Apr 4, 2020

Axios Future

Welcome to Axios Future, where child care in the pandemic age is now primarily being carried out by our iRobot vacuum cleaner.

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  • Today's issue is 1,661 words, a 6-minute read.
1 big thing: Why we're never ready for the big one

Illustration: Aïda Amer/Axios

As the confirmed number of COVID-19 cases passed 1 million on Friday, two words sum up the U.S. response to the coronavirus: not enough. Not enough hospital beds, not enough ventilators, not enough protective equipment. Not enough preparation.

We had plenty of warning that something like COVID-19 was coming. But the reality is no country's health care system is built to withstand the kind of rare but consequential event this pandemic represents.

  • Historically, deaths from infectious disease — like those from most catastrophes, natural and human-made — tend to cluster in a few big events, rather than being spread evenly from year to year.
  • A single pandemic — the 1918 flu pandemic — killed at least 25 million people, and perhaps as many as 100 million around the world. The HIV pandemic, though it unfolded much more gradually, has killed more than 30 million people. But most infectious disease events are more like the 2003 SARS outbreak, which ultimately killed fewer than 800 people.
  • The same is true for deaths from conflict. At least 108 million people died in wars during the 20th century, and the majority of those died in two events: World War I and World War II.

When it comes to national defense, the U.S. has built a system explicitly prepared for those big but rare events. For decades a pillar of American military strategy has been that the armed forces should be capable of fighting two major conflicts simultaneously — one reason why the Defense Department's budget was $686 billion in 2019.

  • But that's not the case for health care, especially infectious disease. The number of hospital beds per 1,000 people in the U.S., for instance, has declined by more than 60% since 1970.
  • This hasn't been a huge problem until now, in part because more care could be done on an outpatient basis and in part because health threats shifted to chronic conditions like cancer.
  • "If you're not running your hospital at 85% capacity, you're losing money," says David Hunter, an epidemiologist at the University of Oxford. "So there's no surge capacity."

The big picture: Our health care system is built to respond to known threats. The number of deaths from heart disease or cancer, or even seasonal influenza outbreaks, might rise or fall year to year, but it stays within predictable bounds — bounds our health care system can meet.

  • But an explosive, global pandemic like COVID-19 breaks those bounds. The result is precisely what we're seeing now: too many sick people and too few medical resources to meet their need.
  • At the same time, supporting a health care system capable of meeting the demands of a global pandemic that might only occur every few decades might be prohibitively expensive.

The ideal solution would be to create a system with plenty of surge capacity, capable of rapidly scaling up to respond to a major outbreak. But while digital systems are largely able to do just that, it's far more difficult to scale up the manufacturing and distribution of physical things like masks, ventilators and beds.

  • The shift to telemedicine (see below) and automation in health care provides some hope for the future, as does the growth of 3-D printing.
  • But health care remains a high-touch, inefficient enterprise — albeit one we count on for our very lives.

The bottom line: Our preparation for low-probability, high-consequence events like COVID-19 has largely been not to prepare — and we're seeing the painful results of that flawed strategy in real time.

2. Telemedicine doesn't waste a crisis

Illustration: Sarah Grillo/Axios

We're going to see more medical care delivered remotely — both during the pandemic and after.

The big picture: Health care has always been one of our most regulated industries, which slows the pace of innovation. But the emergency nature of COVID-19 is taking the shackles off telemedicine.

As part of the $2 trillion CARES Act passed last week by Congress to respond to COVID-19, the Federal Communications Commission plans to spend $200 million to support telehealth programs.

  • It's one of a number of efforts to leverage remote technology to expand health care at a moment when the demand for services is high but face-to-face contact presents its own risks for patients and providers.

Be smart: Telemedicine isn't just about patients speaking to a remote doctor via a smartphone app like Teladoc, which last month reported virtual visits increasing by 50% because of the pandemic. Hospitals can take advantage of remote doctors by outsourcing specialities, such as radiology.

  • Collaborative Imaging is an alliance of radiologists who remotely view X-rays or CT scans from a hospital and confer with attending physicians on patient care via a smartphone app.
  • Besides allowing for hospitals to tap a wider range of sub-specialists than they might be able to bring on board in person, remote work is also safer in the time of COVID-19. "In case I'm infected, I don't have to worry about infecting others, and vice versa," says Dhruv Chopra, CEO of Collaborative Imaging.

Regulations that required radiologists to be licensed in the states of the hospitals they were reading for, even if they were working remotely, held back the practice. But after President Trump declared a state of emergency on March 13, the Centers for Medicare and Medicaid Services provided blanket waivers for telemedicine providers to practice across state lines.

  • There are still complexities around private insurance networks that vary from state to state, but Chopra expects remote radiology to continue to grow. "This is going to change the industry dramatically. You won't go back to the days of lots of radiologists under one roof."

The bottom line: Crises have a way of knocking aside the barriers to innovation — even in a practice as regulated as medicine.

3. Robotaxis revisited

llustration: Sarah Grillo/Axios

In two weeks, the coronavirus has brought the entire U.S. auto industry to a screeching halt. When it finally sputters back to life, many companies may be forced to change, defer — or even abandon — their ambitious plans for self-driving vehicles, my Axios colleague Joann Muller writes.

The big picture: Auto factories are shut down across North America to prevent the spread of the virus among workers, while stay-at-home orders have kept car shoppers away from showrooms. The resulting financial shock means carmakers have shifted their focus to survival, not investing in expensive technologies with no clear payoff.

Autonomous delivery seems made for a pandemic like this, on the other hand. People who are afraid to go out have discovered the convenience of home delivery in huge numbers.

  • Small delivery robots like Starship, Kiwibot and Amazon's Scout were already piloting delivery services before the coronavirus hit.
  • "This is a tremendous market opportunity for them, and I think they're definitely going to go for it," says Gary Silberg, head of automotive consulting at KPMG.

What's next: Industry consolidation is likely to accelerate within the next six to 12 months.

Go deeper

4. The era of uncertainty

Illustration: Sarah Grillo/Axios

Never have the known unknowns been bigger.

At a time of crisis, we tend to crave certainty — the one thing we have less of than ever, my Axios colleague Felix Salmon writes.

The markets, of course, are full of uncertainty. Record-high volatility indicates that price discovery is breaking down.

The virus comes with even bigger error bars.

  • The number of undetected cases, the fatality rate, how likely asymptomatic individuals transmit the virus, how dangerous it is to touch an infected surface or to pass within 6 feet of others, how family members in close quarters don't get infected, how long the incubation period is, whether recovery implies immunity and for how long, whether the virus is seasonal — all these and many more basic facts remain unknown.
  • Social questions have even bigger unknowns. What is the correct public health strategy? How strict should lockdowns be? Should wearing masks be encouraged or mandated? Do masks remind people not to touch their face or make them touch their face more? How much certainty should national authorities evince, given the unknowns?
  • National infection rates are equally unknown. The proportion of Swedes infected with the virus is believed to be between 0.8 and 8.4%. In Spain, the number infected is estimated to be somewhere between 1.8 million and 19 million.

Why it matters: It's unnatural to live with such uncertainty, so we all cobble together our own set of beliefs about what is true. Then, because we all have different beliefs, finding common ground becomes very hard.

The bottom line: The virus is eroding the shared norms and beliefs that underpin both markets and societies. The consequences are unforeseeable but unlikely to be good.

Go deeper

5. Worthy of your time

What everyone's getting wrong about the toilet paper shortage (Will Oremus — Marker)

  • My former Medium colleague gets to the bottom of the TP crisis. Turns out when we all stop using the bathroom at the office, we start doing it a lot more at home.

Forty years with coronaviruses (Susan R. Weiss — Journal of Experimental Medicine)

  • A veteran researcher on what happens when the obscure subject you studied for a lifetime suddenly becomes important to the entire world.

The shockingly recent history of people actually washing their hands (Emily Sohn — Popular Mechanics)

  • Gross but true: it was only in the late 19th century that people (including doctors) began regularly washing their hands, thanks in part to a Hungarian obstetrician.

The apocalypse as an 'unveiling': what religion teaches us about the end times (Elizabeth Dias — New York Times)

  • The pandemic isn't the end of the world, but it shows us unexpected truths about the way we live.
6. 1 hopeful thing: Saving the oceans for the future

A humpback whale dives. Photo: M Swiet Productions

A new scientific review found that marine life has been rebounding in recent years thanks to conservation efforts and that the oceans could be fully restored by mid-century.

Why it matters: The oceans cover almost two-thirds of the Earth's surface, yet for too long we've treated the waters as a dumping ground.

The oceans are not in great shape. Coral reefs are bleaching, fish are being fished out and microplastics are spoiling the water. Despite that ill treatment, the oceans are more resilient than we thought — and humans have helped.

  • Researchers in Nature found that the proportion of marine species threatened with extinction dropped from 18% in 2000 to 11.4% in 2019, thanks in part to conservation efforts.
  • The review authors reported that oceans could be fully restored by 2050 by focusing on rebuilding marine habitats and fighting climate change.

The bottom line: Saving the oceans won't be cheap — the Nature researchers estimate it could cost $10 billion to $20 billion a year. But the benefits could be 10 times that much, and might just be priceless.

In the last edition, Stanford's John Etchemendy was mistakenly quoted as referring to Kansas State. The quote has been corrected.