few days, you’ve figured out what’s going on,” Starbird says. “For COVID-19, the uncertainty is persistent.”

The pandemic’s length traps people in a liminal space. To clarify their uprooted life and indefinite future, they try to gather as much information as possible—and cannot stop. “We go seeking fresher and fresher information, and end up consuming unvetted misinformation that’s spreading rapidly,” Bergstrom says. Pandemics actually “unfold in slow motion,” he says, and “there’s no event that changes the whole landscape on a dime.” But it feels that way, because of how relentlessly we quest for updates. Historically, people would have struggled to find enough information. Now people struggle because they’re finding too much.

It does not help that online information channels are heavily personalized and politicized, governed by algorithms that reward certain and extreme claims over correct but nuanced ones. On Twitter, false information spreads further than true information, and at six times the speed. But “this is not just a problem of the internet,” DiResta says. “For a lot of people, what is true is what the people I’ve chosen to trust in my community say is true.” Those dynamics meant that, at least initially, liberal and conservative Americans had very different understandings of the pandemic.

As the reality of the pandemic becomes clearer, the partisan gap is rapidly closing. But as time passes, misinformation, which refers to misleading stories that are circulated in good faith, will give way to disinformation—falsehoods deliberately seeded “to leverage the disaster for political power,” Starbird says. Amid the psychological loam of fear and uncertainty, conspiracy theories are germinating like weeds.

The daily briefings from the White House have only exacerbated the confusion. Trump has repeatedly tried to downplay the pandemic and rewrite his role in mishandling it. His playbook is his usual one: Deny responsibility, find a scapegoat, incite a culture war, and bend reality to his will by baldly stating his version of it (even when that version contradicts itself). The list of Trump’s lies about the coronavirus is long and growing, as are their consequences. His promotion of hydroxychloroquine led to shortages of the drug. His false claim that anyone who wants a test can get one sent droves of worried well to already-stretched hospitals.

Several journalists and media critics have urged news networks to stop airing the White House briefings live. That seems extreme, but it’s an extreme time when a presidential briefing forces doctors to clarify that people should not consume bleach. “No matter how many tough questions you ask, it really is not possible to prevent him from spreading bad info that could have very serious health effects,” says Jay Rosen, a journalism professor at NYU. “People think that more determined journalists can solve the problem—and they can’t.”  

Rosen also argues that the media’s default rhythm of constant piecemeal updates is ill-suited to covering an event as large as the pandemic. “Journalists still think of their job as producing new content, but if your goal is public understanding of COVID-19, one piece of new content after another doesn’t get you there,” he says. “It requires a lot of background knowledge to understand the updates, and the news system is terrible at [providing that knowledge].” Instead, the staccato pulse of reports merely amplifies the wobbliness of the scientific process, turns incremental bits of evidence into game changers, and intensifies the already-palpable sense of uncertainty that drives people toward misinformation.

If the media won’t change, its consumers might have to. Starbird recommends slowing down and taking a moment to vet new information before sharing it. She herself is spending less time devouring every scrap of pandemic news, and more time with local sources. It’s the equivalent, she says, of “hand-washing for the infodemic.” And it might dispel the illusion that the pandemic can be tracked in real time.  

VII. The Numbers

The rapid pace of new information creates the sense that we can accurately monitor the pandemic as it happens. But daily numbers tell a distorted story. As April wears on, case counts suggest that the pandemic is plateauing in parts of the U.S. But it’s hard to know for sure. As my colleagues Robinson Meyer and Alexis Madrigal have reported, 20 percent of Americans who are tested for the coronavirus are still getting positive results. This figure is higher than almost every other developed country and has held steady over time. It suggests that the U.S. is still mostly testing people who are very likely to be infected and is still missing the majority of cases. If so, cases could have leveled off because the U.S. has maxed out its ability to find infected people.

This concern complicates the government’s plan to start reopening the country after a “downward trajectory of documented cases within a 14-day period.” If the case number is illusory, this criterion is meaningless. “I’d want to know that we’re doing enough testing to be confident that those numbers really are stabilizing,” says Dean, the University of Florida statistician. “I’m still not convinced we’re in a good place.”

When looking at case counts, remember this: Those numbers do not show how many people have been infected on any given day. They reflect the number of tests that were done (which is still insufficient), the lag in reporting results from those tests (which can be long), and the proportion of tests that are incorrectly negative (which seems high). Likewise, daily death counts do not offer a real-time glimpse at the virus’s toll. Because of delays in reporting, they tend to be lower on weekends.

Deaths are hard to tally in general, and the process differs among diseases. The CDC estimates that flu kills 24,000 to 62,000 Americans every year, a number that seems superficially similar to the 58,000 COVID-19 deaths thus far. That comparison is misleading. COVID-19 deaths are counted based either on a positive diagnostic test for the coronavirus or on clinical judgment. Flu deaths are estimated through a model that looks at hospitalizations and death certificates, and accounts for the possibility that many deaths are due to flu but aren’t coded as such. If flu deaths were counted like COVID-19 deaths, the number would be substantially lower. This doesn’t mean we’re overestimating the flu. It does mean we are probably underestimating COVID-19.

The means of gathering data always complicate the interpretation of those data. Consider the reports that the coronavirus can “reactivate” in recovered patients, or that people can become “reinfected.” This really means that patients are testing positive for the virus after having tested negative. But that might have nothing to do with the virus, and everything to do with the test. Diagnostic tests for COVID-19 produce a lot of false negatives, incorrectly telling 15 to 30 percent of infected people that they’re in the clear. And even if these tests were better, the viral levels of a recovering patient would eventually fall below their threshold of accuracy. When such patients are sequentially tested, some will toggle between negative and positive results, creating the appearance of reinfection.

False positives are a problem, too. Many companies and countries have pinned their hopes on antibody tests, which purportedly show whether someone has been infected by the coronavirus. One such test claims to correctly identify people with those antibodies 93.8 percent of the time. By contrast, it identifies phantom antibodies in 4.4 percent of people who don’t have them. That false-positive rate sounds acceptably low. It’s not. Let’s assume 5 percent of the U.S. has been infected so far. Among 1,000 people, the test would correctly identify antibodies in 47 of the 50 people who had them. But it would also wrongly spot antibodies in 42 of the 950 people without them. The number of true positives and false positives would be almost equal. In this scenario, if you were told you had coronavirus antibodies, your odds of actually having them would be little better than a coin toss.

None of this means that all bets are off and the pandemic is unquantifiable. The case count might be wrong, but it’s almost certainly too low rather than too high, and it’s more likely off by a factor of 10 than 100. The numbers still matter; they’re just messy and hard to interpret, especially in the moment. On my phone, I can see weather patterns, the position of every plane in the sky, and the number of people currently reading this article, all in real time. But I cannot get the same immediate information about the pandemic. The numbers I see say as much about the tools researchers are using as the quantities they are measuring. “I think people underestimate how difficult it is to measure things,” Dean says. “For us who work in public health, measuring things is, like, 80 percent of the problem.”

If measuring the present is hard, predicting the future is even harder. The mathematical models that have guided the world’s pandemic responses have been often portrayed as crystal balls. That is not their purpose. They instead describe a range of possibilities, and help scientists and policy makers to simulate what might happen pending different courses of action. Models reveal many possible fates, and allow us to choose one. And while distant projections are necessarily blurry, the path ahead is not unknowable. “The long-term is like modeling the trajectory of a falling leaf, but the short-term is like modeling a falling bowling ball,” says Dylan Morris, an infectious-disease modeler at Princeton. Uncertainties about the year ahead shouldn’t cloud “how devastatingly and terrifyingly certain we can be” about the immediate consequences if the pandemic isn’t controlled, he adds.  

VIII. The Narrative

In the final second of December 31, 1999, clocks ticked into a new millennium, and … not much happened. The infamous Y2K bug, a quirk of computer code that was predicted to cause global chaos, did very little. Twenty years later, Y2K is almost synonymous with overreaction—a funny moment when humanity freaked out over nothing. But it wasn’t nothing. It actually was a serious problem, which never fully materialized because a lot of people worked very hard to prevent it. “There are two lessons one can learn from an averted disaster,” Tufekci says. “One is: That was exaggerated. The other is: That was close.”

Last month, a team at Imperial College London released a model that said the coronavirus pandemic could kill 2.2 million Americans if left unchecked. So it was checked. Governors and mayors closed businesses and schools, banned large gatherings, and issued stay-at-home orders. These social-distancing measures were rolled out erratically and unevenly, but they seem to be working. The death toll is still climbing, but seems unlikely to hit the worst-case 2.2 million ceiling. That was close. Or, as some pundits are already claiming, that was exaggerated.

The coronavirus is not unlike the Y2K bug—a real but invisible risk. When a hurricane or an earthquake hits, the danger is evident, the risk self-explanatory, and the aftermath visible. It is obvious when to take shelter, and when it’s safe to come out. But viruses lie below the threshold of the senses. Neither peril nor safety is clear. Whenever I go outside for a brief (masked) walk, I reel from cognitive dissonance as I wander a world that has been irrevocably altered but that looks much the same. I can still read accounts of people less lucky—those who have lost, and those who have been lost. But I cannot read about the losses that never occurred, because they were averted. Prevention may be better than cure, but it is also less visceral.

The coronavirus not only co-opts our cells, but exploits our cognitive biases. Humans construct stories to wrangle meaning from uncertainty and purpose from chaos. We crave simple narratives, but the pandemic offers none. The facile dichotomy between saving either lives or the economy belies the broad agreement between epidemiologists and economists that the U.S. shouldn’t reopen prematurely. The lionization of health-care workers and grocery-store employees ignores the risks they are being asked to shoulder and the protective equipment they aren’t being given. The rise of small anti-lockdown protests overlooks the fact that most Republicans and Democrats agree that social distancing should continue “for as long as is needed to curb the spread of coronavirus.”

And the desire to name an antagonist, be it the Chinese Communist Party or Donald Trump, disregards the many aspects of 21st-century life that made the pandemic possible: humanity’s relentless expansion into wild spaces; soaring levels of air travel; chronic underfunding of public health; a just-in-time economy that runs on fragile supply chains; health-care systems that yoke medical care to employment; social networks that rapidly spread misinformation; the devaluation of expertise; the marginalization of the elderly; and centuries of structural racism that impoverished the health of minorities and indigenous groups. It may be easier to believe that the coronavirus was deliberately unleashed than to accept the harsher truth that we built a world that was prone to it, but not ready for it.

In the classic hero’s journey—the archetypal plot structure of myths and movies—the protagonist reluctantly departs from normal life, enters the unknown, endures successive trials, and eventually returns home, having been transformed. If such a character exists in the coronavirus story, it is not an individual, but the entire modern world. The end of its journey and the nature of its final transformation will arise from our collective imagination and action. And they, like so much else about this moment, are still uncertain.