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In the case of the coronavirus pandemic, however, some Republicans and conservative commentators have begun to make an argument more radical than “people will die.” It’s this: People should die.

Patrick apparently sees a dilemma—two options and no other choices: Either we try to save people now, including the elderly, and risk immense damage to the economy, or we get back to work immediately and get the economy moving again by letting the elderly die, perhaps even encouraging them to welcome death for the greater good.

Especially troubling is that some of the people who are making the case that we should intentionally concede lives to the coronavirus—especially the lives of the elderly, the disabled, the vulnerable, the infirm—are prominent figures in the pro-life movement

a number of people who have built their careers on being pro-life have abandoned that, converting to prosperity gospel by way of Bishop Trump.

Consider the argument posed by Rusty Reno in the pages of the magazine he edits, the largely conservative Catholic First Things. Reno criticizes New York governor Andrew Cuomo for saying “I did everything we could do. And if everything we do saves just one life, I’ll be happy.” To Reno, Cuomo’s statement represents a “disastrous sentimentalism” because “there are many things more precious than life.”

Responding to Reno’s article, Erick Erickson writes: It is sad to see a religious publication try to cast the extraordinary effort of stopping a global pandemic [as] “demonic.” But that is what it does. It cheapens the effort to save lives as sentimental and essentially advances a materialistic approach of wanting to make money and let people die because people are always going to die. Now, of course, the writer knows he is doing this so he chooses to denounce materialism while essentially advocating for it.

And in the liberal Catholic magazine Commonweal, Jared Lucky powerfully rebuts Reno’s argument, pointing out that “today’s quarantine restrictions complement centuries of Christian response to epidemics.

Few Christians would ask for this cup, but we must drink it—to serve God by serving our neighbors, and to grow closer to God through the contemplation of death. . . . Quarantine is . . . a costly act of service that meets the urgent human needs of our neighbors. That service may involve going to work—at a hospital or a testing center—or staying home. But make no mistake: these sacrifices are not a surrender to death. They are a sacrifice to the God who gives life.

you need not be a cynic to wonder whether it is mostly driven by a desire to protect the president.

Certainly the medical and economic stakes are, in Trump’s own mind, jumbled together with the political calculus for his re-election, as he made clear in a typically paranoid, anti-media tweet on Wednesday:

Thankfully, not everyone in the Republican leadership and conservative punditry has adopted the view that we should sacrifice the vulnerable by prematurely ending social distancing and getting back to work. Here, for example, is Wyoming representative Liz Cheney:

Kulkarni likened the rise of hate against Asian Americans since the pandemic began to the 19th century era of "yellow peril," during which racist laws as well as stereotypes of East Asian immigrants as a threat to society proliferated in the US.

From then through the end of 2020, the organization received more than 2,800 firsthand reports of anti-Asian hate across 47 states and Washington, DC, according to data released this week.

The majority of those incidents -- about 71% -- were cases of verbal harassment, while shunning or avoidance made up about 21%. About 9% of the incidents involved physical assaults, and 6% included being purposely coughed or spit on, according to a Stop AAPI Hate news release.

A report published Wednesday by the Asian American Bar Association of New York noted that from January 1 to November 1, 2020, the New York Police Department saw an eight-fold increase in reported anti-Asian hate crimes compared to the same period in 2019.

From 2017 to 2019, the organization received less than 500 reported instances of hate against Asian Americans. But from February to December last year, they said they estimate there have been 3,000 incidents of hate cataloged by their group and others.

Yang attributes the rise of anti-Asian hate in the US partially to former President Donald Trump, who repeatedly referred to the coronavirus as the "China virus" in the early days of the pandemic.

Experts also blame the insecurity and fear brought on by the pandemic. People may respond to threats of disease or other crises by scapegoating another group perceived as falling outside the cultural norms -- in this case Asian Americans, the authors of the Asian American Bar Association report wrote.

Asian Americans are seen as easy targets for crime, perhaps because of language and cultural barriers that might prevent them from reporting incidents, according to Yang. And the elderly are particularly vulnerable, with concerns that they could be targeted for robberies as they are out shopping for the Lunar New Year.

But community leaders say that more needs to be done.Both Kulkarni and Yang are calling on community solutions to help address the problem. Yang called for bystander intervention training and local efforts such as neighborhood walk services and shopping services for the elderly. Kulkarni has called for more support and resources for Asian Americans to help them address incidents of assault and harassment.

In the past two decades, the list of British calamities, policy misjudgments, and forecasting failures has been eye-watering: the disaster of Iraq, the botched Libyan intervention in 2011, the near miss of Scottish independence in 2014, the woeful handling of Britain’s divorce from the European Union from 2016 onward

What emerges is a picture of a country whose systemic weaknesses were exposed with appalling brutality, a country that believed it was stronger than it was, and that paid the price for failures that have built up for years

The most difficult question about all this is also the simplest: Why?

Like much of the Western world, Britain had prepared for an influenza pandemic, whereas places that were hit early—Hong Kong, South Korea, Singapore, Taiwan—had readied themselves for the type of respiratory illness that COVID-19 proved to be.

Britain’s pandemic story is not all bad. The NHS is almost universally seen as having risen to the challenge; the University of Oxford is leading the race to develop the first coronavirus vaccine for international distribution, backed with timely and significant government cash; new hospitals were built and treatments discovered with extraordinary speed; the welfare system did not collapse, despite the enormous pressure it suddenly faced; and a national economic safety net was rolled out quickly.

One influential U.K. government official told me that although individual mistakes always happen in a fast-moving crisis, and had clearly taken place in Britain’s response to COVID-19, it was impossible to escape the conclusion that Britain was simply not ready. As Ian Boyd, a professor and member of SAGE, put it: “The reality is, there has been a major systemic failure.”

“It’s obvious that the British state was not prepared for” the pandemic, this official told me. “But, even worse, many parts of the state thought they were prepared, which is significantly more dangerous.”

When the crisis came, too much of Britain’s core infrastructure simply failed, according to senior officials and experts involved in the pandemic response

The human immune system actually has two parts. There is, as Cummings correctly identifies, the adaptive part. But there is also an innate part, preprogrammed as the first line of defense against infectious disease. Humans need both. The same is true of a state and its government, said those I spoke with—many of whom were sympathetic to Cummings’s diagnosis. Without a functioning structure, the responsive antibodies of the government and its agencies cannot learn on the job. When the pandemic hit, both parts of Britain’s immune system were found wanting.

The consequences may be serious and long term, but the most immediately tragic effect was that creating space in hospitals appears to have been prioritized over shielding Britain’s elderly, many of whom were moved to care homes, part of what Britain calls the social-care sector, where the disease then spread. Some 25,000 patients were discharged into these care homes between March 17 and April 16, many without a requirement that they secure a negative coronavirus test beforehand.

There was a bit too much exceptionalism about how brilliant British science was at the start of this outbreak, which ended up with a blind spot about what was happening in Korea, Taiwan, Singapore, where we just weren’t looking closely enough, and they turned out to be the best in the world at tackling the coronavirus,” a former British cabinet minister told me.

The focus on influenza pandemics and the lack of a tracing system were compounded by a shortfall in testing capacity.

Johnson’s strategy throughout was one that his hero Winston Churchill raged against during the First World War, when he concluded that generals had been given too much power by politicians. In the Second World War, Churchill, by then prime minister and defense secretary, argued that “at the summit, true politics and strategy are one.” Johnson did not take this approach, succumbing—as his detractors would have it—to fatalistic management rather than bold leadership, empowering the generals rather than taking responsibility himself

“It was a mixture of poor advice and fatalism on behalf of the experts,” one former colleague of Johnson’s told me, “and complacency and boosterism on behalf of the PM.”

What it all adds up to, then, is a sobering reality: Institutional weaknesses of state capacity and advice were not corrected by political judgment, and political weaknesses were not corrected by institutional strength. The system was hardwired for a crisis that did not come, and could not adapt quickly enough to the one that did.

Britain’s NHS has come to represent the country itself, its sense of identity and what it stands for. Set up in 1948, it became known as the first universal health-care system of any major country in the world (although in reality New Zealand got there first). Its creation, three years after victory in the Second World War, was a high-water mark in the country’s power and prestige—a time when it was a global leader, an exception.

Every developed country in the world, apart from the United States, has a universal health-care system, many of which produce better results than the NHS.

When the pandemic hit, then, Britain was not the strong, successful, resilient country it imagined, but a poorly governed and fragile one. The truth is, Britain was sick before it caught the coronavirus.

In asking the country to rally to the NHS’s defense, Johnson was triggering its sense of self, its sense of pride and national unity—its sense of exceptionalism.

Before the coronavirus, the NHS was already under considerable financial pressure. Waiting times for appointments were rising, and the country had one of the lowest levels of spare intensive-care capacity in Europe. In 2017, Simon Stevens, the NHS’s chief executive, compared the situation to the time of the health sevice’s founding decades prior: an “economy in disarray, the end of empire, a nation negotiating its place in the world.”

Yet from its beginnings, the NHS has occupied a unique hold on British life. It is routinely among the most trusted institutions in the country. Its key tenet—that all Britons will have access to health care, free at the point of service—symbolizes an aspirational egalitarianism that, even as inequality has risen since the Margaret Thatcher era, remains at the core of British identity.

In effect, Britain was rigorously building capacity to help the NHS cope, but releasing potentially infected elderly, and vulnerable, patients in the process. By late June, more than 19,000 people had died in care homes from COVID-19. Separate excess-death data suggest that the figure may be considerably higher

Britain failed to foresee the dangers of such an extraordinary rush to create hospital capacity, a shift that was necessary only because of years of underfunding and decades of missed opportunities to bridge the divide between the NHS and retirement homes, which other countries, such as Germany, had found the political will to do.

Ultimately, the scandal is a consequence of a political culture that has proved unable to confront and address long-term problems, even when they are well known.

other health systems, such as Germany’s, which is better funded and decentralized, performed better than Britain’s. Those I spoke with who either are in Germany or know about Germany’s success told me there was an element of luck about the disparity with Britain. Germany had a greater industrial base to produce medical testing and personal protective equipment, and those who returned to Germany with the virus from abroad were often younger and healthier, meaning the initial strain on its health system was less.

However, this overlooks core structural issues—resulting from political choices in each country—that meant that Germany proved more resilient when the crisis came, whether because of the funding formula for its health system, which allows individuals more latitude to top up their coverage with private contributions, or its decentralized nature, which meant that separate regions and hospitals were better able to respond to local outbreaks and build their own testing network.

Also unlike Britain, which has ducked the problem of reforming elderly care, Germany created a system in 1995 that everyone pays into, avoids catastrophic costs, and has cross-party support.

A second, related revelation of the crisis—which also exposed the failure of the British state—is that underneath the apparent simplicity of the NHS’s single national model lies an engine of bewildering complexity, whose lines of responsibility, control, and accountability are unintelligible to voters and even to most politicians.

Britain, I was told, has found a way to be simultaneously overcentralized and weak at its center. The pandemic revealed the British state’s inability to manage the nation’s health:

Since at least the 1970s, growing inequality between comparatively rich southeast England (including London) and the rest of the country has spurred all parties to pledge to “rebalance the economy” and make it less reliant on the capital. Yet large parts remain poorer than the European average. According to official EU figures, Britain has five regions with a per capita gross domestic product of less than $25,000. France, Germany, Ireland, Austria, the Netherlands, Denmark, and Sweden have none

If Britain were part of the United States, it would be anywhere from the third- to the eighth-poorest state, depending on the measure.

Britain’s performance in this crisis has been so bad, it is damaging the country’s reputation, both at home and abroad.

Inside Downing Street, officials believe that the lessons of the pandemic apply far beyond the immediate confines of elderly care and coronavirus testing, taking in Britain’s long-term economic failures and general governance, as well as what they regard as its ineffective foreign policy and diplomacy.

the scale of the task itself is enormous. “We need a complete revamp of our government structure because it’s not fit for purpose anymore,” Boyd told me. “I just don’t know if we really understand our weakness.”

In practice, does Johnson have the confidence to match his diagnosis of Britain’s ills, given the timidity of his approach during the pandemic? The nagging worry among even Johnson’s supporters in Parliament is that although he may campaign as a Ronald Reagan, he might govern as a Silvio Berlusconi, failing to solve the structural problems he has identified.

This is not a story of pessimistic fatalism, of inevitable decline. Britain was able to partially reverse a previous slump in the 1980s, and Germany, seen as a European laggard in the ‘90s, is now the West’s obvious success story. One of the strengths of the Westminster parliamentary system is that it occasionally produces governments—like Johnson’s—with real power to effect change, should they try to enact it.

It has been overtaken by many of its rivals, whether in terms of health provision or economic resilience, but does not seem to realize it. And once the pandemic passes, the problems Britain faces will remain: how to sustain institutions so that they bind the country together, not pull it apart; how to remain prosperous in the 21st century’s globalized economy; how to promote its interests and values; how to pay for the ever-increasing costs of an aging population.

“The really important question,” Boyd said, “is whether the state, in its current form, is structurally capable of delivering on the big-picture items that are coming, whether pandemics or climate change or anything else.”

Lena Einhorn, a virologist who has been one of the leading domestic critics of Sweden’s coronavirus policy, told the Observer that the government and the health agency were still resisting the most obvious explanations.

The agency’s advice to those managing and working at nursing homes, like its policy towards coronavirus in general, has been based on its judgment that the “spread from those without symptoms is responsible for a very limited share” of those who get infected.

Its advice to the care workers and nurses looking after older people such as Bondesson’s 69-year-old mother is that they should not wear protective masks or use other protective equipment unless they are dealing with a resident in the home they have reason to suspect is infected.

the central protective measure in place is that staff should stay home if they detect any symptoms in themselves.

For 40 years, Cowen believes, “we have been building toward stasis” with a diminishing “sense of urgency.

Declining labor mobility is partly the result of the domestic protectionism of occupational licensing. “In the 1950s,” Cowen writes, “only about 5 percent of workers required a government-issued license to do their jobs, but by 2008, that figure had risen to about 29 percent.”

There is “more pairing of like with like” (assortative mating, economically homogenous neighborhoods, segregation by educational status), and the nation is losing the capacity and will “to regenerate itself.”

In the 19th century and much of the 20th century, travel speeds increased dramatically; since the 1970s, ground and air congestion has slowed travel.

The Steuerle-Roeper Fiscal Democracy Index measures how much of the allocation of government revenue is determined by current democratic processes and how much by prior decisions establishing permanent programs running on autopilot. The portion of the federal budget automatically spent by choices made years ago is approaching 90 percent

An aging population is devouring an increasing portion of national resources — federal revenue disbursed by the entitlement state to provide Social Security and Medicare to the elderly, the nation’s past. This will worsen. Because government is more important to its elderly beneficiaries than to any other age cohort, the elderly vote at a higher rate than any younger group.

Even before Covid, it was clear to anyone who looked at the data that child care allowed parents to get to their jobs, and a lack of it did the opposite. In 2016, nearly two million American parents said they had to quit their job, refuse a new one, or significantly change the one they had thanks to problems with child care. One of the reasons that the United States has fallen so far behind our international peers when it comes to the share of women in the labor force is that we invest so few resources in child care and early education. Since the 1990s, the rising cost of private day care has reduced employment for American mothers of children ages 5 and younger by 13 percent.

If child care is infrastructure, then, it should be nearly self-evident that care for the elderly and disabled is, too. Children aren’t the only members of our families who require daily care. But we offer miserly support for those who need to secure and pay for it. Medicare doesn’t cover nursing home or assisted living stays, only Medicaid does, requiring families with resources to spend them down before they can get assistance with the exorbitant cost. Medicare also doesn’t cover in-home care, and not all state Medicaid programs cover it.

Paid leave helps mothers in particular stay connected to their jobs before and after the arrival of a new child. On top of that, an analysis of more than 10,000 companies found that after they offered paid leave the majority had an increase in revenue and profit per each employee — in other words, it allowed workers to perform better.

All of these things clearly undergird the functioning of our economy, just as a smooth road allows trucks to transport goods to stores and drivers to get to their workplaces. It’s one thing to debate whether or not to invest in them. But there’s no rational argument for why they should be excluded from Mr. Biden’s focus on repairing and upgrading the systems that keep our country running.

it wears off faster among the young and energetic than among the older, more world-weary but also more patient

Middle-class Singaporean families often refer to themselves nowadays as the “sandwich generation,” by which they mean that between needing to care for elderly parents and spending heavily on tuition or tutoring and uniforms for school-age children, they have little left to spend on themselves

There are more than 10,000 cases, and numbers are rising fast. More than 800 cases were registered in just five and a half days this past week, more than the previous all-time record for a full week.

The Singaporean system lacks an open-ended entitlement akin to the U.S. Social Security system. It uses a market-based system with much to commend it, but it isn’t perfect. The system is designed to rely in part on multigenerational families taking care of the elderly, so as is the case everywhere, when a family doesn’t cohere well for one reason or another, its elderly members often suffer most.

with the coming of Singapore’s second monsoon season, the island is suffering the worst bout of dengue fever infections in more than a decade.

No country in the world has benefited more than Singapore from U.S. postwar grand strategy, except perhaps China. Which is an interesting observation, often made here, in its own right.

He proceeded to explain that the U.S. effort in Vietnam had already bought the new nations of Southeast Asia shelter from communist onslaught for three to four precious years.

LKY’s son, current Prime Minister Lee Hsien Loong, repeated the same conclusion in a recent Foreign Affairs essay. He added that ever since the Vietnam War era, regardless of the end of the Cold War and dramatic changes in China, the U.S. role in East Asia has been both benign—he did not say error-free—and stabilizing.

More than that, U.S. support for an expanding free-trade accented global economic order has enabled Singapore to surf the crest of burgeoning economic growth in Asia, becoming the most successful transshipment platform in history. It has enabled Singapore to benefit from several major technological developments—containerization is a good example—that have revolutionized international trade in manufactures

Few realize that military power can do more than either compel or deter. Most of the time most military power in the hands of a status quo actor like the United States neither compels nor deters; it “merely” reassures, except that over time there is nothing mere about it

The most important of these reasons—and, I’ve learned, the hardest one for foreigners to understand—is that the Protestant/Enlightenment DNA baked indelibly into the American personality requires a belief in the nation’s exceptionalist virtue to justify an activist role abroad

Singapore has ridden the great whale of Asian advancement in a sea of American-guaranteed tranquility.

Singapore’s approach to dealing with China has been one of strategic hedging. There is no getting around the need to cooperate economically and functionally with China, for Chinese influence permeates the entire region. Do a simple thought experiment: Even if Singaporeans determined to avoid China, how could they avoid the emanations of Chinese relations with and influence on Malaysia, Indonesia, the Philippines, Vietnam, Thailand, Japan, and Korea? Impossible.

Singapore’s close relationship with the United States needs to be seen as similarly enmeshed with the greater web of U.S. relationships in littoral Asia, as well as with India and the Middle East. It is misleading, therefore, to define the issue as one of Singapore’s confidence, or lack thereof, that the United States will come to Singapore’s aid and defense en extremis.

The utility of the U.S. role vis-à-vis China is mainly one of regional balancing that indirectly benefits Singaporean security.

Singapore’s hedging strategy, which reflects a similar disposition throughout Southeast Asia with variations here and there, only works within certain ranges of enabling reality. It doesn’t work if American power or will wanes too much, and it doesn’t work if the broader Sino-American regional balance collapses into glaring enmity and major-power conflict.

Over the past dozen years the worry has been too much American waning, less of capability than of strategic attention, competence, and will. Now, over the past year or two, the worry has shifted to anxiety over potential system collapse into conflict and even outright war.

It’s no fun being a sentient ping pong ball between two behemoths with stinging paddles, so they join together in ASEAN hoping that this will deflect such incentives. It won’t, but people do what they can when they cannot do what they like.

the flat-out truth: The United States is in the process of doing something no other great power in modern history has ever done. It is knowingly and voluntarily abdicating its global role and responsibilities

It is troubled within, so is internally directed for reasons good and otherwise. Thus distracted from the rest of the world in a Hamlet-like act sure to last at least a decade, it is unlikely ever to return in full to the disinterested, active, and constructive role it pioneered for itself after World War II.

The recessional began already at the end of the George W. Bush Administration, set roots during the eight years of the Obama presidency, and became a bitter, relentless, tactless, and barely shy of mad obsession during the Trump presidency.

the strategy itself is unlikely to be revivified for several reasons.

One Lee Kuan Yew vignette sums up the matter. In the autumn of 1968, at a dinner in his honor at Harvard, the Prime Minister had to sit through a litany of complaints from leading scholars about President Johnson’s disastrously escalatory war policies in Vietnam. When they were through, no doubt expecting sympathy from an Asian leader, LKY, never one to bite his tongue, turned on his hosts and announced: “You make me sick.”

When, for justifiable reasons or not, the nation loses its moral self-respect, it cannot lift its chin to look confidently upon the world, or bring itself to ask the world to look upon America as a worthy model, let alone a leader.

That fact that most Americans today also increasingly see expansive international engagement as too expensive, too dangerous, too complex to understand, and unhelpful either to the “main street” American economy or to rock-bottom American security, is relevant too

the disappearance of a single “evil” adversary in Soviet communism, the advent of near-permanent economic anxiety punctuated by the 2008-9 Great Recession—whatever numbers the stock market puts up—and the sclerotic polarization of American politics have left most Americans with little bandwidth for foreign policy narratives.

Few listen to any member of our tenured political class with the gumption to argue that U.S. internationalism remains in the national interest. In any event, few try, and even fewer manage to make any sense when they do.

In that context, pleas from thoughtful observers that we must find a mean between trying to do too much and doing too little are likely to be wasted. No thoughtful, moderate approach to any public policy question can get an actionable hearing these days.

what has happened to “the America I knew and so admired” that its people could elect a man like Donald Trump President? How could a great country deteriorate so quickly from apparent competence, lucidity of mind, and cautious self-confidence into utterly debilitating spasms of apparent self-destruction?

The political culture as a whole has become a centrism incinerator, an immoderation generator, a shuddering dynamo of shallow intellectual impetuosity of every description.

in the wake of the George Floyd unrest one side thinks a slogan—“law and order”—that is mighty close to a dogwhistle for “shoot people of color” can make it all better, while the other side advocates defunding or abolishing the police, for all the good that would do struggling inner-city underclass neighborhoods.

To any normal person these are brazenly unserious propositions, yet they suck up nearly all the oxygen the U.S. media has the inclination to report about. The optic once it reaches Singapore, 9,650 miles away, is one of raving derangement.

Drop any policy proposal into any of the great lava flows of contemporary American irrationality and any sane center it may possess will boil away into nothingness in a matter of seconds

It’s hard for many to let go of hoary assurances about American benignity, constancy, and sound judgment

It is a little like trying to peel a beloved but thoroughly battered toy out of the hands of a four-year old. They want to hold onto it, even though at some level they know it’s time to loosen their grip.

Since then the mendacious narcissism of Donald Trump, the eager acquiescence to it of nearly the entire Republican Party, and its deadly metathesis in the COVID-19 and George Floyd contexts, have changed their questions. They no longer ask how this man could have become President. Now they ask where is the bottom of this sputtering cacophonous mess? They ask what will happen before and then on and after November 3

Singapore’s good fortune in recent decades is by no means entirely an accident of its ambient geostrategic surroundings, but it owes much to those surroundings. While Singaporeans were honing the arts of good government, saving and investing in the country, educating and inventing value-added jobs for themselves, all the while keeping intercommunal relations inclined toward greater tolerance and harmony, the world was cooperating mightily with their ambitions. At the business end of that world was the United States

The U.S. grand strategy of providing security goods to the global commons sheltered Singapore’s efforts in more ways than one over the years

In 1965, when Singapore was thrust into independence from the Malaysian union, a more fraught environment could barely have been imagined. Indonesia was going crazy in the year of living dangerously, and the konfrontasi spilled over violently onto Singapore’s streets, layering on the raw feelings of race riots here in 1964. Communist Chinese infiltration of every trade union movement in the region was a fact of life, not to exclude shards of Singapore’s, and the Cultural Revolution was at full froth in China. So when U.S. Marines hit the beach at Da Nang in February 1965 the independence-generation leadership here counted it as a blessing.

this is exactly the problem now: Those massively benign trends are at risk of inanition, if not reversal.

While China is no longer either Marxist or crazy, as it was during Mao’s Cultural Revolution, it is still Leninist, as its recent summary arrogation of Hong Kong’s negotiated special status shows. It has meanwhile grown mighty economically, advanced technologically at surprising speed, and has taken to investing grandly in its military capabilities. Its diplomacy has become more assertive, some would even say arrogant, as its Wolf Warrior nationalism has grown

The downward economic inflection of the pandemic has exacerbated pre-existing economic strains

After 2003, Italy became one of the first countries in Europe to put in place a national plan to mitigate the impact of extreme heat, based on the guidelines from the World Health Organization.

“Older people with pre-existing illnesses are more vulnerable,” Andrea Ungar, the president of Italy’s Society of Gerontology and Geriatrics, said in a phone interview. “But poverty and isolation also play a crucial role.”

Europe’s hottest summer on record, in 2003, left more than 70,000 people dead, by some estimates, and since then Italy has only grown older. It has struggled to adapt.

Almost 30 percent of the 61,000 people estimated to have died last summer from extreme heat in Europe were Italians, with age playing a significant factor. The number of Italians over 80 is now about 4.5 million, almost double the number of 20 years ago.

The measures include an alert system to warn people to modify their behavior to safeguard their health

Days like Wednesday, when the heat wave peaked, are marked in red on the daily bulletin that Italy’s Health Ministry issues to warn residents. Television channels periodically broadcast the ministry’s guidelines, advising people to stay indoors during the hottest hours; to wear light clothes and sunscreen; to drink lots of water, eat fresh fruits and avoid coffee and alcoholic beverages; and to be particularly careful when going outside.

The hottest summer on record killed 15,000 in France, the majority of them older people, living alone in city apartments or retirement homes with no air conditioning

Last summer, when successive heat waves hit the country, more than 2,800 French people died, some 80 percent over the age of 75

Even those who don’t need medical aid, assistance remains crucial and, for many vulnerable people, associations like Caritas are still the most reliable weekly help. Ms. Antonelli, the social worker, carried two cases of slightly fizzy water up two flights of stairs for Francesca Azzarita, a 91-year-old who lives alone with nothing to cool herself but a piece of cardboard to use as a fan

we can’t simply replace one simplistic narrative, about the super power of mitigation policy, for another, focused only on the burdens it imposed and not at all on the costs of doing much less — or nothing at all.

Let’s start with the title. What is the big failure, as you see it?

McLean: I think it gets at things that had happened in America even before the pandemic hit. And among those things were, I think, a failure to recognize the limits of capitalism, a failure of government to set the right rules for it, particularly when it comes to our health care system; a focus on profits that may have led to an increase in the bottom line but created fragility in ways people didn’t understand; and then our growing polarization that made us incapable of talking to each other

How big is the failure? When I look at The Economist’s excess mortality data, I see the U.S. had the 53rd-worst outcome in the world — worse than all of Western Europe, but better than all of Eastern Europe.

McLean: I think one way to quantify it is to take all those numbers and then put them in the context of our spending on health care. Given the amount we spend on health care relative to other countries, the scale of the failure becomes more apparent.

o me, the most glaring example is the schools. They were closed without people thinking through the potential consequences of closing down public schools, especially for disadvantaged kids.

to compound it, in my view, public health never made the distinction that needed to be made between the vulnerabilities of somebody 70 years old and the vulnerabilities of somebody 10 years old.

In the beginning of the book you write, in what almost feels like a thesis statement for the book: “A central tenet of this book is that we could not have done better, and pretending differently is a dangerous fiction, one that prevents us from taking a much needed look in the mirror.”

This claim, that the U.S. could not have done any better, runs against your other claim, that what we observed was an American failure. It is also a pretty extreme claim, I think, and I wanted to press you on it in part because it is, in my view, undermined by quite a lot of the work you do in the book itself.

Would the U.S. not have done better if it had recognized earlier that the disease spread through the air rather than in droplets? Would it not have done better if it hadn’t bungled the rollout of a Covid test in the early months?

McLean: Everything that you mentioned — the point of the book is that those were set by the time the pandemic hit.

in retrospect, what we were doing was to try to delay as much spread as we could until people got vaccinated. All the things that we did in 2020 were functionally serving or trying to serve that purpose. Now, given that, how can you say that none of that work saved lives?

McLean: I think that the test failure was baked into the way that the C.D.C. had come to operate

But the big question I really want to ask is this one: According to the C.D.C., we’ve had almost 1.2 million deaths from Covid. Excess mortality is nearly 1.4 million. Is it really your contention that there was nothing we might’ve done that brought that total down to 1.1 million, for instance, or even 900,000?

McLean: It’s very — you’re right. If you went through each and every thing and had a crystal ball and you could say, this could have been done, this could have been moved up by a month, we could have gotten PPE …

When I came to that sentence, I thought of it in terms of human behavior: What will humans put up with? What will humans stand for? How do Americans act? And you’ve written about Sweden being sort of average, and you’ve written about China and the Chinese example. They lock people up for two years and suddenly the society just revolts. They will not take it anymore. They can’t stand it. And as a result, a million and a half people die in a month and a half.

Well, I would tell that story very differently. For me, the problem is that when China opened up, they had fully vaccinated just under two-thirds of their population over 80. So to me, it’s not a failure of lockdowns. It’s a failure of vaccinations. If the Chinese had only achieved the same elderly vaccination rate as we achieved — which by global standards was pretty poor — that death toll when they opened up would have been dramatically lower.

What do you mean by “lockdown,” though? You use the word throughout the book and suggest that China was the playbook for all countries. But you also acknowledge that what China did is not anything like what America did.

Disparities in health care access — is it a dangerous fiction to think we might address that? You guys are big champions of Operation Warp Speed — would it not have been better if those vaccines had been rolled out to the public in nine months, rather than 12

. But this isn’t “lockdown” like there were lockdowns in China or even Peru. It’s how we tried to make it safer to go out and interact during a pandemic that ultimately killed a million Americans.

McLean: I think that you’re absolutely right to focus on the definition of what a lockdown is and how we implemented them here in this country. And I think part of the problem is that we implemented them in a way that allowed people who were well off and could work from home via Zoom to be able to maintain very much of their lives while other people couldn’t

And I think it depends on who you were, whether you would define this as a lockdown or not. If you were a small business who saw your small business closed because of this, you’re going to define it as a lockdown.

n the book you’re pretty definitive. You write, “maybe the social and economic disasters that lockdowns created would have been worth it if they had saved lives, but they hadn’t.” How can you say that so flatly?

I think there are still open questions about what worked and how much. But the way that I think about all of this is that the most important intervention that anybody did anywhere in the world was vaccination. And the thing that determined outcomes most was whether your first exposure came before or after vaccination.

Here, the shelter-in-place guidelines lasted, on average, five to seven weeks. Thirty nine of the 40 states that had issued them lifted them by the end of June, three months in. By the summer, according to Google mobility data, retail and grocery activity was down about 10 percent. By the fall, grocery activity was only down about 5 percent across the country

Nocera: Well, on some level, I feel like you’re trying to have it both ways. On the one hand, you’re saying that lockdowns saved lives. On the other hand, you said they weren’t real lockdowns because everybody was out and about.

I don’t think that’s having it both ways. I’m trying to think about these issues on a spectrum rather than in binaries. I think we did interrupt our lives — everybody knows that. And I think they did have an effect on spread, and that limiting spread had an effect by delaying infections until after vaccination.

Nocera: Most of the studies that say lockdowns didn’t work are really less about Covid deaths than about excess mortality deaths. I wound up being persuaded that the people who could not get to the hospital, because they were all working, because all the doctors were working on Covid and the surgical rooms were shut down, the people who caught some disease that was not Covid and died as a result — I wound up being persuaded about that.

We’re in a pandemic. People are going to die. And then the question becomes, can we protect the most vulnerable? And the answer is, we didn’t protect the most vulnerable. Nursing homes were a complete disaster.

There was a lot of worry early on about delayed health care, and about cancer in particular — missed screenings, missed treatments. But in 2019, we had an estimated 599,600 Americans die of cancer. In 2020, it was 602,000. In 2021, it was 608,000. In 2022, it was 609,000.

Nocera: See, it went up!But by a couple of thousand people, in years in which hundreds of thousands of Americans were dying of Covid.

Nocera: I think you can’t dispute the excess mortality numbers.I’m not. But in nearly every country in the world the excess mortality curves track so precisely with Covid waves that it doesn’t make sense to talk about a massive public health problem beyond Covid. And when you add all of these numbers up, they are nowhere near the size of the footfall of Covid. How can you look back on this and say the costs were too high?

Nocera: I think the costs were too high because you had school costs, you had economic costs, you had social costs, and you had death.

McLean: I think you’re raising a really good point. We’re making an argument for a policy that might not have been doable given the preconditions that had been set. I’m arguing that there were these things that had been put in place in our country for decades leading up to the pandemic that made it really difficult for us to plant in an effective way, from the outsourcing of our PPE to the distrust in our health care system that had been created by people’s lack of access to health care with the disparities in our hospital system.

How would you have liked to see things handled differently?Nocera: Well, the great example of doing it right is San Fran

I find the San Francisco experience impressive, too. But it was also a city that engaged in quite protracted and aggressive pandemic restrictions, well beyond just protecting the elderly and vulnerable.

McLean: But are we going to go for stay-at-home orders plus protecting vulnerable communities like San Francisco did? Or simply letting everybody live their lives, but with a real focus on the communities and places like nursing homes that were going to be affected? My argument is that we probably would’ve been better off really focusing on protecting those communities which were likely to be the most severely affected.

I agree that the public certainly didn’t appreciate the age skew, and our policy didn’t reflect it either. But I also wonder what it would mean to better protect the vulnerable than we did. We had testing shortages at first. Then we had resistance to rapid testing. We had staff shortages in nursing homes.

Nocera: This gets exactly to one of our core points. We had spent 30 years allowing nursing homes to be owned by private equity firms that cut the staff, that sold the land underneath and added all this debt on

I hear you saying both that we could have done a much better job of protecting these people and that the systems we inherited at the outset of the pandemic would’ve made those measures very difficult, if not impossible, to implement.

But actually, I want to stop you there, because I actually think that that data tells the opposite story.

And then I’m trying to say at the same time, but couldn’t we have done something to have protected people despite all of that?

I want to talk about the number of lives at stake. In the book, you write about the work of British epidemiologist Neil Ferguson. In the winter of 2020, he says that in the absence of mitigation measures and vaccination, 80 percent of the country is going to get infected and 2.2 million Americans are going to die. He says that 80 percent of the U.K. would get infected, and 510,000 Brits would die — again, in the abs

In the end, by the time we got to 80 percent of the country infected, we had more than a million Americans die. We had more than 200,000 Brits die. And in each case most of the infections happened after vaccination, which suggests that if those infections had all happened in a world without vaccines, we almost certainly would have surpassed two million deaths in the U.S. and almost certainly would’ve hit 500,000 deaths in the U.K.

In the book, you write about this estimate, and you endorse Jay Bhattacharya’s criticism of Ferguson’s model. You write, “Bhattacharya got his first taste of the blowback reserved for scientists who strayed from the establishment position early. He co-wrote an article for The Wall Street Journal questioning the validity of the scary 2 to 4 percent fatality rate that the early models like Neil Ferguson’s were estimating and that were causing governments to panic. He believed, correctly as it turns out, that the true fatality rate was much lower.”

Nocera: I know where you’re going with this, because I read your story about the nine pandemic narratives we’re getting wrong. In there, you said that Bhattacharya estimated the fatality rate at 0.01 percent. But if you actually read The Wall Street Journal article, what he’s really saying is I think it’s much lower. I’ve looked at two or three different possibilities, and we really need some major testing to figure out what it actually is, because I think 2 percent to 4 percent is really high.

He says, “if our surmise of 6 million cases is accurate, that’s a mortality rate of 0.01%. That is ⅒th the flu mortality rate of 0.1%.” An I.F.R. of 0.01 percent, spread fully through the American population, yields a total American death toll of 33,000 people. We have had 1.2 million deaths. And you are adjudicating this dispute, in 2023, and saying that Neil was wrong and Jay was right.

hird, in the Imperial College report — the one projecting two million American deaths — Ferguson gives an I.F.R. estimate of 0.9 percent.

Bhattacharya’s? Yes, there is some uncertainty around the estimate he offers. But the estimate he does offer — 0.01 percent — is one hundred times lower than the I.F.R. you yourselves cite as the proper benchmark.

Nocera: In The Wall Street Journal he does not say it’s 0.01. He says, we need to test to find out what it is, but it is definitely lower than 2 to 4 percent.

Well, first of all, the 2 percent to 4 percent fatality rate is not from Neil Ferguson. It’s from the W.H.O.

But I think that fundamentally, at the outset of the pandemic, the most important question orienting all of our thinking was, how bad could this get? And it turns out that almost all of the people who were saying back then that we shouldn’t do much to intervene were extremely wrong about how bad it would be

The argument then was, more or less, “We don’t need to do anything too drastic, because it’s not going to be that big a deal.” Now, in 2023, it’s the opposite argument: “We shouldn’t have bothered with restrictions, because they didn’t have an impact; we would have had this same death toll anyway.” But the death toll turned out to be enormous.

Now, if we had supplied all these skeptics with the actual numbers at the outset of the pandemic, what kind of audience would they have had? If instead of making the argument against universal mitigation efforts on the basis of a death toll of 40,000 they had made the argument on the basis of a death toll of more than a million, do you think the country would’ve said, they’re right, we’re doing too much, let’s back off?

McLean: I think that if you had gone to the American people and said, this many people are going to die, that would’ve been one thing. But if you had gone to the American people and said, this many people are going to die and a large percentage of them are going to be over 80, you might’ve gotten a different answer.

I’m not arguing we shouldn’t have been trying to get a clearer sense of the true fatality rate, or that we shouldn’t have been clearer about the age skew. But Bhattacharya was also offering an estimate of fatality rate that turned out to be off by a factor of a hundred from the I.F.R. that you yourselves cite as correct. And then you say that Bhattacharya was right and Ferguson was wrong.

And you, too, Joe, you wrote an article in April expressing sympathy for Covid skeptics and you said ——Nocera: This April?No, 2020.Nocera: Oh, oh. That’s the one where I praised Alex Berenson.You also cited some Amherst modeling which said that we were going to have 67,000 to 120,000 American deaths. We already had, at that point, 60,000. So you were suggesting, in making an argument against pandemic restrictions, that the country as a whole was going to experience between 7,000 and 60,000 additional deaths from that point.

when I think about the combination of the economic effects of mitigation policies and just of the pandemic itself and the big fiscal response, I look back and I think the U.S. managed this storm relatively well. How about each of you?

in this case, Congress did get it together and did come to the rescue. And I agree that made a ton of difference in the short term, but the long-term effects of the fiscal rescue package were to help create inflation. And once again, inflation hits those at the bottom of the socioeconomic distribution much harder than it does those at the top. So I would argue that some of what we did in the pandemic is papering over these long-term issues.

I think as with a lot of the stuff we’ve talked about today, I agree with you about the underlying problems. But if we take for granted for a moment that the pandemic was going to hit us, when it did, under the economic conditions it did, and then think about the more narrow context of whether, given all that, we handled the pandemic well. We returned quickly to prepandemic G.D.P. trends, boosted the wealth of the bottom half of the country, cut child poverty in half, pushed unemployment to historical lows.

What sense do you make of the other countries of the world and their various mitigation policies? Putting aside China, there’s New Zealand, Australia, South Korea — these are all places that were much more aggressive than the U.S. and indeed more than Europe. And had much, much better outcomes.

Nocera: To be perfectly honest, we didn’t really look, we didn’t really spend a lot of time looking at that.

McLean: But one reason that we didn’t is I don’t think it tells us anything. When you look at who Covid killed, then you have to look at what the pre-existing conditions in a country were, what percentage of its people are elderly. How sick are people with pre-existing conditions?

I just don’t think there’s a comparison. There’s just too many factors that influence it to be able to say that, to be able to compare America to any other country, you’d have to adjust for all these factors.

But you do spend a bit of time in the book talking about Sweden. And though it isn’t precisely like-for-like, one way you can control for some of those factors is grouping countries with their neighbors and other countries with similar profiles. And Sweden’s fatality rate in 2020 was 10 times that of Norway, Finland and Iceland. Five times that of Denmark. In the vaccination era, those gaps have narrowed, but by most metrics Sweden has still done worse, overall, than all of those countries.

On the matter of omniscience. Let’s say that we can send you back in time. Let’s put you both in charge of American pandemic response, or at least American communication about the pandemic, in early 2020. What would you want to tell the country? How would you have advised us to respond?

McLean: What I would want is honesty and communication. I think we’re in a world that is awash in information and the previous methods of communication — giving a blanket statement to people that may or may not be true, when you know there’s nuance underneath it — simply doesn’t work anymore

o I would’ve been much more clear — we think masks might help, we don’t know, but it’s not that big of an ask, let’s do it. We think the early data coming out of Italy shows that these are the people who are really, really at risk from Covid, but it’s not entirely clear yet. Maybe there is spread in schools, but we don’t know. Let’s look at this and keep an open mind and look at the data as it comes in.

Ansar al-Sharia, an umbrella group for al Qaeda militants in Yemen, said it is not responsible for the attacks. It warned journalists to avoid reporting that it is responsible.

"Our honorable people of Aden, we Ansar al-Sharia deny any connection or relation to the operation that targeted the elders' house," the group said in a statement Sunday. "This is not our operation and it's not our way of fight."

The impoverished Muslim nation has faced violence for years, some of it tied to al Qaeda elements that call it home

The latest round of unrest started in 2014 amid angry protests

The Houthi rebels seized the presidential palace in January last year, forcing out President Abdu Rabu Mansour Hadi on the way to taking over Sanaa, the capital city, and other areas.

In January, he reported over 8,100 casualties, including 2,800 deaths. That number is expected to go up when new numbers are released.

The Houthi rebels seized the presidential palace in January last year, forcing out President Abdu Rabu Mansour Hadi on the way to taking over Sanaa, the capital city, and other areas.

If those effects were repeated in Medicaid, it could prove disastrous for the health of the program’s beneficiaries. Especially in states that expanded Medicaid under Obamacare, work requirements could create a new underclass of people ineligible for any health insurance. That includes a large contingent of people with disabilities who don’t qualify for Supplemental Security Income and vulnerable populations like young men with felonies. Caught in a vicious cycle, those people would then be less healthy and less financially secure, and thus less likely to be able to work and make it out of poverty

Such a program would have its most drastic effects on wages, productivity, and reducing racial and class-based wealth inequality if it were implemented as a universal program. But it could probably achieve CMS’s goals of long-term health benefits and poverty reduction if it were instituted solely for current Medicaid beneficiaries. If the 4.4 million non-elderly adults who aren’t working; aren’t caregivers, retired, or students; and don’t qualify for disability insurance are used as a floor, providing jobs for them would cost a little more than Lowrey’s total of $158 billion, around 30 percent of Medicaid’s annual budget of over $550 billion. If people who self-report as ill or disabled are excluded from that number, Medicaid would need to pay for a maximum of 880,000 jobs, or $35 billion a year, 6 percent of the annual Medicaid budget.

A Medicaid jobs guarantee could serve to amplify both of those roles. It could essentially set a wage floor for Medicaid enrollees, who often work near the bottom of the wage scale and often barely crack the poverty line even while working full-time hours (or more). Integrating Medicaid into bespoke job structures for people with disabilities could provide transportation and rehabilitation, and further increase the accessibility of those positions, thus creating more synergy between health and employment.

Similar to how employer-sponsored insurance has become a backbone to the economic growth of the middle class, a jobs guarantee for Medicaid would take the largest health-insurance program in America and transform it into a nexus of anti-poverty policy and health equity. Put more simply: The easiest way to make sure people receive the health benefits of employment could be to employ them.

if the UK’s GDP falls by more than 6.4% per person as a result of the lockdown, more years of life will be lost than saved.”

(there’s a great takedown of the argument here).

Let’s just agree nonetheless that in principle, at some point, there will be a crossover moment when quarantine and lockdown cease to have the net-positive impact they are now having. The question is simply when that cross-over occurs, and how we can get there soonest.

If we declare victory before we achieve it, we could have the worst of both worlds — a burst in new infections leading to a second shutdown, a collapse of faith in the authorities, more deaths, and a deeper depression.

Letting up on an epidemic before it has run its course can create a second wave, as in 1918, and as feared in China right now, that would take the country down in the fall of an election year.

At the same time, if quarantine and social distancing are stretched out too long, we could be losing more lives in the aggregate than we would be saving. We could also be risking ever-more extremist politics or even civil disorder

What matters is the timing. Getting that right is the single biggest challenge as we go forward. But that requires a huge amount of data we don’t yet have: specifically, a much better sense of just how widespread COVID-19 is in the broader population.

we need equipment we don’t yet have: tests for the virus that are quick and easy and ubiquitous; and, perhaps more importantly, serological tests, to see who is now immune and can return to work and normal life.

If we’re luckier still, we could get a breakthrough in treatments as doctors and nurses understand this disease better and we buy some time.

If we’re lucky and we find out more people have already gotten COVID-19 without the worst symptoms than we now believe, then the return to semi-normal could come more quickly

At best, we could get the virus to peak at a level that does not overwhelm our medical system and manage economically until a vaccine is available. At best.

The goal is not to “beat” the virus, because it can’t be beaten. Now that it’s a pandemic, it’s here to stay

The goal is not to fight it, or wage war on it.  COVID-19 is not a rival military. The goal is to find the optimal path to living with it.

I want Anthony Fauci making that decision. Right now, as complete a shutdown as possible is the only sane option.

if we make that collective pro-life decision — and, mercifully, we are — we are also saying something quite profound about who we are as Americans. We are saying that the lives of the elderly, and the poor, and the vulnerable matter more, when all is said and done, than our GDP.

In this century, the Evangelical right has embraced the cult of prosperity, the efficacy of torture, and the denial of health care to the poor. They upped the ante in 2016, of course, by embracing a pagan worshipper of Mammon, with a sideline in philandery, cruelty, gluttony, pride, deceit, envy, insatiable greed, and the foulest abuse of women

In an apparent attempt to defend a president who clearly dismissed and for too long ignored the greatest threat to the U.S. since 9/11, they’ve decided to embrace what they once called the “culture of death.”

The correct response to COVID-19, many pastors have declared, is to let it rip.

The elderly, instead of protecting themselves, should sacrifice what’s left of their lives to save the jobs of the young and to help Trump keep the economy going. Wealth, it appears, is far preferable to life — or at least when a Republican is president.

But if by ignoring “social distancing,” we individually and collectively guarantee someone’s death down the line, why is that not a kind of indirect killing?

Yes, Christians should not cower in constant fear of death. But we don’t have to embrace it either. I’m trying to think of a version of the Gospels where Jesus meets a leper and tells him not to worry, he’s going to die some day anyway, and make the best of it; or when he tells Martha and Mary to suck it up, and accept that Lazarus is dead, and move on. He didn’t. In fact, he risked and lost his own life by raising Lazarus from the dead.

The authors applied the same analysis to two other towns and in both came up with anomalous deaths 6.1 times the number officially attributed to COVID-19

The authors go on to speculate or argue that the answer is something like universal infection from COVID-19. They note that if all citizens of the town had been infected, 158 deaths would equal to 1% mortality, which is close to the ballpark estimate most epidemiologist are working with. (11,500 residents and 123 fatalities, when you subtract the average of 35 deaths from the recorded number of 158.)

it also seems possible to me that some significant part of this is people dying from other ailments they might have survived because of the degraded standard of care amidst a pandemic.

The authors quite reasonably speculate that most of this additional fatalities are “largely elderly or frail people who died at home or in residential facilities, without being hospitalized and without being swabbed to verify that they have actually become infected with Covid-19.” Italy does have a relatively large elderly population.

What seems clear is that death toll tied to the COVID-19 epidemic – whether clinically caused by or caused by the larger epidemic – is dramatically higher than the official numbers.

The numbers as described really don’t leave a lot of room for interpretation

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.

During the arguments, it seemed clear both liberal and conservative justices believe police should be able to enter a home in limited circumstances, though they worried about how to ensure police aren’t given too much leeway.

Justice Samuel Alito said what troubles people about a “caretaking exception” is that “doesn’t seem to have any clear boundaries.”

Prior court decisions allow police to enter a home without a warrant in emergencies. Justice Brett Kavanaugh suggested allowing police warrantless entry into homes for community caretaking is most likely to be relevant in two scenarios: when an elderly person hasn’t been heard from and where there are potential suicide concerns. He suggested he was worried about police officers “backing away from going into houses” in those scenarios.