Pandemics and Epidemiology (COVID-19, monkeypox, etc.)

Shakespeare spent most of his career in London, where the theaters were, while his family lived in Stratford-upon-Avon. During the plague of 1606, the playwright was lucky to be spared from the epidemic—his landlady died at the height of the outbreak—and his wife and two adult daughters stayed safely in the Warwickshire countryside. Newton, meanwhile, never married or had children. He saw out the Great Plague of 1665–6 on his family’s estate in the east of England, and spent most of his adult life as a fellow at Cambridge University, where his meals and housekeeping were provided by the college.

For those with caring responsibilities, an infectious-disease outbreak is unlikely to give them time to write King Lear or develop a theory of optics. A pandemic magnifies all existing inequalities (even as politicians insist this is not the time to talk about anything other than the immediate crisis). Working from home in a white-collar job is easier; employees with salaries and benefits will be better protected; self-isolation is less taxing in a spacious house than a cramped apartment. But one of the most striking effects of the coronavirus will be to send many couples back to the 1950s. Across the world, women’s independence will be a silent victim of the pandemic.

...As much of normal life is suspended for three months or more, job losses are inevitable. At the same time, school closures and household isolation are moving the work of caring for children from the paid economy—nurseries, schools, babysitters—to the unpaid one. The coronavirus smashes up the bargain that so many dual-earner couples have made in the developed world: We can both work, because someone else is looking after our children. Instead, couples will have to decide which one of them takes the hit.

Many stories of arrogance are related to this pandemic. Among the most exasperating is the West’s failure to learn from history: the Ebola crisis in three African countries in 2014; Zika in 2015–6; and recent outbreaks of SARS, swine flu, and bird flu. Academics who studied these episodes found that they had deep, long-lasting effects on gender equality. “Everybody’s income was affected by the Ebola outbreak in West Africa,” Julia Smith, a health-policy researcher at Simon Fraser University, told The New York Times this month, but “men’s income returned to what they had made pre-outbreak faster than women’s income.” The distorting effects of an epidemic can last for years, Clare Wenham, an assistant professor of global-health policy at the London School of Economics, told me. “We also saw declining rates of childhood vaccination [during Ebola].” Later, when these children contracted preventable diseases, their mothers had to take time off work.

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According to the British government’s figures, 40 percent of employed women work part-time, compared with only 13 percent of men. In heterosexual relationships, women are more likely to be the lower earners, meaning their jobs are considered a lower priority when disruptions come along. And this particular disruption could last months, rather than weeks. Some women’s lifetime earnings will never recover. With the schools closed, many fathers will undoubtedly step up, but that won’t be universal.

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The evidence we do have from the Ebola and Zika outbreaks should inform the current response. In both rich and poor countries, campaigners expect domestic-violence rates to rise during lockdown periods. Stress, alcohol consumption, and financial difficulties are all considered triggers for violence in the home, and the quarantine measures being imposed around the world will increase all three. The British charity Women’s Aid said in a statement that it was “concerned that social distancing and self-isolation will be used as a tool of coercive and controlling behaviour by perpetrators, and will shut down routes to safety and support.”

Researchers, including those I spoke with, are frustrated that findings like this have not made it through to policy makers, who still adopt a gender-neutral approach to pandemics. They also worry that opportunities to collect high-quality data which will be useful for the future are being missed. For example, we have little information on how viruses similar to the coronavirus affect pregnant women—hence the conflicting advice during the current crisis...

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Wenham supports emergency child-care provision, economic security for small-business owners, and a financial stimulus paid directly to families. But she isn’t hopeful, because her experience suggests that governments are too short-termist and reactive. “Everything that's happened has been predicted, right?” she told me. “As a collective academic group, we knew there would be an outbreak that came out of China, that shows you how globalization spreads disease, that’s going to paralyze financial systems, and there was no pot of money ready to go, no governance plan … We knew all this, and they didn't listen. So why would they listen to something about women?”

Paris-based psychiatrist Marie-France Hirigoyen recently recounted the plight of one woman stuck at home with a partner prone to violence.

“When her husband drinks, the effects are already terrible – she frequently suffers from psychological and physical violence," said Hirigoyen, who counsels a number of domestic violence victims. “But with the lockdown, that risk has increased. She just called me saying he went out to do some shopping and buy alcohol; she's terrified of when he returns."

France has been in lockdown since March 17 – a situation that could last for weeks and possibly months. It is an unprecedented scenario that could have enormous repercussions for the safety of those confined with an abusive partner.

Since the start of the lockdown, Hirigoyen has received several calls and messages from patients fearing for their safety.

“Domestic violence perpetrators are already fragile individuals who cannot bear frustration, so the confinement will only worsen the situation,” she told FRANCE 24.

Measures to address the problem

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With the whole of France now on lockdown, activists, women’s groups and health workers need only look at what happened in China at the height of the coronavirus epidemic.

Attacks in China tripled in February compared to the same period the previous year, according to a former police officer from Hubei province who has founded an association combatting domestic violence.

In a report earlier this month that looked at the impact of coronavirus on women, Human Rights Watch cited local Chinese media reports on the uptick in domestic abuse.

It noted the lockdown had triggered a “greater incidence of domestic violence for reasons including increased stress, cramped and difficult living conditions, and breakdowns in community support mechanisms”.

“Crises can often further limit women’s ability to get away from abuse, and place victims in an environment without appropriate access to services, such as a safe shelter away from abusers and accountability for abuse,” Human Rights Watch wrote.

A worrying silence

There was much concern among French NG Os working with sufferers of domestic abuse when the French government announced the lockdown.

“Times of crisis are always conducive to a rise in violence,” said Caroline De Haas, a member of the French feminist collective Nous Toutes (All of us).

“For those suffering at home, it can quickly go from psychological abuse to physical, sexual violence, and maybe even lead to femicide.”

In response, Marlène Schiappa, the French minister for gender equality, said the emergency hotline for victims (3919) would remain open during this period.

However, FRANCE 24's attempts to call the hotline this week were unsuccessful. Officials later told us that calls to the hotline are “in the process of being transferred to the numbers of other associations”.

Those working on the front line are extremely worried that their phones are not ringing.

“Since March 17, we have had practically no calls; usually it's four to seven calls per week," said Delphine Zoughebi, a lawyer in Paris who specialises in defending domestic violence victims.

Zoughebi said one client has not been in contact since the court summoned her abusive partner several days ago.

“The situation is very worrying, I know that spouses often look at their partners’ cell phones,” she said. “My client is a mother who lives with her child under the same roof as her spouse. For the last few days, she has been locked up with him.”

Urgent court hearings are still being held despite the lockdown, allowing judges to issue emergency protection orders so the accused is no longer permitted to live with the affected partner or the family. But these hearings are limited in number.

Nowhere to go

The question remains as to what options women have when everyone is under government order to stay home. As Pauline Baron from Nous Toutes explained: “Currently, they cannot go to a hotel, can’t take refuge with relatives; they really have no other solution.”

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Zoughebi said there was one remaining line of defence that does not require additional government resources: “Solidarity between neighbours. If you hear furniture falling, chairs being thrown, angry shouting, you need to see what is happening or alert the police. That is the best thing to do in these times of confinement.”

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France does not have to look far for a model of how to deal with domestic violence in the era of coronavirus. Neighbouring Spain, the second European country to be hard hit by COVID-19 after Italy, has already implemented innovative measures to combat domestic violence. Madrid has established an instant messaging service with a geolocation function and offers an online chat room that provides immediate psychological support to victims.

In some cases, it’s a lag in reporting, caused by delays and possible breakdowns in logging positive tests and making them public. In other, more troubling, cases, medical experts told Buzz Feed News they think it’s because people are not being tested before or after they die.

In the US, state and county authorities are responsible for collecting data on cases of COVID-19, the disease caused by the novel coronavirus, and deaths. The data is then reported to the Centers for Disease Control and Prevention.

In California, one ER doctor who works at multiple hospitals in a hard-hit county told Buzz Feed News, “those medical records aren't being audited by anyone at the state and local level currently and some people aren’t even testing those people who are dead.”

“We just don't know. The numbers are grossly underreported. I know for a fact that we’ve had three deaths in one county where only one is listed on the website,” the doctor said.

A spokesperson for the California Department of Health told Buzz Feed News in an email that “local health jurisdictions are required to report all positive COVID-19 cases to the state. In addition, when a death or impending death from COVID-19 occurs, health care facilities must immediately notify their local health jurisdiction and the state."

They did not immediately address the question of whether they’re confident their death count is accurate given the shortage of testing for COVID-19.

And two of the hardest-hit areas in the nation — New York City and Los Angeles County — released guidance earlier this week encouraging doctors not to test patients unless they think the test will significantly change their course of treatment. That means that potentially more people in both places could be admitted to hospitals with severe respiratory symptoms and recover — or die — and not be registered as a coronavirus case.

LA County and New York City’s health departments did not immediately respond to requests for comment.

Doctors and nurses working in several hospitals around the country, who spoke with Buzz Feed News on the condition of not being named out of fear of repercussions, said that the official counts of COVID-19 related deaths are not comprehensive for three main reasons: a lack of tests and protective equipment means not everyone who contracted or dies of COVID-19 is diagnosed; overwhelmed hospitals may be running behind on reporting the numbers to state and county authorities; and some hospitals reporting their totals on a daily basis say they’re not being reflected promptly in county and state reports.

This doesn’t necessarily mean that authorities are underestimating how deadly the disease is. States across the US have implemented stay-at-home orders in part because there are an unknown number of people who have COVID-19, including some who may never even have symptoms or get mildly sick and recover but are still capable of spreading the virus.

What it does mean is that we don’t have a fully accurate picture of how widespread COVID-19 deaths are, or where they’re happening at the highest rates. While staff at hospitals prioritize treating patients and saving lives — testing doesn’t usually change the course of treatment for COVID-19 — the lack of reliable numbers becomes a real problem when it comes to understanding the true scope of the crisis, and where resources are most urgently needed, according to doctors and disaster response experts.

The lack of available COVID-19 tests has crippled the US response to the coronavirus. The initial tests distributed to major state and city labs in February proved to be unreliable, and the FDA did not allow state and clinical laboratories to make and administer their own tests until the end of the month.

Although the CDC issues guidance and guidelines, local authorities in each state have the power to decide who, alive or dead, can be tested and how the tests are administered. That’s why there has been such variation in COVID-19 testing depending on where you live. The lack of federally mandated rules on reporting positive cases and deaths reflects an ongoing problem with major disaster responses in the US — the CDC’s guidelines and recommendations don’t add up to a cohesive national system, because states can choose if and when they use those recommendations.

The way states and counties make that information public has varied significantly — in Los Angeles, COVID-19 cases are listed by neighborhood. New York City makes that data available only by county.

The process by which medical professionals report COVID-19 cases to the CDC is standardized across the country. The CDC does not publicize the number of cases or deaths it studies.

For months, the CDC instructed state and local health departments to send tissue samples from all suspected COVID-19 deaths to them so the CDC could test for the disease. On Wednesday the agency issued new guidelines, since access to tests is increasing: Now, the agency only recommends that departments incapable of testing people, both alive and dead, send samples to the CDC.

The CDC did not immediately respond to request for comment on the volume of postmortem tests they’ve been processing and how quickly results are available and sent back to local health authorities.

Some medical professionals said that it isn’t just a lack of testing that’s leading to a probable under-counting of people who contracted COVID-19 and the deaths caused by COVID-19. They said there’s also a lag in county and state records reflecting the positive COVID-19 test results and deaths they’re seeing first hand. It’s not clear why that’s the case.

“We have confirmed at least 5 cases in our hospital, but official state reporting only lists one case in our entire county,” said one department head at a small hospital in Mississippi, referring to patients who had tested positive for COVID-19 but were not reflected in county numbers.

The Mississippi Department of Health did not immediately respond to a request for comment.

A nurse in Texas told Buzz Feed News the lag is partly because test results are slow to come back — the nurse said they have seen some patients either be sent home as they start to feel better or die from the disease before their results come in.

The Texas Department of Health said in an email to Buzz Feed News on Wednesday that on Tuesday night they “updated [their] process for collecting info for [their] online case count to speed up how quickly new cases show up there,” collecting information from data that counties and local health departments make public every day, rather than waiting for those agencies to send them official case reports, “which was creating a larger lag in numbers.”

“We always encourage people to go to their local health department for the most updated numbers. They get case reports first and will have the latest information,” the Texas health department spokesperson said in the email.

How cases are reported has frustrated health care workers.

“From the beginning when it was easier to track, we'd had confirmed cases in our ER and on my unit all while the news and dot gov websites continued to claim our county and affiliated hospital counties were still at zero cases,” another nurse at a large teaching hospital in New Jersey told Buzz Feed News.

“I have still not seen any reports on COVID patients of ours who died this week,” the nurse said.

“It is beyond my capacity to constantly monitor this and I am not sure why things aren't being reported as we have rigorous documentation and reporting procedures in place for the CDC,” the nurse added, referring to the COVID-19 reporting form released by the CDC for health departments to report cases.

Robert Jensen, CEO of Kenyon International, a private company that specializes in disaster response where there’s a significant death count, said that it’s not surprising that the official numbers have not caught up to what medical professionals are seeing on the front lines.

“Right now, everyone is just doing it ad hoc. I don't think the documents have even caught up because I think those things take weeks, and I don’t think they’ll catch up for some time,” he said.

Jensen added that knowing exactly how many people are contracting and dying of the disease will be important down the track when COVID-19 vaccines become available, to get those resources to the most vulnerable communities.

“When a vaccine comes out you have to identify who’s at risk, and that's why the data is so key,” he said.

The uncertainty and lack of available testing has left some families in the US wondering about the recent deaths of people close to them, even if they can’t definitively link those deaths to the outbreak. One 44-year-old woman in Massachusetts, who also asked not to be named out of fear of repercussions online, told Buzz Feed News she’s left without answers about whether her father, who died in January, was a casualty of the virus.

She believes there’s a strong chance he had COVID-19, and at the very least thinks he should have been tested. Her father, 74, was admitted into a hospital on Jan. 22, and died about a week later, on Jan. 30, his cause of death listed on his death certificate as “respiratory failure.” She said he had a dry cough and a high fever, but wasn’t tested for COVID-19 while he was alive or after he died. He tested negative for the flu. The first CDC reported death related to the disease caused by the new coronavirus in the US was in Washington on Feb. 29. The first confirmed case of COVID-19 was diagnosed on Jan. 20 in Washington.

“The shortness of breath was why he called the ambulance,” she said. “Now my dad was not the healthiest guy. He had heart troubles and also suffered from COPD and emphysema, but he had had pneumonia numerous times and this was different for him. And the dry cough, he never had that before.”

She said she had to make the decision to take him off a CPAP ventilator when it became clear that his condition had deteriorated.

“This was the hardest decision to make, but he just kept getting worse. I wish he was tested, but obviously that can't happen now. I wouldn't wish that on my worst enemy. It was hard on him and my family,” she said.