Fifth weekly Sunday off-the-record chat with experts

19 April 2020 (minor typos corrected 20 April)

Each Sunday, a friend organises a two-hour call for friends (many of whom are senior figures from finance, industry, and academia) to hear 10-15 experts talk about the COVID-19 crisis. This has now grown to more than 1,000 attendees, with a consistently all-star cast of speakers drawn from many different fields.

Tonight’s installment, the fifth in five weeks, covered very wide ground: the likely duration and path of the pandemic and our reaction; the historical context from the 1918 pandemic; political and economic considerations; what we’re learning from serological testing; the perspective from small business; what’s coming in therapeutics; implications for medical education; ethical considerations; and more. We had a range of prominent speakers including a superstar public health expert frequently quoted in the press.

As with past conversations, it was held under the Chatham House Rule, meaning I can share a summary of the content but not the names of the participants. I have removed obviously identifying details as well. As with each of these, the notes are as near-verbatim as I can make them, and almost real-time (apologies for typos).

As always, the conversation was fascinating and wide-ranging. Here were a few of the most important takeaways for me:

1. Without exception, all speakers agreed that there was a very long road ahead — 12-18 months or even more. No speaker thought we could return to normal quickly.
2. We had one of the authors of the Santa Clara serological study I mentioned earlier this week on the call. She cautioned that because of the high rate of false positives of the test they used, and the real possibility of selection bias of who volunteered to participate in the study, that the results were very likely not indicative of the overall prevalence of infection in the broader population. While some are trying to interpret the study as meaning that many more people have been infected than was previously thought, she does not believe that that is the case.
3. There appeared to be a consensus that not more than 5% of the US population had been infected so far (though of course rates could be higher in some places). So a long way to go to herd immunity.
4. Similarly, several speakers thought that herd immunity (whether achieved organically or with the help of a vaccine) was the only route out of this. One prominent public health official pointed out that the virus is like water — it seems to find holes and start new waves every time a country relaxes its measures. We don’t yet have a playbook other then lockdown or letting the virus spread rapidly.
5. Testing & contact tracing as a strategy is challenged by a WW shortage of reagents for testing.
6. One way in which this is more challenging than the Spanish Flu is that it is likely more infectious, and that the incubation period is much longer so it takes longer for the pandemic to spread through a given community.
7. While no speaker thought we were likely to have an active vaccine prior to 12-18 months, and some were more pessimistic than this, having a passive vaccine (i.e., using antibodies produced from outside of the patient’s body, perhaps from blood serum) could be as soon as 3-6 months away.
8. Several speakers discussed open questions around the duration of infectivity, and about immunity. Some COVID-19 patients who appear to have recovered, in terms of symptoms, are still shedding virus up to six weeks later! We don’t think this is reinfection but we don’t fully understand it. Most were convinced that some, but not all, recovered patients had gained immunity.
9. In the US, the fact that the outbreaks happened first in blue states combined with political polarization has influenced the (slow) response to the pandemic. Now it is spreading to red states; that may again change the response.
10. Current incentives in the US are for a huge number of people not to go back to work even when they can, because they get more money for not working than they earn working. This needs to be fixed.

In the summary below, note that questions listed at the start of each section were pre-submitted by organizer to the speakers; not all were answered.  Questions inline were asked live. At the end is a Q&A; I was not able to identify the respondent in each case.

Topic:  “Federal polarization”

The ideological and partisan disagreements across states and between states and the federal government.   Federal polarization has grown dramatically over the past 20 years and has clearly been the major impediment to a coordinated public health response.  I will also talk about the election as the two are related.

Bio:    Professor of Political Science at a major university

Questions:

1.      Chris DeMuth in this Weekend’s WSJ Op-Ed mentions that this Administration is acting differently than previous administrations in that it is focusing on a decentralized and deregulatory response.  It is not centralizing authority but is instead empowering local and state government and encouraging private enterprise responses with less than normal regulatory oversight. Do you think this will continue?  Is this the future Federal government? Or will this be unique to this administration?

2.      What will happen when Trump wants to open the economy and the governor does not?  Do you think that when Trump calls upon the public to make demands on the governors that this political and democratic process is the right way to handle the problem?

• Focused on partisanship
• Four-decade long increase in ideological polarization
• Republics & Dems vote less together than in the aftermath of the Civil War
• Focusing now on state government.  OVer last 20 years it looks like this in most states as well.  Half of states are more polarized than the US legislature
• More ideological variation across states (between states) than previously.
• Three trends at the Federal level
  • 1. Polarization as per above.
  • 2. Increased propensity for a single party to win both legislative chambers
  • 3. Increased propensity for Governor to be in the same party as the legislature.
• So moving towards 50 one-party enclaves, state by state.  Highly divergent choices.
• Also greater difference between “out party” states and the Federal government.
• This is visible in this crisis.
• Crisis like this requires high coordination between states and federal, but not happening.
• High disagreement across states about the right decisions.
• Liberals and conservatives view the tradeoffs differently, and this shows up in different views about re-opening the economy.
• Misiformation that preys on confirmation bias exacerbates it.
• One clear manifestation: very different plans about reopening, appearing in cross-state pacts.  Three such: NE, Midwest, PAcific coast. 17 states in all. 14 of the 17 have Democratic governors.  
• Federal polarization in an election year heightens the stakes.
• Federal relief efforts in natural disasters can be exacerbated by politics.  Worse than usual here, administration encouraging voters to see this through a political lens.
• Also biggest outbreaks in Democratic states.
• This incentivizes administration on quick economic reopening.
• Huge gamble that outbreak doesn’t spread to the red states.
• Now that it’s in Michigan and Penn, seems to have been a miscalculation.
• Huge challenge we need to confront.

Topic:  The Pandemic and Future Legislation

Bio:    Republic politician with medical background in emergency care

• Significant body of work suggesting that there is a genetic difference in people that influences response to virus.   This may hold the key to who gets sick.
• My network includes many medical providers.
• We may have misread the [angiotensin] receptor.  Sample sizes too small to draw population conclusions.  SUggestion is that hte virus is creating something like pulmonary edema, so patients don’t respond to ventilation.  High-flow oxygen may be better. In one study 68% of patients on ventilators died.
• [How will Congress respond?]
• Three bills: one focused on testing, one Families First to help small businesses, one CARES act.  On latter we will be focused on fixing holes in earlier CARES Act.
• In 14 days SBA loaned 14 years worth of loans.  $36B loaned out.
• President wants $251B, Senate tried to just add that amount, Democrats blocked it in the Senate.  Negotiations have been going on all weekend long. (This is on the PPE program which is depleted.)  The other aspects of the CARES program are not yet depleted.
• The Left is trying to add to it, focused on areas like more money for hospitals.
• Democrats are not making the same push for things like the Green New Deal or the Kennedy Center for the Performing Arts (pork).  Good negotiations are going on now on substantive topics. We will vote by Tuesday or Wednesday.

Topic:  Santa Clara Randomized Study of Covid19

Bio: Medical researcher

Questions

1.      What does the high asymptomatic rate mean for the expected death rate from the virus?

2.      Does this mean that we should open the economy?

3.      Will there be frequent random surveys in the same county to better evaluate rate of increase of exposure under both lockdown and free movement with some social distancing?

4.      What do you suspect will happen when asymptomatic patients are exposed to the virus again?

5.      Why do so many people who take the Covid19 test are negative even with symptoms, is it because they have a different variant of the flu?

• I was on the call last week and was careful not to give out numbers for how many people had immunity in a random community study. That’s because I was waiting for our paper to come out.
• It’s not out and it’s not peer reviewed.  There are a lot of criticisms about it. I shared the critique.
• We used Facebook questionnaires to get 3K people to take finger prick tests for serological tests.
• We used a toolkit that might not be idea but is what we had at the time.  There are three other toolkits now available that are probably better in terms of precision and accuracy, but this is what we had three weeks ago.
• The test has a false positive rate.  When you look at the data in a population, the random population could have had  a different coronavirus previously, not COVID-19. 
• There could be a cross-reaction.
• So we need to be very careful in drawing conclusions given false positive rate.
• Clear lesson from his study that we need better tools and larger population
• They came across with a rate that 1 in 100 in the Bay Area had been infected.
• But if you look at the trends, we thought i would be 1 in a 1000 to 1 in 2000.  So this was surprising.
• What does it mean?  It means we need better tools to test; we need to understand if someone is immune, — “titers” — whether someone has enough immunity to fight the virus if they had it again
• South Koreans have done a lot of long-term monitoring of those who had it originally.
• A lot of them are still shedding virus 6 weeks later!
• Reports of patients having positive results, then going negative, then going positive again.
• We think that reflects the tools not that they have been reinfected but we don’t know enough.
• We don’t know if people can go back to work.
• We don’t think there’s enough to get to herd immunity.
• We need therapeutics.
• [Q: one complaint about your study is that it wasn’t random enough, that people who had symptoms would be been aggressive in trying to get onto site because of lack of general testing]
• You always have to wonder about who signs up to a study and why.  It’s possible that they were incentivized by having symptoms, having someone they know have COVID-19, etc.
• This is not a large enough sample to know if it was random the way we wanted it to be.  
• It seems like this was not a random population.

Topic:  Comparing Covid19 and the 1918 Flu

Bio:    Author, historian

Questions:

1.      How would you contrast the government response of 1918 and Covid19?

2.      How do you think the education of the current heads of the CDC and public health officials plays a part in the current decision making process?  And does it matter that medical technology and knowhow is progressing at such a fast rate?

3.      Communication is so much faster and doctors can communicate the world over to make contributions in the race against Covid19, what do you make of the international medical response to making better informed clinical decisions?

• Viruses tend to be seasonal.  DOn’t think this wil lbe the case here.  The issue is susceptibility.  
• In 1918 the population was highly susceptible.  Second wave started in July in Switzerland. Australia, 1919 was the last place in the world to be hit because they had a rigid quarantine.  That hit in summer.
• At least 95% of the US population has not been exposed.  Modellers think there are at the extreme, up to 20x infected who have been exposed — that is the outside estimate.  THat will prove much more important than seasonality.
• Predict we will see swells, not peak and trough.
• Second big difference is the incubation period.  This is much longer. Flu is 1-4 days, median 2. This one is 1-14, most people sick at 5-6 days.  
• It is in the body longer as well. Each generation of transmission takes much longer.
• Flu will go through a community, seasonal or 1918m, in 6-10 weeks and then largely gone unless another wave comes.
• That will not be the case here.
• [Q: How does the education of the relevant officials impact their response?]
• Totally different situation.  In 1918 it was the Surgeon General of the Army.  
• Today we have every nation in the world with top-flight scientists and biotech industry who are cooperating to a remarkable extent instead of competing.  Good information sharing.
• Controlling this medium-term is therapeutics, vaccine long-term.
• Expect immune systems to be more effective the 2nd or 3rd time around.
• The Virus is here to stay but may not be a serious threat in the future.

Topic:  Treatment and Testing of Covid19

Bio:    Professor of Anesthesiology at a major hospital

• Convalescent plasma at our hospital, in 120 patients so far. This is immunoglobulin therapy, taking from people at least 3 weeks out from COVID disease.
• We have a world-class virology lab and were able to more the research assay into our clinical laboratory.  We got qualitative approval from the FDA.  
• We’ve identified patients who are “high titers”.
• We don’t know if it will work. 
• Have had a lot of support from the FDA.
• Not clear what the role of Immunoglobulin will be.
• Many of us are working on creating a consortium to work on 
• Seems that the virus is injuring lining of small blood vessels and then activating the coagulation system. Clotting is part of the mechanism of the disease causing injury to lung and other organs.
• Attempting to block the coagulation.
• Sickest patients: also trying research protocols to use other drugs like EPA.
• Very intense disease, frightening to treat.
• About 5% of people who enter hospital will become long-term ventilator dependent.  That has long-term implications for capacity across the country, for inpatient rehabilitation, etc. 
• [Q: COuld there be 40K patients on long-term ventilators?]
• Depends on how well we do as a nation in controlling disease.  It could be.
• People don’t come off ventilators with high frequency.  50% of patients intubated are still intubated. A proportion do very well, a proportion die rapidly.
• Remdesviir, some other inhibitors, we’re hoping some cocktail will help us improve the clinical course and the survival rate.

Topic:  How will the biotech industry, pharmaceutical firms, and medical supply companies respond with new products in the pandemic?

Bio:    CEO of a therapeutics company

Questions

1.      How rapidly can private firms provide testing, treatments and vaccines?

2.      Are you pleasantly surprised at the change in the FDA regulations during the crisis and do you think it will last?

3.      How can biotech specifically improve the situation?  What does it mean for drug, testing, and vaccines?

• Most laypeople believe that one therapy is as good as another
• Three types:
  • 1. What can be used to prevent the infection in the first place.  E.g., vaccine. Active = you take the virus, attenuate them = partially kill them, inject, expect patient to develop antibodies.  Passive = could include convalescent serum, antibodies are manufactured externally. Either could prevent infection. Active is 12-18 months away, passive could be 3-6 months away.  For disclosure, I am on the BoD of a company developing one such.
  • 2. How do you control the spread of the disease?  Viruses turn the host into a virus factory. Antivirals come into play, goal is to stop the virus from replicating.  There are several antivirals under exploration including remdesivir. Early, encouraging population data for remdesivir that it can shorten the period.
  • 3. Not targeted, but prevent or reverse end-organ damage. We think this virus creates a significant inflammatory response.  Some therapies will try to mute this response. One drug approved for arthritis is being tested.
• [Q: FDA has changed process to encourage quicker applications of drugs and treatments.  How will that deregulatory process will speed things up?]
• This is the fastest I’ve ever seen industry respond with clinical trials.
• May have an answer for remdesivir very soon, and for passive vaccine by end of summer which would be a record.
• Then need to cooperate with regulatory agencies around the world to get approval.
• FDA seems open to it, and to processing applications quickly if effective and safe.  Expect this to be similar around the world.

Topic:  Medical School Education and the Pandemic

Bio:    Professor of Medicine at a major medical school

Questions

1.      What are medical schools teaching methods and content that do not belong in medical schools?

2.      What is the appropriate role for a medical school teaching hospital in a pandemic?

3.      Should medical students be shipped out to hot spots in the pandemic?

4.      How do we bring pandemics into the medical school curriculum?

• My discussion is more theoretical.
• My ideas are somewhat controversial.
• Medical schools have decided to reduce basic science and clinical science compnents of education, to emphasize social and organizational aspects.
• Required clinical now just 1 year, basic science just one year.  Lots of electives.
• Insufficient time to hard science, almost no time to disaster preparedness like epidemics.
• I supervisted my school’s curriculum so I take some blame.
• Some want to more education even further away from science to focus on social inequalities.  So they think we should focus on “Intersectionality”; e.g., racism.
• My view is that medicalization of social problems is a profound error.
• Our true role is to care from those suffering from illness.
• Of course inequalities exist and this impact outcomes.
• But physicians have little to contribute in correcting these problems.  This distracts from the required political and economic solutions.
• My view is that this shows we need more rigorous training including learning about epidemics.
• That does not denigrate the courageous work of the frontline healthcare works who have been spectacular.
• But we have a shortage of those trained in critical care.
• Sending medical students into hotspots would be a terrible mistake.  It was done in WWII. But they are not ready for this intense work without a lot of supervision.  Might be required in a crisis but would be dangerous for patients and clinicans.
• Impact on African Americans has been blamed on the care they receive.  But the same disproportionality has been seen on people of African origins in the UK. So can’t just be the US system.  More likely it’s about poverty.

Topic:  Medical Ethics and the Pandemic

Bio:    Director of Ethics Education at a medical school

Questions:

1.      In a world of scarcity, finite ventilators and finite masks and finite nurses, who should get the hospital care?  And who should be the decision makers?

2.      Should we give out the vaccines if we do not how safe it is?

3.      We are going to violate a number of FDA protocols, should we do so if the risk/reward in public health demands it?

4.      Should we force certain citizens to be vaccinated if we do not know if is safe for those supporting an at risk population like nursing home workers?

• All evidence suggests that my field has not contributed as much as it should have.
• Rationing fortunately didn’t come to pass, but this could resurge or there will be a new one.
• So we have to think about how to improve bioethics going forward.
• Rationing of ventilators, ICU beds, etc — we lack a consistent national policy about how to allocate resources in a crisis.
• Only 26 states have publicly available standards of care.  And they differ hugely across states.
• This isn’t necessarily because of federalism or a difference of cultural values.
• We have uniformity in the definition of death in almost all states.  Same for the standards for qualifying for organ transplants. So it’s possible.
• Not clear who should establish guidelines or what criteria to use.
• Some lessons.  Clearly physicians in the field should not be asked to make the judgement. That could have devastating effects on their long-term mental well being; and it would lead to very different rules being applied.
• Whatever policy we choose it should be applied blindly — without knowing who the patient is.  By an independent party. This prevents ratinoing from undermining relationship with doctor.
• We also need community buy-in including underrepresented communities and those with underlying conditions.
• Will be important for vaccination decisions.
• Two unresolved questions:
  1. What test to use?  Assume not first come first serve; is it life expectancy?
• 2. Needs of COVID vs non-COVID patients.  E.g., some patients who require ventilators may not be able to get them.
• [Q: Does it matter who had the ventilator first?]
• Maybe we want to have a a system which allows us to take people off ventilators so that we are not reluctant to put them on in the first place.
• [Q: we’ll have vaccines at some point, we may want to release them before we know that they are safe.  Thoughts?]
• 1. For the system to work well we need collective buy in.
• 2. Some people will be serving vulnerable populations, we may have to have higher standards for them.
• 3. Should we mandate flu shots going forward?

Topic:  Battle Plan for the Pandemic

Bio:    Professor of Public Health at major university, prominent thinker on the pandemic.

1.      Are you optimistic about vaccines – quality and timing?  In your book you mention that you were particularly concerned about not getting an HIV vaccine, do you think there is significant risk of no vaccine in the foreseeable future?

2.      What are your thoughts on the efficacy of the treatments?

3.      What is your view of the large segment of the population who appears asymptomatic?

4.      Do you think that asymptomatic patients will not have sufficient antibodies in case they are exposed again?

5.      Do you think the CDC did a good job?

6.      Do you see more pandemics coming or is this a once in a 100 year event?

7.      Testing has its flaws, do you think that it is critical to opening the economy, or do you think it is bogus due to high error rates?

8.      An Israeli mathematician, Isaac Ben-Isreal, who holds some positions of importance has been claiming that the data from Sweden, Taiwan and Singapore show that the virus might be following a pattern of peaking after 40 days and going away after 70 days in a manner that seems to be independent of how much a society has locked itself down. This theme has been getting picked up and amplified. Is it quackery, or might this perspective have merit as policy makers try to figure out the path forward?

9.      There is a growing chorus of experts (Josh Mitteldorf being one) who suspect that the virus has characteristics that make it plausible that it was genetically engineered and didn’t arise naturally in the bat population, possibly coming out of some Bio-warfare research, which is supposedly illegal in the US. Is this also quackery, or is there a decent probability that this story is accurate. Some interesting implications for the future if this is what happened.

• Thoughts about where we are going in the coming months.
• We have been preparing for a long time, but we don’t know how it will end.
• “We’re not at the end, we’re not even at the beginning of the end, we’re at the end of the beginning.”  At best.
• No more than 5-7% of the population has been inefected, even in hotspots. Much lower in some parts of the country.
• This virus is going to spread until we get to 60-70% range to get to herd immunity.
• We have a long ways to go.
• I worry about, as a nation, that we want to get back to normal.  We never will; there will be a new normal.
• We are considering policies not in our best interest.
• We can look at models; I think of them — whether Imperial College or U Washington — they are black-box analysis with assumptions that vary a lot.  
• Regardless of what your estimates are, 320 million Americans, say half will be infected.  Even consider those who will be clinically il.. 80% will be mild to asymptomatic. 20% will seek medical care.  10% of those could be hospitalized, 5% will need intensive care, 1% will die.
• 0.5-1% of 160M = 800K – 1.6M people who will die if you believe that.  So we have a long way to go.
• Two lanes of decision making.
• 1. Shutdown like Wuhan.  It took that incredibly draconian limitation of population movement to get to where they are now.  As they go back to workplace, in multiple countries, seeing 
• We may or may not get a vaccine, we don’t know timeline.
• Shutdown isn’t a good long-term model, will destroy the economy.
• 2. We could just let it go.  The implications on health care system — NY, Italy, etc — have dramatic implications.  Impacts all patients not just COVID-19.
• Trying to figure out how to thread the needle.
• How can we allow those who have lower risk to be active part of society & economy?
• At the same time protect those who are at higher risk?  Try to stave off infection until we have a vaccines.
• We odn’t have many tools.
• We have suppression.
• We have testing and trying to do contact tracing.  Many chalalnges to that including a major shortage of reagents WW.
• Some challenges about the predictive value of positives.
• You would get as many false positives as true positives with antibodies today.
• In next 16-18 months or more we will face many more challenges.
• There may be many more curves to come.

Topic:  How Mid-Sized Companies in Construction are Faring in the Pandemic

Bio:    President of a construction supplier

Questions:

1.  What were the challenges for the NJ hospitals to create negative pressure rooms for Covid patients? 

2.  Cuomo’s decision to close all work sites in NY was hugely problematic for you.  How did this impact supply chains, working capital, and warehousing? Can NYC construction reopen without a hitch?

3. Working Capital Problem.  You used Wells before the 2008 crash and Wells not only did not extend credit, but they withdrew it in last financial crisis. You switched to a small local bank, how responsive have they been, and did they get your SBA PPP loan immediately?  Do you think the ever greater concentration of deposits and corporate lending hurts small business?

4.  We need to figure out how to use your labor force in this intermezzo period?

• We are 3rd generation small business
• 45 employees
• Commerical building supply in tri-state area.
• First two weeks of March were business as usual.
• Started getting emergency calls from hospital to create negative-pressure rooms.
• We were furnishing lights and view panels into flush doors, plus automatic door closeres to keep doors closed.  Plus lots of plywood and plexiglass to install HEPA filters where there had been windows — to create positive pressure.  Also to be able to keep an eye on patient from outside room.
• Last two weeks were very hectic.  Then all non-essential construction was shut down.
• We had a lot of orders coming in for NY and NJ for major clients.  They were all shut down.
• This created a warehouse problem as we have lots of things waiting to go to job sites.  Had to rent trailers to store material.
• Creates potential cash flow problem for us.  Vendors want to be paid. Don’t know if customers will pay for stored materials prior to being shipped.
• On April 3 applied for our PPE loan.  On April 15 received funding.  
• Felt fortunate to be working with a small bank where I feel valued.
• Worked with a big bank previously and they were difficult on our industry.  Very happy that I moved to a small localbank.

Topic:  Unemployment Insurance and Getting Back to Work

Bio:    Professor of Labor Economics at major university.

Questions:

1.      How will we get people back to work if we pay them more than their daily wage?

2.      Would you propose that workers earn both unemployment insurance and a wage for a period to encourage work?

3.      How do we decrease unemployment insurance payouts to achieve our objective of more work?

4.      How will labor markets adapt

• We’re getting a better estimate of the labor and economic depression.
• Expressed annually, $7 trillion, or $15K/household PER QUARTER.  Employment has fallen 28 million.
• Scholars have the well-developed national accounts.
• Calendar years have a varying number of workdays which let us estimate what a quarter would be like if it had just weekends and holidays. 
• GDP would be 25% below normal, hours worked 28% below.
• 28% below normal work hours is exactly what we are seeing in the data.
• Capital utilization is 30% below normal.  So real GDP is around 28% below normal.
• The published data does not express data like this.   This data is talking about what Would happen if there was no change for three more quarters.
• Economic pie has shrunk in unequal way.  
• But legislatinos does not produce goods and services.
• The legislation further shrinks the pie.
• This is equity/efficiency tradeoff.
• There are 9 separate provisions.  Each of them is large by historical standards.
• $600/week for unemployed on top of normal benefits.
• Over 100M people are eligible for this assistance.
• Don’t see we can have a recovery when most people can make more money not working than working.
• Policy options:
  Wait for privions to expire
  • Let people going back to work to keep some benefit
  • Inflation
  • Somebody put some sand in the system.
• Employee retention tax credit appears to subsidize employees on the payroll, but another provision offsets this negatively and removes the incentive.
• “Human capital” accumulation is important. Not all accounted for in GDP.  Schooling is not happening, also young adults at early stages of the career.  $100B less human capital for each quarter.
• Civil liberties are not included in that $7 trillion cost.
• Is the cure worse than the disease?
• It will get worse before it gets better.  Recovery will be slow as long as there are artifical incentives in there.  Either money will run out or washington will realise that it is time to get back to work.

Topic:  Conflict between Civil Liberties and Public Health

Bio:    Professor Emeritus at a  Law School, author

Questions

1.      What is the inherent conflict between civil liberties and public health?

2.      China and South Korea are using cell phone data to track your whereabouts.  Do you think this is a good idea if it saves lives? Do you think if we start doing it, the government will track you in times where there is no public health demand?

3.      Why are you so worried that government powers can be limited to national emergencies?

4.      How do you feel about federalism and the role of the states in handling local public health problems?

5.      Should the federal government executives issues orders that undermine FDA regulatory authority during a pandemic?

• If this goes on a long time the civil liberties issuse are even more urgent.
• 1905 decision Jacobson vs Mass., Supreme Court, a man who refused to be vaccinated for smallpox.  Court said: Police power of the state to protect public is within the discretion of the state if not exercised in an arbitrary measure.  No absolute right in each person to be free of restraint.
• So the States have tremendous powers to impose the kinds of regulations we are now living under –stay at home, masks, gloves.
• But over time people worry that the cure is worse than the disease.
• People will start violating regulations; can they be stopped? Punished? Told they can’t congregate in a political protest or in their churches?
• These issues will be coming up in lawsuits. 
• Last 3-4 years, huge assault on 1st amendment rights — speech, press, assembly.  This is exacerbating that. Hostility to the press as “enemy of the people”, deplatforming attempts.  
• The next few months we need to think more about the obvious public health needs of the country with individual rights.

Topic:  Solidarity

The surge of social solidarity that we are seeing and its consequences for the near future.  The consequences will include support for universal assistance such as universal child care, wage subsidies, etc.  The length of the crisis means that our social relations and politics may be changed for a year or more.

Bio:    Professor of Sociology at a major university

1.      Why do you think that the social solidarity will increase during this crisis?  We are seeing pushback for a demand to work in Michigan and elsewhere, why can’t we see the opposite impact?

2.      There may be winners and losers in the pandemic, are you concerned about this causing a rift?

3.      Why do you think that if there is a work stoppage and the Federal government has the largest near term deficits since WW2 that the government will use this as a chance to expand entitlements and new social programs?  The states are going to be under enormous budgetary conflicts, my expectation is that services will be cut, won’t this issue of scarcity drive us apart and not closer?

4.      Basic family solidarity will be under stress from long-term quarantines.  Do you expect an increase in divorce, spousal abuse, alcoholism, depression as well as an increased temporary birth rate (like in previous blackouts),

• Will talk about social consequences of the crisis
• Cold War: 1950s and 60s, Civil Defense AGency focused on how Americans could survive a nuclear attack by Soviet Union.  Duck & cover.
• Officials feared anarchy like Cormac McCarthy’s The Road.
• Gov’t funded study to see what usually happens after disasters.  In fact, people pull together, volunteer, surge of solidarity.
• But the surge didn’t last.  It declined to usual levels after a time. Empathy lessened.
• Disasters also uncover hidden inequalities and provide opportunities for actors to advance their own interests.
• We’ve already seen a sharp rise in solidarity.
• Lots of focus on those who are most impacted, least protected.
• We’ve seen a run on guns.
• Some states have tried to push prolife agenda
• But what is different than all prior disasters is length. Solidarity is highest in the period when people are suffering and dying.  But this could go on for a year or more.
• The floodwaters of this disease may not recede for some time.
• COuld have one of two possible effects.
• Optimistic: could prolong the period of solidarity.  Maybe support for extending health insurance could expand.
• Pessimistic: Or solidarity fatigue will set in soon.  Hoarding could grow. Interest groups could try to use this to their advantage.  
• We don’t know what will happen.
• 1918 flu epidemic didn’t lead to much social change.
• Will charitable giving increase?
• Will other states follow CA in assisting undocumented immigrants?
• The silver lining would be if we narrow the social divisions of pre-COVID America.

Topic:  The Pandemic and Religious Faith

Bio:    Rabbi, author

1.      Some governors are banning religious services even in parked cars in the church parking lots, do you think this is appropriate?

2.      Minyans have to be done in person.  Have orthodox shuls adopted appropriate social distancing in the pandemic?

3.      There is a reason that Jews use minyans as prayer is a social activity.  Should we undermine these norms in this risky time?

4.      Telereligious services are taking off.  Do you think this is where Reform Judaism is headed?  And will this be a net harm?

5.      Shivas and funerals have to be sparsely attended. How do you think this harms the surviving family? 

• I was on the way to Morroco in March, leading a mission.  At that point Africa virtuall untouched. A few days later, borders were closed and I got the last plane out.
• We were debating how to manage at the synagogue — e.g., minimizing physical contact.
• My colleagues studied it and decided to shut down completely, even before this being suggested by the CDC or the government.
• We canceled weddings, bar mitzvahs, etc. Shut down all buildings.
• The highest Jewish value is saving lives, it is above all mitzvahs.
• When we left Morocco, there was an outbreak immediately afterwards traced to a single wedding that had 200 French who had flown in — this became the nexus of the contagion.
• So it was a good thing that we shut down such celebrations.
• We also cut down funerals.  We made them small, outdoors — e.g., 10 people.
• In those for days my colleagues transformed our synagogue, one of the largest, into a virtual community.  
• It’s been amazing.  Our attendance soared.
• When we do a Passover seder (meal), we get typically 600 people.  Our virtual seder had 15,000 people.
• It’s also my biggest worry. I worry that our success may end up killing us.
• My congregants may like it too much.  They like the idea that they can sit at home.
• I’m pessimistic about the short & mid term in terms of our ability to gather.
• We will create an amazing High Holy Days with high production values and it will be more convenient for everyone..
• Will this become a replacement for gathering?
• Gathering is a high Jewish ideal — we are meant to be 10 or more gathered together to pray.
• I believe people will come back to their religious institutions because of the innate spiritual need to be with other people.
• May it be your will, oh God.  Amen.
• [Q: Will it be different for Reform vs Orthodox?]
• Orthodox community is tech savvy.  We [Reform] also have the need to get together.   The question is how to we get back to gathering in person.  Will be true for all religions.

Q&A among speakers

Q: How will families adapt to confinement?

A: Two phases: things will be fine or will even get better. People pull together for a while.  But if it lasts too long we will see problems. So far reports of domestic violence are down. Could be that people are not reporting it.  Long-term, if it’s a long time, not all families will be able to.

Q: (to economist) Hidden tax in the employee retention tax credit?  I didn’t understand.

A: It is phased out with the revenue of the company. They get a good tax refund on their return, but they lose it as revenues return to normal.  That’s a problem.

Q: You mentioned that the unemployment insurance is more than some workers earn, and hinted that Congress might change thet terms?

A: In prior stimulus, only 4-5 million people could earn more on unemployment than in their jobs. Now it’s 10s of millions.  In some countries like DE they are going to bear the costs for some time of letting people work and get these benefits.  

Q: (to construction company) What is your plan in terms of keeping your workers?

A: I got the loan on Wed night, on Friday met all hourly employees, said we were fortunate to get PPE loan.  I’m not going to lay you off. We have 8 weeks to clean things up since we’re not doing our normal work. We will find things to do. They were very happy to hear that.  I said, I don’t know what will happen in 8 weeks. Hopefully things will relax and we can return to almost normal.

Q: (to epidemiologist) We’re seeing the number of infections declined dramatically in China and South Korea. Why is that?  Will they too have ⅓ to ½ the population get the disease? Why aren’t we seeing a rekindling?

A: People are making conclusions on data today where we see something very different the next week. E.g., Singapore in a state of public emergency.  Japan is in state of emergency as well. In Korea, active transmission happening there. The virus is highly contagious; if you let up to allow the economy to return, the virus escapes.

Concerned about the numbers in China, they have been reporting 20+ cases of transmission per day and 1 clinical case; that can’t be right.

Will take time for these outbreaks to build.

If any country can contain it China can, because of what they can bring to bear.

Over and over again we find the virus in places that thought they didn’t have it.

Q: Will the draconian policies reduce the total attack rage? Could we reduce it to 5-10%?

A: We don’t have clear lessons from the past.  We’re making assumptions that this is highly infectious and a long incubation period.  It is like water, it will find the holes and leak out, until we have herd immunity. It will be like whack-a mole.In 2918 we had some peaks that went away on their own too. Nature plays a role.  But it can cut both ways. You have to prepare for the worst. It will keep burning until you get to herd immunity or a vaccine.

Q: You’ve talked about HIV where there was a lot of optimism about a vaccine.   Might we not find a vaccine?

A: HIV was very unusual situation. Our vaccine technology at the time couldn’t do it.  There may be challenges here too. One is the effectiveness of the vaccine. Looking at SARS and MERS, it may be hard.  But some work is more optimistic. One issue we have to resolve is the safety issue. Antibody-dependent Enhancement (ADE).  Sometimes if you make a little bit of antibody and get infected, you create an immunological cascade that can be fatal. We saw a bit of that with SARS research. This is also why the Dengue Fever vaccine was removed from the market. We need to understand ADE more before we put a vaccine out.

Q: (to ethics expert) During Obamacare the Republicans were concerned about death panels.  

A; Needs to be broad consultation.  This would apply if someone was going to die because there weren’t enough ventilators.  

Q: Will Congress try to fix the incentives in the legislation?

A: Will be challenging.  The idea of continuing the $600 bonus once someone is on employment is an interesting idea.  We face similar challenges when someone on welfare goes back to work and loses money. We need to work on this; clearly want people to return to work.

Q: If disease is here 18-24 months should we change medical school curriculum right now?

A: Classes are shut down, online only right now.  Students aren’t involved in clinical activities. There will be a dramatic change.  The response will be about how to protect yourself, isolate patients, treat patients.  It will happen in a dramatic way.  

Q: Is quarantining 14 days enough given evidence of shedding beyond that period?

A: (University researcher) We don’t know, we need to get the data. Some people have become immune and gone negative permanently.  We’re studying health care workers. I’m optimistic that we’ll have better data. We don’t understand why some people have not gone negative.

A: (From major hospital) Looking at 5,000 people including titers, after 21 days almost zero, at 28 days 100% zero — but small study still.  We’re all being cautious for now. We cannot 100% guarantee that reinfection is not possible, but patterns suggest that when the virus disappears, after 21-28 days immunoglobulin is appearing.

Q: Substantial errors in testing with false positives.  In your study showing 5% of population having antibodies, what proportion do you think that are false positives?

A: We need to be very careful.  When false positive rate is what we think, we’re worried that a large proportion of the positives could have been false positives.

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