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But the pandemic has revealed a dearth of reliable data about the key parts of the nation’s health-care system now under assault. That leaves decision-makers operating in the dark

Given the limitations, The Washington Post assembled data to analyze the availability of the critical-care resources needed to treat severely ill patients who require extended hospitalization. The Post conducted a stress test of sorts on available resources, which revealed a patchwork of possible preparedness shortcomings in cities and towns where the full force of the virus has yet to hit and where people may not be following isolation and social distancing orders.

More than half of the nation’s population lives in areas that are less prepared than New York City, where in early April officials scrambled to add more ICU beds and find extra ventilators amid a surge of covid-19 patients.

To compare available resources across the country, The Post examined a year-long scenario in which the coronavirus would sicken 20 percent of U.S. adults, and about 20 percent of those infected would require hospitalization

Under that scenario, about 11 million adults would need hospitalization for nearly two weeks, and almost 2.5 million would require intensive care.

This level of hospitalization is considered by Harvard researchers to be a conservative outcome for the pandemic, while others have described it as severe.

about 76 million people, or 30 percent of the nation’s adult population, live in areas where the number of available ICU beds would not be enough to satisfy the demand of virus patients. The scenario for ventilator availability is even more dire: Nearly half of the adult population lives in regions where the demand would exceed the supply.

We need to know where our weapons are. We need to coordinate all of that,” said Retsef Levi, a Massachusetts Institute of Technology professor leading a health-care data initiative called the COVID-19 Policy Alliance. “This is a war.”

Kahn likened the task of evaluating the current readiness of the U.S. health-care system to peering into a dark room.

By The Post’s analysis, the general Seattle region would need all of its available ICU beds — plus a 15 percent increase — to handle an outbreak in which 20 percent of the population is infected with the coronavirus and 20 percent of those people need hospitalization. But the demand for ICU beds could be lower because the curve of infections in Washington appears to be flattening, according to officials.

Bergamo, as the ground zero of the Italian outbreak, was beset by ICU bed and ventilator shortages. “We think Italy may be the most comparable area to the United States, at this point, for a variety of reasons,” Vice President Pence said April 1 in a CNN interview.

The MIT research group, the COVID-19 Policy Alliance, has mapped high-risk areas in the United States where sudden spikes could inundate hospitals as the surge in northern Italy did.

In their U.S. analysis, MIT researchers considered several risk factors, including elderly population, high blood pressure and obesity.

The takeaway, the researchers said, is that across the nation, “micro-geographies” of individual Zip codes or small towns have the potential to generate surges of covid-19 patients that could overwhelm even the most-prepared hospitals.

Levi said nursing home populations should be prioritized for virus testing across the country, because outbreaks in such close quarters can rapidly sicken dozens of people, who then flood into area hospitals.

“We’re outside of it, and we’re all looking through different keyholes and seeing different aspects of it,” he said. “But there’s no way to just open the door and turn on the lights, because of how fragmented the data are. And that is a really, really depressing thing at all times, let alone during a pandemic, that we don’t have an ability to look at these things.”

The Society of Critical Care Medicine estimates that there are nearly 29,000 critical-care specialized physicians like Johnson who are trained to work in ICUs in the United States. Yet about half of all acute-care hospitals have no specialists dedicated to their ICUs. Because of the demands of treating covid-19 patients, the lack of dedicated physicians “will be strongly felt” through a lack of high-quality care, the society said in a statement.

The society also projects that the nurses, respiratory therapists and physician assistants specially qualified to work with ICU patients may be in short supply as patient demand increases and the ranks of medical workers are thinned by illness and quarantine.

what has the hospital been doing as a prevention epicenter in the four years between the Ebola epidemic and the emergence of the coronavirus pandemic?

“Drilling and preparing for it,” said Jorge Salinas, an infectious-disease physician working on the effort. “You may be preparing and training for 10 years and nothing happens. But if you don’t do that, when these pandemics do occur, you will not be prepared.”

Salinas said the pandemic has exposed the long-standing flaws in the nation’s “individualistic” health-care system, where hospitals look out for themselves. Electronic health-monitoring systems vary hospital to hospital. Supply tallies are kept in-house and generally not shared. To counter this in Iowa, he said, all hospitals have begun sharing daily information with state officials.

“The name of the game is solidarity,” Salinas said. “If we try to be individualists, we will fail.”

But with 1,295 deaths, Germany’s fatality rate stood at 1.4 percent, compared with 12 percent in Italy, around 10 percent in Spain, France and Britain, 4 percent in China and 2.5 percent in the United States. Even South Korea, a model of flattening the curve, has a higher fatality rate, 1.7 percent.

There are several answers experts say, a mix of statistical distortions and very real differences in how the country has taken on the epidemic.

The average age of those infected is lower in Germany than in many other countries. Many of the early patients caught the virus in Austrian and Italian ski resorts and were relatively young and healthy, Professor Kräusslich said.“It started as an epidemic of skiers,

“The reason why we in Germany have so few deaths at the moment compared to the number of infected can be largely explained by the fact that we are doing an extremely large number of lab diagnoses,”

Another explanation for the low fatality rate is that Germany has been testing far more people than most nations. That means it catches more people with few or no symptoms, increasing the number of known cases, but not the number of fatalities.

But there are also significant medical factors that have kept the number of deaths in Germany relatively low, epidemiologists and virologists say, chief among them early and widespread testing and treatment, plenty of intensive care beds and a trusted government whose social distancing guidelines are widely observed.

TestingIn mid-January, long before most Germans had given the virus much thought, Charité hospital in Berlin had already developed a test and posted the formula online.

By the time Germany recorded its first case of Covid-19 in February, laboratories across the country had built up a stock of test kits.

the average age of contracting the disease remains relatively low, at 49. In France, it is 62.5 and in Italy 62, according to their latest national reports.

At the end of April, health authorities also plan to roll out a large-scale antibody study, testing random samples of 100,000 people across Germany every week to gauge where immunity is building up.

Early and widespread testing has allowed the authorities to slow the spread of the pandemic by isolating known cases while they are infectious. It has also enabled lifesaving treatment to be administered in a more timely way.

Medical staff, at particular risk of contracting and spreading the virus, are regularly tested. To streamline the procedure, some hospitals have started doing block tests, using the swabs of 10 employees, and following up with individual tests only if there is a positive result.

If it slows a little more, to between 12 and 14 days, Professor Herold said, the models suggest that triage could be avoided.

One key to ensuring broad-based testing is that patients pay nothing for it, said Professor Streeck. This, he said, was one notable difference with the United States

By now, Germany is conducting around 350,000 coronavirus tests a week, far more than any other European country

Tracking

In most countries, including the United States, testing is largely limited to the sickest patients, so the man probably would have been refused a test.

Not in Germany. As soon as the test results were in, the school was shut, and all children and staff were ordered to stay at home with their families for two weeks. Some 235 people were tested.“Testing and tracking is the strategy that was successful in South Korea and we have tried to learn from that,” Professor Streeck said.Germany also learned from getting it wrong early on: The strategy of contact tracing should have been used even more aggressively, he said.

All those who had returned to Germany from Ischgl, an Austrian ski resort that had an outbreak, for example, should have been tracked down and tested, Professor Streeck said

A Robust Public Health Care System

Before the coronavirus pandemic swept across Germany, University Hospital in Giessen had 173 intensive care beds equipped with ventilators. In recent weeks, the hospital scrambled to create an additional 40 beds and increased the staff that was on standby to work in intensive care by as much as 50 percent.

“We have so much capacity now we are accepting patients from Italy, Spain and France,”

All across Germany, hospitals have expanded their intensive care capacities. And they started from a high level. In January, Germany had some 28,000 intensive care beds equipped with ventilators, or 34 per 100,000 people

By comparison, that rate is 12 in Italy and 7 in the Netherlands.

By now, there are 40,000 intensive care beds available in Germany.

The time it takes for the number of infections to double has slowed to about eight days

“A young person with no health insurance and an itchy throat is unlikely to go to the doctor and therefore risks infecting more people,” he said.

Trust in Government

many also see Chancellor Angela Merkel’s leadership as one reason the fatality rate has been kept low.

Ms. Merkel has communicated clearly, calmly and regularly throughout the crisis, as she imposed ever-stricter social distancing measures on the country.

The restrictions, which have been crucial to slowing the spread of the pandemic, met with little political opposition and are broadly followed.

“Maybe our biggest strength in Germany,” said Professor Kräusslich, “is the rational decision-making at the highest level of government combined with the trust the government enjoys in the population.”

lower costs are going to be about finding ways to get people to take more responsibility for their health — for losing weight, for example, or bringing their blood pressure down.

there are other concerns, such as whether an all-encompassing system like Kaiser’s can really be replicated and whether the limits it places on where patients can seek care will be accepted by enough people to make a difference.

Or whether, as the nation’s flirtation with health maintenance organizations, or H.M.O.’s, in the 1990s showed — people will balk at the concept of not being able to go to any doctor or hospital of their choice.

its integrated model is in favor again. Hospitals across the country are buying physician practices or partnering with doctors and health insurers to form accountable care organizations, or A. C.O.’s, as a way of controlling more aspects of patient care. Doctors are also creating so-called medical homes, where patient care is better coordinated.

The days when doctors, hospitals and other providers are paid separately for each procedure will disappear eventually, health experts say. Instead, providers will have financial incentives to encourage them to keep people healthy, including lump sums to care for patients or provide comprehensive care for a specific condition. “All of care is going to move down this path, and it has to,” Mr. Halvorson said. “Medical homes are doing it; the very best A. C.O’s are going to figure out how to do it.”

there are downsides to the creation of large health care systems that may be motivated by the desire to increase their clout in the market, making it easier to fill beds and charge the insurers more for care. “They become these huge local monopolies,”

“We have all the pieces,” said Philip Fasano, Kaiser’s chief information officer. “Anything a patient needs you get in the four walls of our offices,

its plans are typically at least 10 percent less expensive than others, especially where they control all the providers

Kaiser has also been using the information to identify those doctors or clinics that excel in certain areas, as well as those in need of improvement. The organization has also used the records to change how it delivers care, identifying patients at risk for developing bed sores in the hospital and then sending electronic alerts every two hours to remind the nurses to turn the patients. The percentage of patients with serious pressure ulcers, or bed sores, dropped to well under 1 percent from 3.5 percent.

What is clear is that, despite years of Western involvement and billions of dollars in humanitarian aid to Afghanistan, children’s health is not only still a problem, but also worsening, and the doctors bearing the brunt of the crisis are worried.

Nearly every potential lifeline is strained or broken here. Efforts to educate people about nutrition and health care are often stymied by conservative traditions that cloister women away from anyone outside the family. Agriculture and traditional local sources of social support have been disrupted by war and the widespread flight of refugees to the cities. And therapeutic feeding programs, complex operations even in countries with strong health care systems, have been compromised as the flow of aid and transportation have been derailed by political tensions or violence.

Perhaps nowhere is the situation so obviously serious as in the malnutrition ward at Bost Hospital, which is admitting 200 children a month for severe, acute malnutrition — four times more than it did in January 2012, according to officials with Doctors Without Borders, known in French as Médecins Sans Frontières, which supports the Afghan-run hospital with financing and supplementary staff.

One patient, a 2-year-old named Ahmed Wali, is suffering from the protein deficiency condition kwashiorkor, with orange hair, a distended belly and swollen feet. An 8-month-old boy named Samiullah is suffering from marasmus, another form of advanced malnutrition in which the child’s face looks like that of a wrinkled old man because the skin hangs so loosely.

Médecins Sans Frontières helped Bost Hospital nearly double the number of beds in the pediatric wing at the end of last year, and there are still not enough — 40 to 50 children are usually being treated each day, mostly two to a bed because they are so small. Nearly 300 other children, less severely malnourished, are in an outpatient therapeutic feeding program.

“It’s quite an unusual situation, and it’s difficult to understand what’s going on,” said Wiet Vandormael, an M.S.F. official who has helped coordinate with Bost Hospital.

People have to understand that when we overrun our healthcare – our hospitals – that people will still come in with heart attacks, people will still have car accidents. These things that happen every day on top of Covid-19 will make our healthcare system collapse in the same way that you’re seeing that happen in New York and you’re seeing it happen across the globe,”

Until Wednesday morning, Georgia also had the fourth-highest death toll of coronavirus patients, until Louisiana’s cases soared. With over half a dozen Georgia hospitals shutting down during the past decade across rural communities, much of the state’s healthcare has been lacking. In 2017, a study found Georgia had one of the worst healthcare systems in the country, ranking it 49th for access.

To contain such a pathogen, nations must develop a test and use it to identify infected people, isolate them, and trace those they’ve had contact with. That is what South Korea, Singapore, and Hong Kong did to tremendous effect. It is what the United States did not.

That a biomedical powerhouse like the U.S. should so thoroughly fail to create a very simple diagnostic test was, quite literally, unimaginable. “I’m not aware of any simulations that I or others have run where we [considered] a failure of testing,”

The testing fiasco was the original sin of America’s pandemic failure, the single flaw that undermined every other countermeasure. If the country could have accurately tracked the spread of the virus, hospitals could have executed their pandemic plans, girding themselves by allocating treatment rooms, ordering extra supplies, tagging in personnel, or assigning specific facilities to deal with COVID-19 cases.

None of that happened. Instead, a health-care system that already runs close to full capacity, and that was already challenged by a severe flu season, was suddenly faced with a virus that had been left to spread, untracked, through communities around the country.

With little room to surge during a crisis, America’s health-care system operates on the assumption that unaffected states can help beleaguered ones in an emergency.

That ethic works for localized disasters such as hurricanes or wildfires, but not for a pandemic that is now in all 50 states. Cooperation has given way to competition

Partly, that’s because the White House is a ghost town of scientific expertise. A pandemic-preparedness office that was part of the National Security Council was dissolved in 2018. On January 28, Luciana Borio, who was part of that team, urged the government to “act now to prevent an American epidemic,” and specifically to work with the private sector to develop fast, easy diagnostic tests. But with the office shuttered, those warnings were published in The Wall Street Journal, rather than spoken into the president’s ear.

Rudderless, blindsided, lethargic, and uncoordinated, America has mishandled the COVID-19 crisis to a substantially worse degree than what every health expert I’ve spoken with had feared. “Much worse,”

“Beyond any expectations we had,” said Lauren Sauer, who works on disaster preparedness at Johns Hopkins Medicine. “As an American, I’m horrified,” said Seth Berkley, who heads Gavi, the Vaccine Alliance. “The U.S. may end up with the worst outbreak in the industrialized world.”

it will be difficult—but not impossible—for the United States to catch up. To an extent, the near-term future is set because COVID-19 is a slow and long illness. People who were infected several days ago will only start showing symptoms now, even if they isolated themselves in the meantime. Some of those people will enter intensive-care units in early April

A “massive logistics and supply-chain operation [is] now needed across the country,” says Thomas Inglesby of Johns Hopkins Bloomberg School of Public Health. That can’t be managed by small and inexperienced teams scattered throughout the White House. The solution, he says, is to tag in the Defense Logistics Agency—a 26,000-person group that prepares the U.S. military for overseas operations and that has assisted in past public-health crises, including the 2014 Ebola outbreak.

The first and most important is to rapidly produce masks, gloves, and other personal protective equipment

it would also come at a terrible cost: SARS-CoV-2 is more transmissible and fatal than the flu, and it would likely leave behind many millions of corpses and a trail of devastated health systems.

This agency can also coordinate the second pressing need: a massive rollout of COVID-19 tests.

These measures will take time, during which the pandemic will either accelerate beyond the capacity of the health system or slow to containable levels. Its course—and the nation’s fate—now depends on the third need, which is social distancing.

There are now only two groups of Americans. Group A includes everyone involved in the medical response, whether that’s treating patients, running tests, or manufacturing supplies. Group B includes everyone else, and their job is to buy Group A more time. Group B must now “flatten the curve” by physically isolating themselves from other people to cut off chains of transmission.

Given the slow fuse of COVID-19, to forestall the future collapse of the health-care system, these seemingly drastic steps must be taken immediately, before they feel proportionate, and they must continue for several weeks.

Persuading a country to voluntarily stay at home is not easy, and without clear guidelines from the White House, mayors, governors, and business owners have been forced to take their own steps.

when the good of all hinges on the sacrifices of many, clear coordination matters—the fourth urgent need

Pundits and business leaders have used similar rhetoric, arguing that high-risk people, such as the elderly, could be protected while lower-risk people are allowed to go back to work. Such thinking is seductive, but flawed. It overestimates our ability to assess a person’s risk, and to somehow wall off the ‘high-risk’ people from the rest of society. It underestimates how badly the virus can hit ‘low-risk’ groups, and how thoroughly hospitals will be overwhelmed if even just younger demographics are falling sick.

A recent analysis from the University of Pennsylvania estimated that even if social-distancing measures can reduce infection rates by 95 percent, 960,000 Americans will still need intensive care.

There are only about 180,000 ventilators in the U.S. and, more pertinently, only enough respiratory therapists and critical-care staff to safely look after 100,000 ventilated patients. Abandoning social distancing would be foolish. Abandoning it now, when tests and protective equipment are still scarce, would be catastrophic.

If Trump stays the course, if Americans adhere to social distancing, if testing can be rolled out, and if enough masks can be produced, there is a chance that the country can still avert the worst predictions about COVID-19, and at least temporarily bring the pandemic under control. No one knows how long that will take, but it won’t be quick. “It could be anywhere from four to six weeks to up to three months,” Fauci said, “but I don’t have great confidence in that range.”

there are three possible endgames: one that’s very unlikely, one that’s very dangerous, and one that’s very long.

The first is that every nation manages to simultaneously bring the virus to heel, as with the original SARS in 2003. Given how widespread the coronavirus pandemic is, and how badly many countries are faring, the odds of worldwide synchronous control seem vanishingly small.

The second is that the virus does what past flu pandemics have done: It burns through the world and leaves behind enough immune survivors that it eventually struggles to find viable hosts. This “herd immunity” scenario would be quick, and thus tempting

The U.S. has fewer hospital beds per capita than Italy. A study released by a team at Imperial College London concluded that if the pandemic is left unchecked, those beds will all be full by late April. By the end of June, for every available critical-care bed, there will be roughly 15 COVID-19 patients in need of one.  By the end of the summer, the pandemic will have directly killed 2.2 million Americans,

The third scenario is that the world plays a protracted game of whack-a-mole with the virus, stamping out outbreaks here and there until a vaccine can be produced. This is the best option, but also the longest and most complicated.

there are no existing vaccines for coronaviruses—until now, these viruses seemed to cause diseases that were mild or rare—so researchers must start from scratch.

The first steps have been impressively quick. Last Monday, a possible vaccine created by Moderna and the National Institutes of Health went into early clinical testing. That marks a 63-day gap between scientists sequencing the virus’s genes for the first time and doctors injecting a vaccine candidate into a person’s arm. “It’s overwhelmingly the world record,” Fauci said.

The initial trial will simply tell researchers if the vaccine seems safe, and if it can actually mobilize the immune system. Researchers will then need to check that it actually prevents infection from SARS-CoV-2. They’ll need to do animal tests and large-scale trials to ensure that the vaccine doesn’t cause severe side effects. They’ll need to work out what dose is required, how many shots people need, if the vaccine works in elderly people, and if it requires other chemicals to boost its effectiveness.

No matter which strategy is faster, Berkley and others estimate that it will take 12 to 18 months to develop a proven vaccine, and then longer still to make it, ship it, and inject it into people’s arms.

as the status quo returns, so too will the virus. This doesn’t mean that society must be on continuous lockdown until 2022. But “we need to be prepared to do multiple periods of social distancing,” says Stephen Kissler of Harvard.

First: seasonality. Coronaviruses tend to be winter infections that wane or disappear in the summer. That may also be true for SARS-CoV-2, but seasonal variations might not sufficiently slow the virus when it has so many immunologically naive hosts to infect.

Second: duration of immunity. When people are infected by the milder human coronaviruses that cause cold-like symptoms, they remain immune for less than a year. By contrast, the few who were infected by the original SARS virus, which was far more severe, stayed immune for much longer.

scientists will need to develop accurate serological tests, which look for the antibodies that confer immunity. They’ll also need to confirm that such antibodies actually stop people from catching or spreading the virus. If so, immune citizens can return to work, care for the vulnerable, and anchor the economy during bouts of social distancing.

Aspects of America’s identity may need rethinking after COVID-19. Many of the country’s values have seemed to work against it during the pandemic. Its individualism, exceptionalism, and tendency to equate doing whatever you want with an act of resistance meant that when it came time to save lives and stay indoors, some people flocked to bars and clubs.

“We can keep schools and businesses open as much as possible, closing them quickly when suppression fails, then opening them back up again once the infected are identified and isolated. Instead of playing defense, we could play more offense.”

The vaccine may need to be updated as the virus changes, and people may need to get revaccinated on a regular basis, as they currently do for the flu. Models suggest that the virus might simmer around the world, triggering epidemics every few years or so. “But my hope and expectation is that the severity would decline, and there would be less societal upheaval,”

After infections begin ebbing, a secondary pandemic of mental-health problems will follow.

But “there is also the potential for a much better world after we get through this trauma,”

Testing kits can be widely distributed to catch the virus’s return as quickly as possible. There’s no reason that the U.S. should let SARS-CoV-2 catch it unawares again, and thus no reason that social-distancing measures need to be deployed as broadly and heavy-handedly as they now must be.

Pandemics can also catalyze social change. People, businesses, and institutions have been remarkably quick to adopt or call for practices that they might once have dragged their heels on, including working from home, conference-calling to accommodate people with disabilities, proper sick leave, and flexible child-care arrangements.

Perhaps the nation will learn that preparedness isn’t just about masks, vaccines, and tests, but also about fair labor policies and a stable and equal health-care system. Perhaps it will appreciate that health-care workers and public-health specialists compose America’s social immune system, and that this system has been suppressed.

Attitudes to health may also change for the better. The rise of HIV and AIDS “completely changed sexual behavior among young people who were coming into sexual maturity at the height of the epidemic,”

Years of isolationist rhetoric had consequences too.

“People believed the rhetoric that containment would work,” says Wendy Parmet, who studies law and public health at Northeastern University. “We keep them out, and we’ll be okay. When you have a body politic that buys into these ideas of isolationism and ethnonationalism, you’re especially vulnerable when a pandemic hits.”

Pandemics are democratizing experiences. People whose privilege and power would normally shield them from a crisis are facing quarantines, testing positive, and losing loved ones. Senators are falling sick. The consequences of defunding public-health agencies, losing expertise, and stretching hospitals are no longer manifesting as angry opinion pieces, but as faltering lungs.

After COVID-19, attention may shift to public health. Expect to see a spike in funding for virology and vaccinology, a surge in students applying to public-health programs, and more domestic production of medical supplies.

The lessons that America draws from this experience are hard to predict, especially at a time when online algorithms and partisan broadcasters only serve news that aligns with their audience’s preconceptions.

“The transitions after World War II or 9/11 were not about a bunch of new ideas,” he says. “The ideas are out there, but the debates will be more acute over the next few months because of the fluidity of the moment and willingness of the American public to accept big, massive changes.”

One could easily conceive of a world in which most of the nation believes that America defeated COVID-19. Despite his many lapses, Trump’s approval rating has surged. Imagine that he succeeds in diverting blame for the crisis to China, casting it as the villain and America as the resilient hero.

One could also envisage a future in which America learns a different lesson. A communal spirit, ironically born through social distancing, causes people to turn outward, to neighbors both foreign and domestic. The election of November 2020 becomes a repudiation of “America first” politics. The nation pivots, as it did after World War II, from isolationism to international cooperation

The U.S. leads a new global partnership focused on solving challenges like pandemics and climate change.

In 2030, SARS-CoV-3 emerges from nowhere, and is brought to heel within a month.

On the Global Health Security Index, a report card that grades every country on its pandemic preparedness, the United States has a score of 83.5—the world’s highest. Rich, strong, developed, America is supposed to be the readiest of nations. That illusion has been shattered. Despite months of advance warning as the virus spread in other countries, when America was finally tested by COVID-19, it failed.

“Losing two months is close to disastrous, and that’s what we did,” Ashish Jha, director of the Harvard Global Health Institute, told Bloomberg.

if we are being honest with ourselves, we would have to admit that the United States has long been failing. We remain one of the richest countries in the world, but by international standards we look more like a Third World nation.

we lag in almost every measure of societal well-being among the wealthy nations (now 36) of the Organization for Economic Cooperation and Development (OECD).

we had the second-highest poverty rate, the highest level of income inequality and the highest level of obesity.

We were also below average on renewable energy, infrastructure investment and voter turnout.

We spent the most on education but produced less-than-average results

We are the only OECD nation that doesn’t mandate paid family leave.

One area where we do lead is gun violence. Our homicide rate is nearly 50 percent above the OECD average.

We spend more on health care than any other country in the world, but we are the only OECD country without universal medical coverage (27.9 million Americans lacked health insurance in 2018)

Child mortality in the United States is the highest in the OECD, and life expectancy is below average

We have far fewer hospital beds per 1,000 people than other advanced democracies (2.4 compared to 12.2 in South Korea), which makes us particularly vulnerable to a pandemic.

Why has America become so backward? That is a complex topic. I would direct readers to the work of analysts such as Jonathan Rauch, Francis Fukuyama, and Norman Ornstein and Thomas Mann

I would ascribe a lot of what’s wrong to growing partisan polarization that makes it almost impossible to address our most pressing needs. Republicans are getting more conservative and Democrats more liberal — although not to the same degree. The GOP is far more extreme than the Democratic Party.

President Trump has exacerbated the problem, but he didn’t start it. He is himself the product of decades of right-wing revolt against government and increasingly against reason itself.

America is unusual in having a major party — and a major television network — devoted to climate denialism and protecting the “right” of everyone to own an assault rifle. The GOP and the right-wing media have long been a hotbed of nutty conspiracy theories, and their reluctance to face the reality of the new coronavirus set back efforts to save lives.

The Republicans’ decades-long demonization of government has consequences

the federal civilian workforce has fallen as a percentage of total nonfarm employment from 18 percent in 1980 to 15 percent today, and their salaries top out at just under $200,000 — “only slightly more than an entry-level engineer makes at Google.”

There are still plenty of high-quality civil servants, but their ranks are too thin, and they are too much at the mercy of political yahoos.

“When a typical European parliamentary government changes hands from one party to another, the ministers and a handful of staffers turn over,” Fukuyama notes. “In the U.S., a change of administration (even within the same party) opens up some 5,000 ‘Schedule C’ job positions to political appointees.”

We must not only beat this pandemic; we must also address a host of other ills that have been festering for decades. In recent years, America has been “exceptional” mainly in the scale of our governmental failures compared with those of other industrialized democracies.

Dr. Neil M. Ferguson, a British epidemiologist who is regarded as one of the best disease modelers in the world, produced a sophisticated model with a worst case of 2.2 million deaths in the United States.

I asked Ferguson for his best case. “About 1.1 million deaths,” he said.

one can argue that the U.S. is not only on the same path as Italy but is also less prepared, for America has fewer doctors and hospital beds per capita than Italy does — and a shorter life expectancy even in the best of times.

up to 366,000 I.C.U. beds might be needed in the United States for coronavirus patients at one time, more than 10 times the number available. A Harvard study reached a similar conclusion.

This is an interval of quiet when the United States should be urgently ramping up investment in vaccines and therapies, addressing the severe shortages of medical supplies and equipment, and giving retired physicians and military medics legal authority to practice in a crisis

During World War II, the Ford Motor Company turned out one B-24 bomber every 63 minutes; today, we should be rushing out ventilators and face masks, but there’s nothing like the same sense of urgency.

After initial missteps in Wuhan, where the coronavirus was first discovered, China adopted protocols for protective gear that are more rigorous than those in the United States, involving N95 masks and face shields, double gowns, gloves and shoe covers, plus special areas to remove protective clothing — and all this worked. Not one of the 42,000 health workers sent to Wuhan is known to have become infected with the coronavirus. The United States isn’t protecting health workers with the same determination; it seems to be betraying them.

This crisis should be a wake-up call to address long-term vulnerabilities. That means providing universal health coverage and paid sick leave — and if you think that the coronavirus legislation Trump signed on Wednesday achieves that, think again. It guarantees sick leave to only about one-fifth of private-sector workers. It’s a symbol of the inadequacy of America’s preparedness.

“We are all making dying contingency plans at this point just in case,” she said. “Wills, backup people to take care of kids, recording bedtime stories.”

The United States is in a weaker position than some other countries to confront the virus because it is the only advanced country that doesn’t have universal health coverage, and the only one that does not guarantee paid sick leave

with infectious diseases, the burden will be shared by all Americans

In Italy, 8.3 percent of coronavirus cases involve health workers. A doctor in the Seattle area who is forced to reuse N95 masks told me that she and her colleagues fear that the lack of supplies will be deadly.

We may dodge a bullet this time, but experts have been warning for decades that a killer pandemic will come;

if we, too, can be scared enough to invest in public health and fix our health care system, then something good can come from this crisis — and in the long run, that may save lives.

Ferguson questions whether South Korea and other countries can sustain their success for 18 months until a vaccine is ready, even as new cases are constantly being imported

America and South Korea reported their first Covid-19 cases on the same day, but South Korea took the epidemic seriously, promptly created an effective test, used it widely and has seen cases go down more than 90 percent from the peak.

In contrast, the United States badly bungled testing, and President Trump repeatedly dismissed the coronavirus, saying it was “totally under control” and “will disappear,” and insisting he wasn’t “concerned at all.” The United States has still done only a bit more than 10 percent as many tests per capita as Canada, Austria and Denmark.

Peter Hotez, an eminent vaccine scientist at Baylor College of Medicine, told me that he and his colleagues have a candidate vaccine for the coronavirus but still haven’t been able to line up sufficient funding for clinical trials.

BUT IF WE START EXTREME SOCIAL DISTANCING BY MARCH 23 (12 days from original writing), WE AVOID OVER 1.4 MILLION PEOPLE GETTING CRITICALLY ILL AND OVERWHELMING THE HOSPITALS

the math is very different, as the exponential growth will only be 2 to the 4th power (12 days divided by the doubling rate of every 3 days equals the exponent of 4):2 x 2 x 2 x 2 = 16

So instead of 10 Million cases in the United States if we wait 30 days, if we act 18 days sooner, we will have only 160,000 cases (16 times the estimated 10,000 actual cases as of today), of which 15% are likely to require hospitalization.

This is 24,000 critical patients (a huge difference compared to 1.5 million acute patients). The difference between taking extreme measures now, versus waiting even a few days, is very large due to how exponents work in math.

Finally, the article that I posted yesterday written by Tomas Pueyo has been read 30M times in the last few days and has been updated with new information. It’s worth reading again.

https://medium.com/…/coronavirus-act-today-or-people-will-d…

More than 131,300 people are now hospitalized with Covid-19, according to the COVID Tracking Project.

On Tuesday, Arizona reported a record-high 5,082 hospitalized Covid-19 patients. The same day, it broke a second record: more than 1,180 Covid-19 patients in ICU beds.

More than a quarter of the population in 30 US counties comes from full-time enrollment at higher education institutes, according to the National Center for Education Statistics. In 10 of those counties, at least 90% of staffed ICU beds are occupied, according to the NCES. Those counties include Oktibbeha County, home to Mississippi State University, where almost all ICU beds are occupied by Covid-19 patients.

In Williamsburg, Virginia -- home to William & Mary -- Covid-19 cases nearly tripled in one week.

While vaccinations continue to lag behind predictions, health experts are begging Americans to hunker down in their bubbles for these next few months as soaring hospitalizations lead to record daily deaths.

Mass vaccinations, warmer weather, a new presidential administration and a population building immunity could lead to a "dramatically better" summer, he said.

Two "remarkably effective" vaccines are already being administered, and two more vaccines -- from Johnson & Johnson and AstraZeneca -- "are right around the corner," Offit said.

The incoming Biden administration "isn't into this cult of denialism"

If another 55% to 60% of the population can be vaccinated -- something Offit said can be done if the US gives 1 million to 1.5 million doses a day -- "then I really do think that by June, we can stop the spread of this virus."

"We are telling states they should open vaccinations to all people ... 65 and over and all people under age 65 with a comorbidity with some form of medical documentation," Azar said.

The Pfizer vaccine doses should be spaced 21 days apart, and the Moderna doses should be 28 days apart.More than 27.6 million vaccine doses have so far been distributed, according to CDC data, and more than 9.3 million people have received their first dose -- a far cry from where some experts hoped the country would be by now.

Fauci said, "When people are ready to get vaccinated, we're going to move right on to the next level, so that there are not vaccine doses that are sitting in a freezer or refrigerator where they could be getting into people's arm."

And starting in two weeks, vaccines will be distributed to states based on which jurisdictions are getting the most doses into arms and where the most older adults reside. "We will be allocating them based on the pace of administration as reported by states and by the size of the 65 and over population in each state," Azar said.

Only six states have administered more than 50% of the doses distributed to them, according to data from the Centers for Disease Control and Prevention: Connecticut, Montana, North Dakota, South Dakota, Tennessee and West Virginia.

Nearly 2.3 million children tested positive for Covid-19 from the pandemic's start through January 7, a new report from the American Academy of Pediatrics and the Children's Hospital Association shows

More than 171,000 of those cases were reported between December 31 and January 7, while over two weeks -- between December 24 through January 7 -- there was a 15% increase in child Covid-19 cases, the report said.

The findings mean children now represent 12.5% of all infections in the US.

They paint a granular picture of the strain on hospitals across the country that could help local citizens decide when to take extra precautions against COVID-19.

Withholding this information from the public and the research community is a missed opportunity to help prevent outbreaks and even save lives, say public health and data experts who reviewed the documents for NPR.

"At this point, I think it's reckless. It's endangering people," says Ryan Panchadsaram,

The documents show that detailed information hospitals report to HHS every day is reviewed and analyzed — but circulation seems to be limited to a few dozen government staffers from HHS and its agencies,

"The best possible measure of where we are in the pandemic, and the one we would want to anchor modeling to, is daily hospitalizations," he says, which give an early warning of deaths that will likely follow.

For instance, the most recent report obtained by NPR, dated Oct 27, lists cities where hospitals are filling up, including the metro areas of Atlanta, Minneapolis and Baltimore, where in-patient hospital beds are over 80% full. It also lists specific hospitals reaching max capacity, including facilities in Tampa, Birmingham and New York that are at over 95% ICU capacity and at risk of running out of intensive care beds.

Hospitalization data is invaluable in looking ahead to see where and when outbreaks are getting worse, says Dr. Christopher Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington. "Right now, as we head into the fall and winter surge," Murray says, "we're trying to put more emphasis on predicting where systems will be overwhelmed."

NPR has reviewed several of these reports generated in the past month. They present trends in hospital use, including increases in ventilator usage, along with a growing number of inpatient and ICU beds being occupied by COVID-19 patients. The Oct. 27 report showed that all three measures have increased by 14%-16% in the past month.

About 24% of U.S. hospitals are using more than 80% of their ICU capacity, based on reporting from nearly 5,000 "priority facilities," and more hospitals have joined their ranks in recent weeks.

Researchers say observing these trend lines can help the nation know how to prepare for surge and be ready to intervene before systems become overwhelmed.

Only one member of the White House Coronavirus Task Force, Adm. Brett Giroir, appears to receive the documents directly.

HHS tells NPR that more than 800 state-level employees have access to the daily hospitalization data it gathers, but only for their own state, unless another state grants them permission to view its data.

Without a larger view into national or regional data, some states — like Tennessee, which has eight bordering states — are missing out on valuable regional data, says Melissa McPheeters, who directs the Center for Improving the Public's Health through Informatics at Vanderbilt University.

"It's very challenging for states to get the multistate view of things," she says. "It's just a lot easier when there's a knowledgeable third-party who can pull the data together, make them consistent across states and actually tell the story of what the information shows." Typically, she says, this role would be fulfilled by the CDC, but the agency was stripped of its role in collecting COVID-19 hospital data in July.

McPheeters and colleagues at Vanderbilt put out a report this week that found that Tennessee counties without mask mandates had more rapid increases in hospitalizations.

Experts who reviewed the internal documents for NPR say that even for the limited group of federal employees who get them, the daily reports are not as useful as they could be.

Health data experts NPR consulted had ideas on how to improve the analysis. For instance, Panchadsaram suggested that some of the county-level charts, currently presented as raw numbers, would be more useful if analyzed per capita. "You really need to adjust it to the number of people [in an area] to get a sense of where things are being overwhelmed," he says.

And the quality of the underlying data is a concern. Health experts say the data quality was compromised by a controversial shift in data collection from the CDC to HHS in July, and that the issues with data quality have not been fully resolved.

According to HHS data posted on Monday, just 62% of the nation's hospitals reported all the required information last week.

But greater transparency, even of incomplete data, can be invaluable in a crisis, experts say.

their daily energy expenditure is about the same as most Americans, suggesting physical activity is not the reason for their relative good health.

The prevailing notion in sleep medicine is that humans evolved to go to bed when the sun goes down, and that by and large we stay up much later than we should because we are flooded with artificial light

Dr. Siegel and his colleagues found no evidence of this. The hunter-gatherer groups they studied, which slept outside or in crude huts, did not go to sleep when the sun went down. Usually they stayed awake three to four hours past sunset, with no light exposure other than the faint glow of a small fire that would keep animals away and provide a bit of warmth in the winter. Most days they would wake up about an hour before sunrise.

In a typical night, they slept just six and a half hours — slightly less than the average American

“I think this paper is going to transform the field of sleep,” said John Peever, a sleep expert at the University of Toronto who was not involved in the new research. “It’s difficult to envision how we can claim that Western society is highly sleep deprived if these groups that live without all these modern distractions and pressing schedules sleep less or about the same amount

in the new study, the hunter-gatherer societies were found to have a sleep period — meaning the time they were actually in bed — of roughly seven to eight and a half hours, which he said was consistent with his group’s recommendations.

the question of how much sleep people require was a delicate one. “Really it’s just the amount that allows people to wake up feeling refreshed and alert,

Dr. Siegel said he worried that putting a number on the amount of sleep people require could push those who get less to resort to using sleeping pills, which carry severe side effects. About 5 percent of Americans take sleeping pills, a percentage that has doubled in the past two decades.

called the new study “excellent and very timely,” and he said it suggests that sleep quality is much more important than quantity.

Some historians have also argued that it is not natural for people to sleep straight through the night. They say that before the introduction of artificial light it was normal for people to sleep in two intervals separated by an hour of wakefulness, a phenomenon known as segmented sleep, or “first” and “second” sleep.

But Dr. Siegel said he always questioned those assertions because there were no rigorous studies of sleep behaviors back then. He and his colleagues decided that one way to get some insight was to study cultures relatively unaffected by artificial light.

Among those they chose to follow were the Hadza people, who spend their days hunting and foraging in northern Tanzania, much as their ancestors have for tens of thousands of years; the San of Namibia, who have lived as hunter-gatherers in the Kalahari for at least 20,000 years; and the Tsimané, a seminomadic group that lives in the Andean foothills of Bolivia, near the farthest reaches of the human migration out of Africa.

The researchers found that in addition to sleeping roughly similar amounts each night, the three groups rarely took naps during the day and did not sleep in two separate intervals at night.

“The Hadza and the San live in the area where we know humans evolved, and then the Tsimané live in some sense at the end of the human migration,” he said. “The fact that we see very similar sleep times gives me great confidence that this is how all of our ancestors slept.”

Their sleep did not seem to be problematic. Chronic insomnia, which affects 20 percent to 30 percent of Americans, occurred in just 2 percent of the hunter-gatherers. The San and the Tsimané did not even have a word for it in their languages.

ambient temperature may be a major factor. The groups did not go sleep at sunset and they did not wake up at sunrise, suggesting that light exposure did not have much influence on their sleep patterns. But they almost always fell asleep as temperatures began to fall at night, and they would wake up right as the temperatures were rising again.

This suggests that humans may have evolved to sleep during the coldest hours of the day, perhaps as a way to conserve energy

“Today we sleep in environments with fixed temperatures, but none of our ancestors did,” Dr. Siegel said. “We evolved to sleep in a natural environment where the temperature falls at night. Whether we can treat insomnia by putting people in an environment where the temperature is modulated in this way is something to be studied in the future.

High powered jobs come with high-powered workloads, high-powered commitments and, often, high-powered salaries. If that's what a person -- male or female, kids or no kids -- chooses, trade-offs will always be involved, whether you're trading your sleep, your health, your leisure time, your social life, or time with your kids.

any reasonable adult would explain that the world does not revolve around one particular person; that the child can't be two places at the same time; that she must choose one activity or the other; and that, in so choosing, she gains one opportunity but forfeits another.

How does a smart woman like Slaughter still believe in the childlike notion that people (of either gender) can have whatever they want whenever they want it, regardless of life's intrinsic constraints?

I work from home three days a week and am away at my office the other two, and as far as my son is concerned, my being home is no different from my being at the office. Am I spending quality time with my son when I'm working from home? No. I'm working! Would I get any work done if I were interacting with my son while trying to focus and write on deadline? Of course not.

So why do women with choices have such a hard time accepting this? Thirty years ago women used to complain that they wanted "a wife." Now that women like Slaughter have wives (in the guise of her husband who, functioning as a single dad, took care of two kids and the entire household every weekday for two years while he also held down a job and earned a living), they don't like being the husband very much. To their surprise, it turns that husbands don't "have it all" either. And Slaughter is mad as hell to have worked this hard and given up so much only to discover that being the husband kind of sucks. Being the husband requires far more compromise than she and many high-powered women ever imagined.

Most women, given the luxury of choice, might or might not decide to work in some capacity, but they wouldn't decide to be high-powered executives, even if they had the talent, education, and opportunity to do so. As Slaughter discovered about her own desires, they'd rather be doing the carpools and play dates and volunteering at school and staying home when their child has strep throat without suffering massive amounts of guilt. They don't want to die young and look ten years older than their actual age because of undue amounts of stress trying to keep up with their kids' lives and hold down a demanding job at the same time.

Just as Slaughter wants it both ways, so does the rhetoric around gender. Look at the recent covers of this magazine. On the one hand, women are told that they're superior to men (Hanna Rosin's "The End of Men," Kate Bolick's there's-a-scarcity-of-men-in-my-league "All the Single Ladies") and in the same breath, that they're victims of them (Slaughter's piece).

The real problem is that technology has made it possible to work 24/7, so that the boundary between work and our personal lives has disappeared. Our cubicles are in our pockets, at the dinner table, next to our beds and even next to our children's beds as we're tucking them in. In many households, one income isn't enough, and both men and women have to work long hours -- longer hours than ever before -- to make ends meet.

The problem here is that many people work too much -- not just women, and not just parents.

“They beat me. They did terrifying things,” he said quietly in a recent interview. “I don’t want to remember that day.”

Martini is, in some ways, typical: mostly apolitical but firmly opposed to Assad’s regime and to the Islamist groups that are vying with other armed opposition groups for control of rebel-held areas.

Now, he lives alone in makeshift quarters in the offices of the aid organization he helped found in this Turkish border town. He heads the group’s relief operations in northern Syria and the Turkish border regions, overseeing the delivery of medical care to hundreds of thousands of Syrian refugees.

Martini is deeply skeptical of peace talks scheduled for this month in Geneva, which are supposed to facilitate negotiations between Assad’s government and rebel groups.

“We must keep working. Whether the time is long or short, this regime will fall,” Martini said. “Then we must rebuild our country.”

. Then he crossed the border into Jordan, which aid agencies say shelters more than 563,000 refugees.

When he left Syria, Martini said, he lost everything. The government seized all nine of his houses, along with his bank accounts, a clinical laboratory and 2,000 olive trees. The loss of the olive grove seems to have stung particularly; Idlib is known for its production of the bitter fruit.

In Jordan, the doctor briefly treated patients in the Zaatari refugee camp. Then he fled the difficult conditions to join his wife and youngest child in the United Arab Emirates. His older children escaped Syria, too, and are studying medicine in the United States.

At first, the effort paid for treatment for Syrians in Turkish hospitals. Operations were soon expanded to include the building of a 144-bed medical unit in the city of Antakya, near the Syrian border. Then hostility from Antakya’s Alawites — many of whom support Assad, who is also Alawite — prompted Orient to move the facility to Reyhanli. Alawites are members of a Shiite-affiliated sect.

Orient’s medical ventures expanded into rebel-held areas of Syria, where it now runs 12 hospitals and several rehabilitation centers and employs more than 400 doctors. Facilities in Turkey include a day clinic, a school for displaced Syrians and a sewing workshop that trains and provides work for many Syrian women.

It is an unusual arrangement for an organization of Orient Humanitarian Relief’s size — staff members said Orient programs and facilities helped nearly 400,000 people last year. But the setup offers a strategic advantage. A member of an aid organization working with Orient said it is able to move faster than any of its peers, making quick decisions unhampered by complicated bureaucracies and approval processes.

The many doctors and surgeons in the Martini clan are scattered across Europe and the United States. One uncle founded Martini Hospital in the Syrian city of Aleppo, where fighting between rebels and government forces has been sustained and brutal. Ammar Martini worked at that hospital, now heavily damaged, for 10 years.

When his father died recently in Syria, Martini was not able to return home to attend the funeral.

Unlike malnutrition crises elsewhere in the world, this one has not been connected to specific food shortages or crop failures. In addition, parents are not showing up malnourished, even when their children are.

His colleague Dr. Khan blamed another problem. “The main cause of malnutrition in Afghanistan is lack of breast feeding,” he said. “They see beautiful pictures of milk cartons, and they think it’s better.”

In addition, where women commonly have many children, often with less than a year between them, it is difficult for mothers to provide enough nourishment, by breast or bottle. Ahmed Wali, the 2-year-old Bost Hospital patient with kwashiorkor, is the ninth of 10 children of his mother, Baka Bebi, who is in her mid-30s. She weaned him onto powdered milk mixed with stream water as soon as she could.

Poverty is another factor. In Afghanistan, the poverty line is defined as a total income sufficient to provide 2,100 calories a day to each family member. Some 36 percent of Afghans are below that threshold, according to the Health Ministry.

In 2013, Unicef raised its target for providing therapeutic foods to severe acutely malnourished Afghan children, to 52,144 from 35,181. Therapeutic foods are specially made for the severely malnourished, who have difficulty digesting normal food.

“Managing a feeding system is difficult; there is a long way for Afghanistan to go,” he added. “But even countries like Sri Lanka, with an outstanding health system, are still struggling to manage therapeutic feeding supplies.”

Cases of acute severe malnutrition are running at more than 100 a month, including five to 10 deaths, at Indira Gandhi Children’s Hospital in Kabul, and such cases have doubled since 2012, said Dr. Aqa Mohammad Shirzad, who is in charge of pediatric malnutrition programs there.

Each of the hospital’s 17 beds for severely malnourished patients has at least two patients, and some have three. The malnutrition intensive care ward there has an incubator that does not work, one suction pump and oxygen bottles, for respiratory masks, propped up without stands or proper connection

A 5-year-old boy who weighs less than 20 pounds was being treated recently on a bench because the infusion line would not stretch to a bed. Two window panes nearby were missing glass.

“I’m old enough to know that when somebody says words like ‘never,’ or ‘forever,’ or ‘the rest of eternity’ in the Middle East, it usually means something like six months to 30 years. If anyone had said to me as a young man that one day I would travel to Egypt or Jordan with Egyptian and Jordanian visas stamped in my passport, I would have said, ‘Let’s not get carried away.' ”

“I have seen people change. They are not born again but they change, somewhat.

Children learn about the mechanics of sex—or rather, that mechanics is the whole of sex—by watching women who may have been blood-tested and “verified” professionals, or who may have been so impoverished and desperate that they would have done literally anything for cash or drugs

although the party line is that consumers bring their own desires to it and simply find the porn that suits them, the influence runs in the other direction.“If you’re with somebody for the first time,” a sex researcher at Indiana University helpfully tells her students, “don’t choke them, don’t ejaculate on their face, don’t try to have anal sex with them. These are all things that are just unlikely to go over well.”

we can’t pretend that the things people expect to do in bed, or expect partners to do in bed, have not been hugely—almost entirely, by this point—influenced by online porn

Culture is progressive and cumulative, and so is porn, restlessly seeking and crossing the next boundary, and thereby making whatever came before it seem tame and ordinary.

The right understands porn as a thing for sale, and so has a grudging respect for it. “It’s Trump,

It’s natural that this would become the venue for these troubled girls; porn is the main determinant of high-school kids’ sexual imaginings. Girls who feel uncomfortable or shamed about their body are deeply drawn to it. “I liked the attention I got,” Caitlin says of her first foray into selling pictures online; she liked “being called beautiful. I enjoyed it because it made me feel good about myself.”

it seems to me that a troubled teenager, desperate to be called beautiful, will have her sense of self deeply affected by work in that industry, which will quickly seek to put her in ever more extreme forms of on-camera behavior

What has happened is that within a few years of porn’s arrival, the country quickly learned what it was dealing with—something it had no power to control, something it couldn’t even keep small children from encountering—and so modern life simply adjusted itself around the new, imperial leader.

The left decided to champion porn in a variety of ways, beginning with reconceiving the women who work in it as fully liberated, empowered feminists

Do you know what percent of the vast, global porn industry these self-actualized porn workers represent? Not a large one.

The problem is that there are some very old human impulses that must now contend with porn. One of them is the tendency of deeply troubled teenage girls to act out sexually as a kind of distress signal, an attempt to get the attention of adults who may not be getting the message that they’re in a crisis.

The right destroyed the one force capable of challenging porn’s ubiquity: social conservatism. It gleefully elected a sleazeball whose personal history is that of a man with contempt for the ideas of personal responsibility and duty to others that were once central to social conservatism.

there isn’t anything left of the social conservatism of yesteryear but money, and selling any valuable commodity we have remaining, from our natural resources to our international reputation to our young girls.

The only person questioning any of these notions seems to be Caitlin herself, who labors under the delusion that she’s not living on a darkling plain. “The only hard thing so far is making sure I have enough money,

Maybe she had gained—from Napoleon Dynamite and Ellen—the impression that the she lives in a society where the center holds, and where promising girls are not left to drift so far beyond the shoreline that no one feels impelled to consider a rescue.

“Other than that”—here she is, the daughter that you and I made together, letting us know how she’s doing—“I’ve honestly been doing really good with myself.”