Well, the first step is to see if any of your insurance policies provide for business interruption or business disruption coverage. It is certainly possible that you have a separate policy for business interruption, but not infrequently, this may be covered under an overall comprehensive coverage policy or as part of a property/casualty policy. It could be covered as part of a rider to one of these policies, or in rare situations, you might have a specific policy for an infectious outbreak or pandemic event (a so-called bespoke policy).

If you have an insurance broker, ask your broker for assistance in reviewing your policies to see if you have business interruption or disruption coverage and the answers to the questions below. If you don’t have a broker, speak with your business’ attorney.

Step 1. Determine what kind of coverage you have. For purposes of this blog post, I am going to assume the most common situation, that if you have coverage, it is part of a property/casualty insurance policy. We are going to look at the potential for at least four ways that you might be able to claim coverage. The first is business interruption. The problem is that if this is part of a property/casualty policy, the coverage is likely tailored to damage to the policyholder’s own property. This can present a couple of problems. First, does coronavirus qualify as damage to the property? Second, if the business is renting the property and does not have its own policy, the business may not be covered under the landlord’s policy.

The second potential source of coverage is contingent business interruption coverage. That will ordinarily mean interruption to a supplier’s business that then limited your own, but could also extend to a loss of customers. As an example, one could imagine that a food processor might have had to cut down production because they could not get access to face masks and gloves that were being redirected to health care providers and this in turn might have reduced deliveries to a restaurant or store that then lost sales volume due to decreased shipments of certain items they depend on. With respect to a loss of customers, one could imagine that a business that provides event planning services that suffers losses due to the prohibitions on gatherings of more than ten people.

A third source of coverage, which would be very important in the case that your business could have gone on just fine, did not have property damage and your supply chain remain intact, but you had to close or reduce your business because of the governor’s order and this provision in a policy is often referred to as an order of civil authority. An interesting declaratory action case has been filed – Cajun Conti, LLC et al. v. Certain Underwriters at Lloyd’s, London et al. in the Civil District Court for the Parish of Orleans, State of Louisiana- in which a restaurant is seeking the court’s ruling that closure pursuant to the Governor’s order will trigger coverage under the company’s business interruption insurance. A decision will not be binding on courts in other jurisdictions, but it may nevertheless be instructive, and perhaps even persuasive.

Finally, even if your business remained open, did not suffer any “property damage,” was able to continue getting the supplies it needed, and was not shuttered by an order of civil authority, it might still be covered if this business is one that depends on patrons from a nearby business that was shuttered (a so-called leader property) and there is a provision in the policy that may be referred to as Loss of Attraction, or something similar. An example might be a private bookstore that is located adjacent to a college or university and typically sells books and college-themed apparel to the students of the college or university that is now closed for the remainder of the school year.

If your policies don’t cover any of these, then you are likely out of luck, but be sure to consult with your insurance broker or attorney just to make sure.

Step 2. If you do have one or more of these coverages, then determine what is the event that triggers coverage. Most often, if the business interruption coverage is under your property/casualty policy, the critical question will be whether you incurred property damage. If you are fortunate that you have a separate business interruption policy or bespoke policy that covers an infectious outbreak or pandemic, then often the triggering event will be the date that the infection became reportable to authorities. In the U.S., that was January 8, 2020. If you have coverage for an order of civil authority and your business operates in Idaho, that date would be March 25, 2020.

But, in most cases, the question is was there property damage. The key question will be whether the mere presence of coronavirus constitutes property damage. While coronavirus does not cause damage in the typical sense, the virus may be present in the air handling system or on surfaces in the business. There are legal cases where the courts have decided that the presence of a harmful substance does constitute property damage. This may be an easier case to make if you have had workers documented to have become infected. Essential businesses, where there is an ongoing threat of the virus being present in the business may be in the best position to prevail on this point. (But even if the business can prevail on this point, the bigger hurdle is the next step).

Step 3. Check for exclusions. This is not the first epidemic or pandemic. Insurance companies have been aware of the likelihood of another pandemic for some time, and many modified their policies many years ago to exclude pandemics and other public health threats. Read your policy carefully. There may very well be an exclusion.

Step 4. If you do have coverage, then you need to look at the policy to determine what is exactly covered. For example, coverage may be limited to certain types of costs such as the cost to sanitize your business or with opening up an alternative location for your business and might not cover your lost revenues or profits. Additionally, even if you have broad coverage, the amount you can recover may be subject to a cap.

So, this all is very complicated. Be sure to read your policy because every policy is different and every business’ impact from this pandemic may be different. Reach out to your insurance broker or business attorney for help to understand if you are covered, what you are covered for and deadlines by which you need to submit your claim.

This is also a time to review what your coverage is and if you want to change it for the future. Keep in mind the factors above and discuss this with your insurance broker. Unfortunately, the occurrence of this pandemic is not likely to result in insurance coverage that is more expansive or lower cost, but to the extent that any carriers will still offer coverage for these events, you may want to consider whether it is worth it to you to pay more to get at least some coverage for a future event.

Life is tough enough when everything is going relatively well. But, at a time like this, with fear, uncertainty, loss of autonomy, a decrease in our social interactions, an endless news cycle of bad news, and financial hardship, anyone can be vulnerable to depression, anxiety, suicidal thoughts or a relapse for alcoholics or drug addicts.

So, I asked my sister, a psychiatrist and chief of psychiatry at a hospital in the Texas Medical Center in Houston to write this guest blog piece to provide you with advice on how to care for your mental health during a time like this. We want you to know that you are important, your life is valuable and there are many people who care about you. The bravest thing you can do is to ask for help if you need it.

So, here is my sister, Dr. Jennifer Pate, who I am very proud of, with her advice to all my blog readers.

Let’s face it, these tiny red fuzz balls have impacted every aspect of life down to the last square of toilet paper.  Many of you have families or friends directly impacted and we are here to let you know we care and support you.

I appreciate my brother Dr. David Pate allowing me to guest post.

As a psychiatrist, I am receiving many calls from distraught or suicidal patients, especially those living alone.  Please reach out to your single friends who live alone.  This is especially important for our seniors.  Many seniors who are otherwise quite functional are struggling and becoming confused due to lack of stimulation in isolation.  We can all relate to the fact that days seem like weeks and weeks seem like years. I remember days on a cruise ship (of all places) where they would announce the day and date.  We should do the same especially at senior living facilities where people cant leave their rooms to lessen confusion.

Make sure that you are not overusing your meds.  You may think it is okay to take one or two more pills, but it may not be safe to do that.

In a post where I am trying to perk you up, this topic may seem odd.  Make this an opportunity to update your medication list in the event you are hospitalized and even more importantly, update your advance directives.  Have a conversation with your family about what you would and would not want with regards to a trial on a ventilator, dialysis, and other medical care.  Please, understand that you are never having to choose to “pull the plug”, you are verbalizing what your family member is unable to articulate.  You should know what is wanted from having had a conversation BEFORE the crisis.

This is an excellent opportunity to write your obituary, plan your funeral and inventory all financial accounts and passwords. Our father wrote his obituary and just left the date off and this is a gift I appreciate daily.   Make sure you and your spouse know where all financial accounts are and passwords for the accounts.

This is an opportunity to organize and spring clean.  Perhaps you have never had time to clean out that closet and now you do.

Maintain a routine.  Try to sleep and get up at normal hours.

Exercise is a known antidepressant.  Take advantage of each day with weather allowing you to get outside.

If you are struggling with child abuse or domestic violence, reach out to community resources.

I have had multiple suicidal patients this week.  Please reach out to the suicide hotlines.  If you need to be seen, try to go to a free-standing mental health facility and not a hospital ER.  There are many therapists online and you can explore options at PsychologyToday.com.

People in recovery from alcohol or drugs are incredibly prone to relapse.  Contact AA Intergroup to connect with online meetings.

Limit your exposure to media coverage as that may be traumatizing as well.  I tell my patients to chose two sessions of news daily.  One in the morning and one in the evening.  Otherwise sign up with your favorite news outlet and receive notifications on your phone regarding any urgent news.

If you are healthy and live in a low risk household, offer to get groceries or run errands for those who can’t.

Our shelter pets need us, too.  Many shelters are allowing you to apply online to foster.  You then pull up to the shelter and they load the foster pet in your car.  We all know the many health benefits of pets.

Stay safe, Stay sane and thank you for following the stay at home orders to protect all of us!

We are all better together apart!

If you are suicidal or thinking about suicide, call your doctor or call the national suicide prevention lifeline at 1-800-273-8255.

If you or someone you know is being abused, get help as soon as possible. You can cal the Idaho Legal Aid Service’s domestic violence hotline at 208-746-7541.

For AA meeting locations and times, call 1-844-334-6862.

Today, Idaho’s governor Brad Little announced his much-awaited decision as to the fate of his March 25, 2020 order to stay-in-place that would have expired tonight at midnight. His decision was to extend the current order until April 30 and to amend it to include three new provisions:

1. Anyone traveling to Idaho from out of state other than those coming to seek medical attention, must self-isolate for 14 days;
2. Non-essential businesses that can re-open and sell their services or products by curbside, drive-in, drive-through, mail or delivery can do so; and
3. Those non-essential businesses that cannot re-open safely can still undertake efforts to sanitize their facilities, order personal protective equipment, make policies and procedures to implement social distancing, and otherwise prepare for an eventual reopening.

What does this mean:

1. Idahoans have done a great job with social distancing, washing our hands, working from home, restricting our travel, etc. It has flattened the curve, but flattening the curve does not mean it is over or there is no longer a threat.
2. We can’t give up now. Our efforts have undoubtedly saved lives and prevented us from overwhelming our hospitals. The more cases of COVID we prevent, the fewer times we expose our health care workers. While the Governor has made a great compromise to allow more Idahoans to get back to work and to help our businesses recover, the truth is that the virus is not gone, the overwhelming majority of Idahoans remain susceptible and letting up on our infection control practices will simply cause a new wave of infections, hospitalizations and deaths.

This leads to a lot of questions:

1. When will we be able to get back to normal?

This is the most difficult question. The only thing I am relatively certain about is that it won’t be this summer, as it seems most of the White House briefings and tv pundits seem to suggest.

Everyone has seen the models on the internet and on tv that show a bell curve and show that the number of cases comes down to zero sometime over the summer. I just can’t figure out why. I can only think of four reasons that could possibly happen, and I don’t think any of them are likely. First, the virus could mutate in such a way that it no longer is transmitted efficiently. That is possible. RNA viruses such as the coronavirus do mutate fairly frequently, but generally not to the degree of changing its fundamental nature. So, yes, that could occur, but it would not be reasonable for us to plan on it.

Second, we could develop a medication that if taken at the onset of symptoms might prevent the illness from becoming severe, requiring hospitalization or causing death. Again, possible, but I don’t think we should be planning on that.

Third, we could have so many people who become infected that we develop so-called herd immunity, which means that there are so few susceptible individuals that the virus cannot efficiently be transmitted. We are not sure what percent of the population would have to be infected to achieve herd immunity through natural infection, but virologists seem to think it is more than 50 – 60%, and perhaps in excess of 80%. I simply cannot imagine the scenario by which more than half of all Idahoans are infected by this summer. Our hospitals would be overwhelmed and the death count would be horrible.

Fourth, we achieve herd immunity, not through natural infection, but by vaccination. However, no one believes that the vaccine can be ready in less than a year, and that is if everything goes perfectly.

So, I think we will be dealing this virus for the next year or two. Certainly, not at the level we have been, and most likely in ebbs and flows, but it seems some level of continued social distancing will be necessary until we have a vaccine and can immunize a sufficient percentage of the population.

• Can we just test people for the virus and if they are negative, allow them to return to work?

No. The test for the virus is a test that you have seen on tv where a healthcare worker sticks a swab way back into someone’s nose. There are now some other ways to get the sample for this test. It is a test that identifies portions of the virus. The presence of virus is often used as an indicator of infection, but the presence of virus does not necessarily mean infection.

Nevertheless, even if a test were negative today, that wouldn’t mean someone would not be infectious the next day. The test’s best use is to look for evidence of the virus in the setting of symptoms consistent with COVID-19. It simply is not a practical method to screen a workforce that is asymptomatic to determine who might be infected.

• Can we screen employees for antibodies and then if positive, allow those persons to return to work without the need for social distancing and personal protective equipment?

Not yet. There is only one antibody test that has received an Emergency Use Authorization from the FDA, and that was just a little over a week ago. An Emergency Use Authorization (“EUA”) is not the same thing as being FDA approved.  An EUA is issued when there is an urgent need for the product, but we don’t yet know its effectiveness. The EUA allows a new product to be put to use and requires that as it is used, the manufacturer will submit data to the FDA that will allow it to determine its effectiveness. So, first of all, the antibody test is not yet widely available. Second, we don’t know whether a positive test might result as a result of cross-reactivity with the ordinary coronaviruses that people have been exposed to, and therefore might not be specific for this novel coronavirus infection. Even if a positive test does mean that the person is or was infected with coronavirus, we don’t know whether that means that the person is immune to subsequent infection with the coronavirus, and if so, for how long?

We are fighting a war, and while doing so it can be difficult to look forward into the future. Right now, we are just trying to decide when will this disease “peak,” level off and decline and when is it safe to relax restrictions that have been placed on Americans.

But, for the purposes of this blog post, I want to look beyond this pandemic. One day, this pandemic will be history. And, as the oft quoted saying goes, “those who do not learn history are doomed to repeat it.” We must be bold enough to admit that there are many opportunities for improvement and we must capture those soon, and put improvements in place, before life returns too much back to normal and this is no longer at the top of our consciousness. The following are the conclusions I think we need to come to, and then at then end, I will list my recommendations:

1. Let’s stop saying that no one could have foreseen this. I understand that the public at large never imagined this, but scientists, health care experts and the government have contemplated this kind of event for nearly two decades (and not only have we had other pandemics, we have had a number of close calls), and the realization of such a threat is very well documented. This is not our first pandemic, and I hate to tell you, but this will not be our last. If we can stop talking about this like it is unimaginable or some kind of fluke event, we can start preparing for the next one. We will then have the opportunity to avoid some of the loss of life and damage to the world’s economies that we are experiencing now.  
2. Let’s also not pretend that this health crisis has been led and managed perfectly and the outcome we are suffering could not have been avoided to some extent. If we don’t, then we will not take advantage of all the lessons that can be learned to improve our response the next time. To just reinforce my point, there will be a next time, perhaps not in my lifetime, but I cannot imagine there will not be another pandemic, or at least epidemic posing the risk of a pandemic, in my children’s or grandchildren’s lives.
3. Let’s admit that we were not prepared. This is not about Trump-bashing. Let me be clear, no president in modern history has been prepared for the kinds of disasters that scientists, health care experts and even members of their own administrations have warned them about. It seems to me that one of the failings of having public health and disaster planning under the President and subject to his budget is that politicians are generally not rewarded for major long-term investments that their constituents cannot feel the benefit of and that may only pay off when they are no longer in office.
4. Let’s realize that we were slow to act in a day and age that requires a much faster response to a pandemic threat than before we were a global society and economy. And, this is always likely to be the case as long as the decision to act will be under the direction of a politician, and it is hard to fault them. No one wants to be criticized for “overreacting.” But, in a world where more than 115 million people travel internationally a day and about 320,000 people arrive to the U.S. every day from other countries, it is not hard to see how quickly an infectious disease can spread across the world, when the doubling time of an infection is measured in days.
5. Let’s also realize that we need the cooperation of the world to adequately defend against these threats. We all need to share public health and medical information real-time. This is probably a good time for us to reach international agreement on this. Further, any time we identify a “novel” virus, as we did on January 10, 2020, this must be our highest level and quickest response from all over the world. A “novel” virus means (1) we don’t know who has the infection, (2) who can transmit the infection, (3) how the infection is transmitted, (4) whether someone can be infected yet asymptomatic, (5) whether someone who is asymptomatic (or more likely, pre-symptomatic) can transmit the virus, (6) how long it takes to develop symptoms once someone is infected, (7) how deadly the virus is, (8) how to contain the virus and prevent its spread, (9) how to prevent health care workers from being infected, and (10) how to treat someone infected with the virus. Thus, when we first detect an outbreak of a novel virus, we must have the world’s agreement that we are going to shut that area of the world down immediately. No one travels in or out of that area until we can answer a good number of these questions.

Just to emphasize this point, in the time between we knew that there was an outbreak of infection with a novel virus until the time we restricted travel from China to the U.S., we likely had more than 6 million travelers arrive in the U.S. from foreign countries. Even with the restriction, we were allowing people from China to return to the U.S. if they were residents without knowing yet that perhaps 20% of those who are infected are asymptomatic and yet, contagious. Thus, temperature screening of travelers turned out not to be an effective way to prevent someone from inadvertently bringing the infection into the U.S.

Now, in full transparency, I have no proof that even a full lock-down by the time we become aware of an outbreak with a novel virus would be fast enough to contain the outbreak. There is still likely to have been travel by the time we realize this is a new type of infection. Nevertheless, it seems likely if we can limit the number of people coming into the U.S. who are infected, perhaps we can slow down the spread and give us additional time to prepare and develop our testing capabilities.

If we can agree on some or most of the above, here are my recommendations:

1. When we get to a more stable situation, we need to have a neutral party (someone who does not have to worry about political embarrassment or grandstanding) do a comprehensive review of the preparation and response, including the successes and missed opportunities of the White House, the CDC, FEMA and all levels of the federal government, the state governments, local governments and health care providers. We must capture best practices to embed in our pandemic plans for the future, as well as learn from the challenges and failures we experienced so as to make them less likely in the future. The party doing this study should also document the lessons learned from the successes and failures of the WHO and other countries.
2. When this review is completed, we need to bring together those who were involved in the management of the COVID response from the Trump administration and from state governments, as well as leaders involved in public health and disaster planning from past administrations, pandemic experts from the government, academic and private sectors; and members of Congress to review the findings, prepare a new pandemic plan for the future and identify the changes in government structure, function and funding required to prepare us for the next threat.
3. We should also bring the WHO and the world’s leaders together to share lessons learned and to develop better systems to monitor the world for new health threats and to better coordinate the world’s response to these threats. This should begin with pressure on China from all the world’s governments and the WHO to outlaw the wet markets, where exotic animals are kept in close proximity and sold for consumption. We have now had two novel coronaviruses that previously were limited to animals, but spread to humans from China and very likely from these markets. This is no longer a China issue; this is a world health issue.
4. As I mentioned above, the world’s response to a novel virus must be swift and much more drastic than in the past. Before, we could not contemplate a situation where we would implement a strict travel ban, not allowing citizens to return home for a period of time. However, we have now seen first-hand that the consequence is relatively fast spread to most of the countries of the world. I am not suggesting that U.S. citizens remain trapped overseas, but rather that anyone in the area of an outbreak with a novel virus remain there until the home government can provide for safe travel home that protects others from possible spread of the infection and a period of isolation or quarantine upon arrival home to the U.S. until we can learn enough about the infection to ensure that the likelihood that they will transmit it to their families, co-workers and others is very low.
5. The plan for the next pandemic needs to be clear about roles and responsibilities. I, and I think most of my colleagues who are health care leaders, thought that the federal government was well-prepared for this scenario, including ample supplies in the Strategic National Stockpile. That proved not to be the case. Most of us were shocked when we heard the White House tell physicians, hospitals and health systems that we should rely on our traditional supply chains, not the federal government or the Strategic National Stockpile. Our traditional supply chains were broken. There was hoarding, price gouging and limitations on supplies and equipment that we could purchase, even if providers were willing to pay the asking price. Further, this meant that hospitals were negotiating and competing for supplies with other hospitals, states, the federal government and the approximately 160 other countries who were all trying to buy supplies. Further, we learned that over the years, budgets for the Strategic National Stockpile and maintenance of equipment in the Stockpile had been reduced, and, as a consequence, most of what was available could only be directed to the several states who were in most need.
6. The plan for the next pandemic must provide for multiple sources of tests and supplies, not just the CDC. The sole reliance on the CDC to develop the test for the coronavirus meant that there was no back-up plan if something went wrong, and something did go wrong. This led to serious delays and a missed opportunity for containment strategies. Further, we need to appreciate that having a test is only as good as the ability to ramp up testing capacity, attain testing reagents, attain testing supplies that are needed to obtain specimens and personal protective equipment (PPE) to protect health care workers in obtaining the specimen from a patient.
7. Every disaster the U.S. has ever responded to has required private industry. The U.S. simply does not have all the resources needed under control of the government. Yet, we have to acknowledge that private industry, while we have seen numerous acts of amazing community support, often acts according to economic incentives. As an example, many companies that were producing badly needed equipment and supplies for the American heath system, were at the same time exporting these goods to other countries who were in need. I am certainly not suggesting that we should not help other countries. However, before we do, we must ensure that we have Americans taken care of. This in of itself would be a good reason to use the powers of the Defense Production Act. Further, we are more than four months into this pandemic and we still have health care providers who do not have sufficient PPE, medications, ventilators, testing reagents, and testing supplies. As a consequence, we cannot be sure who is infected and who is not, which causes us to utilize more PPE than we ordinarily would and unfortunately, we have had many health care workers exposed or infected, which can further compromise our response to this health crisis. We are just now getting rapid testing deployed to some areas of the country. But, until recently, it was not unusual to not have test results back for 7 – 10 days, a situation that further compromises our ability to respond to a public health threat effectively. My point being that in the future, we should be far quicker and more aggressive in utilizing the authority under the Defense Production Act. Americans would understandably be upset if we sent our young men and women into war without an adequate supply of uniforms, bullet-proof vests, weapons and ammunition, tanks, etc., but that is in essence exactly what has happened with our health care workers as we have sent them in to fight this war against an invisible invader.
8. We have seen first hand how important it is to have real-time data on numbers of new cases, hospital admissions, ICU admissions, number of patients on ventilators, deaths, days of supplies on hand, etc. Much of this has required reporting by hospitals and laboratories to their states, the CDC and many other agencies and systems that need this data. Let’s take this opportunity to see how much of this we can automate, so that we don’t have to recreate it for the next health emergency, and let’s look at the opportunity to utilize artificial intelligence so that perhaps this can augment our disease surveillance and reporting for other infectious diseases that we deal with annually or even year-round, even when we are not dealing with a pandemic.
9. Finally, we need to have a difficult conversation about how we manage a disease outbreak within the U.S. At the time the U.S. was imposing a travel ban on persons from Ireland travelling to the U.S., NYC actually had more confirmed cases than Ireland did. People debate the wisdom and effectiveness of travel bans. I get it. However, even those who argue against them seem to agree that it can slow down the spread of an infectious disease. That is what the U.S. needed – more time. More time to better understand the virus, to study potential therapeutic options, to develop a vaccine and to prevent our hospitals from becoming overwhelmed. So, should we implement travel restrictions within the U.S.? Ask those towns that are ski resorts. Almost all of them have significantly higher numbers of cases of COVID than other parts of the U.S. Why? People who were infected elsewhere and did not realize it, traveled to these resorts and transmitted the virus to others.

I’m sure I will have more about this in future blog posts, but I think this is an important discussion for us to have as a country.

I want to express my admiration for our health care professionals – doctors, physician assistants, nurse practitioners, nurses, respiratory therapists, radiology technicians, pharmacists, infection control practitioners, laboratory technologists, nursing and medical assistants and everyone else involved in caring for our patients, as well as those who make it possible for them to provide that care – environmental services workers, supply chain professionals, food service workers, security, health care leaders, those who serve as reception and registration staff, and everyone else who contributes to the operations of our urgent care centers, emergency departments and hospitals.

Think about how scared you have been hearing about the sickness and death caused by this pandemic. Now imagine caring for these patients, seeing the shocking rapid deterioration of a patient in his or her 30s or 40s who was talking to you yesterday, but sedated and paralyzed on a ventilator today. Think about being that nurse, alone with a patient, holding their hand as the patient takes his or her last breath.

Health care professionals are scared too. We are scared when we don’t totally understand a communicable disease and aren’t convinced we have the ability to prevent ourselves from becoming infected. It doesn’t help when we hear about our colleagues who have been infected or died, or in dreadful situations, where we have to put a breathing tube into someone we were working along side just last week.

Though we get scared too, I have never known of a situation where one of us did not come to work willing to take the chance that we might become sick, because, like law enforcement and first responders, it is our calling, our duty, and our passion to care for others. More often, what wears on us is not the concern that we might become ill, or perhaps even die, it is the concern for our families – that we might inadvertently bring this disease home to one of our family members. That is far worse in our minds.

So, I want to take this opportunity to tell all those who show up to work at urgent care centers and hospitals in the midst of this pandemic – you inspire me. I am extremely proud of you, and I can never thank you enough for your courage, your dedication and your talents. I pray for your health and safety every day.

President Trump was right – we are fighting a war against an invisible enemy – the novel coronavirus. In this case our health care professionals are the soldiers in this fight. Therefore, I ask the President to provide recognition to health care workers who die of this disease during their courageous service to win this war in a manner analogous to how we honor fallen soldiers. And, when we do win this war, I would ask the President’s consideration of a national day of celebrating our health care heroes and honoring the memory of those health care workers who give their own lives to save the lives of others.

God bless all these brave men and women.

Here are some of the questions I have been asked lately and my responses:

1. What is the difference between the terms coronavirus and COVID?

The virus that is causing this current pandemic is a member of the coronavirus family. The specific name of this virus is SARS-CoV-2.

COVID, or specifically, COVID-19 is the name for the disease caused by SARS-CoV-2. For convenience, I will just refer to the virus as the coronavirus. Specifically, COVID-19 is an abbreviation for coronavirus disease and the 19 refers to the fact that this disease was first reported in 2019.

2. Are cases of COVID really going up or is the increase we are seeing just due to more testing?

The cases are really going up. Yes, we are doing more testing, but we are still greatly limited in our ability to test and because of the limitations, we are still being restrictive in who we test. We are seeing more patients with severe enough disease to require hospitalization, more patients requiring critical care services and more patients requiring a ventilator to help them breathe.

3. Why is it called the “novel” coronavirus?

We have had circulating coronaviruses since at least the 1960s. There are four strains that commonly infect humans and typically cause common colds. This coronavirus is a zoonotic infection – in other words, this virus was one that circulated in animals, but made a jump to humans in Wuhan, China late last year. This virus was a new or “novel” infection to humans. The significance of that is that no humans had immunity to this virus and all are susceptible to infection.

4. We have seen the curves depicting the number of projected cases of COVID-19 over time and we have been told that we need to “flatten” the curve. What does that mean?

Because we are all susceptible to infection, the virus can readily be transmitted from person to person. If we do nothing to prevent contact between persons who are infected with persons who are susceptible, the virus will rapidly be spread and we will experience large numbers of cases of infection very quickly. The concern about large numbers of infections is that a certain number of those infected will require hospitalization, a significant number of those will require critical care in an ICU, and a significant number of those will require a ventilator to support their breathing. Given that all 325 million people in the U.S. would be susceptible to infection, if even a small percentage of Americans were infected, it could quickly overwhelm our health care system. We simply don’t have enough hospital beds, ICU beds, ventilators, staff and PPE (personal protective equipment) to take care of all the projected cases under that curve in that short a period of time. That is why we want to “flatten” the curve.

We had an opportunity to stop this infection in its tracks. That is no longer possible. So, at this time, we must focus on slowing the spread so that our health care system can handle the load of patients.

5. When will cases peak in Idaho?

That is a very difficult question. It depends on many things. How many people are currently infected that we don’t even know about because of our lack of ability to test? How compliant will people be with the Governor’s order to shelter in place? What will happen if the Governor lifts the order to shelter in place too soon? There are many models that are all based on different assumptions. They project a peak as early as the third week in April to the very end of August.

6. Will this be behind us by end of summer/beginning of fall?

It is not impossible, but it is very unlikely. The curve that the President showed during his press conference and the curves that you have seen online associated with different models are just the first wave of the infection.

If this virus does not mutate and continues to infect those are susceptible, in general, transmission will not be slowed until the population achieves “herd immunity.” Herd immunity is the percentage of people who are immune to the virus either because they have been previously infected and developed immunity or they received the vaccine and now have immunity from the vaccine.

Some good news. Ordinarily, herd immunity often would require numbers in excess of 90 percent immunity. Not long ago, we thought based on the nature of this virus that perhaps we would only need to achieve a bit over 80 percent immunity to achieve herd immunity. Most recently, it appears that even much lower levels of immunity may be possible to achieve herd immunity, perhaps as low as 50 – 60 percent.

A vaccine is at least 12 – 18 months away. And, even once it is developed, it has to be manufactured, distributed and administered to a sufficient number of people to achieve herd immunity before we can dramatically reduce the transmission of this virus.

The only other way to achieve herd immunity would be immunity achieved from natural infection. But, even if it meant half of Americans being infected, we would overwhelm the health care system and have an unacceptable number of deaths.

Thus, the curves that you have seen that return to baseline in July, August or September are just the first wave. Past pandemics typically have two to three waves and this pandemic is unlikely to be different.

While we know that this virus likes cooler and drier conditions and we are hopeful that the transmission will diminish over the summer months, we don’t know that will happen for sure. It would be great to get a reprieve, but we should be prepared for transmission of infection to pick up again in the fall/winter.

7. Should we all be wearing masks?

Ordinarily, the answer to this question would be no. But, this is not an ordinary situation. Unlike a lot of other infections where people are not contagious until they are sick, and therefore, it is much easier to isolate people and prevent the spread of infection, with this infection, we know that a not insubstantial number of people can be asymptomatic or pre-symptomatic and yet shedding the virus with the ability to spread the infection to others.

Masks don’t prevent the wearer from being infected from someone else. On the other hand, a mask can trap droplets from an infected person when they cough or sneeze, or even just normally breathe or talk. Thus, since someone may be infectious for one or several days before becoming ill, the only way to prevent them form unknowingly infecting someone is keeping them physically away from others (social distancing), ensuring that no one else has touched surfaces where the infected person’s droplets have landed (we now know the virus may be able to survive for hours to days on common surfaces) or to put a mask on everyone since it is not possible to know who is infected.

While I have not been a proponent of people wearing a mask (I have explained why in a couple of previous blog posts), because of this transmission from asymptomatic persons, and also new information indicating that perhaps as many as 30 percent of people who were tested for COVID-19 may have a false negative test result (the test is negative despite the fact that the person really is infected).

8. Can we ease up the restrictions for young adults and children since it is only the older individuals and those with underlying medical conditions who are at particular risk of dying?

It is true that adults less than 60 who are otherwise healthy are very unlikely to die from coronavirus and it is exceedingly rare for children to get severely ill or die from coronavirus. But, young adults in their 30s, 40s and 50s still can get severe illness and end up in the ICU and on ventilators, even though they overwhelmingly survive. Thus, it would not be wise to let up on our shelter-in-place restrictions and the guidance for social distancing because these young adults still take up hospital beds, ICU beds and ventilators.

So, for now, take this seriously. Stay home except if you need to be at work because you provide an essential service or because you need to go to the grocery store. When you are out, maintain that six feet of separation from others. Wash your hands for a full twenty seconds. When you are out, try not to touch counters, banisters, elevator buttons, etc. If you must, wash your hands carefully before touching your face. Stay home if you are ill. If you have to go to the doctor, warn them you are coming so they can provide you with instructions and meet you prior to coming into the office or urgent care. If you are short of breath, go to the emergency room, but give them the heads up, as well.

This question has come up again, most recently in an article appearing in the Washington Post yesterday that claimed that confidential sources in the government indicated the CDC is considering whether to make a recommendation that the public wear masks when they are out and about.

This past weekend, I ran to the store and saw a couple wearing masks. As a health care professional, I tend to look at these things opposite to how the public does. The public thinks the masks are for the protection of the person who is wearing the mask. Health care professionals realize that we put masks on patients to protect us from the person wearing the mask. I have to say that I was a bit unnerved when I first reacted and thought, “what are sick people doing out of their homes?!!” Then, I considered it further and suspected that these people probably thought they were protecting themselves from being infected while they were out in public.

So, first, let me be very clear. Wearing a cloth or even a surgical mask is very unlikely to prevent you from being infected by someone else with the coronavirus in a public setting.

As I wrote previously on my blog, a major mode of transmission of coronavirus is droplets, i.e., the small virus surrounded by secretions when it leaves the infected person’s mouth or nose. These droplets are big enough when leaving the mouth or nose to be caught up in the person’s mask. That is how a mask on the patient helps protect others around them.

On the other hand, by the time the droplet travels several feet in the air, much of the surrounding secretions fall on surfaces or the ground or evaporate and the small virus can easily penetrate these common masks being worn by the person who is not infected. Additionally, the risk, perhaps even the greater risk, is that someone touches the surface where the droplets have landed and places their hand to their mouth, nose or eyes allowing the virus to infect the person.

So, why would the CDC be considering making a recommendation that the public wear masks? Well, it appears that asymptomatic (or pre-symptomatic) persons with infection likely are shedding the virus for at least 1 – 2 days prior to becoming symptomatic. Further, we have some studies that show that normal breathing and talking spread droplets, not just coughing or sneezing. We still want everyone to cover their coughs and sneezes, because both of these probably propel droplets much further than normal talking or breathing, but covering coughs and sneezes may not be enough to prevent the transmission of this virus by droplets.

The problem is we curretly have no way of knowing who is infected, but asymptomatic or pre-symptomatic. Thus, if people who are feeling well are going to be allowed to go out in public for essential services, the only way to prevent them from spreading the virus to others would be to put masks on everyone so that those who are asymptomatic will be wearing a mask. That is certainly an appealing thought to further mitigate the spread of this virus.

However, there are also reasons not to take this step. First, it will be hard to change the public’s thinking that wearing a mask protects you from being infected. Thus, the fear is that people wearing a mask will be complacent and not perform other measures that are probably far more effective in preventing infection – social distancing and hand washing.

Second, we have a shortage of masks, and even though it is suggested that the recommendation would be for the public to wear cloth masks and homemade masks, my fear is that this will lead to faulty reasoning that if a homemade mask is good, a surgical mask will be better and an N-95 masks will be best. This would likely further compromise the supply of surgical and N-95 masks for health care professionals, who are the ones to most benefit from wearing masks.

Finally, while for some, wearing a mask will be a conscious reminder not to unconsciously touch our faces, for others, they may increase the touching of their faces while adjusting the mask and putting the mask on and taking the mask off for eating, drinking and entering or leaving their homes. This is likely to pose a greater risk of infecting the individual if they have not washed their hands well than going without a mask and social distancing.

Today, the recommendation is that persons who are well do not wear a mask out in public. We will see if the CDC changes this recommendation.

The simple answer is, no one knows. And, I hate to tell you that you are very likely misunderstanding the President’s comments on this subject and misinterpreting those prediction models you are looking at.

Asked when the U.S. might expect to turn a corner in its efforts to rein in the virus, President Trump replied, “If we do a really good job, we’ll not only hold the death down to a level that is much lower than the other way, had we not done a good job, but people are talking about July, August, something like that.”

First of all, as a country, we have not done and are not now doing a really good job. In fact, we have missed many opportunities to have better responded to this virus. There are many things I can point to, but that is for a later blog post. Suffice it to say, the country is two month’s behind what would have been an optimal response. We are already seeing the consequences of that in the New York City metro area, California, and the western part of the state of Washington. And, watch, within 10 days, New Orleans will be at the breaking point that New York City is today and not far behind it will be parts of Michigan and Cook County in Illinois.

Also, note that “rein in” is not the same thing as this will all be over, which I fear is the way most people interpreted the President’s comments.

And those nice prediction models that you have been looking at – you know, the bell curves that seem to peak in April or May depending upon what part of the country you are in and then come back down to the baseline during the summer? I hate to tell you, but that is the first wave.

So, let me explain and propose what I think are the possible scenarios.

There are only two realistic circumstances under which this virus goes away. The first is that it mutates (viruses commonly do that) in a way that makes it less likely or unable to infect people. I am not betting on this. The second way is that we develop so-called “herd immunity.” Herd immunity is when enough of us become immune to the virus that it cannot efficiently spread, even to those few who are not immune. How many of us would have to be immune? We don’t know, but most experts I talk to think that number is at least 80 percent, perhaps higher. There are two ways that we can become immune. We can become infected, recover and develop protective antibodies, or we can develop antibodies in response to a vaccine instead of infection.

The vaccine is at least a year, perhaps a year and a half away, and that is if everything goes really well. What do I mean? Well, we are good at making influenza vaccines, but we haven’t always been successful in developing vaccines for some other viruses (note, e.g., HIV first began causing infections in the mid-1980s and we still don’t have a vaccine today.) This vaccine will be significantly different from the influenza vaccine, and in fact, uses a new methodology that we have never used before. Will it work? Will it be safe? Will it induce immunity? What dose is the right dose? How many shots does it take to create immunity? Is it effective in the very young and the elderly? How long does the immunity last? How long will it take for manufacturers to produce sufficient amounts of the vaccine? These are all questions we have to have answered. I very much doubt we have a vaccine ready for distribution before next summer, and then if we do, we still have to get it distributed all over the world and get a sufficient number of people immunized.

So, back to the question of this blog post. How long will this pandemic last?

Option 1. It goes away this summer. I doubt this and believe this is the least likely scenario. A lot of viruses do better in the cooler weather, and that certainly seems to be the case for this novel coronavirus (called SARS-CoV-2). Further, this SARS-CoV-2 virus appears to like lower humidity. So, this has led many to think that perhaps SARS-CoV-2 will be seasonal and go away during the summer.

Unfortunately, the fact that no one in the world is immune to this virus, other than those who have already been infected (we think), probably will ensure that this virus continues to be transmitted even during the summer, though I am optimistic that its transmission will not be as effective as it is right now (in other words, we will see new cases, but not at the same rate we are seeing them now). And, keep in mind, when we are having summer, those on the other side of the hemisphere are having their winter.

Option 2. The transmission and activity of the virus slows down over the summer and ramps up again next fall/winter. I think this is extremely likely. Thus, for all of you who have been studying predictive models and the curve we are on, that curve will take place and cases will come down over the summer, but then we will see another curve late fall/early winter. The next curve will likely be less severe, as perhaps 30 percent or more of our population becomes immune from the first curve and hopefully, we more readily accept social distancing and have altered our practices by not shaking hands, washing our hands frequently, covering our coughs and sneezes and decreasing our interactions at work.

Option 3. We have continuous spread until we achieve high levels of immunity approaching levels needed for herd immunity. This is certainly possible.

My guess is option 2, but that it continues to have these up and down curves of activity until we reach the levels of infection/vaccination needed to produce herd immunity, and I don’t think that will occur before fall of 2021.

Now, keep in mind that during this time (in fact, I think we are only a month or two away), we will develop therapeutic options. Some of these treatments might be to prevent infection, while others will be to treat infection to lessen its severity and the mortality rate from this infection. So, even if we continue to have significant amounts of disease, things will improve.

Once we have the vaccine, it is possible that this virus will be eradicated as we have eradicated some other diseases if there is excellent compliance with immunization world-wide and the virus does not mutate, or alternatively, it may be that the virus recurs, but we have an annual vaccine to protect people from it.

As I said at the beginning. When you ask the question, when will this pandemic end, no one can tell you the answer. However, I felt compelled to write this blog piece because I think many people are misled into thinking that this will all be over this summer. That seems very unlikely. I don’t write this to alarm you, because I don’t think this calls for alarm. It just means that we are going to likely have recurring cycles of isolating and social distancing, even while at the same time we are developing treatments for this disease. And, when we do have a vaccine that has been proven safe and effective, we are dependent upon as many people as possible getting vaccinated to protect those for whom the vaccine may not work, those who may have medical contraindications to taking the vaccine, or unfortunately, those who simply refuse to be vaccinated.

In a week, it will be three months, let me say that again, three months- a quarter of a year – since all of us learned about the outbreak of the novel coronavirus infections in China.

No one could have predicted this?

Is it true that no one could have predicted this? No. As a hospital and health system CEO, I have been worrying about the threat of a new infection for at least two decades. Was I some kind of prescient genius? No. These concerns have been widely held. In fact, it was a good thing that the briefing room was not filled with physicians, health care executives, insurance executives, scientists, and even the government’s own U.S. Government Accountability Office (GAO) when the President asked, as he so often does, “who could have imagined this?” because every hand would have been raised.

How did we know?

• This is not our first (and, unfortunately, will not be our last) pandemic. I am not even listing epidemics, here is just a list of pandemics:
  • 1918-1919 (yes, more than 100 years ago) H1N1 virus – this was an influenza pandemic – some call it the “Spanish Flu.”
  • 1957-1958 H2N2 virus – another influenza pandemic – the so-called “Asian Flu.”
  • 1968 H3N2 virus – another influenza virus- the so-called “Avian Flu.”
  • 2009 H1N1 virus – another influenza virus, which was completely new to animals and humans.
• So, you say, well all of these were influenza pandemics. Perhaps we could have imagined another influenza pandemic, but could anyone have imagined this new coronavirus pandemic? Yes. We already dodged this bullet twice with new coronavirus outbreaks (in fact, one of these previous outbreaks was also from China) that could have, but thank God did not become pandemics. Remember SARS in 2003 and MERS in 2012? Like the current novel coronavirus – 2019, the SARS and MERS coronaviruses were also novel coronaviruses that made the leap from animals to humans.
• Okay, so yes, we could have imagined another pandemic, and yes, we could have imagined a novel coronavirus emerging and potentially becoming a pandemic, but could we have imagined a novel coronavirus emerging from China and causing a pandemic. It turns out the answer is yes, and we did in…wait for it…2007. Scientists published an article entitled, “Severe Acute Respiratory Syndrome Coronavirus as an Agent of Emerging and Reemerging Infection” in Clinical Microbiology Reviews in 2007. Even just from the title, we get “Severe Acute Respiratory Syndrome” – that is SARS, ”Coronavirus”, “Agent” – cause, “Reemerging Infection.” Do you now what the scientific name for this novel coronavirus that we are currently battling is? SARS-CoV-2 – SARS Coronavirus – 2. In fact, in 2007, we knew that the 2003 SARS virus came from bats and civet cats. Guess where we think our current coronavirus came from – a bat.
• Well, then in the President’s defense, you suggest people can hardly be blamed for overlooking one single article in 2007. Well, it turns out that the fear and high mortality that the 2003 SARS virus epidemic caused and the economic disruption that this virus caused resulted in more than 4,000 articles on this subject.
• In fact, this article in Clinical Microbiology Reviews even identified the Chinese wet markets, where large numbers and varieties of exotic wild game animals are sold for food consumption in overcrowded cages with a lack of biosecurity measures, as a likely breeding ground for this virus and a risk for transmission from animals to humans. Guess where we believe the current coronavirus came from? You guessed it – a Chinese wet market in Wuhan.

Were we prepared?

If we have foreseen this for at least 13 years, were we prepared? No.

I have to say I was far more gullible than I should have been. All this time, as the hospitals and health system I oversaw prepared and then updated our pandemic plans over the past many years, I always thought that if things became bad, we would rely on the federal government and the Strategic National Stockpile. It turns out that in a time of crisis, states are largely left to their own and there isn’t nearly as much stockpiled in the Strategic National Stockpile as I thought there was. And, even what is there is pretty darn hard to access.

Unfortunately, because of inadequate stockpiles and inadequate federal response, our brave healthcare providers are on the front lines of fighting this “war,” as President Trump called it, without adequate supplies. To listen to the White House and White House Coronavirus Work Group press conferences, you would get the impression that we are having a few hiccups, but overall, our government’s response has been nearly perfect. Can you imagine if we were fighting a traditional war, and our troops were complaining that they don’t have adequate equipment and supplies and were going into battle vulnerable and exposed? Can you imagine what cries of outrage would emerge from our citizens? Well, that is what is happening in our war against the coronavirus. We are experiencing such severe shortages in protective equipment and supplies that we are sending in our healthcare providers in some parts of the country vulnerable and exposed.

So, don’t take it from me. Here are what some officials and health care providers from across the country are saying.

UCSF Medical Center

@UCSFHospitals

PLEASE SHARE: Help front-line UCSF providers caring for all who need it during the #covid19 pandemic by donating critical supplies such as masks, disposable gloves & more at three sites in #SanFrancisco and #Oakland starting tomorrow.

https://ucsfh.org/2WA28DG #coronavirus #sf

City of New York

@nycgov

“Our health care leadership here in the city has made it clear that supplies and medical equipment are a deep concern…but the most important factor is personnel.” –

@NYCMayor

on NYC’s need for supplies to fight COVID-19 Learn more at http://nyc.gov/coronavirus

In case you might be thinking, well that is California and New York that have been especially hit hard, but the rest of the country, my town or city should be fine, this is from the chairman of the department of emergency medicine at OSF LCMMC in Evergreen Park, Illinois, not necessarily a place most of us would think of as a hotbed of coronavirus activity:

Sunil A.

Chair of Emergency Medicine at OSF LCMMC

“Am I scared? I sent my wife and two kids to another state, as have other front line physicians. Exposure to them was a major factor but knowing full well that WE will need to cover for our sick colleagues made this a time when home and duty cannot co-exist…. Scared is the only logical emotion that can go along with that scenario. A nation that is ok with sending their troops in without protection needs to take a long deep look in the mirror and decide if this is what they wanted.”

It really is shocking that South Korea was performing more coronavirus testing in a day than we did in our entire country for the first more than two and a half months.

It is shocking that the world’s most advanced, richest country has not been able to provide enough testing kits, reagents, testing supplies (like swabs and viral transport media), gowns, masks, goggles, and face shields, even as of today. Our government’s solution, despite the fact that it is not consistent with the manufacturer’s advice is to wear masks for extended periods of time and sanitize the masks periodically with hand sanitizer (which is also in short supply). Worse, imagining the time when we are completely out of masks, the CDC has advised providers to wear scarves or bandanas over their mouths and nose as if we were some developing country.

So, should the President have exercised authority under the Defense Production Act?

Yes, about two months ago. At that time, the President had not yet implemented his “travel ban” from China, yet the disease was not isolated to China. It had already spread to more than 20 other countries. We also knew that this was a novel virus for which no one in the world had immunity. Given the globalization of economies and travel, I don’t think any epidemiologist would have told the President that the virus could not come into the U.S. and spread swiftly through the population.

Further, while many of us believed that there were ample supplies in the Strategic National Stockpile and the President could rapidly deploy those, we were mistaken. Here we are two months later and hospitals, physicians, nurses, mayors and governors are begging for these supplies. Surely the President’s advisors informed him that there was no way the federal government could meet the needs of hospitals all across this country were the virus to spread.

We first relied on a flawed CDC test. Finally, this month, the government allowed large commercial labs to offer the testing. At least two of those labs have been overwhelmed and stopped accepting specimens, at least temporarily. The others have been ramping up testing, but the turnaround for these tests can be 4 – 5 days, compared to the public health labs’ capability to turn these tests around in less than 24 hours. Further, providers still face shortages of testing supplies to be able to submit specimens to these labs. And, current testing puts the person testing at risk, so they have to have personal protective equipment, and this remains in short supply.

So, private businesses have not saved us so far and neither has the federal government. We are told that is about to change, however, we have been told that for more than a week. Now, in the world’s most medically advanced country, we are telling providers to reuse their supplies, to use scarves and bandanas to cover our faces, to consider using ventilators for multiple patients, and volunteers in our communities are sewing home-made face masks for us.

We are told that the private sector will come through for us. Let’s pray that happens, because the federal government has failed us.

This is a scary time – there is no doubt. But, I am amazed by the generosity and caring of Idahoans. Instead of feeling like victims of having to give up social events, having to take their classes online from home instead of attending school, or having to work from home, Idahoans are rising to the occasion finding ways to help each other and volunteering their skills and talents to hospitals and donating to worthy cases.

I am so proud of our health care workers – their dedication to helping people, even if doing so means putting themselves at risk. But did you know that you can save lives?

Unfortunately, the coronavirus pandemic has caused the cancellation of many blood drives. While we are absorbed with this health threat, we must not forget that every day, patients across the country need nearly thirty-six thousand life-saving units of red blood cells, seven thousand units of platelets and ten thousand units of plasma. Every single day. While we may feel helpless to prevent the coronavirus deaths, we can make sure that kids and adults with cancer or other medical conditions or those with life-threatening injuries don’t have to needlessly die due to lack of blood.

If you have fever, cough, shortness of breath or have been diagnosed with or had close contact with a person with COVID-19 in the last month, stay home and protect others. But, if you are healthy and feeling well, please reach out to your local donor center, schedule a donation, and encourage your friends and family to do so, as well. Blood donation is safe and instead of staying home and watching tv, you can save a life. Visit www.redcross.org. I have donated 27 units of blood in Idaho and I will be back to donate again next month!