The Washington Post National Weekly. April 19, 2020.

SUNDAY, APRIL 19, 2020

.

IN COLLABORATION WITH

ABCDE National Weekly

the coronavirus pandemic

Seeking relief

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The Fix

Guidelines let states decide

BY J OSH D AWSEY, S EUNG M IN K IM, F ELICIA S ONMEZ AND C OLBY I TKOWITZ

P

resident Trump unveiled Thursday broad guidelines for states to follow as they begin reopening amid the persistent coronavirus pandemic while leaving the specific plans to the governors.

The guidance, formally introduced by the president, provides state leaders a phased list of criteria to lift social distancing restrictions.

For governors to start the process, they must first show coronavirus cases in their state are decreasing.

“We’re starting our life again. We’re starting rejuvenation of our economy again in a safe and structured and very responsible fashion,” Trump said.

The guidance doesn’t set a specific timeline, and Trump wouldn’t hypothesize what the country will look like by milestone dates like Memorial Day, the Fourth of July and Labor Day. But Trump predicted there are 29 states that can begin the opening soon and several that could start the process right away, though he didn’t name them.

Earlier Thursday, Trump explained the parameters to governors on a conference call, assuring them, “You’re going to call your own shots,” according to a recording of the call obtained by The Washington Post. But he emphasized that the federal government will be involved to support the states in the process.

Trump’s decision to defer to the governors is a change from his earlier stance, when he declared he had “total authority” to unilaterally open the country — a statement that drew blowback from governors and even some congressional Republicans who argued the assertion was contrary to the Constitution.

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Jabin Botsford/The Washington Post

President Trump speaks with members of the coronavirus task force at a briefing this week.

The White House plan states that hospitals should be able to “treat all patients without crisis care” and have a “robust testing system in place for at-risk health care workers” before proceeding to a phased reopening. Some governors appealed to Trump for more testing kits and supplies, pointing to shortages of key equipment in their states.

The White House guidance describes three phases for a gradual return to normalcy. In Phase 1, large venues like restaurants, movie theaters, sport stadiums and gyms may reopen if they can “operate under strict physical distancing protocols.” But bars should remain closed, as well as schools and day cares, the guidance says.

In that first phase, people are encouraged to continue practicing social distancing, vulnerable populations to stay home and employers to allow telework.

This publication was prepared by editors at The Washington Post for printing and distribution by our partner publications across the country. All articles and columns have previously appeared in The Post or on washingtonpost.com and have been edited to fit this format. For questions or comments regarding content, please e-mail weekly@washpost.com. If you have a question about printing quality, wish to subscribe, or would like to place a hold on delivery, please contact your local newspaper’s circulation department. © 2020 The Washington Post / Year 6, No. 28

If there’s no indication of a coronavirus rebound, a state can move into Phase 2, which allows schools to open, nonessential travel to resume and large venues to begin to ease physical distancing.

Phase 3 lifts most remaining safety restrictions, though it still advises large venues continue “limited” social distancing.

Trump rejected that these phases represent a “new normal,” remaining committed that one day restaurants and sports venues will again be filled.

During a call with senators Thursday, the president largely held back and listened to them, as both Democrats and Republicans alike pressed him on the need for more broad testing availability, according to senators on the call and other officials briefed on it.

Democrats in particular expressed wariness to the president about reopening the economy until the testing was robust enough, according to one of the officials, who spoke on the condition of anonymity to discuss a private conference call.

Still, some GOP senators also spoke of their vision for what a restart of the economy would look like.

But the eagerness of Trump and some other Republicans to reopen the stalled economy alarmed the Democrats on the call, who all pressed the president for more expansive testing. Trump and Vice President Pence told senators that the current testing capacity was about 120,000 tests per day, said Sen. Tammy Duckworth (D-Ill.), who also participated on the call.

“We need to do this in a methodical way and not just rush forward and put lives at risk,” said Duckworth, one of the 13 Democratic senators selected for the president’s task force on reopening the economy. n

Contents The coronavirus 4 Lifestyles 14 Travel 15 Medicine 16 Books 18 Opinion 20 Five Myths 23

On the cover A man wearing a mask walks through an almost empty 30th Street Station in Philadelphia. HANNAH YOON/ Bloomberg News

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THE CORONAVIRUS PANDEMIC

Students will su≠er from closures

BY L AURA M ECKLER, V ALERIE S TRAUSS AND J OE H EIM

O

nly weeks after the coronavirus pandemic forced American schools online, education leaders across the country have concluded that millions of children’s learning will be severely stunted and are planning unprecedented steps to help them catch up.

In Miami, school will extend into the summer and start earlier in the fall, at least for some students. In Cleveland, schools may shrink the curriculum to cover only core subjects. In Columbia, Mo., this year’s lessons will be woven into next year’s.

Some experts suggest holding back more kids, a controversial idea, while others propose a halfgrade step-up for some students, an unconventional one. A national teachers union is proposing a massive national summer school program.

“We have to have a recovery plan for education,” said Eric Gordon, chief executive for the Cleveland Metropolitan School District. “I’m really worried that people think schools and colleges just flipped to digital and everything’s fine and we can just return to normal. That’s simply not the case.”

The ideas being considered will require political will and logistical savvy, and they are already facing resistance from teachers and parents. They’ll also require money, and lots of it, at a time when a cratering economy is devastating state and local budgets, with plunging tax collections and rising costs. As Congress considers another coronavirus spending package, schools’ ability to make up ground may hinge on how much more they can pry from Washington.

The $2 trillion stimulus package approved last month included $13.5 billion for K-12 education. In the next round, a coalition of school administrators and teachers unions is seeking more than $200 billion, citing those depleted state budgets.

Matt Rourke/Associated Press

Summer school, longer days could help them catch up, experts say In New York state, for instance, schools were poised for deep cuts, with the state anticipating revenue losses as high as $10 billion.

The stimulus package will reverse those cuts, but without more bailout money, schools won’t get any extra funding to deal with the crisis.

‘An educational catastrophe’ Just a month ago, most American children were attending school as normal. Today, virtually every U.S. school building is closed. Seventeen states have ordered campuses shuttered through this academic year, another three recommend it, and educators and parents across the country are bracing for a lost spring — and maybe more.

Dr. Anthony S. Fauci, director

of the National Institute of Allergy and Infectious Diseases, said recently that he expects schools can reopen in the fall. But he can’t be sure, he said.

Whenever schools return, researchers say, the likely result is a generation of students forced to play catch-up, perhaps for years to come. Most vulnerable are those who are always the most vulnerable: homeless children, those living in deep poverty and students with disabilities. While some students are adapting to distance learning, others are struggling to find quiet spaces to study, lack reliable Internet access or must care for younger siblings during the day, among other barriers.

“This may be the biggest challenge public education has had to

Terrell Bell looks at a learning guide he picked up for his sister at John H. Webster Elementary School in Philadelphia. The city’s public schools are still in the process of moving students online.

face in the four-plus decades I’ve been doing this work,” said Michael Casserly, executive director of the Council of the Great City Schools, a nonprofit coalition of 76 of the nation’s largest urban public school systems. He said that online learning is probably failing many low-income families and that without “substantial” new spending, schools won’t have the money to reverse the damage.

“We are facing an educational catastrophe.”

In some districts, the problem is just getting kids to show up.

In the Los Angeles Unified School District, the country’s second-largest system, 1 in 4 students have not logged on at all. Older students were more likely than elementary children to be con-

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THE CORONAVIRUS PANDEMIC nected, but on any given day in one recent week, a quarter of high school students didn’t log in.

Before the coronavirus crisis, only about 1 in 4 students in the high-poverty Baltimore City Public Schools had computers. More Chromebooks are on order, but for now, teachers are trying to reach families by phone and Instagram, and the district is broadcasting lessons over its television station.

“What we are providing now is not going to make up fully for all of the time lost,” chief executive Sonja Brookins Santelises said.

In Atlanta’s public schools, about 6,000 children still don’t have computers, and about 10 percent of students have not yet logged in to the remote-learning system, Superintendent Meria Joel Carstarphen said.

One recent day, Carstarphen visited the home of a family whose children had not logged in. She found their mother struggling to provide food and discovered the house was in an Internet “dead zone.” She also realized she knew the family’s oldest child, a “super sweet kid,” from her visits to his high school football team.

“He’s the man of the house, and he’s only a junior right now,” Carstarphen said. “He has not been doing his work, and neither have his siblings for three weeks.”

Even when students have computers, parents and caregivers fear that minimal learning is underway. Billie Stewart is raising her 8-year-old grandson, Tony, on Detroit’s east side. She’s received little direction from his school, she said, and trying to keep up with the online offerings has been “almost overwhelming.”

Stewart, 73, has worked hard to lay out a daily schedule for Tony but finds herself unable to keep up. “If I get asked for another password, I don’t know what I’ll do.”

Students are facing “historic academic regression,” said MiamiDade County Public Schools Superintendent Alberto M. Carvalho, who is planning to extend this school year and start next year early for some students.

In Philadelphia’s public schools, teachers have been told not to teach new material because of concerns that lessons cannot be equitably provided to all. Philadelphia plans to begin remote education later this month, but for weeks, families have been left

Lynne Sladky/Associated Press

largely on their own.

“We’ve been looking for guidance from teachers, but they don’t really know what they’re supposed to be doing,” said Stacy Stewart, who has two children in a North Philadelphia elementary school, plus 1-year-old twins.

“Ever since they’ve been out of school, there’s been no structured virtual learning. It’s just been flying by the seat of their pants.”

The school provided a study packet for Mikail, a second-grader, but no direction for Abdul Malik, who’s in kindergarten, other than links to a few education websites. There’s only one computer in the house, which Stewart needs for work, and it’s been a struggle to keep her kids engaged in anything that looks like learning. “I mean, I’m not really a teacher,” she said.

To understand how deep the setbacks may be, researchers are examining data on the “summer slide,” in which students, particularly those in low-income families, lose months of reading and math knowledge. Research differs on the magnitude of the loss, but there’s broad agreement that this year’s losses will be greater than normal.

NWEA, a nonprofit that offers student assessments, used testing data to forecast how much further behind students will fall. In one scenario, it projected that students will return next year having

gained 70 percent of what would typically be expected in reading over the course of the previous year and less than 50 percent of the expected gains in math.

Lots of ideas are on the table Some districts are still working to implement and refine remote learning for this academic year.

But elsewhere, school leaders are already weighing, planning and in some cases lobbying for a range of ideas to arrest the inevitable academic losses.

In Cleveland, the schools are considering an August “jumpstart” session to get students ready for school. Gordon, the district CEO, said the schools may also need to consider a pared-back curriculum for a “recovery year” focused on the basics.

The American Federation of Teachers, the second-largest national teachers union, is proposing a one-month summer school for vulnerable kids across the country. “We have to figure out something in terms of the summer to actually nurture kids,” said Randi Weingarten, president of the union.

But even such a simple idea has detractors, proving how challenging change will be.

“The newest building in our district is 55 years old, and none of them have air conditioning,” said Becky Cranson, who teaches middle school English in rural Bron-

Miami-Dade County Public Schools Superintendent Alberto M. Carvalho said it’s possible the most at-risk students, including those who live in poverty, will see “historic academic regression.”

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son, Mich. “How much learning would happen in a room filled with 30 students when the temperature outside reads 90 degrees? None.”

In Maryland, state Sen. Paul G. Pinsky (D-Prince George’s), chairman of the education committee, has proposed year-round school.

Baltimore is considering that for its underperforming schools, along with extending the school day and possibly starting earlier in the fall.

But similar suggestions didn’t go far in Atlanta, said Carstarphen, the superintendent. She floated the idea of a longer school day or school year, she said, but was quickly shut down by middleclass parents who don’t want to give up extracurriculars. Instead, Carstarphen is hoping to channel thousands of additional students into existing summer enrichment programs that focus on topics such as science and the arts. But she said doing so depends on new funding.

Miami-Dade County Public Schools has a more targeted plan: remediation for the most at-risk students, including those who live in poverty or have disabilities, newly arrived immigrants and those learning English. Superintendent Alberto M. Carvalho said it’s possible these students will see “historic academic regression.”

The district plans to use online log-in data to determine who has fallen behind and then target interventions. Some students will see school extend into the summer, and some will come back early. The district plans to redeploy staff members who have less work during the pandemic, forming a new one-to-one digital mentoring program for students who need help.

Michael J. Petrilli, president of the Thomas B. Fordham Institute, a right-leaning think tank, has a more radical idea: Holding back all students in high-poverty elementary schools.

That idea was rejected by many educators, who said it was akin to punishing children for being poor. A more modest idea is to create half-grades to accommodate children who are socially but not academically ready to move up, said Keri Rodrigues of the National Parents Union, an advocacy group.

“Maybe it’s 3.5 until they are ready for fourth grade,” she said. n

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LIFESTYLES

The new normal is getting old fast BY

M AURA J UDKIS

T

here’s no telling how late Mandy Mallott would sleep in, if not for the cats.

They don’t know about the coronavirus pandemic.

They’re up at 7:30 a.m. waiting for their kibble, and therefore so is Mallott, enjoying a brief moment of normalcy in turn with her hungry pets.

“If I could sleep all day, I would, so the cat saying, get up and feed me, that’s very helpful,” she says.

“Once you’re up, you’re up.”

Everything else about her schedule is out of whack. Mallott, 34, who works for the city government of Columbus, Ohio, has been teleworking. Her grooming schedule depends on the timing of her video calls. Foods no longer correspond to particular meals; she has occasionally found herself eating leftover lo mein for breakfast and then a piece of cheese for lunch. The weekdays and the weekends blur together.

Silvia Manrique is up at all hours. The 43-year-old Chicagoan has always been a night owl, a tendency her marketing job used to keep in check before it went telework-only. Each night, she aims to go to bed before midnight. “The next thing I know, I watch five episodes of ‘Terrace House’ until three in the morning,” she said.

So much for settling into the new normal: The new normal is unsettled. It has been just over a month since the Beforetimes fell away — that Wednesday in March when the World Health Organization declared a pandemic, the NBA suspended its season, Tom Hanks announced he and his wife were covid-19-positive and President Trump gave a sober prime time address from the Oval Office.

You might have thought we’d have gotten the hang of this stayat-home thing by now. But flattening the curve has warped our lives. The arc of self-quarantine is long, and it bends toward bad habits.

“My routines around eating have fallen apart completely,” said Carl-Magnus Kjellman, 32, of

Roberto Cigna for The Washington Post

Flattening the curve has bent us out of shape.

Will we ever get comfortable?

Washington, D.C. He used to eat breakfast at 7 a.m., lunch at 12:30 p.m. and dinner at 7:30 p.m. “Now it’s like, yeah, sure, breakfast at 10, why not? I’ll eat lunch at 3:30.”

But, reader, what difference does a few hours make, anyway?

As long as we are all exercising some discipline and maintaining a balanced — “I ate an entire bag of Ruffles today.”

Oh. Look, we are trying. “I think a lot of us are mentally exhausted, because the energy it takes to mentally manage everything that’s happening is very draining,” says Vaile Wright, director of clinical research and quality for the American Psychological Association. “The habits that we’ve worked to develop over time to keep us healthy and productive can fall by the wayside.”

Showering. Grooming. Meals that are not cheese.

And sleeping. Kate Ahern has read a lot about sleep hygiene,

and she knows to limit her screen time and keep a consistent bedtime. But all the self-care in the world cannot keep the 39-yearold graphic designer from lying awake at 3 a.m. after a brief period of restless sleep. Sometimes, she cannot resist scrolling through Twitter — even though the light of her phone keeps her awake. At least there, misery has company.

“Someone jokingly called it the insomniac club,” Ahern says.

“Like, okay, it’s 3:30, time to meet up.”

In the Beforetimes, Lisa Devlin longed for days that were free of morning obligations. Alas, she had to drop her 5-year-old off at school every morning around 8.

When the end of in-person classes turned her kid’s school into an 11:15 a.m. Zoom session, it seemed like she would finally get those nice, long mornings. “At first I was like, ‘This is great — I get to chill out, be in my pajamas, do breakfast whenever, slow and

easy,’ ” says Devlin, 40, a stay-athome mom. “And then I realized very quickly that just turns the day into an amorphous mess.”

Typically that mess looks like Devlin attempting to entertain her children (post-Zoom School) until 4 p.m., at which point “everyone kind of hits a wall,” and she throws on a movie to bridge the gap to dinnertime. Then it’s kid bedtime, ushering in the time of day when Devlin gets to zone out until she falls asleep, which has lately been 1 a.m. Stress and insomnia might rouse her about four-and-a-half hours later, making for a different kind of long morning than the one she used to fantasize about.

The new normal is getting old.

When will it end? How will it end?

There is a fantasy brewing about The Aftertimes, when we will just carry on the way we had been. People who got up at 7 a.m., ate salad for lunch and did not start happy hour until 5 p.m. will re-adhere themselves to their healthy routines. We will stop being slobs. We will start wearing pants with buttons. We will be healed, all of a sudden, by Real!

Human! Interaction!

It may not be that simple, says Wright.

“I think, very similar to when you’re coming off a long vacation, there will be a transition that feels challenging,” she said. “But we will get back on track.”

Caitlin Irr hopes so. “I would say that normally I’m pretty type-A as a worker,” says the 28-year-old, who works at a trade association. “I like to be involved in a lot of things.”

But anxiety about the state of the world has made it hard to focus. She has found herself abandoning her mostly-vegetarian diet. Some days, she has no appetite at all. She is re-watching “Gossip Girl.” She is spending too much time on TikTok. “I have a few fitness apps that I try to use,” she says, “but it’s just like, what’s the point?” She thinks back across the void of April and March for the answer to her question: “I guess, to be healthy.” n

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THE CORONAVIRUS PANDEMIC

A chaotic search for virus treatments BY

C AROLYN Y . J OHNSON

I

n a desperate bid to find treatments for people sickened by coronavirus, doctors and drug companies have launched more than 100 human experiments in the United States, investigating experimental drugs, a decades-old malaria medicine and cutting-edge therapies that have worked for other conditions such as HIV and rheumatoid arthritis.

Development of effective treatments for covid-19 would be one of the most significant milestones in returning the United States to normalcy. But the massive effort is disorganized and scattershot, harming its prospects for success, according to multiple researchers and health experts. Researchers working around-the-clock describe a lack of a centralized national strategy, overlapping efforts, an array of small-scale trials that will not lead to definitive answers and no standards for how to prioritize efforts, what data to collect or how to share it to get to answers faster.

“It’s a cacophony; it’s not an orchestra. There’s no conductor,” said Derek Angus, chair of the department of critical care medicine at University of Pittsburgh School of Medicine, who is leading a covid-19 trial that will test multiple therapies. “My heart aches over the complete chaos in the response.”

The global biomedical research establishment could be one of most powerful assets in the campaign against the new virus, with experts all over the world — and especially the scientific and medical powerhouse of the United States — in rare alignment in their focus on a single enemy.

Some large trials designed to be definitive have launched. But with more than 500 human clinical trials worldwide, the lack of coordination puts the world at risk of ending up with a raft of inconclusive and conflicting studies and little idea of what interventions work for the next wave of illness.

Craig Lassig/Reuters

Devising plans for partnerships to organize research, officials say Francis Collins, director of the National Institutes of Health, the nation’s largest biomedical research agency, acknowledged researchers’ and doctors’ frustrations but said in a recent interview he has been working behind the scenes to launch an unprecedented, public-private partnership to address the problems. He said the framework involves top pharmaceutical companies such as Pfizer and Johnson & Johnson, domestic and international government agencies including the European Medicines Agency, and academic research centers.

Collins said the month-long discussions have been kept under wraps to ensure buy-in for an approach likely to require sacrifices of personal recognition, sci-

entific credit and profit — a centralized decision, for example, not to proceed with tests of one company’s drug to move faster on a competitor’s.

“I think we have the necessary clout to steer this whole complicated ecosystem,” he said. “ . . . I want to know what works, and I want to have it answered by June or July.”

Agency officials said further details would be released in coming days.

Anthony S. Fauci, director of the National Institute of Allergy and Infectious Diseases (NIAID), said in an email that the partnership led by Collins is the “functional equivalent of a National Strategy."

While Collins was working on

Kylene Karnuth, a clinical lab scientist at the Microbiology Research Facility in Minnesota, talks with colleagues as researchers begin a trial to see whether malaria treatment hydroxychloroquine can prevent or reduce the severity of covid-19.

developing that strategy, hospitals, drug companies, government labs and individual doctors were flooding the system with proposals for drugs and other interventions to test against the virus — an outpouring that reveals how siloed and fragmented the research enterprise remains.

For example, there are 26 separate U.S. trials listed for the anti-malarial drug hydroxychloroquine, all with different designs. That will make it more difficult to conclude whether, or in what circumstances, the drug may work.

Collins said a working group is addressing this problem by sifting through about 100 possible covid-19 treatments to decide which are the six to eight most

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THE CORONAVIRUS PANDEMIC promising drugs to move forward in large-scale trials. Those will be deployed in large clinical trial networks.

The new federal effort is motivated in part by what happened in China. Clifford Lane, deputy director for clinical research and special projects at NIAID, traveled to the origin of the outbreak in February as part of an international delegation to help the world learn from the Chinese experience. He was troubled by the lack of a strategic plan to prioritize and fast-track the most promising treatments, leading to a mosaic of inconclusive findings.

At the heart of the problem is the basic question of whether a drug really works. Typically, drugs and medical interventions are first tested in small clinical trials that establish safety before the most promising ones are funneled into bigger trials, in an iterative and years-long process.

These trials, which typically randomly assign patients to receive either a drug or a placebo, prove that medicines, vaccines and medical procedures are effective and safe. But with the urgency of the coronavirus threat, timelines have been squeezed, doctors are doing uncontrolled experiments as they administer regular care and the typical model for research is too slow.

Prioritizing research David Boulware, an infectious disease physician and scientist at the University of Minnesota, has gotten at least 50 emails from companies and researchers with treatments they want to test. The urgency to find something — anything — for patients who have nothing other than supportive care has led researchers to pull everything off the shelf: a mix of existing drugs that show promise, stem cell treatments and brand new compounds designed specifically against covid-19.

The energy is remarkable, but it needs to be channeled. Clinical trials, whether for an HIV drug or a brand new medicine, compete for many of the same patients. If there are too many trials at a hospital, none of them may enroll enough patients to get clear results. If there are too many similar small trials running in parallel, their results individually may be inconclusive and the data could have so many differences

Jabin Botsford/The Washington Post

they may not be able to be pooled.

“There’s all sorts of people wanting to try anything, because people are desperate,” Boulware said.

Some large-scale efforts are already underway: The World Health Organization has organized a massive trial in 90 countries of four promising therapies.

The National Institutes of Health is conducting a test of the antiviral medication remdesivir at more than 50 institutions and recently launched a large trial for an anti-malarial medication. A $50 million effort at the Duke Clinical Research Institute will test hydroxychloroquine in 15,000 health-care workers and create a registry that can be tapped to speed up future trials, such as for a vaccine.

“People should not be fatalistic that we’re going to have a paucity of evidence for things that provide benefit,” Collins said.

But as the federal effort has proceeded largely in secret, individual institutions have scrambled to set up committees of experts who evaluate which trials make sense to move forward. At the University of Pennsylvania, a weeks-old committee gives priority scores to trials based on criteria such as whether they will compete with existing efforts and how they are to enroll all the patients needed to get a result.

“There’s a lot of stuff bubbling up. It would seem like a sensible thing to do would be to align everyone around the same trials, not one trial for each context and not have each institution do its own thing and at the end of the

“People should not be fatalistic that we’re going to have a paucity of evidence for things that provide benefit,” said National Institutes of Health Director Francis S. Collins.

“There’s all sorts of people wanting to try anything, because people are desperate.”

David Boulware, infectious disease physician and scientist at the University of Minnesota

day everyone has done a small trial . . . and we don’t know what to make of it,” said Steven Joffe, a bioethicist at the University of Pennsylvania.

Boulware is halfway through one such hydroxychloroquine trial, which examines whether the drug is effective at preventing the disease or in treating people with mild cases. People who participate will receive either the drug or a vitamin in the mail.

He plowed ahead with his hydroxychloroquine trial weeks before he heard the National Institutes of Health had declined to fund it. He found international collaborators through chance and social media when some Canadian researchers emailed to ask if he would share his trial design with them. He ended up connecting the Canadians with each other and is now working on overcoming the complex legal requirements to share data. But now, his trial is potentially competing with a bunch of others that also test hydroxychloroquine all across the country — and enrollment has slowed in recent days.

Risks of inconclusive evidence in the social media age Small trials and even anecdotal reports of treatments that appear to have worked on small groups of patients already are being shared, sowing both hope and confusion about the evidence.

As more small-scale studies are designed, the risks of inconclusive but suggestive results multiply — and paradoxically, they could make it harder to conduct well-designed clinical trials that get to the bottom of whether a treatment works. Well-designed clinical trials require patients to be willing to be randomly assigned to receive the treatment — or a placebo.

Emma Meagher, chief clinical research officer at the University of Pennsylvania’s Perelman School of Medicine, said her institution’s study of the malaria drug in severely ill patients does not have a comparison group that receives a placebo because the media around the drug has made it the standard of care despite the lack of evidence.

In some ways, designing research studies when clinicians have an imperative to give their patients the best care possible is

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an inherently tricky situation.

Outside of top-tier research hospitals, patients may not have access to trials, so clinicians may have little option but to give them drugs in what amounts to an uncontrolled experiment.

“Do we really want to have [some] people trying new different things and the rest of you sit and wait?” asked Benjamin Linas, an infectious disease physician working on oversight of clinical trial protocols at Boston Medical Center.

Lost time Many researchers have said they are hopeful a national strategy will help unify and speed up the search but lament the time already lost. Collins said he had never seen research move faster, but in a pandemic that can still feel slow.

“We have imperfect networks.

I mean there are some there, but they’ve never been tested in this way,” said Adrian Hernandez, vice dean for clinical research at Duke University School of Medicine. “Having a common infrastructure that can do rapid cycle trials — that would be beneficial.”

Collins said he began partnering with private companies, research institutions and other agencies in mid-March. Had he started sooner, he said, the urgency of the situation might not have been clear to those groups he had to convince to work together. He disagrees significant time has been lost and noted the efforts were able to piggyback on an existing framework for pursuing drugs with industry collaboration called the Accelerating Medicines Partnership.

“I think it is a world record for anything of this sort; it might have been difficult to get full unanimous agreement to what is clearly unprecedented — for a willingness to give up control,” Collins said.

“The problem is we need to remember to invest in preparedness, at times when we’re not affected with a pandemic or epidemic,” said Barbara Bierer, director of the regulatory foundations, ethics and the law program of the Harvard Clinical and Translational Science Center.

“And it’s hard to repurpose or commit resources to something that doesn’t appear immediate on the horizon.” n

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THE CORONAVIRUS PANDEMIC

The danger of being sick at home

BY A RIANA E UNJUNG C HA AND E MILY R AUHALA

S

andy Brown’s husband knew he was infected. The 59-year-old church elder had the trademark dry cough and fever of covid-19, but when she drove him to the emergency room gasping for air, the doctor’s advice was to go home and stay home.

So he did.

Soon, their 20-year-old son was sick, and within 12 days, both had died.

The standard prescription from the Centers for Disease Control and Prevention for the mildly ill to self-isolate at home is something doctors and nurses in coronavirus hot spots repeat hundreds of times each day. But there’s a devastating cost to the public policy decision: multiple families with multiple deaths.

An 86-year-old matriarch and her three adult sons in New Orleans.

High school sweethearts married for 57 years in Grove City, Ohio, and their son.

Sisters in Chicago. A mother and daughter in Baltimore.

All dead within days of each other because of the coronavirus.

Amid the family tragedies come increasing calls for U.S. officials to isolate the mildly ill and infectious away from their homes — in convention centers, school gyms, anywhere else.

It’s not just a public health issue but an economic one.

Focusing restrictions more narrowly on the infected and their contacts, so that others can be freed from lockdown, has become a vital pillar of proposals to reopen the country.

The issue is especially critical in light of research that suggests genetics may partly explain the wide disparity in how people react to covid-19, with some shrugging off the virus without even knowing they are infected and others facing death.

On March 30, the World Health Organization’s Michael Ryan warned of a new stage of transmission in countries that

Brittany Greeson For The Washington Post

Deaths within U.S. families raise questions of whether the ill should isolate outside the home instituted lockdowns and social distancing, but left many of the contagious at home.

“In a sense,” Ryan said, “transmission has been taken off the streets and pushed back into family units.”

China’s success with isolating family members separately has been held up as a model for breaking transmission chains.

But images of Chinese officials forcibly taking people from their homes drew visceral reactions from many.

“We couldn’t under any circumstance do what China did,” said Thomas J. Bollyky, a senior fellow at the Council on Foreign Relations and director of its Global Health Program. “Largescale, non-voluntary quarantines would be challenging from a legal point of view.”

Yale University’s Gregg Gonsalves, an epidemiologist, tweeted Wednesday that family separation “is a cruel overreaction and a violation of human rights.”

But other experts, such as Carl Minzner, a professor of law at Fordham University, believe isolation and quarantine can be done voluntarily, in a way that respects civil liberties. Minzner is especially worried about poor people living in dense housing, who, according to early reports, make up a disproportionate number of the infected.

“Many people,” he said, “are terrified about infecting their family members and want to self-isolate but have nowhere to go.”

Several U.S. communities recently began experimenting with isolation centers.

On April 1, Hillsborough County in Florida set up two motels for those who have suspected or confirmed infections and are concerned about exposing vulnerable family members. Wisconsin and North Carolina have done the same in their largest cities. Other jurisdictions have set up “safe” housing for first responders such as doctors and police.

Sandy Brown visits the bodies of her husband, Freddie Brown Jr., and her son, Freddie Brown III in Flint, Mich.

Different countries, different experiences South Korea, Singapore and Taiwan, which have been relatively successful at controlling the spread of the virus, isolated the mildly ill, while Italy and Spain, where infection rates skyrocketed, did not. Public health experts have said a steady stream of household infections may be to blame for that spike in numbers.

China’s experience may be the most instructive. The country initially ordered people to stay at home. But as infections mounted, it turned to isolation, separating those with covid-19 from non-infected people, and quarantine, separating those who had come in contact with an infected person to see if they also became sick.

When China shut down Wuhan on Jan. 23, the scope of the lockdown was unprecedented in modern times. Flights and trains were stopped. Public transportation was suspended. All of a sudden, millions were told to stay at home.

Through late January and early February, the city’s hospitals were overrun. With intensive care units packed, people with mild illness were advised to stay home. The problem, of course, was that sick people spread the virus through households.

Some tried to keep family members with symptoms in a separate room. But the virus spread through the city’s apartment blocks. In some case, whole families got sick.

In early February, China adopted a new tactic: mass quarantine and isolation. In Wuhan, more than a dozen makeshift hospitals and quarantine centers were opened.

On a visit to Wuhan, Vice Premier Sun Chunlan ordered medical workers to scour homes for confirmed cases, suspected cases, people with close contact with confirmed cases, and people with fevers.

People who did not cooperate would be compelled into quarantine. The vice premier warned of “wartime conditions,” saying “de-

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THE CORONAVIRUS PANDEMIC serters” would be “nailed to a pillar of historical shame.”

In some cases, healthy people were sent to live in close quarters with the sick, fueling the spread of disease. In some facilities, patients languished without adequate care. Social media posts showed people being dragged away against their will to quarantine or isolation.

The alternative is also terrifying. Italy’s lack of isolation centers, along with its multigenerational households, has been cited as a reason for its high infection and death rates.

Zeke Emanuel, a medical ethicist who was an adviser in the Obama administration; Scott Gottlieb, a physician who was President Trump’s first Food and Drug Administration commissioner; and others who have released detailed plans for how to end the crisis safely have argued that there is a middle ground.

They point to the threat of large fines and appeals to people’s sense of moral obligation to their families and communities as effective strategies used in other parts of the world to get those suspected or confirmed to be infected to leave their homes.

Harvey Fineberg, a former president of the National Academy of Medicine who now heads the Gordon and Betty Moore Foundation, has proposed that the United States consider what he calls a “smart quarantine.”

Anyone who shows symptoms would be separated in a temporary shelter until test results return. If they test negative, they would remain in quarantine and be retested at 14 days. If that second test is negative, they could return home. If they test positive, they would go into a different type of facility for care.

To be effective, he argues, the proposal must be part of a broader strategy: testing, isolating confirmed or presumptive cases, and contact tracing. Isolating the infected wouldn’t be possible in all cases. After all, scientists believe some people are asymptomatic. But it would slow down the rate of infection.

“We have seen from elsewhere, those who are most at risk are the family members of those who have been exposed,” he said.

Family Photos

He said many people would welcome the opportunity to shelter somewhere outside their home, provided there was adequate care.

“I think that a lot of people, when they really saw it as a way to provide maximum protection to their own family, would welcome this,” he said.

U.S. experiments One of the nation’s first voluntary quarantine and isolation facilities opened in early April in Florida’s Hillsborough County.

Housed in two motels with 362 rooms, the center provides people concerned that they could infect elderly or medically vulnerable family members a free, out-of-home option for shelter.

Iñaki Rezola, operations section chief for Hillsborough’s emergency management team, said that while the center’s main goal is to help people at the beginning of infection — when they are typically shedding the most virus and pose the biggest risk — it is also accepting patients discharged from hospitals.

Rezola said 14 people have already checked in. Referrals for a spot are made by physicians to the county’s department of health.

Rezola said guests (he emphasized that they are not patients) are served three meals a day in

their rooms, paid for by the county. While no medical workers are on site, the staff is available to deliver medicine and will have access to doctors via telemedicine. Each unit has its own air conditioning and heating, so there is little concern of contamination from adjacent rooms.

“Placement is voluntary,” Rezola said. “You chose to go here.

No one is being kept against their will.”

On Wednesday, North Carolina announced that it had secured 16,500 hotel and dorm rooms to be used as recovery centers for those who have recently left the hospital and are possibly still infectious, and, separately, for what the state calls “shelter-inpeace” sites for first responders such as doctors, nurses and police.

The recovery centers will provide medical support such as supplemental oxygen. The “shelter-in-peace” buildings will have reconfigured HVAC systems so that rooms don’t share air; after each room is vacated, it will be sterilized with 135-degree heat for three hours to kill any virus on surfaces, officials said.

Two funerals, three deaths Marcos Melendez wishes that such facilities had existed a few weeks ago near his home in West Jordan, Utah. A Costco cashier, Melendez said he be-

“In a sense, transmission has been taken off the streets and pushed back into family units.”

Michael Ryan, World Health Organization

Left: Freddie Brown Jr., left, and Sandy Brown flank their son, Freddie Brown III, at his high school graduation. Right: Marcos Melendez of Utah believes he was the first member of his family to have the coronavirus. His daughter, Silvia, right, died March 28

KLMNO Weekly

lieves he was the first in his family to become infected.

The second week of March, he said, he came down with a high fever and a cough so bad that he contacted his doctor at the University of Utah via video chat. He said he was told to quarantine for 14 days and call back if he got worse. It wasn’t long before the rest of his household — his wife; two sons, ages 22 and 28; and 24-year-old daughter Silvia — were infected.

“I was surprised they didn’t take me to the hospital. I should have gone to the hospital, and I should have stayed in the hospital so I didn’t infect my family,” Melendez said.

As he feared, Silvia, who a few years ago underwent open-heart surgery because of a genetic condition, became seriously ill.

What he didn’t expect was that his wife would, too. Both were admitted to the hospital. His wife pulled through and is at home recovering. Silvia died on March 28.

On Friday, Sandy Brown buried her husband and her only son in a cemetery near their hometown of Grand Blanc, Mich. She recalled Freddie Brown Jr. as a gentleman who always opened the door for her and “dressed to the nines.” Her son, Freddie Brown III, or “Sonny,” was a defensive lineman for his high school football team and had planned to study kinesthesiology at Michigan State in the fall.

Just hours after her husband’s death on March 26, Brown said, her son suddenly developed a 102.8-degree fever and was having difficulty breathing.

“I know he got it from his dad.

He was fine before,” she said.

Three days later, she was on FaceTime with Sonny at the hospital as medical workers were about to put him on a ventilator.

“I told him to stay calm. He was afraid. His dad died on the same floor. I begged them to be able to be in the room with him,” she said. The doctors refused because of the risk of infection, but a few hours later she got a call telling her to hurry to the hospital. By the time she arrived, he was gone.

“This is a horrible disease,” she said, “a horrible plague. And that’s the story.” n

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THE CORONAVIRUS PANDEMIC

When staying safe meant staying in Shared memories of sheltering in place not for a pandemic, but for turmoil and social upheaval

BY M IRIAM B ERGER, S IOBHÁN O ’ G RADY AND R UBY M ELLEN

M

ore than half of the world is under orders to stay home. For some people, that means adjusting to a new way of living. For others, it recalls previous periods spent sheltering in place — not during an outbreak, but in times of turmoil and political upheaval.

Here are some of their stories.

Syria Ghaith Alhallak, 34, is settling into his second month of lockdown in Padua, Italy, a 15-minute drive west of Venice. He spends hours online in university classes and barely ventures out.

“You can feel the sadness in the street,” he said. “Every day, there is a lot of death.”

He knows that feeling well.

Seven years ago, Alhallak found himself under a very different kind of lockdown. As a conscripted soldier in the Syrian army, he was besieged by rebels in the Damascus suburb of Ghouta and forced to fight for the Assad government, which he opposed.

He spent some 60 days that spring hunkered down, low on water and at times with nothing to eat but grass boiled in a weak soup.

Alhallak deserted later that year, fled to Lebanon and in 2016 made his way to Italy as a political refugee.

Social control measures to stop the spread of the coronavirus in Italy are entirely distinct from his wartime experiences, he said.

“It’s different because I trust here,” he said. The Italian government “will not leave you without food.”

The situation in Syria “was out of my control,” he said. “But now I can control more. You have many ways to spend your time. Not just a fear of death.”

That said, ways of thinking he learned in Syria apply in Italy.

“No problem will last forever.

Even if it takes a long time, there will be a solution,” he said. “Keep patience.”

Illustrations by Lily Padula For The Washington Post

West Bank During the coronavirus outbreak, Mariam Barghouti found solace in the recipes of her childhood in the early 2000s, during the second Palestinian intifada, or uprising, against Israeli occupation. The spinach pies her mother would bake in bulk to freeze for leaner times. The soups she would cook up in hopes of bolstering immunity.

The way everything in the kitchen had multiple uses.

“You have to stay happy, you have to stay happy,” Barghouti remembers her mother repeating as she stuffed her and her siblings with food or sent them running around the house for exercise.

Barghouti is a writer in Ramallah, in the occupied West Bank, where the semiautonomous Palestinian government has banned movement between cities and issued a curfew to slow the spread of the coronavirus. Travel

to Israel is forbidden.

It feels eerily familiar, yet distinct, she said. “The initial reaction for the pandemic was: Oh, here we go again; we have to find new, creative ways to cope.”

During the intifada, the Israeli military imposed curfews, and people lived in fear of violence in the streets.

“Under military curfew, you kind of wanted to do the impossible, to go see people,” she said.

“And now you want to do the exact opposite.”

Barghouti said her basic approach to riding out the pandemic is based on what she learned as a child.

“Find innovative ways of celebrating and grieving and being angry,” she said. Birthdays must still be celebrated. “We continued giving attention to other aspects of our lives instead of just focusing on the disaster in front of us.”

El Salvador Enrique Roldan is waiting out the pandemic in Riverside, Calif. But sometimes in his mind he’s a teenager back in El Salvador in the mid-1970s, hiding under his bed to escape recruitment by both government and guerrilla forces.

It’s the fear of the unknown that connects the two experiences.

“Then, it was a bullet in the head,” Roldan said. “Now, it’s the virus in my lungs.”

In El Salvador, Roldan recalled having to stay inside with his sister and parents for weeks as they waited for the violence to stop.

Their two-room home was small, so as a distraction he and his sister poured themselves into their studies: History, geography and chemistry became a window into the blocked-off world beyond.

This time around, Roldan is finding comfort in the companionship of his wife of five years,

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whom he says he is learning more about each day.

They read to one another, like he and his sister once did. The outbreak has simplified his priorities. “This is the good part about the pandemic,” he said. “It unified the family.”

Still, he knows firsthand the suffering that often begets these moments of clarity.

South Sudan When Angelina Nyajima Jial was a child, bombs fell so often her family named the explosions “breakfast, lunch and dinner.”

Jial, 34, was born in 1985 in what was then Sudan. By the time she was 2, her family was on the run from civil war. She, her mother and several siblings found safety in a refugee camp in Kakuma, Kenya.

The camp was crowded with thousands of other people displaced by the same brutal conflict in Sudan, which eventually paved the way for the southern part of the country, where Jial’s family was from, to declare independence as a new nation, South Sudan.

In the chaos of the long war, some members of Jial’s family were separated from each other. Her father, a teacher, died years later, before they could be reunited.

But Jial said her mother, who found comfort in her Catholic faith, instilled a sense of stability in her children even on the days when it felt less like they were truly living and more like they were desperately struggling to remain alive.

Her mother encouraged her to

believe tomorrow always brings the promise of a better day. “All this will come to pass,” Jial recalled her mother saying. “And it’s true this came to pass, because even after all the struggles that I went through, it built me strong.”

As South Sudan emerges from a more recent civil war and confronts the looming threat of the coronavirus, Jial, who lives in Juba, the capital, said the situation “brings back the dark memories of being in a congested environment.” Millions of South Sudanese people are displaced, and even those living in urban areas don’t have consistent electricity or Internet access.

People sharing tents in camps don’t have the option to distance themselves from one another.

Some don’t have water to wash their hands.

Still, Jial urged people to make

“Learn to sit back. Breathe in, breathe out and know that it will come to pass.”

Angelina Nyajima Jial

whatever changes — big or small — they can to try to control their surroundings and find inner calm even when the outside world feels like it is caving in.

“Panic is what traumatizes people,” she said. “Learn to sit back.

Breathe in, breathe out and know that it will come to pass.”

Bosnia When the first explosion ripped through Sarajevo in 1992, Fedja Mehmedovic was outside kicking a soccer ball — a carefree 9-yearold unaware his entire world was about to be reduced to the size of a tiny room in his basement.

The siege of Sarajevo lasted until 1996, forcing families to spend years huddled inside. Each trip for food or water meant facing the threat of hidden snipers.

Many people spent long periods in their basements, living alongside neighbors from their buildings.

The isolation turned into a master class in improvisation.

Adults and children alike managed to make small miracles happen for each other: Mehmedovic’s parents mysteriously crafted a cake for his sister’s first birthday without any of the usual supplies. A makeshift library and comics shop allowed kids in their building to take turns playing librarian, lending each other books from different apartments. Without electricity to power the television, Mehmedovic desperately missed each week’s new episode of “Teenage

KLMNO Weekly

Mutant Ninja Turtles” but made do with action figures and Legos.

For children, used to finding joy in the freedom of play, the upheaval could feel even more disorienting than it did for adults. “In one moment you don’t have all these things,” Mehmedovic said. “You can’t go to the theater, can’t go to the museums, your school is affected.”

One day, as Mehmedovic lay on the ground daydreaming, an adult neighbor walked by and asked what he was doing. “I’m at the seaside,” he told her. She joined him. They lay together for around 15 minutes, enjoying the sound of waves and children playing in the sand — their imaginations powerful enough to transport them there. His neighbor still recalls the moment as one of her most powerful experiences of the war, he said.

As residents of Sarajevo retreat inside to avoid the spread of the coronavirus, Mehmedovic is tapping into his memories. The current crisis does not approach the upheaval of wartime. But the resilience he learned then is helping him confront the pandemic.

Maintain social connections even if you have to keep a distance, he said. Open your window and call out to your neighbors. Listen to their stories. See time spent inside as an opportunity to learn more about those around you. And find ways to empower children to look beyond their current situation.

“Many parents have time my parents didn’t have during the war,” he said. “They can spend it on creativity.” n

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Should we plan any summer travel?

Experts weigh in on when vacation season might start and how to think about planning

Empty chairs sit on Miami Beach in March.

Government predictions and restrictions aside, it’s not yet clear whether summer travel will be possible from a health perspective.

BY

NATALIE B. COMPTON

D

espite the all­ encompassing disruption of the corona­­virus pandemic, time marches on. April showers are still due to bring May flowers, and spring is still bound to turn into summer.

For many, the arrival of warmer weather used to be a signal that vacations were just around the corner. People plan their summer trips months and even years in advance, usually without factoring in the risk of a global health crisis.

But as the novel coronavirus continues to spread, where does summer travel stand?

What the government thinks Earlier this month, coronavirus task force member Anthony S. Fauci told “CBS This Morning” that although he does not personally take vacations, traditional summer plans “can be in the cards.”

However, the nation’s top infectious-diseases expert continued that “we have to be prepared that when the infections start to rear their heads again, that we have in place a very aggressive and effective way to identify, isolate, contact trace and make sure we don’t have those spikes that we see now.”

For anyone who had plans to take summer trips abroad, note that the U.S. Department of State is still advising Americans to avoid all international travel. It poses health and logistics risks to travelers.

“Many countries are experiencing COVID-19 outbreaks, and implementing travel restrictions and mandatory quarantines, closing borders, and prohibiting non-citizens from entry with little advance notice,” a State Department official told The Washington Post in an email. “Airlines have cancelled many international flights, and several cruise oper-

Lynne Sladky/Associated Press

ators have suspended operations or cancelled trips.”

It’s not only international travel that could severely disrupt your plans. Because state regulations can change without much warning, travelers may find themselves having to follow new protocols like selfquarantining for 14 days on arrival.

What medical experts think Government predictions and restrictions aside, it’s not yet clear whether summer travel will be possible from a health perspective.

According to Gina Suh, head of the Mayo Clinic’s travel clinic, there’s no easy answer.

“Summer vacation plans may have to be delayed to be safe,” she told The Washington Post in an email. “Travel often means congregating at unsafe distances, and that can be a risk. Also,

your destination may be a major factor. The only safe answer here is to stay tuned.”

What travel experts think Like the rest of the world, industry insiders can’t perfectly predict how the pandemic will affect our lives, let alone travel plans.

“Given what’s going on right now, people may be reluctant or unsure of whether they can travel by summer,” says Misty Belles, the managing director of global PR for Virtuoso, a network of agencies specializing in luxury and experiential travel. “And the reality is that nobody really knows at this point.”

Until the government and medical experts say that it’s safe to travel, Americans should be prepared to postpone or cancel summer vacation plans — particularly early

summer trips, as the end dates for state and federal socialdistancing guidelines get extended.

“I’d be very cautious of looking at travel that’s going to be in June, but I would be optimistic toward July, August,” says Roger Dow, president and CEO of U.S. Travel Association.

“I’m hopeful we’re going to see a late-summer recovery to travel.”

One thing is certain during the coronavirus pandemic: Americans are missing travel.

“There’s a tremendous pentup demand,” Dow says. “People are getting a little squirrelly about staying at home, and they’re just waiting for what they think is a credible allclear.”

While the future of travel is uncertain, travelers can still plan trips or fantasize about their next vacation, either practically or for an escape from anxiety.

“If you’re feeling like you need a break from the news cycle, take a moment and pause and start dreaming about where you want to go next, and start the planning process,” Belles says.

Belles has seen Virtuoso pivot from booking immediate trips to focusing on ones that require months or a year of coordination.

“You now have plenty of time to really set up the plan to get the exact trip that you want,” she says. “You have the time to budget for it, and the availability is there as well. So it’s a really strong time to look for airfare and to look for availability in the cities or areas that often don’t for the time of year you want to go.”

People who choose to book trips for summer or further out should do so with caution; the coronavirus pandemic is unpredictable. And many reservations may claim flexibility.

Amid so much unknown, there will be one certainty: the headaches of rescheduling and canceling. n

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MEDIcine

Signs of more than destroyed lungs

BY L ENNY B ERNSTEIN, C AROLYN Y . J OHNSON, S ARAH K APLAN AND L AURIE M C G INLEY

T

he new coronavirus kills by inflaming and clogging the tiny air sacs in the lungs, choking off the body’s oxygen supply until it shuts down the organs essential for life.

But clinicians around the world are seeing evidence that suggests the virus also may be causing heart inflammation, acute kidney disease, neurological malfunction, blood clots, intestinal damage and liver problems. That development has complicated treatment for the most severe cases of covid-19, the illness caused by the virus, and makes the course of recovery less certain, they said.

The prevalence of these effects is too great to attribute them solely to the “cytokine storm,” a powerful immune-system response that attacks the body, causing severe damage, doctors and researchers said.

Almost half the people hospitalized because of covid-19 have blood or protein in their urine, indicating early damage to their kidneys, said Alan Kliger, a Yale University School of Medicine nephrologist who co-chairs a task force assisting dialysis patients who have covid-19.

Even more alarming, he added, is early data that shows 14 to 30 percent of intensive-care patients in New York and Wuhan, China — birthplace of the pandemic — have lost kidney function and require dialysis, or its in-hospital cousin, continuous renal replacement therapy. New York intensive care units are treating so much kidney failure, he said, they need more personnel who can perform dialysis and have issued an urgent call for volunteers from other parts of the country. They also are running dangerously short of the sterile fluids used to deliver that therapy, he said.

“That’s a huge number of people who have this problem. That’s

Jon Gerberg/The washington post

Coronavirus invades other organs and tissues, complicating treatments, doctors say new to me,” Kliger said. “I think it’s very possible that the virus attaches to the kidney cells and attacks them.”

But in medicine, logical inferences often do not prove true when research is conducted. Everyone interviewed for this story stressed that with the pandemic still raging, they are speculating with much less data than is normally needed to reach solid clinical conclusions.

Many other possible causes for organ and tissue damage must be investigated, they said, including respiratory distress, the medications patients received, high fever, the stress of hospitalization in an ICU and the now well-described impact of cytokine storms.

The virus also may be damaging the heart. Clinicians in China and New York have reported myocarditis, an inflammation of the heart muscle, and, more dangerous, irregular heart rhythms that can lead to cardiac arrest in

covid-19 patients.

“They seem to be doing really well as far as respiratory status goes, and then suddenly they develop a cardiac issue that seems out of proportion to their respiratory issues,” said Mitchell Elkind, a Columbia University neurologist and president-elect of the American Heart Association. “This seems to be out of proportion to their lung disease, which makes people wonder about that direct effect.”

In a subset of covid-19 cases, researchers have found, the immune system battling the infection goes into hyperdrive. The uncontrolled response leads to the release of a flood of substances called cytokines that, in excess, can result in damage to multiple organs. In some severely ill covid-19 patients, doctors have found high levels of a pro-inflammatory cytokine called interleukin-6, known by the medical shorthand IL-6.

The unfettered response, also

A scene at Maimonides Medical Center in Brooklyn on April 1. Some studies of coronavirus patients have found that some lose their sense of smell before they show signs of getting sick.

called “cytokine release syndrome,” has long been recognized in other patients, including those with autoimmune diseases such as rheumatoid arthritis or in cancer patients undergoing certain immunotherapies.

Another odd, and now wellknown, symptom of covid-19 is loss of smell and taste. Claire Hopkins, president of the British Rhinological Society, said studies of patients in Italy and elsewhere have shown that some lose their sense of smell before they show signs of being sick.

Intriguingly, Hopkins said, people who lose their sense of smell don’t seem to develop the same severe respiratory problems that have made covid-19 so deadly. But a very small number of patients have experienced confusion, low blood oxygen levels and even lost consciousness — a sign that the virus may have traveled along their olfactory nerve endings straight to the central nervous system.

“Why you get this different expression in different people, nobody knows,” she said.

There are also reports that covid-19 can turn people’s eyes red, causing pinkeye, or conjunctivitis, in some patients. One study of 38 hospitalized patients in Hubei province, China, found that a third had pinkeye.

The virus also is having a clear impact on the gastrointestinal tract, causing diarrhea, vomiting and other symptoms. One study found that half of covid-19 patients have gastrointestinal symptoms, and specialists have coined a Twitter hashtag, #NotJustCough, to raise awareness of them.

Studies suggest that patients with digestive symptoms will also develop a cough, but one may occur days before the other.

“The question is, is it kind of behaving like a hybrid of different viruses?” Spiegel said.

“What we’re learning is, it seems anyway, that this virus homes in on more than one organ system.”

“We’re just seeing so many of these events that we have to investigate further,” he said. n

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SPORTS

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What halting college football means

BY W ILL H OBSON AND E MILY G IAMBALVO

A

s Iowa State Athletic Director Jamie Pollard talked with peers and reporters about the novel coronavirus this month, he used a weather-based analogy to describe how the pandemic could affect his department’s finances.

If the crisis subsides soon, Pollard said, it could be akin to a bad blizzard. If it delays the beginning of the football season, it could be like a long, hard winter. And if the pandemic forces the cancellation of the football season?

“It’s an ice age,” Pollard said in a phone interview. “I don’t know how any of us, how the current NCAA model, could survive if we’re not playing any football games.”

Just weeks after the pandemic forced the cancellation of the NCAA men’s and women’s basketball tournaments and other sports, athletic directors, conference commissioners and network executives are turning their attention to the upcoming football season. In interviews this week, several athletic directors and college sports officials acknowledged a distressing reality: A canceled football season would cost the industry billions, forcing athletic directors to consider layoffs, drastic pay cuts and potentially canceling Olympic or nonrevenue sports.

“Everything is on the table,” Pollard said. “It’s hard today to wrap your head around how challenging that would be if we can’t play any football games. . . . We’d essentially be bankrupt.”

Iowa State’s annual athletics budget hovers around $90 million, and about 75 percent of its revenue comes from football, Pollard said. To deal with a $5 million drop in this school year’s revenue created by the coronavirus-related cancellations, Pollard already has instituted an across-theboard 10 percent pay cut for all coaches and athletic department employees. But he said that wouldn’t come close to helping deal with plummeting revenue in the 2020-2021 school year if no

Charlie Neibergall/AP

Without the revenues from tickets and TV, athletic departments would ‘essentially be bankrupt’ football is played, which is why hybrid season models are under discussion.

“There’s a lot of really smart people out there who will do everything humanly possible to try to find a way to play some or all of the football games,” Pollard said.

For the past few weeks, Tom McMillen, chief executive of Lead1 — a nonprofit group that represents the 130 schools in the Football Bowl Subdivision — has had regular virtual happy hours with small groups of athletic directors, sipping wine and discussing how the coronavirus might affect the football season. They weighed the pros and cons of options that included delaying the season into spring 2021 and relocating games to regions of the country where the pandemic has been contained, as well as the potential impact if the season is lost entirely.

“The optimistic view here is that we will get this under control,” McMillen said. “ . . . But there’s going to be some type of change or impact, no question

about it.”

Even if the season kicks off as scheduled Aug. 29, McMillen said, many athletic directors expect some type of effect on their bottom line because of fears of a resurgence.

“It’s probably going to take a while for people to feel comfortable sitting close to each other in a stadium or arena again,” McMillen said.

Ticket sales are just one of several revenue streams that could be affected by coronavirus concerns, McMillen and others noted. A struggling economy probably would affect donations. Several schools delayed deadlines for donations required to secure football season tickets.

“It’s borderline immoral to be soliciting money from people, given what some folks in our country are going through,” said Tulane Athletic Director Troy Dannen, whose department normally is ramping up its fundraising operations in April, May and June as people renew season tickets.

Athletic directors such as Iowa State’s Jamie Pollard, left, and Gary Barta of the University of Iowa will face dire decisions without football’s revenue.

Some conferences also have reserve funds, but the sums are not enough to mitigate the losses that would be felt at each school in the event of a lost season. The SEC, for example, reported $25.4 million in savings and another $59.3 million in investments in its most recent financial filing to the IRS. At Alabama, just one of the 14 SEC schools, football generated $95.2 million of the athletic department’s $164.1 million of revenue in 2019, school records show.

Spokespeople for the SEC, Pac12, Big Ten, ACC and Big 12 all declined to comment or did not respond to requests to comment for this story.

“A situation with more questions than answers right now,” wrote Herb Vincent, associate commissioner for communications at the SEC, in an email declining an interview request.

While the football season is not scheduled to begin for more than four months, social distancing mandates would need to be relaxed well in advance for the season to begin on time. Most teams begin preseason camp around Aug. 1, and schools probably would need to know at least a few weeks in advance, potentially as early as by July 1, whether they have the all-clear to have their football players and coaches be on campus.

Iowa State’s Pollard emphasized the tremendous uncertainty around the coronavirus pandemic at this point, expressing hope the season would begin as scheduled while acknowledging the possibility predicted by some experts that pro and college sports won’t return until 2021. He also noted that, in the grand scheme of things, if college football can’t be played this fall and winter, it probably means there are far more significant problems confronting the nation.

“If we’re not playing college football . . . that probably means the economy in the United States is a lot worse off than it is today,” Pollard said. “So the pain we would feel in college athletics may be minuscule compared to what our country would be feeling.” n

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SUNDAY, April, 19, 2020 sunday, april 19, 2020

Opinions

KLMNO Weekly

Tom Toles

Virus has engulfed USPS in crisis Charles Lane is a Washington Post editorial writer specializing in economic and fiscal policy and is a weekly columnist

For years, experts warned the federal government that a disaster was brewing, yet elected officials of both parties took no action.

And so here we are, scrambling to prevent a possible national tragedy, having squandered precious time that could have been spent preparing for the inevitable.

All of the above refers, of course, to the financial crisis engulfing that venerable, and vital, institution known as the U.S. Postal Service.

The USPS faces $22 billion in expected new losses over the next 18 months, on top of the sea of red ink that was already forecast, according to a recent statement

by Megan Brennan, the postmaster general and chief executive of the USPS. Insolvency cannot be ruled out.

Obviously, the Postal Service cash hemorrhage stems from the wider economic shutdown caused by the novel coronavirus pandemic and the measures government and business took to counter it.

Still, the USPS could have reached this perilous moment in much better financial shape if Congress had heeded repeated warnings that it faced deep structural problems, stemming fundamentally from

technological obsolescence in an age of text messaging and email.

To cite one of many such analyses, the Government Accountability Office reported in April 2010 that the “USPS’s business model is not viable due to USPS’s inability to reduce costs sufficiently in response to continuing mail volume and revenue declines.”

The volume of first-class mail, the USPS’s bread-and-butter product, has plunged from its alltime high of 103.5 billion pieces in 2000 to 54.9 billion pieces in 2019, a 47 percent decrease at a time when the population grew 16 percent.

Consequently, the service amassed more than $77 billion in losses over the past 12 years, according to subsequent GAO analysis. Its unfunded liabilities, mainly pensions and health-care benefits for its unionized workforce, amount to more than twice its annual revenue, which

was $71.1 billion in fiscal 2019.

“Urgent” change was needed, the GAO said in 2010, to right-size a far-flung network of post offices and other USPS installations, and to reduce labor costs that accounted for 80 percent of spending.

Among expert recommendations over the years: ending mandatory Saturday delivery, relaxing regulations that subject products that account for 76 percent of USPS revenue to rate caps and shifting retiree health costs to Medicare.

Nothing fundamental was done, despite repeated legislative efforts, because Congress refused to act. Congress balked because beneficiaries of the status quo — subsidized commercial mailers, rural congressional districts and postal unions — resisted structural change.

Undoubtedly the USPS’s cash flow would have been easier in recent years without this law, as the lobbies protested, but the underlying problem, declining first-class mail, remained.

The other big distraction is more recent: President Trump’s accusation that Amazon, as he put it in one tweet, is “costing the United States Post Office massive amounts of money for being their Delivery Boy.” Not coincidentally, the founder of Amazon is Jeff

Bezos, who owns The Post, whose coverage often annoys the president.

As it happens, package delivery has been one of the few growth areas for the Postal Service in recent years, and there is great debate among specialists as to whether the USPS optimizes revenue from it.

Now, the coronavirus crisis is upon us and the Postal Service is pleading for tens of billions of dollars in aid. Trump refused a Democratic plan to add a $13 billion grant, plus $11 billion in forgiveness of USPS debt, to the Cares Act, consenting only to a $10 billion line of credit, instead.

Some aid is clearly warranted: The “universal service” function the USPS uniquely provides is indeed a valuable one, even if not as vital as in the pre-Internet age.

We cannot let it collapse in the middle of a crisis.

Yet the agency cannot survive over the long term without the structural change that has been postponed for too long.

Like sudden catastrophes before it, this pandemic has revealed which institutions in our society have been working well, and which have not. Tragically, the Postal Service and the congresses that were supposed to oversee it belong to the latter category. n

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