Thursday, March 5, 2020

Corona

The coronavirus with its spiky crown (artist's image)

Rome’s streets are empty, the supermarket shelves loaded with food. My fellow denizens, for once free of the tourist hordes, are enjoying their lives in a state of limbo, waiting for coronavirus to come crashing down around their heads before they start stocking their larders and hunkering down.
At least that’s what things were like yesterday. I can’t say about today, because I just arrived in San Francisco to begin a two-week book tour cum working vacation scheduled months before that damned virus jumped the species barrier deep into China. We were biting our nails until the last moment – would the Americans impose a 15-day quarantine on all travellers from Italy? – and felt some relief at getting away, like Boccaccio’s fictional pals who fled to the hills outside Florence to escape the Black Death. But the first New York Times headline I see on landing is California Declared a State of Emergency, and it’s entirely possible that all the events we’ve come for will be cancelled in the spreading panic. 
When Covid-19, coronavirus disease, struck northern Italy in February like a bolt from the blue, the authorities got their act together surprisingly fast. They isolated the worst-affected areas, set up national and regional telephone hotlines, called in medical trainees and retirees to man them, planned dedicated wards in infectious disease hospitals, instructed practicing physicians in telephone triage, and broadcast two concepts to the general public: people leaving an epidemic area should self-isolate for two weeks even if they have no symptoms, and if you have cough, body pain, or fever you should pick up the phone rather than heading for doctors’ offices or emergency rooms where they might infect the sick and vulnerable. 
Anyone with suspected coronavirus is tested in isolation in the emergency room, if they’re sick enough to be there, or in their own homes by a hazmat team sent by the Health Department to take the swab. Testing is free, preliminary results are available and public within hours, anyone who needs to stay home gets paid sick leave, and under the Italian National Health Service nobody pays a penny for doctors, Emergency Rooms, or intensive care.
Human beings being imperfect, implementation has had some hiccups. A Rome policeman developed a cough on February 28th after hosting a houseguest from Lombardy, the northern region where coronavirus disease is most rampant. Instead of calling his doctor or the hotline he went to an emergency room, where the ER staff left him to stew in the regular waiting room, where he infected at least 15 fellow patients in addition to his wife and children. Not clear who was dumber, the doctors or the cop.
Italy’s response capacity is also hamstrung by its chronic and ever-worsening underfunding. If even wealthy Scandinavia will have trouble rounding up enough ventilators and intensive care unit beds if a true pandemic develops, imagine where Italy will be with half the resources.
And how about on the other side of the Atlantic? How will the United States succeed in handling an epidemic that seems increasingly likely to hit big, either soon or in the fall? 
My guess is badly. As a haven of rugged individualism and for-profit medicine, the US is far less equipped than Europe to mount an adequate response.
To start with, a third of Americans have no paid sick time at all, and few have as much as two weeks. Which means that many people mildly ill from coronavirus will keep going to work, putting everybody around them at risk.
And as we all know, US is one of the few countries where access to medical care depends on access to money. Between deductibles and co-pays even insured Americans often find it hard to afford doctors’ visits, medications, and hospital care. Which means that many who should be tested for coronavirus are likely to skip it in order to avoid starting a chain reaction of medical expenses – some are even being charged for the test itself. Not to speak of the 27 million citizens who have no insurance at all, or the millions of undocumented immigrants who steer clear of hospitals for fear of hovering ICE agents, all primed to swell the pool of infected people who may soon be mingling with the crowds on American streets, subways, stores, classrooms, and baseball stadiums.
Even stocking up on medications in case of preventive quarantine can be impossible in the American context – insurance companies don’t allow it.
In Italy about 30,000 people have been tested for the novel coronavirus, versus only a few hundred people in the vastly larger US. The lag is largely because every test needed advance approval from the Centers for Disease Control; broader testing is set to start now. 
Italy is notorious for disorganization, and has neglected epidemic preparedness. But this time it’s bested the US, which has been unable thus far to enact some obvious measures for containing the coronavirus. The Italian authorities tell a Neapolitan businessman who was obliged to spend a day in Milan for a meeting that he should stay home for two weeks when he gets back. When I landed at San Francisco Airport today the border police chatted me up about my life in Rome, and wanted to know whether I was carrying any cigarettes, but didn’t even ask when I had last been in northern Italy. Scary.
Then there’s the politics of an election year. Our real experts on the science and the handling of epidemics, such as Dr. Anthony Fauci, are being sidelined and even muzzled, while the coronavirus task force is run by Vice-President Mike Pence, who as governor of Indiana suggested the best response to the state’s HIV epidemic was prayer. And while President Trump runs off at the mouth about how a vaccine is at hand and how the coronavirus is just another Democratic hoax. 
Obviously the situation in both my countries is evolving not just day by day but hour by hour, and much of what I’m writing today may be out of date tomorrow. But having scribbled these musings, mostly on the plane, I thought I'd offer them to you anyway. 

16 comments:

  1. Thank you for your well-informed comments. I was staying in an airbnb in Bari when news of the virus in Italy hit. I have elected to stay here for the time being and not to travel.

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    1. Thank, and good luck. It sure is hard to know how to behave - there have been almost no cases in that part of Italy so it might make good case to just sit tight. In bocca al lupo!

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  2. Hi you were doing great until you got political. Dr. Fauci is not being muzzled. He reported that he cancelled a couple of Sunday shows when VP Pence took over as the team wanted to regroup and co-ordinate communication. He rebooked after that was done. Next, Trump did not call the virus a hoax. Rather he called the politicizing of the virus by the Democrats as their "new hoax". I have listened to many of the press conferences. No one is saying a vaccine is in hand - everyone is saying it is at least a year, perhaps longer, away. What people are commenting on is how fast it is being developed. I appreciate your medical perspective of this but please don't parrot talking points from the MSM and people with a political axe to grind.

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    1. Thank you for taking the trouble to write. I had wanted to include some documenting links but decided it was more important to get the piece posted quickly. Re the issues you raise:
      1) Fauci was told to get pre-clearance from Pence's office before speaking: https://www.nytimes.com/2020/02/27/us/politics/us-coronavirus-pence.html
      https://www.washingtonpost.com/politics/trump-coronavirus-effort-undermined-by-mixed-messages-and-falsehoods/2020/03/03/d744c406-5d75-11ea-9055-5fa12981bbbf_story.html
      2) Trump did not call the virus's existence a hoax, but that concern over it was, and has continued to say people are too concerned, e.g.
      THE PRESIDENT: I think every aspect of our society should be prepared. I don’t think it’s going to come to that, especially with the fact that we’re going down, not up. We’re going very substantially down, not up. https://www.whitehouse.gov/briefings-statements/remarks-president-trump-vice-president-pence-members-coronavirus-task-force-press-conference/
      3) re vaccines:
      THE PRESIDENT: We’re rapidly developing a vaccine, and they can speak to you — the professionals can speak to you about that. The vaccine is coming along well.
      https://www.whitehouse.gov/briefings-statements/remarks-president-trump-vice-president-pence-members-coronavirus-task-force-press-conference/
      ******
      THE PRESIDENT: So you’re talking over the next few months, you think you could have a vaccine.”
      DR. FAUCI: Yeah. You won’t have a vaccine. You’ll have a vaccine to go into testing.”
      THE PRESIDENT: All right. So you’re talking within a year —
      DR. FAUCI: A year to a year and a half.
      THE PRESIDENT: Well, but, Lenny is talking about two months, right?
      DR. SCHLEIFER: A little — a little longer. A little longer.
      THE PRESIDENT: A couple of months, right? I mean, I like the sound of a couple of months better, I must be honest with you.
      https://www.whitehouse.gov/briefings-statements/remarks-president-trump-members-coronavirus-task-force-meeting-pharmaceutical-companies/

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    2. Dear Ms Levenstein, I would like to share my support for all your efforts in showing different points of views regarding this very complicated situation which is quickly spreading around the world.
      Firstly, let me tell you - and whoever reads us-, that am an Italian citizen working with your fellow Americans since over 40 years.
      You belong to a great Country, a Country which has well over 300 millions people, therefore no surprise you may have so many and so different opinions. And that's one of the great assets of US.
      But I felt bad in reading some nasty comments about your article on The Local.it.
      As I just said, all opinions are valuable the same, and all will help to create its own, but when opinions are based on numbers, well, those numbers should be better considered.
      In more occasions I read comments reporting that in US there isn't a problem like in Italy, because in Italy there are 150 death ( up to yesterday, Fri Mar 6th) while in USA only 11, and US is about 6 times bigger.
      I would like to update those numbers : unfortunately in Italy up to 6.00 am on today, Sat Mar 7th, the death toll is risen to 198.
      At 1st sight, it may appear that the big problem is only Italian, or only of specific countries, but not US.
      Well, I wish for you, American friends, that it were like that.
      But if we base our opinions on numbers, then we should use numbers in the same way, or it is useless.
      The toll death in Italy - 198 at present - represents ALL DEATHS RELATED TO RESPIRATORY COMPLICATIONS in which Coronavirus played a part. And this is proved by specific tests.
      Now, according to the number I read - 11 DEATHS IN US - I would like to ask : is that the number of ALL DEATHS IN YOUR COUNTRY RELATED TO RESPIRATORY COMPLICATIONS ? Surely not. And how could you cross out that Coronavirus was not one of the causes ? Only one way : specific test. When all DEATHS RELATED TO RESPIRATORY COMPLICATIONS will be tested, then we can use numbers and compare the 2 different situations.
      In Italy over 30.000 tests have been made in over 3 weeks. And tests are free. Also these last are numbers and informations that should be carefully considered if we want to reach a grownup opinion.
      Coming to a closing, I hope nobody reads these words as unfriendly, arrogant or somehow criticizing USA inner dynamics, on the contrary : I LOVE and RESPECT your Country in which I have thousands of friends, and it is for this reason that I am trying to say PLEASE, DO NOT UNDERSTIMATE THE PROBLEM, GET PREPARED and especially try to hear different sources before coming to an opinion.
      With unconditioned friendship. Riccardo

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    3. Why are these people so afraid to come out and just say...NO there will be no vaccine in the near future. NO the numbers are not going down they are going up. NO its not alright to go to work if you think you have a virus. WHY?

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    4. Thank you very much for writing this, Riccardo. Your point about the low number of tests in the US is well taken. I didn't know there had been negative comments at thelocal.it, and when I went just now to check them out I found that my article had unfortunately been placed behind a firewall and I could not view it at all, so I cannot respond specifically. But I know that many of my fellow Americans get defensive when they see any criticism of their government or their health system. I do think that probably the coronavirus is only just now entering the US, a few weeks before it came into Italy, and that this is the main reason why there are few cases and few deaths so far. Unfortunately, though, I believe these numbers are destined to rise - already today, according to the excellent Johns Hopkins webpage https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 the number of confirmed cases in the US has climbed to 343, with 14 deaths certainly attributable to the virus, and I just heard on the radio of two additional deaths in Florida. Thanks again for your thoughtful note.

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    5. Dear Anonymous on March 7: in other, unrelated situations the present administration has not stood out for honesty and openness. I'm not surprised that they are continuing the same pattern around this terrible epidemic, especially if they believe that any negative news makes the President look bad.

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  3. Dr. Levenstein,
    I'm seeing reports from Italian doctors discussing the large surge care required in the ER that they are encountering. And they have said to other countries to prepare for a similar event. Here, often, we are told this is "just the flu"-- and that it's not bad. I believe what we are seeing in Italy is what we will see in the US healthcare, once this begins to occur in larger numbers in our population. Would you please comment on the healthcare surge in Italy and/or the potential for that same situation in the US? I feel we quite unprepared for that due to staffing shortages. And I truly respect what you've written on this topic. Thank you.

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    1. Thanks very much for this thoughtful note, and for your faith in my ability to answer. I'm actually in the US right now, and will remain stranded here at least until the end of April when flights to Italy may start up again. So I have no personal knowledge of the current situation in Italy except from friends with cabin fever and colleagues in my outpatient clinic who are desperately reorganizing to help their patients by phone and Skype. I think if the laissez-faire attitude of the US administration continues the health system will indeed be overwhelmed - see Trump's speech last night which didn't mention the elimination of public gatherings and hardly even mentioned hand-washing, as tho the solution to all problems is closing the border. The US starts out with many more ICU beds and ventilators per capita than Italy has, but if we have 10s of millions needing intensive care those beds (and that staffing, as you point out) will be far from enough. Alas.

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  4. Buongiorno Doc Susan. As you probably know, here in Italy since a couple of days the whole country is on a lock down. People are requested to stay home unless they have to go to work, providing their working environment guarantees strict sanitary rules ( 1 meter minimum between workers, masks, gloves, etc ). Regular shops are shut, so are restaurants and bars. Police carefully checks anybody moving around, as everybody must present a document stating the reason of his trip ( work, emergency, food shopping, etc). It is hard, but now people understand this is a challenge we never experienced since WW2. My thought goes to all those Countries which apparently understimate the problem, not limiting already the free movement of people. Virus has no passport and does not observe borders. And there is no help in blaming somebody else for the spread. Our public hospitals are working 200 % of their possibilities. In Milan, stands of the Fair Centre have been turned into Intensive Care units. The situation is really difficult, especially in the North, where the main clusters appeared. We hope that the strict limitations of movement will bring some help, but it will take at least another 2 weeks ( according to what our Doctors say ). To all of those reading these lines, all my best wishes and - regardless what some politicians say - limit already your movements and observe carefully some basic measures ( do not stay too close to others, wear masks, wash frequently your hands ). In any case " NE VERREMMO FUORI " . Saluti a tutti !!

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    1. Sorry this comment of yours got misplaced in my inbasket and I never posted it! My husband and I don't feel like we can get safely back to Rome so we are staying for now in Berkeley, CA, where we are staying mostly at home but it is much more dolce than the quarantine in Italy. I do think the situation in Italy is improving just as the Doctors were hoping - the increase in covid-19 patients sick enough to need intensive care is slowing down, and I think by next week the deaths will start to go down as well. Italians are really suffering to get through this, but it will feel like it is worthwhile in the end. Coraggio!!!

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  5. Dear Dr. Levenstein,
    I am in the middle of your book and enjoying it very much, so was interested in learning of your take on the coronavirus in Italy and how the medical establishment was responding. As for my country, the US, there is no doubt that the administration has been doing a very bad job--minimizing the problem, inept about getting testing available, giving out false statements. And if they had not eliminated the office in the White House meant to deal with pandemics they would have had more experts and geared up sooner. Just in the last week it seems the people have begun to self-isolate and take this seriously. As for the doctors, as in Italy, they are doing the best they can. I said to my doctor this week "it's terrible that they don't have the testing" and he said "it shows where their priorities are. Good luck to us all and best wishes to you.

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    1. Thank you for the kind words about my book and the blog post. I agree with every word you've said. As soon as I get my head above water (I'm now a coronavirus refugee, can't go home to Italy), I'll write another post.

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  6. Thank you for your clear-eyed analysis of the situation. Seeing that you were in Berkely brought back memories of lunch in Piedmont with your Mom when my Kerry's baby was about 1. He is now 17. I wish you a safe journey here and, eventually, to Rome.

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    1. Hah! That place my mother lived! We've driven past it several times, twice to have hot tubs and massages at the wonderful Piedmont Springs - alas, with the Bay Area lockdown I won't be able to go back every week as I was looking forward to.

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