She's Made of Iron

My uncle was born in February of 1945. By the year’s end millions of people would be dead from the battlefields, amphibious assaults, saturation bombing campaigns, and genocides of the last six months of World War 2. America faired well by global standards, but catastrophic suffering happened here, too. Tens of thousands went to their deaths in the Rhineland, on Iwo Jima and Okinawa, and in the skies over Germany and Japan. In anticipation of an upcoming invasion of Kyushu and Honshu, more than half a million Purple Hearts were manufactured.

My grandfather spent most of the year training young men how to fly the B-29, America’s primary tool of annihilation used against the Japanese home islands. He knew at some point that year his name would be called, and he’d be ordered to ship to Guam, Tinian, or Saipan to begin serving in combat. Perhaps it was luck, perhaps providence, perhaps fate, perhaps the simple unfolding of the initial conditions of the universe, but he was assigned to fly west at the end of August. The work of the Manhattan Project rendered his orders obsolete, and in the event he went home with his wife who’d just turned 20 and his infant son.

My grandparents knew what the state of the world was when they married and when they conceived their first child. 1945 was a low point in world affairs in the 20^th Century, and possibly all of human history. As my grandfather transitioned from AT-6s to B-17s to B-29s, it was no sure thing that he would keep out of combat. Many other couples were similarly optimistic and their children grew up without a father. It’s always seemed remarkable to me that they took this chance on life anyway.

When my wife and I conceived our third child I didn’t think we were making any similar sort of bet. Now here we are, with a new baby at the beginning of the worst pandemic in a century. Our daughter Mira was born a week ago yesterday, a week after schools closed in Seattle and two days before our daycare shut down. Nominally the schools should be open again by the middle of next month, and our daycare in another week. What are the prospects of that happening?

I encourage you to read the report on non-pharmaceutical interventions and COVID-19 released last week by the Imperial College team that modelled the pandemic. The results are based on computer simulations of how the virus spreads through the population and affects those infected, anchored to the best available data from China’s experience with the disease so far. They are sobering.

The virus poses no spectacular risk to myself or my family. For those over 30 and under 40, about one in 600 who catch the disease will need treatment in an ICU. ICU beds are readily available at the time of this writing even in Seattle. Younger cohorts fare even better. Older cohorts fare much worse

 Taking a look at the demographics of the United States, the authors estimate that, even if everyone who needed intensive care could get it, unmitigated spread of COVID-19 will kill more than two million Americans by the end of July. That, in itself, would be an unacceptable disaster. Given the limitations of reality, nearly everyone who would need an ICU bed in that scenario would not get one. Doubling or tripling the estimated death toll is not unreasonable. Unacceptable indeed.

If doing nothing is unacceptable, then what else can be done? Perhaps we can do something by doing nothing. In much of Europe and the United States the economy has been anesthetized. Children are not at school. Toddlers are not at daycare. Adults are not sitting in restaurants, bars, and movie theaters. In Detroit and Fremont the factories are going quiet. If this is maintained, the lives will not be lost. It begs the questions, how long does the lockdown need to be maintained, and how long can it be?

The authors estimate that by the end of the summer the smashed curve of infections will be past. Lockdown measures can be relaxed. Then, with the virus on the loose once again, COVID cases will flare up. Within a month the measures must be put into effect or millions will die. This will continue, an intermittent bang-bang cycle of a frozen, broken economy and short bursts of normal life, until a vaccine is developed. Don’t count on that for another 18 months.

If you haven’t done so already, you should start trying to get your head around what this means. Suppose the will is maintained and everyone sacrifices whatever it takes to beat this virus. There will be no school or childcare for over a year. A mark will be left on the generation now coming of age for the rest of their lives. Without government intervention much more massive than anything now being considered, a large portion of existing small business will fail. Non-emergency medical care will disappear for 18 months. How many people will commit suicide while left alone and unable to reach counseling? How many couples will divorce? Millions, maybe tens of millions, of people will either need to be “forgiven” by their employers for leaving to care for their children or will lose their jobs. The best-case scenario is a recession on the scale of that which followed the 2008 financial crisis. A more conservative expectation is something more like the Great Depression. One hopes that the riots, decline of democracy, and rise of fascism of that epoch might not be repeated…

Does that all seem unacceptable? It is. It’s completely unacceptable. It’s insane that we’re even talking about this, and is probably why so much of the discussion is focused on what’s cancelled this week and not addressing what the long-term scope of what this crisis is. Keep that thought in your mind, and then return to the numeric value of the number of lives lost if these measures aren’t put into place. All of human civilization has been thrust into a dilemma between two unacceptable choices by a virus 90 nanometers in diameter.

Maybe we’ll get lucky. Maybe the reproductive rate of the virus will drop enough to notice as spring turns to summer. Maybe drugs will prove effective at mitigating symptoms and keeping the disease burden manageable. Maybe a vaccine will come along sooner than the experts expect. All of those scenarios are possible and would be great, but there’s no indication in the facts at hand that any will come to pass. A mentor of mine once said “Hope is not a plan.” I recommend plans as well as hope.

In many ways my family and I are in a much better position to weather this storm than many of my peers. My wife will spend less time on maternity leave than is guaranteed by the state in nearly all wealthy countries. It’s still a much longer period of leave than most mothers receive here. Her mother is here, and with her to watch the children I can continue to work from home. The burden of now (having to continue to make progress at work to keep in good standing with my career, and having no help at all from daycare we are still paying for), and imagining a future that goes on like this, still seems intolerably great. It reminds me of our time in residency, and that thought makes me want to go to the toilet and vomit until there’s nothing left inside me. We are skilled, we are strong, we are educated, and we are stubborn. We’ve done everything “right” to be in a good position in life and have families to support us. There is still some point where it’s too much, and we’re going to break. Many, many families will encounter this point before us. We can’t let millions die, and we also can’t destroy millions of families with economic warfare against a coronavirus. Unless one of the “wouldn’t it be nice” options of the last paragraph comes along, I don’t know what will happen

If this has snuck up on you like it snuck up on me, it’s worth acknowledging the scale of what we’re all facing. This is the greatest crisis the world has faced since World War 2. We will need to be clever, resourceful, and probably a bit lucky to get through this intact. The intent of this essay is more to organize my own thoughts than to prognosticate doom. I think I’m actually optimistic by nature, I’m just really tired. And this is scary. It’s okay to say that.

Thinking about how much America, health care, and civilization in general has advanced since the H1N1 pandemic of 1918-1919, I keep thinking about the scene in Titanic just after the ship strikes the iceberg. Bruce Ismay, the director of White Star line, listens in disbelief as the crew informs him that, not only will Titanic not be under way soon, she will sink, and will sink within the next couple of hours. Ismay is intimately familiar with the safety and damage control features of the Olympic-class ships.

“This ship can’t sink!” He scoffs.

“She’s made of iron,” Thomas Andrews, Titanic’s designer replies. “I assure you, she can.”