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The Pandemic Experts Are Not Okay
Saskia Popescu’s phone buzzes throughout the night, waking her up. It had already buzzed 99 times before I interviewed her at 9:15 a.m. ET last Monday. It buzzed three times during the first 15 minutes of our call. Whenever a COVID-19 case is confirmed at her hospital system, Popescu gets an email, and her phone buzzes. She cannot silence it. An epidemiologist at the University of Arizona, Popescu works to prepare hospitals for outbreaks of emerging diseases. Her phone is now a miserable metronome, ticking out the rhythm of the pandemic ever more rapidly as Arizona’s cases climb. “It has almost become white noise,” she told me.For many Americans, the coronavirus pandemic has become white noise—old news that has faded into the background of their lives. But the crisis is far from over. Arizona is one of the pandemic’s new hot spots, with 24,000 confirmed cases over the past week and rising hospitalizations and deaths. Popescu saw the surge coming, “but to actually see it play out is heartbreaking,” she said. “It didn’t have to be this way.”Popescu is one of many public-health experts who have been preparing for and battling the pandemic since the start of the year. They’re not treating sick people, as doctors or nurses might be, but are instead advising policy makers, monitoring the pandemic’s movements, modeling its likely trajectory, and ensuring that hospitals are ready.[Read: America’s patchwork pandemic is fraying even further]By now they are used to sharing their knowledge with journalists, but they’re less accustomed to talking about themselves. Many of them told me that they feel duty-bound and grateful to be helping their country at a time when so many others are ill or unemployed. But they’re also very tired, and dispirited by America’s continued inability to control a virus that many other nations have brought to heel. As the pandemic once again intensifies, so too does their frustration and fatigue.America isn’t just facing a shortfall of testing kits, masks, or health-care workers. It is also looking at a drought of expertise, as the very people whose skills are sorely needed to handle the pandemic are on the verge of burning out.To work in preparedness, Nicolette Louissaint told me, is to constantly stare at society’s vulnerabilities and imagine the worst possible future. The nonprofit she runs, Healthcare Ready, works to steel communities for outbreaks and disasters by ensuring that they have access to medical supplies. She started revving up her operations in January. By March, when businesses and schools started closing and governors began issuing stay-at-home orders, “we were already running on fumes,” she said. Throughout March and April, she got two hours of sleep a night. Now she’s getting four. And yet “I always feel like I’m never doing enough,” she said. “Like one of my colleagues said, I could sleep for two weeks and still feel this tired. It’s embedded in us at this point.”But the physical exhaustion is dwarfed by the emotional toll of seeing the imagined worst-case scenarios become reality. “One of the big misconceptions is that we enjoy being right,” Louissaint said. “We’d be very happy to be wrong, because it would mean lives are being saved.”The field of public health demands a particular way of thinking. Unlike medicine, which is about saving individual patients, public health is about protecting the well-being of entire communities. Its problems, from malnutrition to addiction to epidemics, are broader in scope. Its successes come incrementally, slowly, and through the sustained efforts of large groups of people. As Natalie Dean, a biostatistician at the University of Florida, told me, “The pandemic is a huge problem, but I’m not afraid of huge problems.”[Read: Why the coronavirus is so confusing]The more successful public health is, however, the more people take it for granted. Funding has dwindled since the 2008 recession. Many jobs have disappeared. Now that the entire country needs public-health advice, there aren’t enough people qualified to offer it. The number of epidemiologists who specialize in pandemic-level infectious threats is small enough that “I think I know them all,” says Caitlin Rivers, who studies outbreaks at the Johns Hopkins Center for Health Security.The people doing this work have had to recalibrate their lives. From March to May, Colin Carlson, a research professor at Georgetown University who specializes in infectious diseases, spent most of his time traversing the short gap between his bed and his desk. He worked relentlessly and knocked back coffee, even though it exacerbates his severe anxiety: The cost was worth it, he felt, when the United States still seemed to have a chance of controlling COVID-19.The U.S. frittered away that chance. Through social distancing, the American public bought the country valuable time at substantial personal cost. The Trump administration should have used that time to roll out a coordinated plan to ramp up America’s ability to test and trace infected people. It didn’t. Instead, to the immense frustration of public-health advisers, leaders rushed to reopen while most states were still woefully unprepared.[Read: The U.S. is repeating its deadliest pandemic mistake]When Arizona Governor Doug Ducey began reviving businesses in early May, the intensive-care unit of Popescu’s hospital was still full of COVID-19 patients. “Within our public-health bubble, we were getting nervous, but then you walked outside and it was like Pleasantville,” she said. “People thought we had conquered it, and now it feels like we’re drowning.”The COVID-19 unit has had to expand across an entire hospital wing and onto another floor. Beds have filled with younger patients. Long lines are snaking around the urgent-care building, and people are passing out in the 110-degree heat. At some hospitals, labs are so inundated that it takes several days to get test results back. “We thought we could have scaled down instead of scaling up,” Popescu said. “But because of poor political decisions that every public-health person I know disagreed with, everything that could go wrong did go wrong.”“I feel like I’ve been making the same recommendations since January,” says Krutika Kuppalli of Stanford University. The last time she felt this tired was in 2014, after spending three months in West Africa helping with the region’s historic Ebola outbreak. Everyone who experienced that crisis, she told me, was deeply shaken; she herself suffered from post-traumatic stress upon returning home.The same experts who warned of the coronavirus’s resurgence are now staring, with the same prophetic worry, at a health-care system that is straining just as hurricane season begins. And they’re demoralized about repeatedly shouting evidence-based advice into a political void. “It feels like writing ‘Bad things are about to happen’ on a napkin and then setting the napkin on fire,” Carlson says.A pandemic would have always been a draining ordeal. But it is especially so because the U.S., instead of mounting a unified front, is disjointed, cavalier, and fatalistic. Every week brings fresh farce, from Donald Trump suggesting that the country should do less testing to massive indoor gatherings of unmasked people.“One by one, people are seeing something so absurd that it takes them out of commission,” Carlson says.Public health is not a calling for people who crave the limelight, and researchers like Rivers, the Johns Hopkins professor, have found their sudden prominence jarring. Almost all of the 2,000 Twitter followers she had in January were other scientists. Most of the 130,000 followers she now has are not. The slow, verbose world of academic communication has given way to the blistering, constrained world of tweets and news segments.The pandemic is also bringing out academia’s darker sides—competition, hostility, sexism, and a lust for renown. Armchair experts from unrelated fields have successfully positioned themselves as trusted sources. Male scientists are publishing more than their female colleagues, who are disproportionately shouldering the burden of child care during lockdowns. Many researchers have suddenly pivoted to COVID-19, producing sloppy work with harmful results. That further dispirits more cautious researchers, who, on top of dealing with the virus and reticent politicians, are also forced to confront their own colleagues. “If I cannot reasonably convince people I’ve been friends with for years that their work is causing tangible harm, what possible future do I see on this career path?” Carlson asks.[Read: A dire warning from COVID-19 test providers]Other scientists and health officials are facing the wrath of a nation on edge. Unsettled by months of stay-at-home orders, confused by rampant misinformation, distraught over the country’s blunders, and embroiled in yet more culture wars over masks and lockdowns, Americans are lashing out. Public-health experts—and women in particular—have become targets. Several have resigned because of threats and harassment. Others face streams of invective in their inboxes and on their Twitter feeds. “I can say something and get horrendously attacked, but a man who doesn’t even work in this field can go on national TV and be revered for saying the exact same thing,” Popescu said.Some critics have caricatured public-health experts as finger-wagging alarmists ensconced in an ivory tower, far away from the everyday people who are suffering the restrictive consequences of their advice. But this dichotomy is false. The experts I spoke with are also scared. They’re also feeling trapped at home. They also miss their loved ones. Louissaint, who lives in Baltimore, hasn’t seen her New York–based parents this year.“I feel like I’m living in at least three realities at the same time,” Louissaint told me. She’s responding directly to the pandemic, trying to ensure that patients and hospitals get the supplies they need. She’s running an organization, trying to make sure that her employees keep their jobs. She’s a Black woman, living through a pandemic that has disproportionately killed Black people and the historic protests that have followed the killings of George Floyd, Breonna Taylor, and Ahmaud Arbery. During the ensuing reckonings about race, “I’ve been pulled into so many conversations about equity that people weren’t having months ago,” Louissant said.“Someone said to me, ‘I hope you’re getting tons of support,’” she added. “But there’s no feasible thing that anyone could do to make this better, no matter how much they love you. The mental toll isn’t something you can easily share.”These laments feel familiar to people who lived through the AIDS crisis in the ’80s, says Gregg Gonsalves, a Yale epidemiologist who has been working on HIV for 30 years and who has the virus himself. “I have friends who survived the virus but didn’t survive the toll it took on their lives,” Gonsalves told me. “I’m incredulous that I’m seeing this twice in my lifetime. The idea that I’m going to have to fend off another virus … like, really, can I have just one?”But Gonsalves added that HIV veterans have a deep well of emotional reserves to draw from, and a sense of shared purpose to mobilize. His advice to the younger generation is twofold. First, don’t ignore your feelings: “Your anxiety, fear, and anger are all real,” he said. Then, find your people. “They may not be your colleagues,” he said, and they might not be scientists. But they’ll share the same values, and be united in recognizing that “public health is not a career, but a mission and a calling.”Despite the toll of the work and the pressure from all sides, the public-health experts I talked with are determined to continue. “I’m glad I have a way in which I can be useful,” Rivers said. “I feel like it’s my duty to do what I can."
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A Better Fall Is Possible
The sirens have quieted in New York City. Each week, my husband, a nurse practitioner, reports fewer patients coming in for COVID-19 tests. We watch in horror as Arizona, Texas, and Florida experience the consequences of squandering the time they had had to prevent an outbreak. Again, ICU beds fill. In the Northeast, by contrast, case counts are falling. On June 30, Massachusetts reported zero COVID-19 deaths.What should these states do now? Massachusetts is moving forward with reopening businesses, and, despite indoor dining having been paused in New York City, northeastern governors’ goals seem to be relentlessly commercially driven. Leaders see economic suffering ahead if the federal government does not reinvigorate support for workers and families as federal pandemic unemployment assistance ends on July 30. By prioritizing reopening businesses, states are wasting an opportunity to ensure a better fall for children and families.This is the wrong course. Instead of speeding forward with reopening their economies, these states should do everything in their power to make a return to school possible in the fall—especially for younger children. This must be the No. 1 priority, and all other “reopening” plans should flow from that. This means keeping the case counts of the virus as low as possible, via business closures (with unemployment assistance and stimulus to compensate) and required universal mask wearing.[Read: Just because you can doesn’t mean you should]At the beginning of the pandemic, we made a trade-off: Sacrifice school and day care, with women mostly picking up the slack, for public health. With little known about COVID-19, and knowing that many other respiratory illnesses are spread by children, this was a tough, unfair, but decent, emergency bargain. In the Northeast, these sacrifices, alongside the efforts of health-care and essential workers, and the unemployment of millions—all of which have been borne disproportionately by people of color—have led to successfully driving down case counts.But all of this progress can be reversed if we continue reopening as planned. Bustling bars and shops mean cases will likely rise again. And, because of the way this particular virus works, we won’t know we have a disaster on our hands until it is far too late to fix things easily, and many will die. Amid this, school districts across the country seem to be lumbering toward reopening in the fall by adhering to exactly what they have done in the past, COVID-19-style. That typically means school as we know it—but “hybrid,” with students taking classes in school part-time and online part-time from home. This maintains our demand for maternal sacrifice, and does not take into consideration the different needs and risk profiles by students’ age.Since the beginning of the pandemic, evidence has emerged showing that younger children are at lower risk of getting COVID-19 and are not a major source of spread. However, no scenario is zero-risk, and although less likely, children could transmit the disease to adults. We can take advantage of children’s relatively lower risk only by keeping community transmission rates down and implementing a contact-tracing system.In-person education is crucial for so many reasons. Students attending virtual school have lower test scores and are less likely to graduate high school—and the evidence comes from planned virtual schooling. Outcomes from emergency online education may be worse. Schools provide vital social-emotional support and safety-net policies such as food access, health clinics, and washing machines. Schools help detect child abuse and neglect. A virtual alternative risks exacerbating inequalities, such as access to devices, internet connections, quiet places to work, and adults to assist children in staying on task. The difficulties are greatest for younger children: They are at a higher risk of learning loss, are in a key period for learning how to read, are less able to have online social interactions, and need more supervision at home. School is important for the careers and sanity of parents. Many essential workers must work outside the home, and need school to help care for their children.[Read: What America asks of working parents is impossible]Reopening schools successfully will require tough choices, and the hardest, perhaps, is this: We will not be able to reopen for all children.There are two important constraints. First, teachers and staff should be able to opt out of in-person school if they or their families have a health risk. This will limit the number of staff available. But an opportunity to opt out, along with a reasonable plan for reopening that prioritizes staff health, is both moral and necessary for staff buy-in. Second, teens may be more similar to adults than young children when it comes to disease spread. This limits which students can be safely brought back to school.Where capacity constraints prevent a full reopening, and there’s an obvious difference in risk, learning needs, and supervision requirements by age, there’s one clear conclusion: little kids first. Elementary schools must reopen, spread out across all school buildings and grounds (for as long as the weather permits). Given the intense learning needs of students with disabilities and the difficulty of online alternatives, middle- and high-school students with special needs should also have priority for in-person attendance.[Read: The pandemic is a crisis for students with special needs]Elementary-school students should be assigned to the school building closest to their home to minimize time spent in transit. The goal in spreading spreading out elementary-school students across campuses is not forcing students to distance from one another, but minimizing adult-to-adult interactions, the greater risk for COVID-19 spread. Classrooms should have a stable group of children, and adults rotating into the class, so that if contact tracing is necessary, close contact happens within a “bubble.” To support students returning to schools with different learning needs, small-group tutoring, with an AmeriCorps-style program providing both one-on-one attention for students and jobs for unemployed young people, should augment classroom teaching.The downside of this is that most middle and high schools will need to be online, except for in-person services for older students with special needs. This is hard, really hard. All middle- and high-school students have needs that can be met only at school: an optimal learning environment, access to the school safety net, and interactions with peers. But prioritizing younger grades over older ones recognizes the reality of COVID-19, the unfair burden that having young kids at home places on women, and the capacity constraints that make a full reopening impossible.To make this proposal feasible, we need to reorganize learning in the upper grades. We must trade the norm of individual teachers working in isolation for collective planning. For families that lack or opt out of in-person options, states, consortiums of school districts, and large-school districts should provide centralized online-learning programs for all grades, including remote option for elementary grades, and the basis of fully online learning for upper grades. We should not be recreating the wheel in each school building, when teachers could focus on supporting students.A subset of upper-grade teachers should focus on content generation for these online platforms, and the rest of teachers should be matched to small student groups to provide individualized coaching and tutoring. Reimagining online education in this way would alleviate some of the demands on parents (read: moms) to manage middle- and high-school learning, and improve the experience for students. Some teachers will have to teach outside their typical grade or subject to cover faculty who cannot teach in person because of health risks. And to alleviate the suffering of students who miss their friends and struggle online, school districts could offer small group activities for tweens and teens every other Friday (so a deep clean could occur over the weekend), and have younger children stay home that day so there is adequate space.Families will also need to trade some of their individualism for the collective. Barring medical exceptions, adults must be required to wear masks at drop-off and pickup. Children must be required to be vaccinated for all illnesses if medically possible, including the flu shot. (Avoiding typical childhood illnesses means a lower likelihood of a coronavirus “scare” that turns out to be the flu, as well as protecting children from childhood diseases.) Families that can’t abide by these rules must use the online option.[Read: What happens when kids don’t see their peers for months]Even this partial reopening will not be enough to fully support children’s needs. We should also focus on and fund compensatory support for children now and in the future, such as vacation academies, summer school, and tutoring, as well as student counseling.This transformation will require sufficient funding. Schools are facing deep budget cuts due to lost state tax revenue. If a vaccine appeared tomorrow, schools would still have a fiscal crisis. With balanced budget requirements, states cannot step in: Only the federal government can borrow the necessary funds. The federal government must prioritize a bailout for schools and child-care centers that both covers budget gaps and provides additional funding to manage the special needs of educating children during a pandemic.In some places currently in crisis, even this modified reopening plan may be unsafe. Instead, the focus must be on reducing community spread and caring for the sick. An alternative for these areas would be to delay the start of school and plan on a longer school year. Full school reopening may be possible in low-density areas with little community transmission. The key here is to be flexible based on community transmission and, if faced with a situation where not all students can return, to prioritize younger students and those with the most need.A lot of this proposal might be difficult to fathom—prioritizing younger children over older, changing school culture—but the alternative is not a return to normal. A few communities have recognized this, and announced plans similar to what I suggest here.This fall will be the strangest return to school in memory, and if we continue to reopen businesses as planned, it may very well be all online. When considering this proposal, or any other, we should compare it with reality, rather than magical thinking about returning to what school was like in February.The other day I stood in front of the mirror and cut my own hair. Last month we ordered in from our favorite neighborhood restaurant for a date night at home. I would love to change this. But if the choice is between a haircut and reopening school for our neighbors’ kids and day care for our daughter, I choose children. If the choice is between a drink at the bar and supporting women who are trying to manage a career and parenting during a pandemic, I choose women. Let us be bold together and halt reopening the economy—and choose reopening schools, and a better fall for our families.
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