Category Archives: Covid-19

A glimpse at Lyfts stock price Wednesday, which soared as much as 16.77% after first-quarter earnings were reported, suggested all was well in the ride-hailing companys world.

In this COVID 19-era, well is a relative term. Lyfts net losses did dramatically improve from the year-ago quarter (a loss of $398 million versus $1.1 billion in Q1 2019). However, Lyft was clear in its earnings call: COVID-19 had a profound impact on its customers and its business and the future was uncertain.

It is impossible to accurately predict the duration and depth of the economic downturn we face, Lyft CFO Brian Roberts said during an earnings call Wednesday afternoon. Our business may be impacted for an extended period of time. So we must be prepared to adapt accordingly.

The difficulty of predicting what will happen has hamstrung thousands of companies trying to navigate the COVID-19 pandemic. Last month, Lyft withdrew its previously provided revenue and adjusted EBITDA guidance for full year 2020 because of the vast unknowns.

Given this fluidity, it is impossible for us to predict with any certainty our results, Roberts said. After the requisite warnings, Roberts did eventually provide an outlook for the second quarter and it isnt pretty. The outlook focused on adjusted EBITDA, which doesnt give the most complete financial picture. It provides enough to understand that even with considerable cost-cutting measures, Lyft will suffer losses nearly four times wider than the first quarter.

Roberts said Lyft can manage to keep its second quarter adjusted EBITDA loss under $360 million if rides on its rideshare platform remain at April levels which were down 75% year-over-year for the remainder of the quarter. Lyft reported Wednesday an adjusted EBITDA loss of $85.2 million in the first quarter.

There are some early signs of a recovery. Ridership in the week ended May 3 was up 21% from the lows experienced in mid-April, according to Lyft. However,Lyft cant afford to simply hope rideshare will return. It has to and already has enact a plan that will allow it to navigate the pandemic and come out as a survivor. In other words, Lyft will be judged at how well can stem the losses and find new revenue streams.

Work to cut costs has already started.

The company put together an aggressive plan to strengthen its financial position, Lyft co-founder and CEO Logan Green said during the earnings call. Lyft reduced its more than 5,000-person workforce by 17% and furloughed nearly another 300. Lyft also initiated a three-month pay reduction for all salaried employees, ranging from 10% for its most non-hourly team members, up to 30% for its senior leadership team and board members.

Every other expense line is being scrutinized and no stone will be left unturned, Green said.

The company expects to be able to cut its annualized fixed costs by $300 million by the end of the year. The reductions are based on its original expectations for 2020. Lyft has also ended rider coupons once ridership began to decline in mid-March and paused adding new drivers in nearly all markets.

This reduces costs we incur associated with onboarding new drivers and helps protect utilization and earnings opportunities for existing drivers during this time of lower ride demand, Green said.

Lyft reduced its 2020 capital expenditure plan by $250 million. And its sought out cost savings on the insurance front. (The companysprimary auto insurance policies expire at the end of September; Roberts said theyre considering the best options to reduce future volatility, as well as lower overall costs.)

The company is also shifting attention and resources to projects that executives believe will improve its unit economics. Finding those revenue streams will be tricky. Lyft has already provided a few clues of where its headed.

The company will continue with its Essential Deliveries pilot that launched April 15. The initiative lets government agencies, local non-profits, businesses and healthcare organizations request on-demand delivery of meals, groceries, life-sustaining medical supplies, hygiene products and home necessities.

Green said the company will evaluate any future opportunities based on how it performs. But he quickly added that we have no interest in launching a consumer food delivery service. And so, we will not be doing that.

Green also seemed cautiously optimistic about a new lost cost product called Wait and Save, that allows Lyft optimize the marketplace and be more efficient with matching drivers and riders.

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How Lyft intends to navigate and survive COVID-19 - TechCrunch

But a US medical drone company has been getting blood and medical products to rural clinics and hospitals in Africa for several years and is now focusing its attention on the battle against COVID-19.

Drones are helping to deliver test kits and PPE to fight COVID-19.

Image: Zipline

Medicine for remote communities

An estimated 2 billion people lack access to basic medicines partly because they live in remote locations.

To help solve this problem, drone company Zipline has pioneered medical deliveries to rural communities in Rwanda and Ghana. Its lightweight drones deliver vital packages to clinics up to 85 kilometres away. Trips that might have taken an entire day by car could take 30 minutes or less by drone.

Now the company is using its drone deliveries to support the coronavirus fight in Africa and aims to do the same in the US.

The World Economic Forum is partnering with governments and companies to create flexible regulations that allow drones to be manufactured and used in various ways to help society and the economy.

Drones can do many wonderful things, but their upsides are often overshadowed by concerns about privacy, collisions and other potential dangers. To make matters worse, government regulations have not been able to keep up with the speed of technological innovation.

In 2017 the World Economic Forums Centre for the Fourth Industrial Revolution teamed up with the Government of Rwanda to draft the worlds first framework for governing drones at scale. Using a performance-based approach that set minimum safety requirements instead of equipment specifications, this innovative regulatory framework gave drone manufacturers the flexibility to design and test different types of drones. These drones have delivered life-saving vaccines, conducted agricultural land surveys, inspected infrastructure and had many other socially beneficial uses in Rwanda.

Today, the Centre for the Fourth Industrial Revolution is working with governments and companies in Africa, Asia, Europe and North America to co-design and pilot agile policies that bring all the social and economic benefits of drone technology while minimizing its risks.

Read more here, and contact us if you're interested in getting involved with the Centre for the Fourth Industrial Revolution's pioneering work in the governance of emerging technologies.

Drones have already played an important role in the fight against COVID-19, from disinfecting streets in China, to supplying medicine to a small community in Chile.

When the coronavirus hit Africa, Zipline adapted its cargo. Its distribution centres in Ghana now hold stocks of personal protective equipment (PPE) and its drones also deliver COVID-19 test samples, CNN Business reported.

We are stocking a whole bunch of COVID-19 products and delivering them to hospitals and health facilities, whenever they need them instantly, Zipline CEO and Schwab Foundation Social Entrepreneur, Keller Rinaudo, told CNN Business.

Another way drones could help, Rinaudo believes, is delivering more directly to the elderly and vulnerable who need to self-isolate: Suddenly theres a dramatic need to extend the reach of the hospital network and the healthcare system closer to where people live, he said. A neighbourhood drop-off point is being considered for those with chronic conditions who are often reliant on volunteers to collect and deliver medication.

Rinaudo thinks that drone deliveries could play a vital role both during the current crisis and in the coming months and years.

Elevating the conversation

The World Economic Forum, with partners including Zipline, the World Bank and the International Civil Aviation Organization (ICAO), have been raising awareness of how to accelerate the use of drones for good in Africa and beyond.

In early April, the Forums Aerospace and Drones community brought together more than 400 industry participants to discuss how drones can battle COVID-19 and how best to integrate them into supply-chains. David Moinina Senge, Chief Innovation Officer and Minister of Basic and Secondary Education for Sierra Leone, explained how drones can assist with data capture, medical supply-chain integration, and provide jobs for the developing tech sector.

Ironically for a company that began life in California and already has two distribution centres there, Zipline has no commercial operation in the United States. However, that may change.

In the coming weeks, Zipline will join two other companies - Matternet and Flytex - for an initiative using drones for COVID-19 response, using the technology to deliver PPE or medical supplies in three North Carolina cities.

License and Republishing

World Economic Forum articles may be republished in accordance with our Terms of Use.

The views expressed in this article are those of the author alone and not the World Economic Forum.

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Medical delivery drones are helping fight COVID-19 in Africa, and soon the US - World Economic Forum

Amid COVID-19 precautions, medical centers continue to treat patients with other serious conditions.

By Kelly ServickMay. 6, 2020 , 1:00 PM

Sciences COVID-19 reporting is supported by the Pulitzer Center.

Myron Cohen has run clinical trials through hurricanes and civil unrest. Now, the infectious disease researcher at the University of North Carolina, Chapel Hill, says he and his colleagues are in a new situation: trying to carry out large, international trials in the midst of coronavirus lockdowns. Cohen co-leads a network of HIV prevention trials, some of which have paused during the pandemic. But for other studies, he says, stopping would be of grave consequence to participants. So study teams have bought and shipped protective equipment to personnel at clinical trial sites, secured special permits where necessary for trial participants to leave their homes for medical visits, and arranged their private transportation to avoid public buses.

Not all clinical trials have had to go through such logistical gymnastics. But across diverse fields, investigators have managed to keep treating patients who might benefit from experimental therapies. Slowdowns and pauses in recruiting new participants will delay resultsbut for many studies, data are still flowing in.

Now, research teams are contemplating the ways the pandemic might insert itself into their trial results. Could changes induced by the pandemicincluding less consistent follow-up visits, reduced movement, poorer mental or physical health, or infection with the novel coronavirus itselfblur the statistical signals of a treatments risks and benefits?

Were all going to have to plan for how we account for the impact of COVID, says Janet Dancey, a medical oncologist at Queens University in Kingston, Canada. Many concerns remain hypothetical. Until researchers finish collecting and analyzing their data, they wont know whether coronavirus-related disruptions will undermine results. But Im worried about it, Dancey says.

Though medical centers around the world have shifted staff and resources to COVID-19, they also continue to bring in patients with other life-threatening diseases. Many institutions have stratified their ongoing clinical studies and halted any in which patients didn't stand to benefit directly. But for many cancer patients, participating in a clinical trial can provide the best available treatment, says Monica Bertagnolli, a cancer researcher at Harvard Medical School. Everybody who is already on a clinical trial is there because they have cancer or some serious condition, and this is a really important part of their treatment, she says. You dont want to deny that to patients.

The Alliance for Clinical Trials in Oncology, which conducts clinical trials across the United States and Canada, has not withdrawn any participants from treatment during the pandemic, says Bertagnolli, who chairs the organization. But, she adds, I wont say that the treatment hasnt been changed a little bit. In some cases, the pandemic has delayed imaging appointments and biopsies that can guide treatment plans and gauge how a tumor is changing. As a result, researchers might not be able to document how much a cancer has grown or spread at the exact time points specified in the trial design. (The U.S. Food and Drug Administration has indicated that deviations from study protocol to protect patients safety during the pandemic are justified.)

Im already seeing many more deviations, says Howard Burris, an oncologist and chief medical officer of Sarah Cannon, the Cancer Institute of HCA Healthcare, and president of the American Society of Clinical Oncology. Hes optimistic that small data gaps wont change big-picture trial results. Hopefully, in a randomized trial, those things sort of sort themselves out, he says. I think well be able to adjust.

But trial data might become muddied if some participants are sickened by the novel coronavirus or die from it, Dancey notes. Presumably, SARS-CoV-2 infections would be distributed randomly between a studys treatment and control groups. But they could still make it harder for researchers to pick up signals of benefit or to disentangle negative side effects of the experimental treatment. If there are competing causes of death that are going on, then it will be harder to show differences in outcomes, Dancey says. It reduces our power.

Other effects of the coronavirus pandemic on trial participants might be more subtle. For example, the results of HIV prevention trials depend in part on participants risk of contracting the virus, Cohen notes, and social distancing orders that limit intimacy might change that underlying risk. The researchers will have to take into account the fact that getting an experimental drug was far from the only change in participants lives over the course of the trial.

Trials focused on mental health could face other complications, says Lynnette Averill, a psychologist at the Yale School of Medicine, who is studying the anesthetic ketamine as a potential treatment for post-traumatic stress disorder (PTSD). A global pandemic where youre isolated and potentially have fears of you or your family being ill those things are highly stressful, and potentially traumatic, she says. This experience may be significant enough that there has to be some sort of analysis of the pandemic effect. We may in fact have entirely different cohorts pre- and postpandemic.

Averill also wonders whether investigators running trials of PTSD, anxiety, and depression will see a shift in the demographics of trial participants. The mental health effects of caring for COVID-19 patients in overstretched hospitals may make more health care workers eligible for such trials, for example.

Dancey, who directs both a research network that runs cancer trials and a funding organization that supports them, has been helping develop guidance for researchers on how to adapt studies during the pandemic. The best they can do, she says, is focus on a studys primary endpoint, make data collection as complete as possible, and document any deviations from the study plan. We have to make sure that people are looked afterwhether theyre patients with or without cancer, or health care professionals, she says. And then well look after the trial.

Excerpt from:

Clinical trials press on for conditions other than COVID-19. Will the pandemic's effects sneak into their data? - Science Magazine

A member of the US military who works at the White House, reportedly as one of Donald Trumps personal valets, has tested positive for coronavirus.

We were recently notified by the White House medical unit that a member of the United States military, who works on the White House campus, has tested positive for coronavirus, the deputy White House press secretary, Hogan Gidley, said in the statement.

The president and the vice-president have since tested negative for the virus and they remain in great health.

According to a report from CNN, the valet is a member of the US navy and started exhibiting symptoms on Wednesday morning. The person tested positive on Wednesday, the White House said.

This is the second individual confirmed to have tested positive for Covid-19 while working at the White House. A staffer in vice-president Mike Pences office tested positive for the virus in March. Several people present at Mar-a-Lago, Trumps private Florida club, were also diagnosed with Covid-19 in early March.

The news of the new case at the White House comes as the US begins to reopen its economy, despite urgent warnings from health experts that the move could prove to be a death sentence for many Americans.

Trump has praised governors of states that have started to loosen restrictions on social distancing and business activity, even though he has admitted that people will suffer as a result. Will some people be affected badly? Yes, Trump said on Tuesday. But we have to get our country open, and we have to get it open soon.

Public health experts have pointed out that Covid-19 infections and deaths are mounting dangerously in much of the US.

New York has drawn attention as a global hotspot for the virus but has now flattened its rate of infections, whereas large parts of the country are still to reach their own peak. When New York is discounted, the US is still on an upward trajectory of new infections.

The White House instituted safety protocols nearly two months ago, including temperature checks. Last month it began administering rapid Covid-19 tests to all those in close proximity to the president, with staffers being tested about once a week.

Several valets cater to the president and his guests at the White House, both in the West Wing and in the White House residence.

Excerpt from:

One of Trumps personal valets tests positive for Covid-19 - The Guardian

We werent going to tell him he had it, but I had to, Dahl said. I said You know you have the virus, right? And he said Yes, I do. And thats when I said Im so sorry, and he said Nothing you did.

Dahls father, Kenneth Skoog, died on April 24 at Eventide Senior Living Facility in south Fargo, three days after his 66th wedding anniversary. Dahl, a nurse, said even gently touching her fathers cheek made him cry out in pain. Once, his face turned purple during an uncontrollable coughing fit.

He said he had 90 good years, and he was ready to go, Dahl said. But not like this, not like this. If he had died naturally we would have accepted it more easily. But on Good Friday, he told us that nothing compares to the suffering Jesus endured. The suffering of this virus cant even compare to what our Lord suffered.

Kenneth was on the do not resuscitate list, and the family chose comfort care rather than a higher level of care, which would have meant hospitalization and a ventilator.

Even following the comfort care protocol didn't seem to provide him with the proper amount of pain meds to help relieve his pain, Dahl said.

The Skoog family meets with their mother on May 2 at Eventide for a Happy Hour, shortly after Kenneth Skoog, 90, died from COVID-19. They talk back and forth, sometimes needing to yell over high winds, while Erlys Skoog stay on her second-floor balcony. C.S. Hagen / The Forum

He was North Dakotas number 16, Kenneths son Kevin Skoog said. My dad contracted the virus at Eventide, and he died at Eventide. Prior to Karla being by her dads side, Dad was dying alone, Mom was crying alone and us kids cant do a damn thing about it.

On Monday morning, April 20, Kevin said goodbye to his father over the telephone. The conversation was brief; a long line of children, grandchildren and great-grandchildren wanted their turn. But it was a better day for Kenneth, a Korean war veteran who had been involved in the Berlin Airlift.

Skoog family 2019. Top row left to right: Kurt Skoog, Kirby Skoog, Karla Dahl, Kevin Skoog, Kory Skoog, bottom row: Erlys Skoog and Kenneth Skoog. Special to The Forum

I could tell he was hurting, but he was able to communicate, Kevin said. I remember asking him, Well, Dad, are you in any pain? And he said it couldnt get any worse.

Kenneth suffered with the symptoms for nearly nine days before passing away around 4 a.m. April 24.

On April 15, when the Skoog family learned about Kenneths condition, there were 11 residents and two staff members who tested positive at the Fargo Eventide. As of April 30, the numbers increased to nine residents, 10 staff members who tested positive, with five inactive residents at Eventide in Fargo; three staff members at Eventide in West Fargo; 19 residents and 13 staff members who tested positive with three inactive residents at Eventide in Moorhead, according to the Eventide website.

I want to know how many people have contracted the virus at Eventide and how many have passed away because of it. My dad is one, but are there others, Kevin said.

On May 6, the states department of health reported 31 people in North Dakota have died from any cause with COVID-19.

Kenneth Skoog holds up the message delivery system he and family uses to pass information, cookies, and other items back and forth with their mother, Erlys Skoog, who lives on the second floor of an Eventide apartment. C.S. Hagen / The Forum

A week after Kenneth died, Dahl, Kevin, and other family members gathered on the sidewalk below the apartment where he once lived with his wife, Erlys Skoog, in a second-floor apartment at Eventide. Beers were had. Laughter rang out between stories of long gone days. Tears flowed.

Weve come to visit my mom behind bars, Kevin joked.

Using a plastic cylinder to toss messages, pictures, sometimes cookies and muffins, back and forth, Kevin opened up a picture of his fathers urn. A hunting scene. He wanted to make sure his mother liked the design.

"Don't break the glass," Erlys Skoog says just before her son, Kevin Skoog, tosses up a canister with a picture of her late husband's urn. Kenneth Skoog, 90, died of COVID-19 recently at Eventide. C.S. Hagen / The Forum

Heading into her ninth week of quarantine, Erlys said the isolation doesnt bother her much. She embroiders, spends time on the telephone. She doesnt use the internet, or watch much television, except for the news, but the food at Eventide is good. She plays Bingo some days and eagerly waits for her family to line up on the sidewalk beneath her second-floor apartment. Sometimes she watches as a great-grandchild draws chalk art to cheer her up.

If she could step out of isolation, the first thing she would do would be to, Give everybody a big hug, Erlys said. I havent had a hug in a long time."

The last time Erlys saw her husband was on March 16, when retirement homes began locking down. When the couple first moved to the senior living facility last autumn, they lived together, but Kenneth was moved to the skilled nursing care unit because of dementia. Until the coronavirus hit Fargo, she saw him daily.

The irony behind the living situation is not lost on the Skoog family. If their parents had stayed together in their home in Wahpeton, Kenneth may not have contracted the coronavirus and died. If Erlys had been allowed to visit her husband after lockdown, she too might have contracted the virus.

Stories about Kenneth brought chuckles from everyone, including Erlys. When Kenneth turned 18, he didnt show up for his birthday party at home.

Everyone was there except him; he had signed up for the Air Force, Dahl said his mother told her. Grandpa drove him to Fargo where he took the train to begin his training.

He went AWOL before he joined the Air Force, Kevin joked.

Karla Dahl sits with family on May 2 at Eventide while describing her watch over her dying father Kenneth Skoog, who passed away of COVID-19. C.S. Hagen / The Forum

Honorably discharged in 1950 as a corporal from the U.S. Air Force three years later, he returned to the family farm in Christine, N.D., but didnt stay long. From there he began working for the Great North Railroad, which became the Burlington Northern Railroad. He retired in 1993, and spent his time hunting, woodworking, playing sports and enjoying beers with friends.

He was a spark plug, Kevin said. Our focus is changing. Before it was on Dad, and now its on Mom. I just feel it would be nice to let Mom go to a restaurant. But the last thing we want to do is expose her to the virus.

Erlys, maiden name Ordahl, met Kenneth in a bar named Earls in Breckenridge, Minn., in 1951. Dinner led to romance. The first and only time she can remember saying goodbye to Kenneth was when they were courting.

I thought I thought more of him than he did me. And then one night he walked me to the door, and I said goodbye, and then he put his hand on my shoulder, and he said I dont like that word goodbye, Erlys said. So I tried never to really say it ever again.

Even during her husbands final days.

Kevin Skoog talks to his mother on May 2 who is in quarantine in a second-floor apartment at Eventide. Father Kenneth Skoog, recently died of COVID-19. C.S. Hagen / The Forum

When Karla Dahl learned only one person could go into Kenneths room after he contracted COVID-19, she said she was pleased to spend her dads last days by his side. As a nurse, shes used to wearing personal protective equipment.

After every visit she would go home, place her shoes outside, spray them with Lysol, then take the hottest shower she could stand while breathing in the steam for as long as she could.

I would fill my lungs with the steam, and I sprayed everything with Lysol; I did everything I could to prevent the spread, Dahl said. I wasnt scared at any time I was in there with him. He was my dad.

Kenneth had good days and bad, and Dahl tried to use the times he was feeling better to hold the phone inches from his face so he could talk to his family.

The N-95 mask is a very secure mask, I found that out five days with my dad, Dahl said. I would hold the phone inches from his face while he was coughing.

When Kenneth died, Dahl could plainly see his suffering was over.

Kevin Skoog gets ready to catch a canister from his mother, Erlys, as she's living in quarantine at Eventide in Fargo. C.S. Hagen / The Forum

It was such a relief and comfort to see him in peace. It was good for me to see him at the end, I just wish that everyone could have, because no one got a chance to. I was the only one she said.

You know what Karla? It comforted the rest of us knowing you were with him. We were worried when nobody was there, Tammy, the wife of son Kory Skoog, said.

That was a relief to us, but then I also had a concern about Karla being there and possibly contracting the virus, Kevin said.

Dahl tested negative for COVID-19 after her father passed away.

Kenneth K. Skoog is survived by two sisters and two brothers; by his wife Erlys of 66 years; his children, Kurtis, Kirby and wife Lyn, Karla and husband Tom, and Kevin and wife Lonna, Kory and wife Tammy as well as 10 grandchildren and seven great-grandchildren.

Handwritten letter Erlys Skoog wrote after her husband's death from COVID-19. Special to The Forum

Erlys Skoog's letter, above, was written while she was living in quarantine at Eventide Senior Living Facility shortly after her husband of 66 years, Kenneth K. Skoog, died from COVID-19 on April 24. It reads:

"I'd like to let everyone know how serious this COVID-19 virus is. It's terrible.

"I went every day to see my husband before this virus set in. I gave him a kiss and said 'I'll see you tomorrow.' Little did I know when I left there, I'd never see him again.

"Couldn't go back and forth any more because of this virus. Spent time on phone back and forth. He couldn't understand why I didn't come see him. Told him because of this virus.

"Our first time on iPad was very emotional for both of us. First time I'd seen him in tears."

"Only one could be with him in his last days. Our dear daughter (Karla a nurse) was with him.

"He had a good day before our 66th anniversary. Karla dialed for him so he could say a few words to our kids, grandkids and great-granddaughter. I talked to him twice. Day after anniversary was not a good day, Karla dialed for him and his last words to me was (I love you). All I could understand.

"I just hope and pray everyone will listen and obey rules. Tough world right now. You wouldn't want your loved one going through what we did...

"I miss the hugs from family and friends. I miss my dear husband who was always there for me."

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Family devastated after father dies of COVID-19 can only comfort mother from a distance - INFORUM

Physical and occupational therapists carry bags of personal protective equipment on their way to the room of a COVID-19 patient in a Stamford Hospital intensive care unit in Stamford, Conn., on April 24. This "prone team" turns COVID-19 patients onto their stomachs to help them breathe. John Moore/Getty Images hide caption

Physical and occupational therapists carry bags of personal protective equipment on their way to the room of a COVID-19 patient in a Stamford Hospital intensive care unit in Stamford, Conn., on April 24. This "prone team" turns COVID-19 patients onto their stomachs to help them breathe.

Intensive care teams inside hospitals are rapidly altering the way they care for patients with COVID-19.

The changes range from new protective gear to new treatment protocols aimed at preventing deadly blood clots.

"Things are moving so fast within this pandemic, it's hard to keep up" says Dr. Angela Hewlett, an infectious diseases physician at University of Nebraska Medical Center in Omaha and medical director of the Nebraska Biocontainment Unit. To stay current, she says, ICUs are updating their practices "on an hourly basis."

"We are learning at light speed about the disease," says Dr. Craig Coopersmith , interim director of the critical care center at Emory University. "Things that previously might have taken us years to learn, we're learning in a week or two. Things that might have taken us a month to learn beforehand, we're learning in a day or two."

The most obvious changes involve measures to protect ICU doctors, nurses and staff from the virus.

"There is a true and real probability of infection," says Dr. Tiffany Osborn a critical care specialist at Washington University School of Medicine and Barnes-Jewish Hospital in St. Louis. "You have to think about everything you touch as if it burned."

So ICUs are adapting measures used at special biocontainment units like the one at the University of Nebraska. These units were designed to care for patients affected by bioterrorism or infected with particularly hazardous communicable diseases like SARS and Ebola.

The Nebraska biocontainment unit "received several patients early on in the pandemic who were medically evacuated from the Diamond Princess cruise ship," Hewlett says. But it didn't have enough beds for the large numbers of local patients who began arriving at the University of Nebraska Medical Center.

So the nurses, respiratory therapists and physicians from the biocontainment team have "fanned out and are now working within those COVID units to make sure that all of our principles and protocols are followed there as well," Hewlett says.

Those protocols involve measures like monitoring ICU staff when they remove their protective gear to make sure the virus isn't transmitted, and placing infected patients in negative pressure rooms, which draw air inward, when possible to prevent the virus from escaping.

One of the riskiest ICU procedures is inserting a breathing tube in a COVID-19 patient's airway, which creates a direct path for virus to escape from a patient's lungs. "If you're intubating a patient, that's a much higher risk than, say, going in and doing routine patient care," Hewlett says.

So ICU teams are being advised to add several layers of protection beyond a surgical mask.

Extra personal protective equipment may include an N95 respirator, goggles, a full face shield, a head hood, an impermeable isolation gown and double gloves.

In many ICUs, teams are also placing a clear plastic box or sheet over the patient's head and upper body before inserting the tube. And as a final safety measure, the doctor may guide the tube using a video camera rather than looking directly down a patient's airway.

"It usually takes 30 minutes or so in order to get all of that equipment together, to get all of the right people there," says Dr. Kira Newman, a senior resident physician at UW Medical Center in Seattle. "and that would be a particularly fast intubation."

But most changes in the ICU are in response to an ongoing flood of new information about how COVID-19 affects the body.

There's a growing understanding, for example, that the infection can cause dangerous blood clots to form in many severely ill patients. These clots can kill if they block arteries supplying the lungs or brain. But they also can prevent blood from reaching the kidneys or even a patient's arms and legs.

Clots are a known risk for all ICU patients, Cooperman says, but the frequency and severity appears much greater with COVID-19. "So we're starting them on a higher level of medicine to prevent blood clots and if somebody actually develops blood clots, we have a plan B and a plan C and a plan D," he says.

ICU teams are also recalibrating their approach to ensuring that patients are getting enough oxygen. Early in the pandemic, the idea was to put patients on mechanical ventilator quickly to make sure their oxygen levels didn't fall too far.

But with experience, doctors have found that mechanical ventilators don't seem to work as well for COVID patients as they do for patients with other lung problems. They've also learned that that many COVID-19 patients remain lucid and relatively comfortable even when the oxygen levels in their blood are extremely low.

So many specialists are now recommending alternatives to mechanical ventilation, even for some of the sickest patients. "We're really trying now to not intubate," Osborn says.

Instead, ICU teams are relying on devices that deliver oxygen through the nasal passages, or through a mask that fits tightly over the face. And there's renewed interest in an old technique to help patients breathe. It's called proning.

"Instead of them being on their back, we're turning them on their front," Osborn says. The reason, she says is to open up a part of the lung that is collapsed when a patient is on their back.

See more here:

ICUs Transformed To Care For COVID-19 Patients : Shots - Health News - NPR

Singapore is seeing a spike in coronavirus cases among its hundreds of thousands of migrant workers. Above, a volunteer from a nonprofit group talks to migrant workers now confined to a factory that was converted to a dormitory as part of the effort to contain the spread of COVID-19. Ore Huiying/Getty Images hide caption

Singapore is seeing a spike in coronavirus cases among its hundreds of thousands of migrant workers. Above, a volunteer from a nonprofit group talks to migrant workers now confined to a factory that was converted to a dormitory as part of the effort to contain the spread of COVID-19.

Early on in the coronavirus pandemic, Singapore was praised as a shining example of how to handle the new virus. The World Health Organization pointed out that Singapore's aggressive contact tracing allowed the city-state to quickly identify and isolate any new cases. It quickly shut down clusters of cases and kept most of its economy and its schools open. Through the beginning of April, Singapore had recorded fewer than 600 cases.

By the end of April, however, the case count exceeded 17,000. And not only is all of Singapore now under a strict lockdown, but it has the most coronavirus cases in Southeast Asia.

The vast majority of these cases are in the overcrowded dormitories that house more than 300,000 of Singapore's roughly 1 million foreign workers and the number of cases is expected to continue to rise in the coming weeks.

"We have started our testing with the dormitories where there were a high number of cases detected," Singapore's health minister, Gan Kim Yong, said in a virtual press briefing this week.

Singapore ordered a lockdown on April 7 in response to an uptick in cases in the general population and then began to find a significant number of cases in the dorms.

Gan says Singapore is now testing more than 3,000 migrant workers a day but hopes to expand that number. The virus is spreading so rapidly in the dormitories, however, that the Health Ministry hasn't been able to test all of the suspected cases.

"For dormitories where the assessed risk of infection is extremely high, our efforts are focused on isolating those who are symptomatic even without a confirmed COVID-19 test," Gan says. "This allows us to quickly provide medical care to these patients."

Singapore is a small city-state with a population of just under 6 million inhabitants. On a per capita basis, it's the second-richest country in Asia.

But its economy relies heavily on young men from Bangladesh, India and other countries who work jobs in construction and manufacturing. Singapore has no minimum wage for foreign or domestic employees. The foreign workers' salaries can be as low as US$250 per month, but a typical salary is $500 to $600 a month.

Speaking to the media, Gan credited extensive screening in the dorms with finding many workers who are infected with SARS-CoV-2, the coronavirus that causes COVID-19, but who didn't appear sick.

"So far, the majority of the cases here have had relatively mild disease or no symptoms. And they do not require extensive medical intervention," Gan said. "About 30% require closer medical observation due to the underlying health conditions or because of old age."

As of this week, only a handful of the migrant workers fewer than two dozen were in intensive care units.

The city-state is setting up thousands of what it calls "community care beds" in convention centers and other public buildings to isolate and treat coronavirus patients. The hope is that most of the cases can be managed by medical staff in these temporary wards, rather than in hospitals. So far the city has 10,000 community care beds and plans to expand to 20,000 by mid-June.

It's no surprise that the migrant workers are now being infected, says Mohan Dutta, a professor at Massey University in New Zealand who has done research on these migrant laborers. He says conditions in the dorms put the workers at significant risk of catching a respiratory disease like COVID-19. There are 12 to 20 bunk beds per room.

And even though some of the workers are deemed "essential," most are no longer allowed to leave the dormitories. "There is little room to move around. They have little room to store their things, which really contributes to this sense of the rooms being unhygienic," says Dutta.

Dutta, who founded CARE, the Center for Culture-Centered Approach to Research and Evaluation, at the National University of Singapore in 2012, with a focus on marginalized communities, has just published a paper on migrant workers in Singapore during this pandemic.

He says many of them told him they are concerned about whether they'll get paid during the lockdown (Singapore's Ministry of Manpower insists they will) and about the overcrowding and lack of sanitation facilities in the dormitories.

Dutta says that in many dormitories, 100 workers share a block of five toilets and five shower stalls.

Migrant workers in Singapore congregate on the balcony of a workers dormitory now being used as an isolation facility that houses a cluster of coronavirus cases. Edgar Su/Reuters hide caption

"There is this sense of panic and fear, and part of that is related to this sense of not being able to move outside of the room," he says. "Everyone is pretty much stuck in the room at such close proximity."

Singapore's Health Ministry has moved aggressively to try to address the coronavirus outbreaks in the housing blocks. The government is trying to find alternative accommodations for people in the hardest-hit dorms, but Dutta says it's impossible to come up with safe, short-term lodging for more than 300,000 workers.

But he does believe there could be long-term changes that would help the workers. And Dutta hopes this outbreak will force Singapore to examine how it treats this often overlooked population, bringing major changes in how foreign workers are housed and treated.

Meanwhile, the explosion of cases in Singapore over the last three weeks has remained primarily among foreign workers. For example, on May 1 there were 11 new cases reported among Singapore's permanent residents and 905 new infections among the workers residing in the dorms.

Michael Merson, the head of the SingHealth Duke-NUS Global Health Institute in Singapore, says it's unlikely the outbreaks in the dormitories will spill over to the rest of the city.

"There's very little mixing between the foreign workers and the rest of the population," Merson says. He's confident that Singapore's health officials will be able to isolate the infected workers and give them, in his words, "the best medical care possible."

Nonetheless, the Singaporean government has extended the lockdown for the entire city-state until at least June 1.

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Singapore Was Praised For Controlling Coronavirus. Now It Has The Most Cases In Southeast Asia : Goats and Soda - NPR

The coronavirus has killed so many people in Iran that the country has resorted to mass burials, but in neighboring Iraq, the body count is fewer than 100.

The Dominican Republic has reported nearly 7,600 cases of the virus. Just across the border, Haiti has recorded about 85.

In Indonesia, thousands are believed to have died of the coronavirus. In nearby Malaysia, a strict lockdown has kept fatalities to about 100.

The coronavirus has touched almost every country on earth, but its impact has seemed capricious. Global metropolises like New York, Paris and London have been devastated, while teeming cities like Bangkok, Baghdad, New Delhi and Lagos have, so far, largely been spared.

The question of why the virus has overwhelmed some places and left others relatively untouched is a puzzle that has spawned numerous theories and speculations but no definitive answers. That knowledge could have profound implications for how countries respond to the virus, for determining who is at risk and for knowing when its safe to go out again.

There are already hundreds of studies underway around the world looking into how demographics, pre-existing conditions and genetics might affect the wide variation in impact.

Doctors in Saudi Arabia are studying whether genetic differences may help explain varying levels of severity in Covid-19 cases among Saudi Arabs, while scientists in Brazil are looking into the relationship between genetics and Covid-19 complications. Teams in multiple countries are studying if common hypertension medications might worsen the diseases severity and whether a particular tuberculosis vaccine might do the opposite.

Many developing nations with hot climates and young populations have escaped the worst, suggesting that temperature and demographics could be factors. But countries like Peru, Indonesia and Brazil, tropical countries in the throes of growing epidemics, throw cold water on that idea.

Draconian social-distancing and early lockdown measures have clearly been effective, but Myanmar and Cambodia did neither and have reported few cases.

One theory that is unproven but impossible to refute: maybe the virus just hasnt gotten to those countries yet. Russia and Turkey appeared to be fine until, suddenly, they were not.

Time may still prove the greatest equalizer: The Spanish flu that broke out in the United States in 1918 seemed to die down during the summer only to come roaring back with a deadlier strain in the fall, and a third wave the following year. It eventually reached far-flung places like islands in Alaska and the South Pacific and infected a third of the worlds population.

We are really early in this disease, said Dr. Ashish Jha, the director of the Harvard Global Health Research Institute. If this were a baseball game, it would be the second inning and theres no reason to think that by the ninth inning the rest of the world that looks now like it hasnt been affected wont become like other places.

Doctors who study infectious diseases around the world say they do not have enough data yet to get a full epidemiological picture, and that gaps in information in many countries make it dangerous to draw conclusions. Testing is woeful in many places, leading to vast underestimates of the viruss progress, and deaths are almost certainly undercounted.

Still, the broad patterns are clear. Even in places with abysmal record-keeping and broken health systems, mass burials or hospitals turning away sick people by the thousands would be hard to miss, and a number of places are just not seeing them at least not yet.

Interviews with more than two dozen infectious disease experts, health officials, epidemiologists and academics around the globe suggest four main factors that could help explain where the virus thrives and where it doesnt: demographics, culture, environment and the speed of government responses.

Each possible explanation comes with considerable caveats and confounding counter-evidence. If an aging population is the most vulnerable, for instance, Japan should be at the top of the list. It is far from it. Nonetheless these are the factors that experts find the most persuasive.

Many countries that have escaped mass epidemics have relatively younger populations.

Young people are more likely to contract mild or asymptomatic cases that are less transmissible to others, said Robert Bollinger, a professor of infectious diseases at the Johns Hopkins School of Medicine. And they are less likely to have certain health problems that can make Covid-19, the disease caused by the coronavirus, particularly deadly, according to the World Health Organization.

Africa with about 45,000 reported cases, a tiny fraction of its 1.3 billion people is the worlds youngest continent, with more than 60 percent of its population under age 25. In Thailand and Najaf, Iraq, local health officials found that the 20-to-29 age group had the highest rate of infection but often showed few symptoms.

By contrast, the national median age in Italy, one of the hardest hit countries, is more than 45. The average age of those who died of Covid-19 there was around 80.

Younger people tend to have stronger immune systems, which can result in milder symptoms, said Josip Car, an expert in population and global health at Nanyang Technological University in Singapore.

In Singapore and Saudi Arabia, for instance, most of the infections are among foreign migrant workers, many of them living in cramped dormitories. However, many of those workers are young and fit, and have not required hospitalization.

Along with youth, relative good health can lessen the impact of the virus among those who are infected, while certain pre-existing conditions notably hypertension, diabetes and obesity can worsen the severity, researchers in the United States say.

There are notable exceptions to the demographic theory. Japan, with the worlds oldest average population, has recorded fewer than 520 deaths, although its caseload has risen with increased testing.

And Dr. Jha of Harvard warns that some young people who are not showing symptoms are also highly contagious for reasons that are not well understood.

Cultural factors, like the social distancing that is built into certain societies, may give some countries more protection, epidemiologists said.

In Thailand and India, where virus numbers are relatively low, people greet each other at a distance, with palms joined together as in prayer. In Japan and South Korea, people bow, and long before the coronavirus arrived, they tended to wear face masks when feeling unwell.

In much of the developing world, the custom of caring for the elderly at home leads to fewer nursing homes, which have been tinder for tragic outbreaks in the West.

However, there are notable exceptions to the cultural distancing theory. In many parts of the Middle East, such as Iraq and the Persian Gulf countries, men often embrace or shake hands on meeting, yet most are not getting sick.

What might be called national distancing has also proven advantageous. Countries that are relatively isolated have reaped health benefits from their seclusion.

Far-flung nations, such as some in the South Pacific and parts of sub-Saharan Africa, have not been as inundated with visitors bringing the virus with them. Health experts in Africa cite limited travel from abroad as perhaps the main reason for the continents relatively low infection rate.

Countries that are less accessible for political reasons, like Venezuela, or because of conflict, like Syria and Libya, have also been somewhat shielded by the lack of travelers, as have countries like Lebanon and Iraq, which have endured widespread protests in recent months.

The lack of public transportation in developing countries may have also reduced the spread of the virus there.

The geography of the outbreak which spread rapidly during the winter in temperate zone countries like Italy and the United States and was virtually unseen in warmer countries such as Chad or Guyana seemed to suggest that the virus did not take well to heat. Other coronaviruses, such as ones that cause the common cold, are less contagious in warmer, moist climates.

But researchers say the idea that hot weather alone can repel the virus is wishful thinking.

Some of the worst outbreaks in the developing world have been in places like the Amazonas region of Brazil, as tropical a place as any.

The best guess is that summer conditions will help but are unlikely by themselves to lead to significant slowing of growth or to a decline in cases, said Marc Lipsitch, the director of the Center for Communicable Disease Dynamics at Harvard University.

The virus that causes Covid-19 appears to be so contagious as to mitigate any beneficial effect of heat and humidity, said Dr. Raul Rabadan, a computational biologist at Columbia University.

But other aspects of warm climates, like people spending more time outside, could help.

People living indoors within enclosed environments may promote virus recirculation, increasing the chance of contracting the disease, said Mr. Car of Nanyang Technological University.

The ultraviolet rays of direct sunlight inhibit this coronavirus, according to a study by ecological modelers at the University of Connecticut. So surfaces in sunny places may be less likely to remain contaminated, but transmission usually occurs through contact with an infected person, not by touching a surface.

No scientist has proposed that beaming light inside an infected person, as President Trump has suggested, would be an effective cure. And tropical conditions may have even lulled some people into a false sense of security.

People were saying Its hot here, nothing will happen to me, said Dr. Domnica Cevallos, a medical investigator in Ecuador. Some were even going out on purpose to sunbathe, thinking it would protect them from infection.

Countries that locked down early, like Vietnam and Greece, have been able to avoid out-of-control contagions, evidence of the power of strict social distancing and quarantines to contain the virus.

In Africa, countries with bitter experience with killers like H.I.V., drug-resistant tuberculosis and Ebola knew the drill and reacted quickly.

Airport staff from Sierra Leone to Uganda were taking temperatures (since found to be a less effective measure) and contact details and wearing masks long before their counterparts in the United States and Europe took such precautions.

Senegal and Rwanda closed their borders and announced curfews when they still had very few cases. Health ministries began contact tracing early.

All this happened in a region where health ministries had come to rely on money, personnel and supplies from foreign donors, many of which had to turn their attention to outbreaks in their own countries, said Catherine Kyobutungi, executive director of the African Population and Health Research Center.

Countries wake up one day and theyre like, OK, the weight of the country rests on our shoulders, so we need to step up, she said. And they have. Some of the responses have been beautiful to behold, honestly.

Sierra Leone repurposed disease-tracking protocols that had been established in the wake of the Ebola outbreak in 2014, in which almost 4,000 people died there. The government set up emergency operations centers in every district and recruited 14,000 community health workers, 1,500 of whom are being trained as contact tracers, even though Sierra Leone has only about 155 confirmed cases.

It is not clear, however, who will pay for their salaries or for expenses like motorcycles and raincoats to keep them operating during the coming wet season.

Uganda, which also suffered during the Ebola contagion, quickly quarantined travelers from Dubai after the first case of coronavirus arrived from there. Authorities also tracked down about 800 others who had traveled from Dubai in previous weeks.

The Ugandan health authorities are also testing around 1,000 truck drivers a day. But many of those who test positive have come from Tanzania and Kenya, countries that are not monitoring as aggressively, leading to worries that the virus will keep penetrating porous borders.

Lockdowns, with bans on religious conclaves and spectator sporting events, clearly work, the World Health Organization says. More than a month after closing national borders, schools and most businesses, countries from Thailand to Jordan have seen new infections drop.

In the Middle East, the widespread shuttering of mosques, shrines and churches happened relatively early and probably helped stem the spread in many countries.

A notable exception was Iran, which did not close some of its largest shrines until March 18, a full month after it registered its first case in the pilgrimage city of Qum. The epidemic spread quickly from there, killing thousands in the country and spreading the virus across borders as pilgrims returned home.

As effective as lockdowns are, in countries lacking a strong social safety net and those where most people work in the informal economy, orders closing businesses and requiring people to shelter in place will be difficult to maintain for long. When people are forced to choose between social distancing and feeding their families, they are choosing the latter.

Counter-intuitively, some countries where authorities reacted late and with spotty enforcement of lockdowns appear to have been spared. Cambodia and Laos both had brief spates of infections when few social distancing measures were in place but neither has recorded a new case in about three weeks.

Lebanon, whose Muslim and Christian citizens often go on pilgrimages respectively to Iran and Italy, places rife with the virus, should have had high numbers of infections. It has not.

We just didnt see what we were expecting, said Dr. Roy Nasnas, an infectious disease consultant at the University Hospital Geitaoui in Beirut. We dont know why.

Finally, most experts agree that there may be no single reason for some countries to be hit and others missed. The answer is likely to be some combination of the above factors, as well as one other mentioned by researchers: sheer luck.

Countries with the same culture and climate could have vastly different outcomes if one infected person attends a crowded social occasion, turning it into what researchers call a super-spreader event.

Because an infected person may not experience symptoms for a week or more, if at all, the disease spreads under the radar, exponentially and seemingly at random. Had the woman in Daegu stayed home that Sunday in February, the outbreak in South Korea might have been less than half of what it is.

Some countries that should have been inundated are not, leaving researchers scratching their heads.

Thailand reported the first confirmed case of coronavirus outside of China in mid-January, from a traveler from Wuhan, the Chinese city where the pandemic is thought to have begun. In those critical weeks, Thailand continued to welcome an influx of Chinese visitors. For some reason, these tourists did not set off exponential local transmission.

And when countries do all the wrong things and still end up seemingly not as battered by the virus as one would expect, go figure.

In Indonesia, we have a health minister who believes you can pray away Covid, and we have too little testing, said Dr. Pandu Riono, an infectious disease specialist at the University of Indonesia. But we are lucky we have so many islands in our country that limit travel and maybe infection.

Theres nothing else were doing right, he added.

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The Covid-19 Riddle: Why Does the Virus Wallop Some Places and Spare Others? - The New York Times

People mostly white, sometimes armed, occasionally carrying Confederate flags or hoisting placards emblazoned with a Nazi slogan from the Holocaust have been loudly protesting to push their state governments to reopen business and spaces before enough progress has been made to contain the coronavirus. This is yet another illustration of the race and class divide this pandemic has illuminated in this country.

For some, a reopened economy and recreational landscape will mean the option to run a business, return to work, go to the park or beach, or have a night on the town at a nice restaurant or swanky bar. But for many on the lower rungs of the economic ladder, it will only force them back into compulsory exposure to more people, often in occupations that make it hard to protect oneself and that pay little for the risk.

Georgia was on the forefront of state reopenings. The first businesses that were allowed to reopen were, for the most part, those that provide low-wage jobs that require significant contact like tattoo parlors, barbershops and hair salons, and nail shops.

These are the struggling workers who entertain and aestheticize people of means. These businesses were by no means essential, and they put these workers in danger. There is absolutely no way to practice social distancing while inking someone a tattoo. (Also, what are you so desperate to stamp on your body that you would risk it all during a pandemic?)

And many of the people doing these jobs will have to take public transit to get to work, and search for suitable child care before they leave home. Schools in most cases are still closed.

But, even among professions that we dont immediately consider low-wage or minority-dominated, there are areas of high risk and low wages. For many people, the image that comes to mind about the medical field, those on the front lines, are doctors and nurses, people who are highly educated and highly paid. But there are many other people in those hospitals that make them run.

For instance, a majority of nursing assistants are members of racial minority groups. A third are African-American. Half have completed no formal education beyond high school. And, according to RegisteredNursing.org, the median annual wage for a nursing assistant in a hospital is just $30,000. For those in nursing homes and providing home care, the pay is even lower.

It has been widely reported that the virus is having a disproportionate impact on black and brown people in America, both in terms of infections and death. But that is only one aspect of the disparities. In a country where race and ethnicity often intersect with wealth and class, there are a cascade of other impacts, particularly economic ones, to remain conscious of.

In a Pew Research Center survey conducted last month, 52 percent of low-income workers said they or someone in their household had lost a job or taken a pay cut as a result of the pandemic. But, when you look at this through a racial lens, another striking reality emerges: 61 percent of Hispanic people agree with the statement, compared to 44 percent of African-Americans and just 38 percent of white people.

And, as Pew pointed out, lower-income adults are less prepared to withstand a financial shock than those with higher incomes.

A McKinsey and Company report last month found:

Thirty-nine percent of jobs held by black workers, seven million jobs in all, are vulnerable as a result of the Covid-19 crisis, compared with 34 percent for white workers.

Forty percent of the revenues of black-owned businesses are in the five most vulnerable sectors including leisure, hospitality and retail compared with 25 percent of the revenues of all U.S. businesses.

Beyond the threat to black personal economics, the crisis also poses a threat to black institutions. As the McKinsey report pointed out, the crisis is likely to significantly and quickly hobble historically black colleges and universities.

Even when the country starts to recover, the race and class disparities will most likely still be present and working against minorities in low-wage jobs. As the Center for American Progress wrote last month, Evidence demonstrates that while workers of color are often the first to be fired during economic downturns, they are often the last to be rehired during recoveries.

This pandemic is likely to not only expose inequalities, but also exacerbate them.

America has never been comfortable discussing the inequalities that America created, let alone addressing them. America loves a feel-good, forget-the-past-lets-start-from-here mantra.

But, this virus is exploiting these man-made inequalities and making them impossible to ignore. It is demonstrating the incalculable callousness of wealth and privilege that would willingly thrust the less well off into the most danger for a few creature comforts.

This crisis is exposing the class savagery of American democracy and the economic carnage that it has always countenanced.

The Times is committed to publishing a diversity of letters to the editor. Wed like to hear what you think about this or any of our articles. Here are some tips. And heres our email: letters@nytimes.com.

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Covid-19s Race and Class Warfare - The New York Times

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Levi Sucre Romero remembers hearing the news back in January about a novel coronavirus infecting people in China. I honestly didnt believe it would make it this far, he said. I felt like it was really far away.

A member and leader of the Bribri, one of Costa Ricas largest indigenous groups, Romero lives in Talamanca, a remote, mountainous region in the south of the country full of meandering rivers, dense jungle canopies and a near-constant drizzle of warm rain. Though the thatched-roof wooden homes of Talamanca Bribri, the groups territory, are far removed from the countrys popular tourist hubs, Romero soon realised that it was only a matter of time until the virus reached them.

Romero also realised something else: the virus, he believes, was unleashed by human greed and ill treatment of the planet. Were unbalancing the habitat of species, were cutting down trees, were planting monocultures, were filling the world with cities and asphalt and were using too many chemicals, Romero said. Its a cocktail of bad practices.

Like Sars and Mers, two other recent, deadly coronaviruses, Covid-19 is a zoonotic disease that came from an animal. Evidence points to its likely origin in a bat, followed by a potential crossover into an intermediary species possibly a pangolin before transmission into humans at a wet market in Wuhan, China. While Covid-19s exact origins have yet to be pinpointed, overwhelming research shows that deforestation and commercial wildlife trade heighten the risk of zoonotic diseases that can potentially cause pandemics. And according to Romero, both are human activities that entail the destruction of nature.

My people have cultural knowledge that says when Sib, our God, created Earth, he locked up some bad spirits, Romero said. These spirits come out when were not respecting nature and living together.

Romero coordinates the Mesoamerican Alliance of People and Forests, one of the most important land-rights platforms for indigenous communities in Central America and Mexico, which represents more than 50,000 people who live in the most densely forested lands in the region. He knows for a fact that there is another, more sustainable and respectful way to live in relation to the Earth because the Bribri and many other indigenous groups around the world practice it.

I do not believe this will be the last pandemic of this type

For years, Romero and other indigenous leaders have been urging the rest of the world to adopt a more indigenous-inspired way of coexisting with nature, including leaving habitats intact, harvesting plants and animals at sustainable levels and acknowledging and respecting the connection between human and planetary health. Now, they are reiterating that message in light of the coronavirus.

At a March panel sponsored by the global journalism initiative Covering Climate Now in New York City, held days before the city shut down and later became the global epicentre of the worldwide pandemic, Romero and other indigenous leaders from Brazil and Indonesia emphasised the role that traditional knowledge, practices and land stewardship can play in protecting the planet. These protections, they said, extend not just to lessening climate change and biodiversity loss, but to reducing the risk of future pandemics.

We are convinced that this pandemic is the result of a wrong use of natural resources and a wrong way of living together with these resources, Romero said. I do not believe this will be the last pandemic of this type.

A wealth of research supports the link between novel disease emergence and environmental destruction. Many viruses naturally occur in animal species, and deforestation increases the odds of people coming into contact with an animal carrying a virus that is new to humanity, potentially resulting in a spill-over event. A 2017 Nature Communications paper revealed that emerging zoonotic disease risk is highest in tropical forests that are experiencing land-use changes, including from logging, mining, dam building and road development. As the authors report, such activities carry an intrinsic risk of disease emergence because they disrupt ecological dynamics and increase contact between humans, livestock and wildlife.

Its a stochastic process, said Erin Mordecai, a biologist at Stanford University. Its driven by chance encounters between particular people and particular animals, and what pathogens theyre carrying at that time.

Deforestation can also spread existing diseases. In October, Mordecai and co-author Andrew MacDonald reported in the Proceedings of the National Academy of Sciences that an increase in deforestation in Brazil tends to increase the rate of malaria transmission, with about six-and-a-half new cases occurring per square kilometre of cut-down forest. The reason, they believe, is that cutting trees creates more forest edge the favourite breeding habitat for Brazils malaria-transmitting mosquitoes. Development in frontier regions also brings more people closer to the forest and draws pioneers in from other parts of the country who have never been exposed to malaria and thus have no resistance.

Deforestation tends to lead to these opportunities in which species that dont normally come into contact are coming into contact

While every disease is different, the general pattern, Mordecai told me, is that deforestation disrupts ecosystems and creates edge habitats hovering between domesticated and wild, in which the human and natural world overlap. Deforestation tends to lead to these opportunities in which species that dont normally come into contact are coming into contact, she said. That creates opportunities for pathogens to spill over.

Studies reveal that the both legal and illegal commercial wildlife trade also increase the risk of new diseases emerging by subjecting wild animals to stressful, unhygienic conditions. Still-living species are often mixed together, allowing them to exchange viruses. Trade also often takes place in urban centres, where many people may come into contact with the animals and with each other further encouraging a new diseases spread.

The wildlife trade itself is also linked to deforestation. Hunters and poachers tend to access wilderness areas through roads. As formerly remote areas are opened up by new transportation corridors, wildlife trade tends to follow.

Medical experts and conservationists have been warning of the health risks posed by both deforestation and wildlife trade for decades, but to no avail. In 2003, for example, China briefly banned wildlife trade in response to Sars, but business resumed within a year and has only grown since.

As land stewards, many indigenous groups help to guard against these threats. By protecting indigenous landscapes, youre protecting not only those people and their way of life, but also preventing really rapid transformation of landscapes, Mordecai said. That rapid transformation has huge-scale cultural and environmental consequences, but also disease-transmission consequences.

How travellers can help protect indigenous land

Indigenous tourism directly engages indigenous people to let them share their culture and land on their own terms. According to the United Nations World Tourism Organization, indigenous tourism can spur cultural interaction and revival, bolster employment, alleviate poverty, curb rural flight migration, empower women and youth, encourage product diversification, and nurture a sense of pride among indigenous people.

To ensure that your travel will directly benefit the people whose culture and land you experience, the World Indigenous Tourism Alliance recommends booking indigenous-owned-and-operated tours. Fortunately, indigenous-led travel experiences have recently surged in places like Australia, Canada and the US. In the last few years, the Bribri launched Costa Ricas first indigenous-operated tour agency, which teaches visitors about the groups worldview and spiritual connection to the land, with all funds going back to the community.

A large number of indigenous groups live in tropical forests precisely the landscapes with the highest risk for new disease emergence, and also the places facing the highest rates of deforestation. Tropical deforestation is accelerating and accounts for about 90% of total deforestation worldwide. A 2020 study reported that at least 36% of the worlds remaining intact forests half of which are located in the tropics fall within indigenous lands.

Of course, indigenous people are extremely diverse. Some live in cities, others in forests; some extract resources for profit, others use nature only for subsistence. In general, though, indigenous groups are much more effective at protecting the forest and environment on their lands than most other users, said Mary Menton, a research fellow in environmental justice at the University of Sussex. In certain parts of Brazil, for example, indigenous protection is visible in satellite images from space.

You can see exactly where the lines of indigenous territories are, Menton said. Deforestation eats into forests around where indigenous areas are, and those areas really act as an effective barrier for expansion.

Indigenous peoples lands, by and large, tend to be much better protected than other areas of the forest

This is also supported by scientific evidence. A 2012 study comparing 40 protected areas and 33 community-managed forests revealed that the community-managed areas suffered less deforestation. If we look across the tropics, indigenous peoples lands, by and large, tend to be much better protected than other areas of the forest, even comparing community and indigenous lands to protected areas, Menton said.

Practically speaking, this is partly because indigenous people tend to live on large areas of land with relatively small populations. But even groups that live in smaller tracts of forest in north-east Brazil, for example, live more sustainably than much of the rest of humanity. Its not just that they have lots of forest, its the way they treat and see the forest, and interact with it, Menton said.

Many groups have been living in forested areas for generations and view the landscape as part of their community. Some also believe that their ancestors are part of the forest. Protecting nature, therefore, isnt just about ecology and biodiversity, Menton says, but also about preserving lives, history and culture.

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Indigenous people accomplish this through a variety of means that largely boil down to having a respect and awareness of the effect they have on the forest, Menton said. The Bribri, for example, divide their land into family and community areas, each of which have internal rules designed to promote sustainability. For example, members of the community can cut as many leaves as they want from local suita palms used to make everything from houses to brooms so long as they leave at least five leaves on each harvested plant so it can produce more leaves.

We need to rethink the model of development thats based on accumulating wealth while destroying resources

Many indigenous people also do not treat the forest as a means or impediment to getting rich. Romero, for his part, thinks that hyper-globalisation and consumerism are at the heart of many of the worlds ills. We need to rethink the model of development thats based on accumulating wealth while destroying resources, Romero said. I see an economic model that is predatory to resources and to nature, that causes a lack of balance in the world.

However, profit-driven companies, governments and individuals often view indigenous people as standing in the way of economic growth. Around the world, indigenous land rights are under attack by agriculture, mining and other extractive industries. Between 2002 and 2017, Menton found that more than 1,500 environmental defenders were murdered in 50 countries, and that indigenous peoples died in higher numbers than any other group on the list. In 2015 and 2016, for example, indigenous people represented 40% of all murdered environmental defenders. A report published in April 2020 by the Pastoral Land Commission, a non-profit organisation in Brazil, likewise revealed that one-third of all families who faced land conflicts in rural Brazil in 2019 were indigenous.

Menton adds that indigenous people face additional threats because of racism and perceptions that theyre second-class citizens. Often, this is a problem promoted from the top down. Brazils president, Jair Bolsonaro, recently said, for example, that Indians are evolving to become increasingly human, like us. Indigenous people, in other words, are facing threats both in terms of actual physical conflicts over land, but also cultural threats and attacks over their right to exist, Menton said.

Attacks on indigenous rights are not just attacks on individual cultures, Romero says, but on the health of the planet as a whole. When we have rights over our forests and our lands, that means survival for us, for our families, he said. But it also means we have a better probability of avoiding pandemics.

The Bribri, like much of the world, are now on lockdown. The rhythm of our lives has been cut short, he said. Visits with elders are no longer permitted, sales of produce to the national market have dropped by around 90%, and the groups cultural and ecological tourism efforts including guided trips to mountains and rivers, traditional food tours and home stays on family ranches have stopped as well. I could go on and on. Theres a lot of impacts, Romero said.

Once the world does emerge from Covid-19, Romero hopes that there will be a silver lining to all of the suffering, loss and hardship that it has caused. He hopes that people will be more receptive to the knowledge that he and other indigenous leaders have to offer, and that humanity will begin to re-evaluate its relationship with nature.

I think we have a long way to go, but after the coronavirus, I have faith that this will open up some space with governments, Romero said. After this pandemic, governments should listen more.

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