Opinion | The Wall That Didn’t Stop the Coronavirus - The New York Times

"Hostility toward immigrants is hurting the fight against the pandemic.



The editorial board is a group of opinion journalists whose views are informed by expertise, research, debate and certain longstanding values. It is separate from the newsroom.



Three weeks ago, with much of the United States already gearing up to limit the spread of the coronavirus, the Trump administration’s chief immigration judge sent out a stern order to immigration courts nationwide to take down all public health posters, printed in English and Spanish, on how to deal with the pandemic. “Per our leadership,” the order said, immigration judges did not have the authority to post fliers. “If you see one (attached), please remove it.”



Soon after the order was revealed by The Miami Herald, the Department of Justice, which oversees the immigration courts, reversed course and told the paper that “the signs shouldn’t have been removed.”



A bureaucratic blunder? More like a case in point of how the administration’s obsession with immigrants, undocumented, legal or aspiring, has infected its efforts to control the spread of a pandemic, exacerbating the crisis.



Tough times call for tough measures, to be sure, and the administration’s anticipated order to turn back all asylum seekers and other foreigners trying to cross the southwestern border illegally makes sense in the context of measures already taken to severely restrict movement across other American borders, land and sea.



The immigration system along the southern border is overtaxed, and detention centers across the United States are already bursting with nearly 40,000 people, at enormous risk of contagion. The coronavirus doesn’t discriminate between carriers who are held behind bars and those whose job it is to guard them. The Immigration and Customs Enforcement agency has continued to make arrests and has shown no intention of releasing nonviolent detainees, though judges in some states have ordered some released out of health concerns.



Rounding up undocumented immigrants and shutting down the border is something President Trump has yearned to do since long before the coronavirus began its fateful spread. And his animosity toward undocumented immigrants is affecting the efforts to contain the coronavirus far beyond the border.



As Miriam Jordan of The Times reported, the virus has spread more fear among immigrants, legal and undocumented — the fear that seeking medical or financial help will put them in the cross-hairs of the administration’s repressive immigration policies.



At the beginning of March, more than 700 public health and legal experts addressed a petition to Vice President Mike Pence and other federal, state and local leaders asking, among other things, that medical facilities be declared enforcement-free zones (ICE currently classifies them as “sensitive locations,” where enforcement is avoided but not precluded). The Citizenship and Immigration Service subsequently appeared to signal that it was suspending enforcement of a new “public charge” rule, which makes it harder for immigrants to obtain the green card of a permanent resident if they tap federal benefits, but the suspension has not been publicized.



Those who are not documented are afraid that going to a public health facility will expose them to ICE agents. Immigrants in the country legally and hoping to obtain a green card fear that seeking help will ruin their chances under the public charge rule, which went into effect in February after injunctions blocking it were lifted by the Supreme Court.



These immigrants are particularly at the mercy of the pandemic. They often live in crowded conditions, have little money and no paid sick leave, and so lack the ability to self-quarantine. And according to the Kaiser Family Foundation, 23 percent of noncitizens lawfully in the country and 45 percent of those who are undocumented lack health insurance.



Most immigration courts, meanwhile, were still working at full steam long after state and federal courts across the country sharply scaled back their activities. On Monday, several groups representing lawyers who work with immigrant clients sued the administration to stop in-person immigration hearings during the pandemic. It was only last week that the Executive Office for Immigration Review, the Justice Department agency that oversees immigration courts, closed down some courts and suspended hearings for immigrants not in custody.



The coronavirus does not care which passport its human hosts may carry or tongue they speak. Nor does it serve global public health for only American citizens to wash their hands and practice social distancing. Those are best practices that should transcend borders and walls and help us acknowledge our common plight, and humanity."



Opinion | The Wall That Didn’t Stop the Coronavirus - The New York Times

Utilitarianism, The Coronavirus and Healthcare

Nancy Pelosi: Trump fiddles as people are dying

Who Should Be Saved First? Experts Offer Ethical Guidance - The New York Times

This is one of the issues that scares me most about this pandemic given how America has always discriminated against people of color. Can America change in a crisis? I seriously doubt it. Please prove me wrong.

"How do doctors and hospitals decide who gets potentially lifesaving treatment and who doesn’t?

A lot of thought has been given to just such a predicament, well before critical shortages from the coronavirus pandemic.

“It would be irresponsible at this point not to get ready to make tragic decisions about who lives and who dies,” said Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado.

Facing this dilemma recently — who gets a ventilator or a hospital bed — Italian doctors sought ethical counsel and were told to consider an approach that draws on utilitarian principles.

In layman’s terms, a utilitarian approach would maximize overall health by directing care toward those most likely to benefit the most from it. If you had only one ventilator, it would go to someone more likely to survive instead of someone deemed unlikely to do so. It would not go to whichever patient was first admitted, and it would not be assigned via a lottery system. (If there are ties within classes of people, then a lottery — choosing at random — is what ethicists recommend.)

In a paper in The New England Journal of Medicine published Monday, Dr. Ezekiel Emanuel, vice provost for global initiatives and chairman of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, and colleagues offer ways to apply ethical principles to rationing in the coronavirus pandemic. These too are utilitarian, favoring those with the best prospects for the longest remaining life.

In addition, they say prioritizing the health of front-line health care workers is necessary to maximize the number of lives saved. We may face a shortage of such workers, and some have already fallen ill.

In a recent article in The New York Times, a British researcher said, “There are arguments about valuing the young over the old that I am personally very uncomfortable with,” adding, “Is a 20-year-old really more valuable than a 50-year-old, or are 50-year-olds actually more useful for your economy, because they have experience and skills that 20-year-olds don’t have?”

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Dr. Emanuel disagreed with that interpretation: “The 20-year-old has lived fewer years of life; they have been deprived of a full life. If they have roughly comparable prognoses, then the fact that the 20-year-old has not had a full life counts in their favor for getting scarce resources.”

Some organizations, states and federal agencies have anticipated challenges like these and developed resources and guides for hospitals and health systems.

The Hastings Center has curated a list of resources that health care institutions can use to prepare for responding to the coronavirus, including for shortages. In 2015, the New York Department of Health released a report on the logistical, ethical and legal issues of allocating ventilators during a pandemic-created shortage. This and many other states’ plans are modeled on guidance from the Ontario Ministry of Health on critical care during a pandemic.

Federal health agencies, including the Department of Veterans Affairs and the Department of Health and Human Services, have also published guidance that includes approaches for allocation of scarce resources during a pandemic.

A study in Chest in April 2019 imagined a 1918 flulike pandemic in which there weren’t enough I.C.U. beds and ventilators to meet demand. The authors engaged focus groups in Maryland about views on how to ration care. The preference of the focus groups? Direct resources to those with the greatest chance of survival and the longest remaining life spans — in other words, also the pragmatic utilitarian approach. This study stemmed from work for a Maryland report on allocating scarce medical resources during a public health emergency.

“Key is to be transparent about the principles, save as many lives as possible, and ensure that there are no considerations such as money, race, ethnicity or political pull that go into allocation of lifesaving resources such as ventilators,” said Dr. Tom Frieden, president and C.E.O. of Resolve to Save Lives and former director of the Centers for Disease Control and Prevention.

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Another principle recommended by medical ethicists is to take tough choices out of the hands of front-line clinicians. Instead, have dedicated triage officers decide. Also, decisions should be free of financial considerations or the social status of patients, something that seems to have been violated in the provision of scarce coronavirus tests to N.B.A. players, for example.

“Ethically speaking, rationing by ability to pay is the worst way to allocate scarce medical resources in an emergency,” said Dr. Jerry La Forgia, chief technical officer of Aceso Global and former lead health specialist for the World Bank.

Nevertheless, precisely this kind of rationing is commonplace in the U.S. health system during more normal times.

The Hardest Questions Doctors May Face: Who Will Be Saved? Who Won’t?March 21, 2020

Health economists have also thought deeply about how to allocate finite health care resources, in government budgets for instance. Often there are winners and losers in these calculations — some treatments covered and some not — but they’re not always individually identifiable.

During a pandemic, the winners and losers are both clearly identifiable. They’re right in front of the doctor at the same time. “This shifts the ethical and emotional burden from society or government to the clinician,” said Christopher McCabe, a health economist and executive director and C.E.O. of the Institute of Health Economics in Alberta, Canada. “There’s no perfect way to choose who gets lifesaving treatment. At times like these, society may be more forgiving of utilitarian decision making.”

History offers examples of competing values. During World War II, soldiers received penicillin before civilians. In Seattle in the 1960s, social worth was among the criteria used to ration dialysis machines.

In 2005, Hurricane Katrina caused acute shortages under emergency conditions in Louisiana health centers. “Health care workers were forced to make things up as they went along, amounting to life and death decisions,” Dr. Wynia said. “This was widely viewed as unfortunate for patients, doctors, and not what we want as a society.”

Today, there is greater demand for some organs for transplants than supply can accommodate. The United Network for Organ Sharing is a system for prioritizing patients for transplants. It combines medical condition, waiting time and prognosis into a scoring system that varies by type of organ.

“It has elements of utilitarianism,” said David Vanness, Professor of Health Policy and Administration at Penn State. “But it’s not designed for the urgency of a pandemic.”

In particular, society has had time to consider how to cover the care for patients needing transplants. The vast majority of end-stage kidney disease patients are eligible for Medicare at any age, for example.

When antivirals or vaccines become available, those too will initially be in short supply, and undoubtedly discussion will arise on who should get them first.

Dr. Emanuel predicts we will soon see in the U.S. the kind of rationing happening in Italy, where there are too few ventilators and I.C.U. beds for all the patients who need them. Estimates by researchers at Harvard show that without drastic expansion of supply, many areas of the U.S. will have inadequate numbers of hospital beds.

“When you consider the shortage of coronavirus tests, we’re already seeing rationing,” he said.

Austin Frakt is director of the Partnered Evidence-Based Policy Resource Center at the V.A. Boston Healthcare System; associate professor with Boston University’s School of Public Health; and a senior research scientist with the Harvard T.H. Chan School of Public Health. He blogs at The Incidental Economist, and you can follow him on Twitter at @afrakt

Who Should Be Saved First? Experts Offer Ethical Guidance - The New York Times

Cuomo says possible NY quarantine 'would be chaos and mayhem'

Coronavirus numbers are going to skyrocket doctors say

Coronavirus numbers are going to skyrocket doctors say

‘This all comes down to ventilators:’ Gov. Cuomo on the fight against coronavirus

‘This all comes down to ventilators:’ Gov. Cuomo on the fight against coronavirus

Opinion | Testing Can’t Stop Coronavirus Now, But There Are Still Things We Can Do - The New York Times

Our leaders need to speak some hard truths and then develop a strategy to prevent the worst.

“Respirators, ventilators, all of the equipment — try getting it yourselves,” President Trump said on a recent conference call with U.S. governors.Erin Schaff/The New York Times

Of all the resources lacking in the Covid-19 pandemic, the one most desperately needed in the United States is a unified national strategy, as well as the confident, coherent and consistent leadership to see it carried out. The country cannot go from one mixed-message news briefing to the next, and from tweet to tweet, to define policy priorities. It needs a science-based plan that looks to the future rather than merely reacting to latest turn in the crisis.

Let’s get one thing straight: From an epidemiological perspective, the current debate, which pits human life against long-term economics, presents a false choice. Just as a return to even a new normal is unthinkable for the foreseeable future — and well past Easter, Mr. Trump — a complete shutdown and shelter-in-place strategy cannot last for months. There are just too many essential workers in our intertwined lives beyond the health care field — sanitation workers; grocery clerks, and food handlers, preparers and deliverers; elevator mechanics; postal workers — who must be out and about if society is to continue to function.

A middle-ground approach is the only realistic one — and defining what that looks like means doing our best to keep all such workers safe. It also means leadership. Above all, it means being realistic about what is possible and what is not, and communicating that clearly to the American public.

When leaders tell the truth about even near-desperate situations, when they lay out a clear and understandable vision, the public might remain frightened, but it will act rationally and actively participate in the preservation of its safety and security.

Our leaders need to begin by stating a number of hard truths about our situation. The first is that no matter what we do at this stage, numerous hospitals in the United States will be overrun. Many people, including health care workers, will get sick and some will die. And the economy will tank. It’s too late to change any of this now.

In three to four weeks, there will be a major shortage of chemical reagents for coronavirus testing, the result of limited production capacity, compounded by the collapse of global supply chains when the epidemic closed down manufacturing in China for weeks.

The second hard truth is that at this stage, any public health response that counts on widespread testing in the United States is doomed to fail. No one planned on the whole world experiencing a health conflagration of this magnitude at once, with the need to test many millions of people at the same time. Political leaders and talking heads should stop proffering the widespread-testing option; it simply won’t be available.

Much better, instead, to immediately gear up for epidemic intelligence, based on techniques used for many decades. Among those is so-called illness surveillance, in which epidemiologists survey a sample of doctors’ offices in a given geographic region each day to learn how many patients sought care for illnesses with symptoms of fever, cough and muscle aches. The increasing or decreasing occurrence of patients with these symptoms provides a reliable estimate of influenza activity during the winter months — or now, the incidence of Covid-19.

A third hard truth is that shortages of personal protective equipment — particularly N-95 masks — for health care workers will only get worse in the United States as global need continues to rise precipitously. There is no point holding out the false hope that the Defense Production Act will save the residents of the United States. Not enough manufacturing activities can be converted to produce masks in a matter of weeks. You can’t turn engine-making machinery into an N-95 respirator assembly line just because you want to.

For example, even as 3M was producing at 100 percent of its capacity (35 million N-95 masks a month), a single hospital in New York City used up more than two million masks in February, before the surge in Covid-19 cases there. And new production won’t happen for many months.

If you can’t make nearly enough masks to meet the need, then you must conserve the masks you can make. Unfortunately, some hospitals in the United States are not employing science-based methods for conserving these invaluable lifesaving masks.

Making ventilators — machines that breathe for patients who cannot effectively do so on their own — poses an even more formidable challenge. For example, a Medtronic ventilator has about 1,500 parts, supplied by 14 separate countries. More machines might, at best, be manufactured by the hundreds a month — but not by the thousands, as is needed right now.

It is precisely in the face of such hard truths that a national strategy and leadership are crucial. Otherwise, hospitals, governors and politicians will only vie against one another in the reasonable service of their own constituencies.

“Respirators, ventilators, all of the equipment — try getting it yourselves,” Mr. Trump said on a recent conference call with governors. “We will be backing you, but try getting it yourselves. Point of sales, much better, much more direct if you can get it yourself.”

This is exactly the wrong message. The White House must take charge, keeping track of national inventory, purchasing the precious resources and distributing them where they are most needed at the moment. As Andrew Cuomo, the governor of New York, has suggested, ventilators could then be redistributed as outbreak hot spots shift around the country.

More than anything, what the United States needs right now is for the president to undertake an intellectual Manhattan Project: gather the best minds in public health, medicine, medical ethics, catastrophe preparedness and response; political leadership; and private-sector manufacturing and the pharmaceutical industry.

It took nearly three years to develop the atomic bomb. The effort against Covid-19 will need to be bear fruit within days — and come up with a comprehensive but realistic blueprint for getting America through the next 12 to 18 months, or however long it takes for a vaccine to become widely available or herd immunity to take hold in the population. Once a plan has been devised, the president will have to dispense with any happy talk and instead actually convey what the experts are telling him. He will have to define the new normal for a frightened nation that is looking for facts, direction and a common purpose.

Michael T. Osterholm is director of the Center for Infectious Disease Research and Policy at the University of Minnesota. Mark Olshaker is a writer and documentary filmmaker. They are the authors of “Deadliest Enemy: Our War Against Killer Germs.”

Opinion | Testing Can’t Stop Coronavirus Now, But There Are Still Things We Can Do - The New York Times

Cuomo Extends School Closures, Says New York Cases Could Hit Peak In 21 days | MSNBC. Common sense and excellent leadership in a crisis.

Bill Gates: Returning to normal life in April is not realistic

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Cuomo: Congress "simply failed to address" states' economic needs from coronavirus. The most articulate and knowledgeable example of political leadership to emerge during the coronavirus. I have differed with him on policy issues in the past but the New York Governor, like his father, is a true leader in a time when leadership is desperately needed.

A direct result of the dereliction of duty by Trump and his administration.

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Trump’s utilitarian calculus. He is willing to sacrifice American lives to the pandemic to save the wealth of Wall Street. That is wha it is about.

Trump: I'd Love For U.S. To Be 'Opened Up By Easter' Amid Pandemic Response

Philip EwingMarch 24, 2020

“Updated at 4 p.m. ET

President Trump hopes the United States can begin to get back to normal by the middle of next month, he said on a Fox News TV special on Tuesday.

"I would love to have the country opened up and just raring to go by Easter," Trump told host Bill Hemmer in a show aired from the White House. 

That's April 12, within the timeline of "weeks" that Trump said he hopes is appropriate for curtailing the social distancing, isolation and other measures that officials have outlined to slow the spread of the coronavirus — but have also paralyzed the economy.

The rate of infections inside the U.S. has not stopped climbing — by Tuesday afternoon, there were more than 50,000 confirmed cases nationwide, according to researchers at Johns Hopkins University — and Trump's April 12 target date is far sooner than other milestones set by officials across the country.

The White House's coronavirus task force is holding a briefing Tuesday afternoon. You can watch it live here:

The District of Columbia has closed its schools through April 24, for example; schools in Virginia won't reconvene at all for the rest of this academic year.

Trump and Vice President Pence have talked up what they call the need for the U.S. to reset in stride, as military commanders might say — to continue some mitigation measures to constrain the pandemic but also permit some businesses to reopen.

"You can destroy a country this way by closing it down," Trump said in the Fox special on Tuesday. 

Many public health experts have expressed alarm about Trump's suggestion that some parts of the country could soon ease some measures being taken to slow the spread of the virus. 

The president and vice president framed one focus for the upcoming months on the most vulnerable populations, particularly older people with preexisting medical conditions. 

Under this construction, life might shift away from keeping everyone apart to permitting more people to leave their homes and return to work. For the time being, Trump said Americans might still be discouraged from shaking hands and other such activity. "We can socially distance ourselves and go to work," he said“

Where Rand Paul stands on the Civil Rights Act. A stone cold racist Senator from Kentucky catches Coronavirus and knowingly exposes it to the whole Senate body.

Doctor criticizes Sen. Paul for not self-quarantining

Coronavirus news: global death toll passes 15,000 as total of confirmed cases nears 350,000 - live updates | World news | The Guardian

Coronavirus news: global death toll passes 15,000 as total of confirmed cases nears 350,000 - live updates | World news | The Guardian

Coronavirus in Georgia: 620 confirmed COVID-19 cases, 25 deaths

Coronavirus in Georgia: 620 confirmed COVID-19 cases, 25 deaths

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The Virus Can Be Stopped, but Only With Harsh Steps, Experts Say

“Terrifying though the coronavirus may be, it can be turned back. China, South Korea, Singapore and Taiwan have demonstrated that, with furious efforts, the contagion can be brought to heel.

Whether they can keep it suppressed remains to be seen. But for the United States to repeat their successes will take extraordinary levels of coordination and money from the country’s leaders, and extraordinary levels of trust and cooperation from citizens. It will also require international partnerships in an interconnected world.

There is a chance to stop the coronavirus. This contagion has a weakness.

Although there are incidents of rampant spread, as happened on the cruise ship Diamond Princess, the coronavirus more often infects clusters of family members, friends and work colleagues, said Dr. David L. Heymann, who chairs an expert panel advising the World Health Organization on emergencies.

No one is certain why the virus travels in this way, but experts see an opening nonetheless. “You can contain clusters,” Dr. Heymann said. “You need to identify and stop discrete outbreaks, and then do rigorous contact tracing.”

But doing so takes intelligent, rapidly adaptive work by health officials, and near-total cooperation from the populace. Containment becomes realistic only when Americans realize that working together is the only way to protect themselves and their loved ones.

In interviews with a dozen of the world’s leading experts on fighting epidemics, there was wide agreement on the steps that must be taken immediately.

Those experts included international public health officials who have fought AIDS, malaria, tuberculosis, flu and Ebola; scientists and epidemiologists; and former health officials who led major American global health programs in both Republican and Democratic administrations.

Americans must be persuaded to stay home, they said, and a system put in place to isolate the infected and care for them outside the home. Travel restrictions should be extended, they said; productions of masks and ventilators must be accelerated, and testing problems must be resolved.

But tactics like forced isolation, school closings and pervasive GPS tracking of patients brought more divided reactions.

It was not at all clear that a nation so fundamentally committed to individual liberty and distrustful of government could learn to adapt to many of these measures, especially those that smack of state compulsion.

“The American way is to look for better outcomes through a voluntary system,” said Dr. Luciana Borio, who was director of medical and biodefense preparedness for the National Security Council before it was disbanded in 2018.

“I think you can appeal to people to do the right thing.”

In the week since the interviews began, remarkable changes have come over American life. State governments are telling residents they must stay home. Nonessential businesses are being shuttered.

The streets are quieter than they have been in generations, and even friends keep a wary distance. What seemed unthinkable just a week ago is rapidly becoming the new normal.

What follows are the recommendations offered by the experts interviewed by The Times.

Adm. Tim Ziemer, who led the National Security Council’s pandemic response unit until it was disbanded in 2018.

The White House holds frequent media briefings to describe the administration’s progress against the pandemic, often led by President Trump or Vice President Mike Pence, flanked by a rotating cast of officials.

Many experts, some of whom are international civil servants, declined to speak on the record for fear of offending the president. But they were united in the opinion that politicians must step aside and let scientists both lead the effort to contain the virus and explain to Americans what must be done.

Just as generals take the lead in giving daily briefings in wartime — as Gen. Norman Schwarzkopf did during the Persian Gulf war — medical experts should be at the microphone now to explain complex ideas like epidemic curves, social distancing and off-label use of drugs.

The microphone should not even be at the White House, scientists said, so that briefings of historic importance do not dissolve into angry, politically charged exchanges with the press corps, as happened again on Friday.

Instead, leaders must describe the looming crisis and the possible solutions in ways that will win the trust of Americans.

Above all, the experts said, briefings should focus on saving lives and making sure that average wage earners survive the coming hard times — not on the stock market, the tourism industry or the president’s health. There is no time left to point fingers and assign blame.

“At this point in the emergency, there’s little merit in spending time on what we should have done or who’s at fault,” said Adm. Tim Ziemer, who was the coordinator of the President’s Malaria Initiative from 2006 until early 2017 and led the pandemic response unit on the National Security Council before its disbanding.

“We need to focus on the enemy, and that’s the virus.”

The next priority, experts said, is extreme social distancing.

If it were possible to wave a magic wand and make all Americans freeze in place for 14 days while sitting six feet apart, epidemiologists say, the whole epidemic would sputter to a halt.

The virus would die out on every contaminated surface and, because almost everyone shows symptoms within two weeks, it would be evident who was infected. If we had enough tests for every American, even the completely asymptomatic cases could be found and isolated.

The crisis would be over.

Obviously, there is no magic wand, and no 300 million tests. But the goal of lockdowns and social distancing is to approximate such a total freeze.

To attempt that, experts said, travel and human interaction must be reduced to a minimum.

Italy moved incrementally: Officials slowly and reluctantly closed restaurants, churches and museums, and banned weddings and funerals. Nonetheless, the country’s death count continues to rise.

The United States is slowly following suit. International flights are all but banned, but not domestic ones. California has ordered all residents to stay at home; New York was to shutter all nonessential businesses on Sunday evening.

But other states have fewer restrictions, and in Florida, for days spring break revelers ignored government requests to clear the beaches.

On Friday, Dr. Anthony S. Fauci, chief medical adviser to the White House Coronavirus Task Force, said he advocated restrictive measures all across the country.

In contrast to the halting steps taken here, China shut down Wuhan— the epicenter of the nation’s outbreak — and restricted movement in much of the country on Jan. 23, when the country had a mere 500 cases and 17 deaths.

Its rapid action had an important effect: With the virus mostly isolated in one province, the rest of China was able to save Wuhan.

Even as many cities fought their own smaller outbreaks, they sent40,000 medical workers into Wuhan, roughly doubling its medical force.

In a vast, largely closed society, it can be difficult to know what is happening on the ground, and there is no guarantee that the virus won’t roar back as the Chinese economy restarts.

But the lesson is that relatively unaffected regions of the United States will be needed to help rescue overwhelmed cities like New York and Seattle. Keeping these areas at least somewhat free of the coronavirus means enacting strict measures, and quickly.

Within cities, there are dangerous hot spots: One restaurant, one gym, one hospital, even one taxi may be more contaminated than many identical others nearby because someone had a coughing fit inside.

Each day’s delay in stopping human contact, experts said, creates more hot spots, none of which can be identified until about a week later, when the people infected there start falling ill.

To stop the explosion, municipal activity must be curtailed. Still, some Americans must stay on the job: doctors, nurses, ambulance drivers; police officers and firefighters; the technicians who maintain the electrical grid and gas and phone lines.

The delivery of food and medicine must continue, so that people pinned in their homes suffer nothing worse than boredom. Those essential workers may eventually need permits, and a process for issuing them, if the police are needed to enforce stay-at-home orders, as they have been in China and Italy.

People in lockdown adapt. In Wuhan, apartment complexes submit group orders for food, medicine, diapers and other essentials. Shipments are assembled at grocery warehouses or government pantries and dropped off. In Italy, trapped neighbors serenade one another.

It’s an intimidating picture. But the weaker the freeze, the more people die in overburdened hospitals — and the longer it ultimately takes for the economy to restart.

South Korea avoided locking down any city, but only by moving early and with extraordinary speed. In January, the country had four companies making tests, and as of March 9 had tested 210,000 citizens — the equivalent of testing 2.3 million Americans.

As of the same date, fewer than 9,000 Americans had been tested.

Everyone who is infected in South Korea goes into isolation in government shelters, and phones and credit card data are used to trace their prior movements and find their contacts. Where they walked before they fell ill is broadcast to the cellphones of everyone who was nearby.

Anyone even potentially exposed is quarantined at home; a GPS app tells the police if that person goes outside. The fine for doing so is $8,000.

British researchers are trying to develop a similar tracking app, albeit one more palatable to citizens in Western democracies.

Testing must be done in a coordinated and safe way, experts said. The seriously ill must go first, and the testers must be protected.

In China, those seeking a test must describe their symptoms on a telemedicine website. If a nurse decides a test is warranted, they are directed to one of dozens of “fever clinics” set up far from all other patients.

Personnel in head-to-toe gear check their fevers and question them. Then, ideally, patients are given a rapid flu test and a white blood cell count is taken to rule out influenza and bacterial pneumonia.

Then their lungs are visualized in a CT scanner to look for “ground-glass opacities” that indicate pneumonia and rule out cancer and tuberculosis. Only then are they given a diagnostic test for the coronavirus — and they are told to wait at the testing center.

The results take a minimum of four hours; in the past, if results took overnight, patients were moved to a hotel to wait — sometimes for two to three days, if doctors believed retesting was warranted. It can take several days after an exposure for a test to turn positive.

In the United States, people seeking tests are calling their doctors, who may not have them, or sometimes waiting in traffic jams leading to store parking lots. On Friday, New York City limited testing only to those patients requiring hospitalization, saying the system was being overwhelmed.

As soon as possible, experts said, the United States must develop an alternative to the practice of isolating infected people at home, as it endangers families. In China, 75 to 80 percent of all transmission occurred in family clusters.

That pattern has already repeated itself here. Seven members of a large family in New Jersey were infected; four have already died. After a lawyer in New Rochelle, N.Y., fell ill, his wife, son and daughter all tested positive.

Instead of a policy that advises the infected to remain at home, as the Centers for Disease and Prevention now does, experts said cities should establish facilities where the mildly and moderately ill can recuperate under the care and observation of nurses.

Wuhan created many such centers, called “temporary hospitals,”each a cross between a dormitory and a first-aid clinic. They had cots and oxygen tanks, but not the advanced machines used in intensive care units.

American cities now have many spaces that could serve as isolation wards. Already New York is considering turning the Jacob K. Javits Convention Center into a temporary hospital, along with the Westchester Convention Center and two university campuses.

Gov. Ron DeSantis of Florida said on Saturday that state officials were also considering opening isolation wards.

In China, said Dr. Bruce Aylward, leader of the World Health Organization’s observer team there, people originally resisted leaving home or seeing their children go into isolation centers with no visiting rights — just as Americans no doubt would.

In China, they came to accept it.

“They realized they were keeping their families safe,” he said. “Also, isolation is really lonely. It’s psychologically difficult. Here, they were all together with other people in the same boat. They supported each other.”

Because China, Taiwan and Vietnam were hit by SARS in 2003, and South Korea has grappled with MERS, fever checks during disease outbreaks became routine.

In most cities in affected Asian countries, it is commonplace before entering any bus, train or subway station, office building, theater or even a restaurant to get a temperature check. Washing your hands in chlorinated water is often also required.

“They give you a sticker afterward,” said Dr. Heymann, who recently spent a week teaching in Singapore. “I built up quite a collection.”

In China, having a fever means a mandatory trip to a fever clinic to check for coronavirus. In the Wuhan area, different cities took different approaches.

Cellphone videos from China show police officers knocking on doors and taking temperatures. In some, people who resist are dragged away by force. The city of Ningbo offered bounties of $1,400 to anyone who turned in a coronavirus sufferer.

The city of Qianjiang, by contrast, offered the same amount of money to any resident who came in voluntarily and tested positive.

Some measures made Western experts queasy. It is difficult to imagine Americans permitting a family member with a fever to be dragged to an isolation ward where visitors are not permitted.

“A lot of people’s rights were violated,” Dr. Borio said.

Voluntary approaches, like explaining to patients that they will be keeping family and friends safe, are more likely to work in the West, she added.

Finding and testing all the contacts of every positive case is essential, experts said. At the peak of its epidemic, Wuhan had 18,000 people tracking down individuals who had come in contact with the infected.

At the moment, the health departments of some American counties lack the manpower to trace even syphilis or tuberculosis, let alone scores of casual contacts of someone infected with the coronavirus.

Dr. Borio suggested that young Americans could use their social networks to “do their own contact tracing.” Social media also is used in Asia, but in different ways.

China’s strategy is quite intrusive: To use the subway in some cities, citizens must download an app that rates how great a health risk they are. South Korean apps tell users exactly where infected people have traveled.

When he lectured at a Singapore university, Dr. Heymann said, dozens of students were in the room. But just before he began class, they were photographed to record where everyone sat.

“That way, if someone turns up infected later, you can find out who sat near them,” Dr. Heymann said. “That’s really clever.”

Contacts generally must remain home for 14 days and report their temperatures twice a day.

American experts have divided opinions about masks, but those who have worked in Asia see their value.

There is very little data showing that flat surgical masks protect healthy individuals from disease. Nonetheless, Asian countries generally make it mandatory that people wear them. In China, the police even used drones to chase individuals down streets, ordering them to go home and mask up.

The Asian approach is less about data than it is about crowd psychology, experts explained.

All experts agree that the sick must wear masks to keep in their coughs. But if a mask indicates that the wearer is sick, many people will be reluctant to wear one. If everyone is required to wear masks, the sick automatically have one on and there is no stigma attached.

Also, experts emphasized, Americans should be taught to take seriously admonitions to stop shaking hands and hugging. The “W.H.O. elbow bump” may look funny, but it’s a legitimate technique for preventing infection.

“In Asia, where they went through SARS, people understand the danger,” Dr. Heymann said. “It’s instilled in the population that you’ve got to do the right thing.”

Federal intervention is necessary for some vital aspects of life during a pandemic.

Only the federal government can enforce interstate commerce laws to ensure that food, water, electricity, gas, phone lines and other basic needs keep flowing across state lines to cities and suburbs.

Mr. Trump has said he could compel companies to prioritize making ventilators, masks and other needed goods. Some have volunteered; the Hanes underwear company, for example, will use its cotton to make masks for hospital workers.

He also has the military; the Navy is committing two hospital ships to the fight. And Mr. Trump can call up the National Guard. As of Saturday evening, more than 6,500 National Guard members already are assisting in the coronavirus response in 38 states, Puerto Rico and the District of Columbia.

High-level decisions like these must be made quickly, experts said.

“Many Western political leaders are behaving as though they are on a tightrope,” said Dr. David Nabarro, a W.H.O. special envoy on Covid-19 and a veteran of fights against SARS, Ebola and cholera.

“But there is no choice. We must do all in our power to fight this,” he added. “I sense that most people — and certainly those in business — get it. They would prefer to take the bitter medicine at once and contain outbreaks as they start rather than gamble with uncertainty.”

The roughly 175,000 ventilators in all American hospitals and the national stockpile are expected to be far fewer than are needed to handle a surge of patients desperate for breath.

The machines pump air and oxygen into the lungs, but they normally cost $25,000 or more each, and neither individual hospitals nor the federal emergency stockpile has ever had enough on hand to handle the number of pneumonia patients that this pandemic is expected to produce.

New York, for example, has found about 6,000 ventilators for purchase around the world, Governor Cuomo said. He estimated the state would need about 30,000.

The manufacturers, including a dozen in the United States, say there is no easy way to ramp up production quickly. But it is possible other manufacturers, including aerospace and automobile companies, could be enlisted to do so.

Ventilators are basically air pumps with motors controlled by circuits that make them act like lungs: the pump pushes air into the patient, then stops so the weight of the chest can push the air back out.

Automobiles and airplanes contain many small pumps, like those for oil, water and air-conditioning fluid, that might be modified to act as basic, stripped-down ventilators. On Sunday, Mr. Trump tweeted that Ford and General Motors had been “given the go-ahead” to produce ventilators.

Providers, meanwhile, are scrambling for alternatives.

Canadian nurses are disseminating a 2006 paper describing how one ventilator can be modified to treat four patients simultaneously. Inventors have proposed combining C-PAP machines, which many apnea sufferers own, and oxygen tanks to improvise a ventilator.

The United States must also work to increase its supply of piped and tanked oxygen, Dr. Aylward said.

One of the lessons of China, he noted, was that many Covid-19 patients who would normally have been intubated and on ventilators managed to survive with oxygen alone.

Hospitals in the United States have taken some measures to handle surges of patients, such as stopping elective surgery and setting up isolation rooms.

To protect bedridden long-term patients, nursing homes and hospitals also should immediately stop admitting visitors and do constant health checks on their staffs, said Dr. James LeDuc, director of the Galveston National Laboratory at the University of Texas Medical Branch.

The national stockpile does contain some prepackaged military field hospitals, but they are not expected to be nearly enough for a big surge.

In Wuhan, the Chinese government famously built two new hospitals in two weeks. All other hospitals were divided: 48 were designated to handle 10,000 serious or critical coronavirus patients, while others were restricted to handling emergencies like heart attacks and births.

Wherever that was impractical, hospitals were divided into “clean” and “dirty” zones, and the medical teams did not cross over. Walls to isolate whole wards were built, and — as in Ebola wards — doctors went in one end of the room wearing protective gear and left by the other end, where they de-gowned under the eyes of a nurse to prevent infection.

As of Saturday, schools in 45 states were closed entirely, but that is a decision that divided experts.

“Closing all schools may not make sense unless there is documented widespread community transmission, which we’re not seeing in most of the country,” said Dr. Thomas R. Frieden, a former C.D.C. director under President Barack Obama.

It is unclear how much children spread coronavirus. They very seldom get sick enough to be hospitalized, which is not true of flu. Current testing cannot tell whether most do not even become infected.

In China, Dr. Aylward said, he asked all of the doctors he spoke to whether they had seen any family clusters in which a child was the first to be infected. No one had, he said, which astonished him.

That leaves a quandary. Closing schools is a normal part of social distancing; after all, schools are the workplaces for many adults, too. And when the disease is clearly spreading within an individual school, it must close.

But closing whole school districts can seriously disrupt a city’s ability to fight an outbreak. With their children stuck at home, nurses, doctors, police officers and other emergency medical workers cannot come to work.

Also, many children in low-income families depend on the meals they eat at schools.

Cities that close all schools are creating special “hub schools” for the children of essential workers. In Ohio, the governor has told school bus drivers to deliver hot meals to children who normally got them at school.

China’s effort succeeded, experts said, in part because of hundreds of thousands of volunteers. The government declared a “people’s war” and rolled out a “Fight On, Wuhan! Fight On, China!” campaign.

It made inspirational films that combined airline ads with 1940s-style wartime propaganda. The ads were somewhat corny, but they rallied the public.

Many people idled by the lockdowns stepped up to act as fever checkers, contact tracers, hospital construction workers, food deliverers, even babysitters for the children of first responders, or as crematory workers.

With training, volunteers were able to do some ground-level but crucial medical tasks, such as basic nursing, lab technician work or making sure that hospital rooms were correctly decontaminated.

Americans often step forward to help neighbors affected by hurricanes and floods; many will no doubt do so in this outbreak, but they will need training in how not to fall ill and add to the problem.

“In my experience, success is dependent on how much the public is informed and participates,” Admiral Ziemer said. “This truly is an ‘all hands on deck’ situation.”

Clinicians in China, Italy and France have thrown virtually everything they had in hospital pharmacies into the fight, and at least two possibilities have emerged that might save patients: the anti-malaria drugs chloroquine and hydroxychloroquine, and the antiviral remdesivir, which has no licensed use.

There is not proof yet that any of these are effective against the virus. China registered more than 200 clinical trials, including several involving those treatments, but investigators ran out of patients in critical condition to enroll. Italy and France have trials underway, and hospitals in New York are writing trial protocols now.

One worry for trial leaders is that chloroquine has been given so much publicity that patients may refuse to be “randomized” and accept a 50 percent chance of being given a placebo.

If any drug works on critical cases, it might be possible to use small doses as a prophylactic to prevent infection.

An alternative is to harvest protective antibodies from the blood of people who have survived the illness, said Dr. Peter J. Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine in Houston.

The purified blood serum — called immunoglobulin — could possibly be used in small amounts to protect emergency medical workers, too.

“Unfortunately, the first wave won’t benefit from this,” Dr. Hotez said. “We need to wait until we have enough survivors.”

The ultimate hope is to have a vaccine that will protect everyone, and many companies and governments have already rushed the design of candidate vaccines. But as Dr. Fauci has explained multiple times, testing those candidate vaccines for safety and effectiveness takes time.

The process will take at least a year, even if nothing goes wrong. The roadblock, vaccine experts explained, is not bureaucratic. It is that the human immune system takes weeks to produce antibodies, and some dangerous side effects can take weeks to appear.

After extensive animal testing, vaccines are normally given to about 50 healthy human volunteers to see if they cause any unexpected side effects and to measure what dose produces enough antibodies to be considered protective.

If that goes well, the trial enrolls hundreds or thousands of volunteers in an area where the virus is circulating. Half get the vaccine, the rest do not — and the investigators wait. If the vaccinated half do not get the disease, the green light for production is finally given.

In the past, some experimental vaccines have produced serious side effects, like Guillain-Barre syndrome, which can paralyze and kill. A greater danger, experts said, is that some experimental vaccines, paradoxically, cause “immune enhancement,” meaning they make it more likely, not less, that recipients will get a disease. That would be a disaster.

One candidate coronavirus vaccine Dr. Hotez invented 10 years ago in the wake of SARS, he said, had to be abandoned when it appeared to make mice more likely to die from pneumonia when they were experimentally infected with the virus.

In theory, the testing process could be sped up with “challenge trials,” in which healthy volunteers get the vaccine and then are deliberately infected. But that is ethically fraught when there is no cure for Covid-19. Even some healthy young people have died from this virus.

Wealthy nations need to remember that, as much as they are struggling with the virus, poorer countries will have a far harder time and need help.

Also, the Asian nations that have contained the virus could offer expertise — and desperately needed equipment. Jack Ma, the billionaire founder of Alibaba, recently offered large shipments of masks and testing kits to the United States.

Wealthy nations ignored the daily warnings from Tedros Adhanom Ghebreyesus, the W.H.O.’s director general, that far more aggressive efforts at isolation and contact tracing were urgently needed to stop the virus.

“Middle income and poorer nations are following the advice of international organizations while the most advanced nations find it so hard to implement it,” Dr. Nabarro said. “That must change.”

In declaring the coronavirus a pandemic, Dr. Tedros called for countries to learn from one another’s successes, act with unity and help protect one another against a threat to people of every nationality.

“Let’s all look out for each other,” he said.”