Finding Normal (part 2)
A look at how we calm COVID-19 related anxiety as we move towards finding normal
This is part 2 of the third installment in a series on COVID-19. Click below for the previous pieces:
Recap and Takeaways
The key takeaways from part 1 are:
We will return to a pre-covid sense of normal eventually because history tells us so. In all previous global pandemics, we have managed to move onward and upward. Patience is key.
Our current strain of post-lockdown COVID-19 is a mutated version of the original COVID-19 virus. Post-lockdown our national case fatality rate is approximately 6%, whereas the original pre-lockdown case fatality rate was believed to be 3.4%. By contrast, the normal flu has a case fatality rate of 0.1% and the Spanish flu of 1918 had a case fatality rate of 2.5%. So COVID-19 is far more lethal than previously imagined.
Additionally, as a result of the 30+ mutations of COVID-19 there are concerns that the virus is impacting younger ages than previously expected in a variety of different ways:
Up to 40% of hospitalizations are occurring in those under the age of 54
30-40 year olds are experiencing strokes due to COVID-19 related clotting
Children are exhibiting unusual inflammation of their blood vessels.
We’re also seeing COVID rashes and COVID toe.
There’s just so much we don’t know yet about what COVID does to the human body, regardless of age.
As a result of the mutations, we don’t know if COVID-19 is subject to any prolonged acquired immunity and/or if it is eligible for substantive mitigation through vaccines.
For reference, the normal flu doesn’t appear to give any significant or prolonged immunity, which is why you have to take a flu shot every year and may still get the flu despite having taken the shot. A flu shot is a vaccine that simply guesses as to the strain of flu that will be making its way around the globe that year and hopes to give some limited short term immunity to that particular strain. Despite all those limitations, it is still in the interest of good public health to take your flu shot every year.
The question is, will COVID-19 have any acquired prolonged immunity like a polio, smallpox or measles vaccine, or will it have a limited immunity like the flu?
The WHO recently stated there is no evidence of any acquired immunity with respect to COVID-19.
To better understand how we return to normal, we will take the assumption that COVID-19 is subject to prolonged acquired immunity, meaning once you’ve had it, you are unlikely to get it again, and thus a vaccine may provide long term immunity should one become available. This is an assumption, not a given fact, and one we'll have to revisit as time passes.
As we examined in the part 1, the road to normal begins with a plan that contains the following broad steps:
Step 1: Calm the anxiety
Step 2: Fortify your defenses
Step 3: Attack
In this piece we'll focus on Step 1.
I have anxiety and anxiety sucks
I am anxious that I will get the virus
I am anxious that I will spread the virus
I am anxious that I will be an asymptomatic carrier
I am anxious that I will meet an asymptomatic carrier
I am anxious about all the damage the virus can do
I am anxious for all my family and friends too
I am anxious for all my loved ones working on the front lines
I am anxious for all the patients & families that can only talk via FaceTime
I am anxious for all the seniors that are alone in their nursing homes
I am anxious for all the seniors who will attend graduation via their phones
I’m anxious about those that have grown impatient and now give zero fucks
I have anxiety and anxiety sucks
Mediocre poetry aside the reality is we all have anxiety. It goes with the territory these days. For some of us it is worse than for others.
The challenge is the inverse relationship that exists with anxiety and patience. Patience is key in our fight against COVID-19, and anxiety only serves to undermine that patience.
Fear is the path to the dark side as a wise Jedi master once said. And so it is with COVID-19 where the fear manifests through anxiety. That anxiety leads to anger and even hate, which in turn leads to impatience, and thus suffering. How do we know this? Because we've seen it before.
Impatience in 1918 and 1919
The origins of the Spanish flu of 1918 are believed to have begun in 1917. In 2014, a new theory about the origins of the virus suggested that it first emerged in China, National Geographic reported. Previously undiscovered records linked the flu to the transportation of Chinese laborers, the Chinese Labour Corps, across Canada in 1917 and 1918.
The world was at war at the time, and though the first "wave" of the Spanish flu is tied to early 1918, there's evidence to suggest that it hit European armies at the tail end of 1917.
Just as the first wave of COVID-19 has hit in the spring of 2020, and caused some impatience in the population at large, so was the case in 1918. By summertime, people were tired of the prevention and mitigation measures clamoring for large gatherings in the summertime (sound familiar?). And so in mid 1918 when the city of Philadelphia wanted to have a parade for its war heroes, which was also an avenue to sell war bond and raise funds, the city decided against listening to public health concerns. As Philadelphia planned its parade, bound to be a large gathering, director of public health Krusen had ignored the growing concerns of other medical experts and allowed the parade to proceed, even as a deadly outbreak raged on nearby military bases.
That impatience proved to be deadly.
Within 72 hours of the parade, every bed in Philadelphia’s 31 hospitals was filled. In the week ending October 5, some 2,600 people in Philadelphia had died from the flu or its complications. A week later, that number rose to more than 4,500. With many of the city’s health professionals pressed into military service, Philadelphia was unprepared for the devastation.
But the anxiety and impatience doesn't stop there. Enter the anti-mask league of 1919.
By the fall of 1918 the Spanish flu had arrived in San Francisco (presumably from Chicago) and began to wreak havoc. On October 21, the Board of Health met and issued a strong recommendation to all residents to wear a mask while in public. The wearing of a mask immediately became of a symbol of wartime patriotism. A Red Cross public service announcement stated bluntly, “the man or woman or child who will not wear a mask now is a dangerous slacker,” calling into question the patriotism of those who refused. The local Labor Council issued a warning that no members would be allowed to work unless they wore a mask.
The masks along with other quarantine measures helped flatten the curve, but soon the public grew anxious and impatient. On November 21, 1918 the mayor eased up on the requirement to wear a mask in public as well as other quarantine measures. By December 7, 1918 the epidemic was back on the rise, once again requiring mitigation measures including the wearing of masks, which was re-ordered on January 17, 1919. By this time people were fed up with masks leading to the Anti-Mask League.
Sentiment was so strong against the mask that several influential San Franciscans, including a few physicians as well as a member of the Board of Supervisors, formed “The Anti-Mask League” which held at least one public meeting to denounce the ordinance and to discuss ways to put an end to it. Over 2,000 people attended the event, and by February 1 the mask order was rescinded once again.
Its unknown how many people became sick DUE to the Anti-Mask League event, where 1000s gathered to protest without masks. So we may not know how many people, if any, became sick due to this congregation. But safe to say it was not helpful during pandemic.
People continued to gripe about the masking even after the pandemic had been stalled by it. No one seemed to credit masking for the success of blunting the Spanish Flu in San Francisco — because, well, the crisis faded due to its success.
“Rarely has the evidence in support of a scientific hypothesis been more overwhelming and more deceiving,” writes historian Crosby.
Ultimately San Francisco was one of the American cities hardest hit by the Spanish Flu. Roughly 6,700 per 100,000 people died during the pandemic due to influenza and pneumonia, per University of Michigan. 45K cases total and 3,500 were killed.
There's no telling how many preventable deaths were caused by impatience between 1918-1919. The Philadelphia parade and the Anti-Mask League are just examples of how anxiety leads to impatience which leads to suffering. If only Yoda was there to save them from themselves.
Calm the Anxiety
And so we get to step 1 of our 3 step plan. To defeat COVID-19 we must first calm the anxiety. But how?
Anxiety in the current situation can be grouped in 3 buckets. The first is economic, the second is public health, and the third is a catch-all for everything else.
That third bucket is very important, and comprises things like general mental health, concerns about government overreach, and frustration over stifling one's personal liberties. As important as the third bucket is, it's one I'm going to set aside for this conversation as I'm likely not qualified to get into it.
Meet my hypothetical friends Bert and Ernie. Bert owns a bar and Ernie works in the ER.
2020 was supposed to be Bert's year. His bar was doing so well that he opened a second location at the end of 2019 and business was good. Bert is in his late 30s, and he has his life savings invested in his bars. He was set to make a healthy profit in 2020, setting himself up for the future. His employees count on Bert as well. Then COVID-19 hit. Even though he understands why the shelter in place orders exist and he wants to do his part to flatten the curve (Bert's parents and grandparents are in the at risk population pool), Bert is frustrated and anxious. He's watching his dream slip away. He has $100,000 in inventory sitting in his bars, he's had to donate most of his food because he couldn't sell it all before it spoiled, his employees are looking to him to do right by them, and he owes $15,000 a month in rent alone.
The economic impact of COVID-19 in just a few short months is crushing Bert. He has applied for the PPP, but most of his employees are part time and make their money on tips, plus the PPP won't pay his rent, not to mention the fact that it's been nearly 2 months since he applied and he's still waiting on funds. Bert is ready to reopen the economy and take his chances with COVID-19 rather than stay home and watch his life savings go down the drain. Bert is even starting to wonder if COVID-19 is really as dangerous as people say, after all he doesn't know anyone that has caught it or anyone that has died from it.
Meanwhile, Ernie, who has been friends with Bert since grade school, has been working double shifts in the ER for weeks. He's watched so many patients get intubated, and more than he'd care to count have not made it. Ernie's entire department has been stressed for the past two months as they are overloaded with patients, understaffed, short on PPE, and several of their own have been infected. A few of their own nurses and physicians have even passed away. Ernie has watched nurses, in tears, holding up electronics for final goodbyes because no family was allowed in the patients' rooms. Ernie is mentally and emotionally exhausted.
Ernie has a wife and two kids under the age of 7 but he hasn't seen them in two months. He hasn't held them or even kissed them good night because he's afraid he's going to bring COVID-19 home, so he's been staying in a hotel room across the street from the hospital. At night, after he's taken a deep clean shower and ordered in a pizza, Ernie watches the news. He sees the protests of people screaming at first responders, the car that plowed into nurses during a parade, the armed protesters waiving confederate flags and swastikas in Michigan, the security guard who was killed because he asked a customer to wear a mask. And what's it all for? To get the economy reopened?
Ernie is so tired, but he's also anxious. Don't these people understand that a reopened economy means more disease, more patients, more death? More sleepless nights and double shifts for Ernie, more of his colleagues leaving work only to return as patients. Don't they understand that life and death is more important than cost - benefit? Or in today's world is that not true? Is cost-benefit more important than life and death? This question troubles Ernie every night.
So who is right and who is wrong? Is Bert right for caring more about losing his life savings than about Ernie's plight in the ER? Is Ernie right for choosing a path that will undoubtedly bankrupt his friend Bert?
The reality is neither are wrong. The notion that we must choose american lives or the american economy is a false dilemma. There's nothing to suggest we can't put the american economy into a stasis while we tackle the public health crisis. Why must Bert go broke to help Ernie and his colleagues in the ER? Why can't we save Bert's bars and still find a way to not overburden Ernie's ER? The truth is we can. Unfortunately we, as a nation, have chosen the wrong economic path in this crisis.
Calm the Economic Anxiety
In 2008, the global financial system collapsed as a result of the burst bubble in the mortgage backed securities space. At the time, the government sought to save the economy by giving the banks a blank check which ended up exceeding $700 billion in TARP capital injections. The idea was that the banks would take those funds, and lend them out creating liquidity in the markets so people could pay their bills, including their mortgages, and stabilize the housing market.
Unfortunately that's not what happened. The banks did not lend that money out so that consumers could pay their bills, including their mortgages. Rather, the banks used the funds to fill the huge holes in their balance sheets, they foreclosed on the defaulted mortgages, put the homeowners out on the street, and then went after the collateral securing the mortgages to cover the difference. Where the government failed in 2008 was choosing to save the lenders rather than save the borrowers. If they had guaranteed the mortgages that were underwater, allowed the banks to write off the value of the mortgage that had depreciated, and given the borrowers a cheaper mortgage payment to secure their home, then it is likely that the economy would have stabilized sooner and without the devastating consequences to individual consumer wealth & credit. Rather the government funded the corporations at the expense of the consumers.
“The biggest failure of Treasury when they rolled out TARP was not keeping their promise to Congress to help struggling homeowners,” Barofsky told Yahoo Finance. “People forget about it… but one of the ways TARP passed… was to include a promise to help struggling homeowners and Treasury never fulfilled that promise."
And so it is with COVID-19 economic relief. The US has passed several trillion dollars in stimulus but none of that is really going to help Bert keep his bar. The PPP (Payment Protection Plan) is not setup to cover Bert's rent, licensing fees, business insurance, legal fees, etc. It is intended to cover Bert's payroll, but his staff are likely either not W-2s, or only make a small amount in payroll with most of their salary being based on tips. The EIDL (Economic Injury Disaster Loan) might cover some of Bert's expenses except that Bert would have to pay up to 4% interest on that stimulus which mean's he's borrowing money he can't really afford to repay to cover expenses against which there is no revenue. Bert also has to pay unemployment insurance which will help cover the unemployment expenses his staff may choose to file for because their wages aren't covered under the PPP.
It is this economic hole that's causing the anxiety for people like hair & nail salon owners, barbers, massage therapists, restaurant owners, etc.
The answer is simple, as it was in 2008. Protect the people, not the corporations and you'll stabilize the economy.
The goal for the US economy should be a position of stasis where no one profits and no one loses for a period of 3-6 months while public health officials come up with a strategy to attack the virus. This would not only calm economic anxiety but also reduce the value of the needed stimulus to fill our economic hole.
Force Majeure refers to a clause that is included in contracts to remove liability for natural and unavoidable catastrophes that interrupt the expected course of events and prevent participants from fulfilling obligations.
We are currently in a state of force majeure, and as such everyone should be exempt from their financial expenses and liabilities. If we could impose such an economic policy we would essentially remove the root cause of economic anxiety in society today.
Force majeure related economic policy would look something like this:
No individual / business is allowed to "lose" money as a result of lost wages or income whilst being forced to pay their liabilities or expenses
No individual is allowed to profit beyond the cost of capital, which is likely an interest rate far lower than 5%
All rent, mortgage, credit card, utility, property tax, insurance, etc payments are frozen until further notice
No one is allowed to be fired, laid off, or furloughed
No one is allowed to have their benefits cut or taken from them
What does this look like in practice? Well let's say you were in real estate and had a lot of rental properties. Your tenants are not required to pay you rent, but you are not required to pay your mortgage, property tax, utilities, assessments, etc either.
Since the US is a service based debt based economy, freezing expenses will makeup for lost irreplaceable revenue and will end up being a net positive for all those debt based operations that are not normally raking in a profit. Freezing expenses would also help most households as well as 78% of households live paycheck to paycheck.
To the extent that these policies cost individuals or companies "profits" because they collect income related to expense / liability buckets but have no offsetting expenses of their own, they would be eligible for cost of capital stimulus which is capped at 5%, but such stimulus would only be available to those with a capped net worth so people like Warren Buffett and Bill Gates could not apply for such stimulus.
For anyone that is still put in a bind under these policies, the fed would allow zero percent interest bridge loans with eligibility for loan forgiveness based on certain benchmarks.
These set of policies would reduce economic anxiety, prevent us from having to choose between Bert and Ernie, and allow the country to focus on good sound public health policies without worrying if we are sacrificing the american way of life. Additionally, it would focus stimulus into the pockets of economic inefficiencies identified as the holes in the "no net gains no net losses world" - such as utility companies and municipalities, rather than scattershot trillions blindly spread across the corporate world with no oversight.
But wait there's more. Rather than give monthly checks to everyone, which can be misallocated in a variety of different ways, it would be more reasonable in the force majeure world to allocate a certain ration of credits per household at stores such as target, wal-mart, costco, etc for groceries, prescriptions, and basic necessities. Then the government could reimburse those stores, at cost plus a capped profit margin, in the form of a lump sum stimulus bill.
These policies would take the economic anxiety out of the picture and allow healthcare to become our focus without sweeping economic losses, or uncontrollable black hole deficit spending stimulus bills. This is not a novel idea. Other nations have already implemented these types of policies.
Even the world economic forum has contemplated some form of these policies as a solution to economic anxiety and economic stability.
I've been calling for this economic approach for the past three months - just ask my non-hypothetical friends. Today, as I'm writing this very sentence I see Joe Biden is now calling for similar policies.
Calm the Healthcare Anxiety
Easing Bert's economic anxiety reduces the impatient call for reopening the economy. This in turn eases Ernie's anxiety over the projected increase in patients, deaths, and needed resources to handle such a strain that would have been caused by a premature reopening. Remember, in the example of the Philadelphia parade of 1918, the result was a capacity level strain on the city's healthcare resources.
Now there are other healthcare anxieties that needed to be addressed as well, such as lack of PPE, testing, and hospital staff. Those are items that will be addressed in step 2 of our 3 step plan. However, in case there was any doubt, everyone should know the lack of PPE still persists today.
For reference sake, requests for respirator masks and other PPE placed with the Illinois department of public health two months ago, are as yet still unfilled. The State's DPH currently has zero isolation gowns available.
This cannot be overstated. Hospitals, nursing homes, and frontline providers (even today - two months after the pandemic first launched large scale lockdowns) cannot get the PPE they need for their staff. Imagine the shortage in staff and resources should the economy reopen tomorrow.
Experts project 3,000 daily fatalities by June 1 should the states reopen in the interim. Essentially we would be un-flattening the curve and re-breaking the healthcare system.
How do we fortify these systems as we move to attack COVID-19? Stay tuned...