Scientists and industry are dashing to make more ventilators

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ONE OF THE most worrying symptoms of covid-19 is the way the coronavirus attacks the lungs of those infected. This means some patients need a ventilator to help them breathe until their lungs recover. But there is a dire shortage of these machines in hospitals, so intensive-care units will be overwhelmed. Urged on by worried governments, ventilator manufacturers are working flat out and forming partnerships with carmakers, aerospace firms and others to boost output as fast as possible.

But their efforts will still be not enough to meet soaring demand. So hope is riding on scores of new projects to develop breathing devices that could be made rapidly by non-specialist companies and small workshops. These are mostly simpler devices; some could even be assembled by DIY enthusiasts. The response to this call to arms is unprecedented.

Yet difficulties and dangers lie ahead. At present ventilation is about the only way doctors have to treat those who are seriously ill from the novel coronavirus, and the shortage of available machines is terrifying. In America the Society of Critical Care Medicine estimates that roughly 200,000 ventilators may be available, though many are older machines that have been in storage and may not be capable of supporting patients with severe respiratory failure. By some estimates, nearly 1m Americans may need mechanical ventilation at the peak of the country’s covid-19 epidemic. And the number of potentially critically ill patients who need ventilating could be much higher. At some point the people needing ventilators will probably far outnumber the machines available. Similar shortages exist in other countries, and in some parts of the world the number of ventilators in a hospital can be counted on one hand.

In their desperation some doctors are trying to connect more than one patient to a single ventilator, even though manufacturers do not recommend this because individual patients need different levels of breathing support.

Ventilators work by pumping air, mixed with additional oxygen as required by the patient, into the lungs. Carbon dioxide is expelled as the lungs contract. The air can be supplied to a patient via a mask. If more breathing support is needed, a tube is inserted down the patient’s trachea and into his or her airways, a process known as intubation. Alternatively, air can be delivered through a tube inserted through an incision in the windpipe.

Ventilators need to be carefully adjusted to suit each patient. This includes setting the number of breaths the machine delivers per minute and the “tidal volume” of air that flows back and forth as the patient breathes in and out.

Ventilators can do other things too, such as helping patients start to breathe on their own. The most sophisticated machines, which can cost up to $50,000, are packed with sensors and patient-care features. But even when used by highly trained staff, ventilators can cause serious complications, such as overinflation of the lungs, in some patients. In the hands of amateurs they could be lethal.

Faster, faster

So what chance do science and industry have of dramatically ramping up production? The task is formidable. Some groups have little or no experience in the medical field and are trying to cram into a few weeks processes of design, testing, approval and manufacturing that usually take a couple of years.

Yet that does not mean it is impossible. It all depends on the options that are available, says Tim Minshall, head of the Institute for Manufacturing at the University of Cambridge. At one end of the spectrum, he says, existing ventilator producers can be helped to make more machines. In the middle are simpler designs for respirators that might be more easily manufactured and could be built by skilled companies that regulators trust. Then there are newcomers with prototypes but no direct experience in making medical equipment.

Behind all these efforts are companies, groups and well-intentioned individuals keen to make their open-source designs freely available to anyone prepared to start producing them. Hospitals and regulators will, naturally enough, be cautious, wanting to ensure that equipment is safe and reliable, adds Professor Minshall. It is not just the risk to patients and staff they are worried about, but also legal liability. A fast-track approval service, which some countries are planning, would help.

Existing producers are stretching themselves. Hamilton Medical, a Swiss firm that is one of the biggest manufacturers of ventilators, usually turns out 220 machines a week. After moving office workers onto the production line, it hopes to double that by the end of April. Siare Engineering in Italy produces 160 ventilators a month and aims to triple that with the help of army technicians. Medtronic, an American firm with its headquarters in Ireland, plans to more than double its 250 employees making ventilators at its Irish plant and move to round-the-clock production. In America Ventech Life Systems is collaborating with General Motors to scale up ventilator production, and Smiths Group, a British producer, is looking to see if other firms might be able to make its portable machines.

A number of industry groups have got together in response to a request by the British government for 5,000 new ventilators as soon as possible (the country’s National Health Service presently has access to some 8,000), and more later, bringing the total to 30,000. One group is led by Meggitt, an aerospace firm based in Britain that among other things also makes oxygen systems for aircraft. Another group is led by McLaren, a super-car-maker that runs a Formula 1 team. Like others involved in motorsport, McLaren is expert at prototyping and manufacturing things rapidly. Other firms are getting involved. Dyson, a British maker of vacuum cleaners, says it has a potential order for 10,000 versions of a ventilator it has developed.

Lots of academics are helping. Engineers and doctors from the University of Oxford and King’s College London hope to have prototypes of a simple ventilator that would cost less than £1,000 ($1,177) approved and working in trials at hospitals in London and Oxford in about two weeks. Like some others, the group is mechanising a device widely known as an Ambu (artificial manual breathing unit) bag. This consists of a mask connected to a rubber bag which, when squeezed by hand, pumps air into the lungs. The bag self-inflates when released. Oxygen can also be added to the pumped air through a port in the device. Ambu bags are often used by paramedics to resuscitate people and in emergencies on hospital wards.

The group’s machine, called the OxVent, places the Ambu bag in a sealed perspex box. Compressed air from a hospital airline is fed into the box to squeeze the bag and pump fresh air mixed with additional oxygen into the patient through standard tubing. This allows the device to be controlled by a simple box of electronics with all the essential adjustments needed for patient care, says Mark Thompson, a member of the Oxford team. The next step is to test for reliability and to find ways to manufacture the OxVent quickly. The group has already been in touch with companies eager to help. “It has been absolutely fantastic the support we’ve been offered,” adds Professor Thompson.

A group at University College London rallying ideas for making ventilators has also got a huge response from around the world, says Rebecca Shipley, a professor of health-care engineering. Using proven designs is probably the quickest way to get into production, she reckons. Catherine Holloway, a colleague who leads the Global Disability Innovation Hub, an organisation that promotes technologies to assist disabled people, thinks that “no frills” ventilator designs, already used in some poor countries, might be adopted to boost manufacturing capacity in richer regions.

At a very basic level, some designs could be built at home. Among them is an open-source ventilator developed by a collection of engineers in Barcelona. The oxyGEN machine, as it is called, uses a modified windscreen-wiper motor to squeeze an Ambu bag. Adjustments to the air volume can be made by fitting different-sized parts. But anyone trying to make one should take care. “It is a device designed to avoid life and death situations in emergency triages, not to replace other superior, professional and much safer devices,” the group cautions. Even so, as covid-19 continues to spread, and health-care systems are swamped, some doctors may be so desperate that they take the risk.

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Crowdsourcing to fight covid-19

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“WE ARE TRYING to fly the plane while we are building it.” That is how Richard Hunt from America’s department of health described caring for patients seriously ill with covid-19 in a training session on the subject on March 24th. The session was webcast to almost 2,000 people in 39 countries (most were in America). The questions sent in advance filled 25 pages, said Mr Hunt.

The thirst for clinical guidance is desperate. Three months after doctors in the Chinese city of Wuhan encountered the world’s first covid-19 patients, medics in more than 150 countries are treating growing numbers. British scientists reckon that 4.4% of those infected will need hospitalisation; about one in three of those requires treatment in an intensive-care unit (ICU). Doctors in ICUs treat severe pneumonia, the hallmark of a serious case of covid-19, all the time. But with this new disease they do not yet know which changes in a patient’s symptoms, blood tests or vital signs are critical ones. Some may point to improvements, while others suggest deterioration and the need for more intensive care, such as a ventilator.

Knowing when and for how long to put someone on a ventilator is not just crucial for that patient, says Mark Caridi-Scheible of the Emory Critical Care Centre in Atlanta, one of the instructors on the webinar; it is also important for the sake of the next patient who needs the machine. As hospitals around the world brace for more covid-19 patients than they have ventilators for, that question is at the top of their list.

While the disease spreads, the World Health Organisation (WHO) is crowdsourcing what hospitals are learning. It has asked doctors to submit anonymised covid-19 patient records to its global database, listing the drugs prescribed, procedures carried out and outcomes. But it has received fewer contributions than hoped, says Soumya Swaminathan, the WHO’s chief scientist. Talking to doctors directly seems to work better. Clinicians who treat covid-19 patients in 30 countries chime in at a twice-weekly virtual gathering run by the WHO. Their input, plus the clinical studies that are being published at a steady clip, are distilled into the WHO’s standards of care. Knowledge is evolving so quickly that these standards have been revised five times in less than two months.

Meanwhile, veterans from the earliest battles of the pandemic are taking their knowledge to others. On March 12th eight Chinese doctors, led by Liang Zongang, a professor of cardiopulmonary reanimation, arrived in Italy on a charter flight that brought medical equipment supplied by the Chinese Red Cross. They were followed on March 18th by around 300 Chinese intensive-care doctors.

Online learning about covid-19 is gathering speed, especially in developing countries. Around the world, clinicians already gather online to learn and share their experience on such topics as HIV/AIDS, tuberculosis, cancer and mental health. The ECHO Project, based at the University of New Mexico, has trained and supports hundreds of such groups in 39 countries, mostly in Africa and Asia. Many are now using their sessions to learn about covid-19. The experience at hospitals in China, Italy and Spain suggests that is prudent. As critical-care wards in the affected countries were inundated with coronavirus patients, they rapidly had to train doctors and nurses from unrelated specialisms in how to intubate patients and perform other procedures. Dr Caridi-Scheible, whose hospital is already treating more than a dozen covid-19 patients, warns the medics who are standing by for their first cases to “call in every friend and favour you are owed”.

To save the lives of gravely ill patients, doctors are trying many drugs. They are bombarded with suggestions from all kinds of sources online. But as soon as any particular medication is mentioned, everyone rushes to buy or use it, even preventively, despite the lack of evidence, says John Hick from the Hennepin County Medical Centre in Minneapolis. “Until we take the time to figure out what works, throwing the kitchen sink at every patient might actually harm them,” he adds. Steroids were used in the 2003 outbreak of SARS, a respiratory disease caused by another coronavirus, but studies since then suggest they may in fact have caused some harm.

Reliable answers can only come from proper clinical trials. Hundreds are under way. In early March Bruce Aylward, who led the WHO’s fact-finding mission to China in February, said 200 trials had been registered there. But with so many small trials, it was difficult to enroll enough patients. Small trials cannot distinguish a small effect from chance. Such a lack of data may explain why a trial of Kaletra, an HIV drug combination, in patients with severe covid-19 was not conclusive, says Ana Maria Henao Restrepo of the WHO. Trials from China may yet bear fruit. The earliest, in severely ill patients treated with remdesivir, a drug developed to treat Ebola, is due to finish collecting data on April 3rd.

What is really needed is a large, international trial that collects data about lots of drugs from many hospitals. The WHO hopes that a trial it announced on March 20th will do so. It will test four different possibilities: remdesivir, chloroquine, Kaletra, and Kaletra plus interferon beta, the drugs which currently seem to hold most promise. The hope is that medics, even those working under great pressure, will recruit patients. Patients are enrolled through the WHO’s website, which will randomly assign each of them to a trial drug (which will be limited to those that are available at the time).

The trial is “adaptive”, so it will change as results come in. Data will be monitored by an independent board. Ineffective treatments will be dropped and replaced by more promising ones. This will allow the best treatments to be compared swiftly.

After patients are enrolled in the trial, doctors need only record a few data points. When did each patient leave hospital or die? After how long? Did the patient need oxygen or ventilation?

There will be no placebo and doctors will know which treatment has been given to which patient. Those are not features of high-quality clinical trials in normal times. But the design is the best way to find out in the shortest time which of a number of drugs works best. The WHO has not said how long it expects the trial to take. Countries including Argentina, Bahrain, Canada, Iran, Norway, South Africa, Spain, Switzerland and Thailand have already said they will join. Some 3,200 European patients will participate under the co-ordination of a French biomedical research agency. Other international trials are being planned—for example, to determine whether the drugs being tested in patients work to prevent illness when taken by health-care workers. The pace of discovery is unprecedented. But the stakes could hardly be higher.

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In coronavirus lockdown, sports fans turn to video-gaming contests

E-sports players are reaching huge audiences from their homes; conventional-sports bosses want to do the same

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THE LEAGUE was building up to the playoffs. The commentators were on the edge of their seats, breathlessly describing every attack, feint and parry as they analysed the strengths and tactics of the two teams. It might have been any big weekend sports fixture. Except that in the League of Legends Championship (LCS), the field of contest was a virtual world of Tolkienesque monsters. The athletes, as well as the analysts, were all confined to their bedrooms. After a clash of titans lasting 30 minutes on March 21st, TSM vanquished the Golden Guardians, advancing a step closer to a $200,000 prize pot.

At a time when physical sporting tournaments are being cancelled or postponed around the world because of the covid-19 pandemic—including this summer’s Olympics in Tokyo—video-gaming contests look well placed to claim a larger share of spectators’ attention, and so of advertising dollars. E-sports, in which professional teams play for prestige and prize money, have already been growing impressively in recent years. In 2019 they had a global audience of 443m people, 12% more than in 2018, according to Newzoo, an e-sports-analytics company. Most of these fans are in China and North America.

This reach has gained the attention of brands outside the gaming world. Last year Louis Vuitton, a chic French fashion and luggage house, struck a deal to sponsor the League of Legends world championship in North America. In February Newzoo forecast that the global market for e-sports would exceed $1bn for the first time in 2020, with three-quarters of that coming from sponsorship and media-rights deals.

As with conventional sports, however, covid-19 has turned e-sports upside down. Thousands of fans flock to see teams fight it out in real-world arenas, with millions more watching online. Psyonix, the developer of a game called Rocket League, has cancelled its world championships, which were due to be held in Texas next month. Plenty of other organisers have called off fixtures or postponed them indefinitely. “Most e-sports are at their heart live-event productions,” says Chris Greeley, the commissioner of LCS.

The popularity of e-sports relies on proximity to the pros. Fans are able not only to watch their favourite players, but interact with them and play alongside them. “Imagine if LeBron James went home after practice, turned on a camera and shot baskets in his backyard with his fans,” explains Dan Fiden, the president of Cloud9, currently the top team in LCS. Traditional sports are taking note. America’s National Football League has attempted to bridge the gap between athletes and fans by teaming up with Twitter to give users of the social network behind-the-scenes access to games. But such efforts still feel aloof compared with the direct interaction offered by gamers.

Unlike footballers or tennis players, e-sports players do not need to meet face-to-face to compete. This makes the sector uniquely placed to survive the global contagion, and perhaps even thrive. LCS is continuing as an online-only league, with players competing remotely instead of in front of a live audience in Los Angeles. Other competitions are taking a similar approach. “We’ll have players compete from their homes, but in e-sports, unlike any other competition, that really doesn’t change anything at all,” insists Mr Fiden. All that players need is a reliable internet connection.

There are early signs that the pandemic may help e-sports reach new audiences. With the usual fixtures called off, cooped-up fans of mainstream sports are looking elsewhere for entertainment with competitive bite. Mr Greeley notes that, despite the commercial uncertainty, sponsors’ interest has not abated in recent weeks. The number of hours watched on Twitch, which broadcasts both e-sports and amateur gamers, rose by over 20% in the seven days to March 25th, according to Sully Gnome, an analytics website. Some of this increase will come from more casual gamers discovering e-sports. Last week the servers that power League of Legends were almost overwhelmed with demand. Professional players were given special access so that members of the public could at least watch the pros play via streaming sites, even if they could not take part in the game themselves.

As a response to the pandemic, live sports are taking on e-sports directly. In recent days the organisers of NASCAR, Formula 1, La Liga (Spain’s top football league) and Major League Rugby (a competition in North America) have all announced video-game contests to replace cancelled fixtures. Formula 1’s “virtual Grand Prix” will see this season’s drivers step out of their cars and into simulators to go wheel-to-wheel on computer-generated tracks. The rugby players, meanwhile, will compete on a virtual pitch. Organisers seem to have given little thought to whether athletes used to the real world will make skilled gamers.

These virtual tournaments point to how desperate organisers are to satisfy audiences in a sporting drought. But they also show a desire to cash in on the popularity of e-sports. Few in the e-sports world see that as a threat. The games that dominate e-sports are not recreations of real-world sports, but more nerdy fare. Strategy and battle games tend to be the most popular. When stadiums reopen, many new e-sports viewers will no doubt return to their stands. But a fair few may stay in the virtual realm.

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Armies are mobilising against the coronavirus

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TWO WEEKS ago Xi Jinping, China’s president, made a triumphal visit to Wuhan, capital of Hubei province, ravaged by covid-19, to declare that the virus had been “basically curbed”. His first stop was a hospital built at breakneck speed and run by the People’s Liberation Army (PLA). Now armies across the world are temporarily putting down their guns and playing a frontline role in the war against the virus. That will ease the burden on overwhelmed civilians, but it may have far-reaching implications for the forces’ military proficiency.

In Italy and Spain, where death rates have spiralled upwards in recent weeks, thousands of soldiers have been deployed to quarantined cities to patrol the streets and enforce lockdowns. Turin “seems to have conformed to the rules and camouflages”, noted La Stampa, an Italian newspaper. In Bergamo rows of army trucks carried away bodies to ease the load on overflowing crematoriums. Hungary, Lebanon, Malaysia and Peru have all sent their armies to cajole recalcitrant citizens back into the safety of their homes.

Many countries are uncomfortable with state-mandated lockdowns, enforced by gun-toting soldiers. But they have found other uses for their soldiers. Armed forces are good at mounting big logistical operations at short notice. They have lots of pliant manpower and heavy vehicles, and expertise in moving large amounts of stuff from one place to another. In an average week, the Pentagon’s Transportation Command conducts more than 1,900 air missions and 10,000 ground shipments. “The military has the capacity to plan while it is implementing in a way that most of the civil service does not,” says Jack Watling of the Royal United Services Institute, a think-tank in London.

On March 19th Britain, which had thus far taken a laxer approach to the enforcement of social distancing than Italy or France, announced a new “COVID support force”, which will comprise over 20,000 personnel, bolstered with reservists. Military planners will be deployed to Regional Resilience Councils to identify and resolve bottlenecks in the provision of medical care for the most vulnerable, says Mr Watling. Other military personnel are being trained to drive oxygen tankers for the National Health Service. Other countries are doing much the same. On March 22nd National Guard (ie, reservist) units in three states—California, New York and Washington—were deployed to perform similar duties.

Armed forces are also well placed to help out overloaded health-care systems. For one thing, they often have large stockpiles of vital medical kit. The Pentagon has promised to hand over 5m respirator masks and 2,000 ventilators to civilian authorities. They tend to be good at rapid innovation, too. Israel’s military-intelligence technology unit is not only producing low-tech masks, but also working on the conversion of simple breathing-support devices into more advanced ventilators, according to the Times of Israel. Britain’s Defence Science and Technology Laboratory at Porton Down, which has expertise in biological threats, is supporting the development and testing of vaccines, and the mapping of covid-19 cases. The US Army alone is working on 24 vaccine candidates, in collaboration with other agencies and companies.

Wartime experience can also yield useful insights for civilian medicine. The development of mechanical ventilators to ease Acute Respiratory Distress Syndrome (ARDS)—a potentially fatal condition in which lungs cannot provide vital organs with enough oxygen, common in patients who die of covid-19—emerged from work during the second world war. In recent decades military doctors have made important contributions to advances in ventilation and intensive care.

Military medics also train to operate amid chaos, with insufficient infrastructure and resources. Since January 25th China has sent over 10,000 military personnel into Hubei. In Wuhan, control of medical and essential supplies was handed entirely to the PLA. In Mulhouse in eastern France, where local hospitals have been overwhelmed, army medics are building a 30-bed field hospital for covid-19 cases. Mexico’s president, who said last summer that he hoped to disband the army, has given control of ten new hospitals to the army and navy.

Elsewhere military doctors are taking on more routine cases to free up hospitals for the flood of more serious ones. America is sending a pair of naval hospital ships to Los Angeles and New York to release medical capacity for covid-19 patients; the army is preparing two mobile hospital units. Switzerland’s citizen army has sent one of its four 600-strong hospital battalions to support civilian hospitals.

Military medical aid can also be a tool of diplomacy. On March 22nd Russia’s army, whose operatives are more accustomed to using toxic substances to poison foes around Europe than cleaning them up, began sending nine transport planes full of military disinfectant vehicles, eight brigades of medics, about 100 virologists and epidemiologists, and testing kits to the worst-affected parts of Italy. The lorries and planes bore the slogan “From Russia with Love”, in Russian and Italian.

It is understandable that overwhelmed states want to mobilise their armies for policing, logistics and medicine. But armed forces are designed first and foremost for killing people, rather than issuing fines on street corners or delivering food to supermarkets. And covid-19 will affect military preparedness, both directly and indirectly.

Military personnel are typically young and fit—a group that has been better able to shake off the effects of the virus. But they are not immune. Over half of coronavirus cases in New York state are aged 18 to 49. Troops often live in close quarters, increasing the likelihood and pace of transmission.

Iran’s Islamic Revolutionary Guard Corps, the country’s main armed force, is believed to have been hit badly by the epidemic; a veteran general died on March 13th. The army chiefs of Italy and Poland have both tested positive for covid-19. By March 23rd 133 American military personnel had been infected by the virus. On March 22nd a Pentagon contractor became the first American military fatality of the covid-19 pandemic. Many experts ridicule China’s claim that not a single member of the PLA has been infected.

But even if armies do shrug off the immediate health effects of covid-19, the disruption to their work will have longer-lasting consequences. Self-isolating officers cannot gain access to classified networks from their homes, so many will have their productivity drastically limited. Meia Nouwens, of the International Institute for Strategic Studies, another think-tank in London, says that the crisis has disrupted the supply chains for China’s defence industry.

Social distancing is also preventing armies from honing their fighting skills. Britain has halted almost all its basic training for new recruits. On March 11th Norway called off joint exercises with America and European allies in the Arctic, shortly after 23 American soldiers were quarantined after exposure to an infected Norwegian colleague. Two days later America scaled down Defender 2020, an exercise that would have involved the largest deployment of American troops to Europe since the cold war. America’s top general in Europe was forced to self-isolate after crossing paths with an infected Polish general at a planning meeting for the exercise.

Other European drills have been cancelled entirely; America and South Korea have postponed their annual joint exercises. But armies that stop exercising are liable to grow rusty. “The challenge is when you have the next armoured battlegroup coming through and they haven’t done a stint in BATUS [the British Army’s training area in Canada], for instance, do they still have a certification to deploy into NATO?” asks Mr Watling. On March 23rd Russia offered at least a little respite, saying that it had called off war games on its western borders “as a sign of good will”.

Yet as armies grapple with the pandemic, geopolitical jostling goes on. On March 10th, as Mr Xi visited Wuhan, America’s navy conducted a so-called freedom of navigation operation near a Chinese-controlled island in the South China Sea. On March 19th at least 29 Malian soldiers were killed by suspected jihadists. A day later two Turkish soldiers were killed in a rocket attack in Syria’s Idlib province, and two dozen policemen and soldiers were shot dead in Afghanistan. Troops may be distracted and diverted, but war does not pause for viruses.

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How covid-19 is interrupting children’s education

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CHILDREN USUALLY rejoice in a break from school, assuming it will be a chance to slack off. Not Ryu, a nine-year-old in Tokyo. As the new coronavirus spread across Japan, schools throughout the country closed on March 2nd. His parents have enforced a strict schedule every day. It includes Japanese, science and physical education. He does mathematics on his abacus every morning. On weekdays he is allowed to play in a park for 90 minutes. “I wish I could take him to the park more, but we have limited time as we work from home,” frets his mother, Fujimaki Natsuko.

Ryu is one of almost 1bn students around the world whose schooling has been interrupted as a result of covid-19 (see map). As The Economist went to press, just over 100 countries including China, Italy and South Korea had closed their schools, as had 43 states in America, as part of efforts to contain covid-19. Britain will close all schools on March 20th. Schools, where sticky-fingered children gather every day, sharing toys and sucking on pencils, are an obvious place for diseases to flourish. In 2013 Britain’s Health Protection Agency looked at flu outbreaks that coincided with school closures. It found that shutting them slowed the transmission of the virus, even if it also slowed the transmission of knowledge.

The data on whether school closures will curb covid-19 are limited. Children may not be the “main routes of transmission”, says Michael Head, who studies global health at the University of Southampton. And the economic, social and educational costs are heavy. On March 12th Bill de Blasio, the mayor of New York, said there were “many, many reasons” not to close the city’s 1,800 schools (though on March 16th it did just that, shuttering America’s largest school system for at least four weeks). For all governments, deciding whether or not to close schools is a choice between two bad options.

A study in 2009 modelling the effects of closing all schools and formal day-care centres in America for a month put the cost at 0.1-0.3% of GDP. Some countries seem better prepared to deal with the economic impact. In China the nationwide closures came with government-mandated work-from-home policies and subsidies for companies to enable their employees to do so. But in Japan not all parents are entitled to work from home or to take paid sick leave. In Italy one-fifth of workers are self-employed and so do not qualify for sick pay. People in precarious work may lose their jobs altogether if they have to stay at home to look after children.

For poor children, schools may provide the most nutritious meal of the day. Around 26m children in American schools—roughly half of all students—qualify for free or reduced-price lunches. In New York City 22,000 children sleep in municipal shelters. Some school districts in New York are setting up pickup points so that the hard-up can still get free meals. Britain has said it will continue to provide those children who ordinarily get free school meals with food.

Officials must always take such costs into account. But in the middle of a pandemic there is an extra consideration. The study in 2009 estimated that, if schools are closed for a month, between 6% and 19% of key health-care workers would have to stay at home to take care of their offspring. Britain will keep schools running for vulnerable children and those whose parents are key workers.

For most parents, however, the immediate worry is how prolonged school closures will affect their children’s education. Those preparing to take crucial exams are particularly jittery. The gaokao, China’s single university-entrance exam, is usually held in June. This year it will probably be delayed, says Xu Liangdi of China Policy, a think-tank, although the government has so far made no announcement.

Around 245,000 students in Britain were expecting in May and June to sit their A-levels, the exams that determine which university—if any—will grant them a place. On March 18th the government announced that those exams would be cancelled. Boris Johnson, the prime minister, said that the government would make sure that children still got “the qualifications they need and deserve for their academic career.” That may go some way to assuaging fears that children whose parents lack the cash or knowledge to compensate for schools closing would be worst affected.

For American students the stakes are lower, in part because their transcript—based on their academic performance throughout the year—is the most important part of their university application, but also because they can take SATs, the exams used in college admissions, all year round. Most sit them in the spring. For those hoping to start university in 2021, the March and May tests have been cancelled. They will be rescheduled, however, and students may be able to take them at home.

Nonetheless universities may have to be more accommodating. Covid-19 will “absolutely” affect the admissions procedure for Miami University in Ohio, says Bethany Perkins, the director of admissions—particularly the deadlines. Students with offers from American universities have to choose which to accept by May 1st. But students worry that they will have to make an important decision without being able to visit any campuses. Along with their parents, some are calling for the date to be pushed back to June 1st. Colleges have yet to react. Harvard says it is not changing its application process.

The disruption has lent ammunition to those who disapprove of high-stakes exams, which some education theorists want to scrap. Some institutions have already made SATs optional. Others, including Miami University, were considering doing so. The upheaval caused by covid-19 might accelerate that process, says Ms Perkins. But the flaws of other kinds of assessment may become clear in the coming months, bolstering those who believe that SATs and other high-stakes exams, which offer a relatively objective and transparent measure of ability, are the least unfair way to decide who gets into university.

The pandemic won’t change this. But it will highlight the strengths and weaknesses of teaching online. Online resources are increasingly popular but few countries boast a developed digital infrastructure for all students. A survey by Teacher Tapp, an app, of over 6,000 teachers in Britain found that only 40% of those in state schools would be able to broadcast a video lesson, compared with 69% of teachers at independent schools. Elena Silva of New America, a think-tank, says that few American states have adequate kit for teaching online. “Most states are not that prepared. This is a moment of forced opportunity.”

Teachers have little choice but to seize it. Since Italy closed its schools and universities on March 5th, teachers’ forums have filled with discussions on the relative merits of Zoom, Moodle and virtual classrooms. Some teachers had been trained to use such technology, but many have faced a steep learning curve. Carla Crosato, a teacher in Treviso, in northern Italy, has been uploading videos in which she explains the novels of Italo Svevo and Luigi Pirandello to her students. “I never thought I’d become a YouTuber at 56,” she says.

Even if teachers manage to broadcast their lessons, students may struggle to join them. Not everyone can get online (see chart). In America 7m school-age children cannot access the internet at home. Lin Kengying of 21st Century Education Research Institute, a think-tank in China, says that the closure of schools since the Lunar new year holiday, which began at the end of January, has led his organisation to reconsider the potential of e-learning. “It hasn’t been smooth,” he says, citing problems such as internet access, scheduling classes, teachers unfamiliar with online tuition, and subjects such as physical education being “awkward” to teach remotely. In China teachers have to submit lesson plans for review by censors, which has led to delays. Students have been spamming the main online teaching app with one-star reviews in an effort to get it removed from the app store. And Xue Hua, a mother of two in Jiangxi province, has been printing out all the learning materials for her 16-year-old son, Guo Guo, because she worries about too much screen-time.

Even done properly, online learning is a poor substitute for the kind that happens in a classroom. On average, students fare worse working online, especially those with less strong academic backgrounds, says Susanna Loeb of Brown University. Online courses can be an asset when students cannot be in school, but she reckons that they are “suboptimal for most” and argues that long periods of time spent away from actual schools will probably lead to children’s education suffering.

Online learning has clear potential. Educational technology powered by artificial intelligence can help children in poor countries with iffy schools—supposing they have internet access. In 2018 researchers found that after four and a half months of using an Indian app called Mindspark, which tests basic language and maths skills, children made more progress in these areas than those in the control group. But the success of such initiatives relies on preparation and organisation, not sudden scrambles to teach existing curriculums to entire populations of students in the midst of a pandemic.

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Governments are still struggling to get ahead of the coronavirus

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OF THE SUPPOSED five stages of grief, humanity’s response to the covid-19 pandemic has seemed stuck in the first three: denial (it will not happen to us), anger (it’s another country’s fault, or our government’s) and bargaining (if we make modest changes to our ways of life, it will leave us alone). Monday March 16th may have been the day when the last vestiges of these coping strategies evaporated. Much of the world moved on to the next stage, depression—the heart-sinking realisation that billions of lives will be seriously disrupted for weeks and probably months; that, before it is over, many people will die; and that the economic implications are beyond dire. (For more coverage of covid-19 see our coronavirus hub.)

As stockmarkets in America experienced one of the worst days in their history, in many countries the incremental stepping up of relatively modest measures against the virus gave way to Draconian restrictions on travel and on daily life. This seemed to resolve a debate between advocates of two very different approaches.

Some Western governments, notably America’s and Britain’s, had adopted much milder measures. Britain’s apparently calculated that, since the worst was still to come, there was no point in sowing panic and resentment among its people by imposing restrictions that were still premature. Both countries were slow to institute widespread testing to get a better sense of how many people were already infected. “Relax, we’re doing great,” President Donald Trump told Americans on March 15th. In contrast, three days earlier, Boris Johnson, Britain’s prime minister, had called the pandemic “the worst public-health crisis for a generation” but his government’s response did not involve closing schools, as many countries had done, nor banning mass gatherings.

Other countries had already instituted harsher measures, and seemed to have had some success. The central Chinese province of Hubei, home to 60m people, had in effect been in quarantine for nearly two months. South Korea had tested hundreds of thousands of people and enabled people to check whether they might have had contact with the infected on a website showing their movements. European countries had begun also to shut down, starting with Italy, site of the continent’s worst outbreak.

In recent days, China has started easing restrictions and is cautiously hailing at least a partial victory over the virus. But that may be premature, as a second wave of infections re-imported from abroad remains possible. Hong Kong, Singapore and Taiwan have this week seen renewed infections after apparently suppressing the virus’s spread.

After March 16th, the differences between countries seem less stark. Mr Johnson told people to work from home if they can, not to hold big gatherings, to steer clear of pubs and restaurants and to quarantine their whole households for 14 days if one member shows symptoms of infection (schools remained open for the time being). The change in approach was justified by saying, “It looks as though we’re now approaching the fast growth part of the upward curve”, and, in other briefings, by alarm at new data showing the extent of the crisis in Italy. Britain is also discouraging non-essential travel, but has not banned it. The same day in America, Mr Trump issued tighter new guidelines, including that people should avoid gatherings of ten or more people. In France, President Emmanuel Macron declared “we are at war” with the virus.

Meanwhile, the number of countries closing their borders to arrivals from countries with infections has grown to over 80, including America, Australia, Canada, Japan, Russia. They also include members of the European Union and of the Schengen free-travel zone, which approved a 30-day closure of their external borders.

A joint statement on March 16th from leaders of the G7 seemed to herald a new phase of welcome international co-operation after a period when squabbling seemed more noticeable than co-ordination. It promised “a strongly co-ordinated international approach, based on science and evidence.” But even that appeared to want to make a political point, adding that the approach should be “consistent with our democratic values and utilising the strengths of private enterprise”, as if to add: “Are you listening, China?”

In fact, the boasts of international solidarity and a shared approach are hollow. Countries are still pursuing divergent strategies, and in some cases banning exports of medical supplies. They seem to be competing to show that their method stands the best chance of success. Not long after Mr Johnson announced Britain’s latest measures, for example, Mr Macron unveiled France’s much more sweeping approach. From March 17th nobody is to leave their home except to shop for essentials, attend medical appointments, or do jobs that cannot be done at home. Schools, universities, cafés, cinemas, hairdressers and museums had already closed.

The world’s two most powerful countries, America and China, are meanwhile indulging in a blame game. Also on March 16th Mr Trump irritated China’s leaders by referring to “the Chinese virus”. China’s foreign-ministry spokesman urged America to stop the “despicable practice” of stigmatising China. But Chinese officials have also been guilty, with one lending his name to a bizarre online conspiracy theory that the virus was made by the American army and brought into China. Tensions between the two countries worsened on March 17th when China announced it was expelling reporters from the New York Times, Washington Post and Wall Street Journal. It described the move as “reciprocal”—a response to Mr Trump’s decision last month to cap the numbers in America of journalists working for five state-controlled Chinese news outlets.

If international co-operation on the battle against the virus is going badly, then at least central banks and other monetary authorities are working in cahoots to contain the economic fall-out. The move by America’s Federal Reserve to cut interest rates to close to zero in an emergency intervention on March 15th is in lockstep with the decisions of many other central banks. The record-setting crash on the American stockmarkets the following day was a reflection of how little impact investors and traders think monetary policy can have on the recession—or even depression—that may be looming.

More important are central banks’ efforts to keep credit flowing before companies and the banks they owe money to seize up. On March 17th the Fed announced that, as during the financial crisis of 2008-09, it will start buying up companies’ short-term debt (“commercial paper”). But in the end, the banks and companies are probably going to need their governments’ help—either to spend directly to keep businesses open, or to provide guarantees to the banks.

Most big economies have announced—or are about to unveil—big spending packages to support the economy. Also on March 17th Britain’s finance minister, Rishi Sunak, promised £330bn ($400bn) in lending, grants and guarantees to keep businesses going through the virus-induced slump. France has promised €45bn ($50bn) to help businesses. Mr Trump’s administration wants Congress to approve $1trn in extra spending.

The plight of financial institutions is not yet nearly as bad as it was during the global financial crisis. But the disagreements over how to handle covid-19 and how to attribute blame for its spread do not augur well for future co-operation to stop financial systems sinking to those lows. And, in the meantime, every antiviral and economic measure governments introduce seems to serve partly to heighten the sense that policymakers are floundering against an adversary they still do not understand; and hence to worsen the mounting panic.

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Fatality rates for covid-19 could vary enormously

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AS THE NUMBER of deaths among people infected by the new coronavirus mounts, it is tempting to divide that figure by the number of reported cases and conclude that the result is the fatality rate. Apply such maths to the world’s total of confirmed cases and deaths on March 11th and you get a fatality rate of 3.6%. But this figure, which epidemiologists call the “naive” case fatality rate, may be wrong in two different ways. First, many of the infections detected at this early stage of the epidemic are recent, so some will eventually result in deaths. That will push the fatality rate up. Second, many infections have not been spotted because testing for the virus has been patchy. Lots of mild cases of the disease have gone unnoticed. If all infections were actually counted, the result would be a bigger denominator. That would push the fatality rate down. As China began to trace infections more carefully, its fatality rate fell (see chart 1).

A conclusive measure of the denominator requires testing for antibodies against the virus in a large sample of people in a place which an outbreak has already swept through. Such studies are under way in China. In the meantime, researchers have estimated the fatality rate for covid-19 using a cohort of people for whom there is a full count of infections and deaths: passengers on the Diamond Princess cruise ship. A bungled quarantine on board led to nearly 700 cases of covid-19. Eight people have died so far. A working paper published on March 5th by Timothy Russell at the London School of Hygiene and Tropical Medicine and an international team of researchers estimates that the fatality rate among infected passengers will end up being 1.2%.

The researchers applied the results from the ship to data on covid-19 cases and deaths in China. They conclude that the fatality rate for covid-19 in the country’s outbreak was 0.5%. For comparison, that is five times the fatality rate for the seasonal flu in America.

The covid-19 fatality rate among those on the Diamond Princess was higher partly because their average age was 58, older than the general population in any country. At the same time, they are probably in fairly good shape. They must be healthy enough to embark on an extended holiday. People who go on cruises tend to be richer. So the fatality rate among these passengers may be lower than it would be among people of a similar age in their home countries.

A recent study by researchers at the University of Bern, in Switzerland, sheds more light. It provides estimates of covid-19 fatality by age group in Hubei, the province in China with the worst outbreak of the disease (see chart 2). Fatality is dramatically higher among people older than 60, rising to 18% among those in their 80s or older.

But covid-19 may prove no less devastating for poor countries, which tend to have younger populations. The disease is more severe in people whose immune systems are weakened by chronic diseases, so those who are malnourished or have HIV/AIDS will probably be hit hard.

The fatality rate in any country will depend primarily on the quality of care it can provide—and how many people have access to it. About 5% of people diagnosed with covid-19 in China have needed intensive care, which is in short supply or non-existent in most hospitals in developing countries. A surge in cases even in rich countries can soon overwhelm hospitals and result in higher fatality rates.

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Should other countries copy Italy’s nationwide lockdown?

GIOVAMBATTISTA PRESTI, a psychologist at the Kore University of Enna in Sicily, is an adviser to the Policlinico, Milan’s oldest hospital, which is at the centre of Italy’s covid-19 epidemic. Of great concern now, says Mr Presti, is staff burnout. He is particularly worried about post-traumatic stress disorder among some medics. If hospitals reach the point at which they no longer have the capacity to treat every patient, some of them “will be forced to decide who should go into intensive care and who should be left to die”.

Similar accounts are emerging elsewhere. Daniele Macchini is a doctor at the Humanitas Gavazzeni hospital in nearby Bergamo. It has been overwhelmed by covid-19 patients. “Cases are multiplying. We are getting 15-20 admissions a day,” he wrote on Facebook. “The results of the swabs come in one after another: positive, positive, positive. All of a sudden, accident and emergency is collapsing.” Nurses, he added, have been reduced to tears “because we cannot save everyone”.

These reports are coming out of Lombardy, a wealthy region whose health service is judged to be among the best in a country that last year came second in Europe in a health-care efficiency ranking by Bloomberg. On March 10th Antonio Pesenti, the intensive-care co-ordinator for Lombardy’s crisis unit, told journalists that the region’s health system was “one step from collapse”.

Italy’s epidemic, which is still concentrated in Lombardy, spread rapidly. On February 25th the country’s health authorities had detected 322 cases of covid-19. Two weeks later that number had passed 10,000. Deaths have risen even more steeply as the virus, which is disproportionally lethal to the elderly, has attacked Europe’s oldest population. By March 11th, more than 800 of those infected had died.

The crisis in Italy is sending shivers down spines in Europe and America. In many countries the number of cases being detected is rising on a trajectory that will soon bring them to the point at which Italy currently finds itself (see chart). Governments elsewhere are watching to see whether Italy’s efforts slow its epidemic, spreading infections out over time and giving its hospitals some breathing room.

On March 8th the Italian government imposed nationwide curbs on large gatherings. Big weddings and funerals were banned; museums, cinemas and theatres were closed. Nationwide travel restrictions followed a day later. Italians are not allowed to leave—or travel within—the cities and towns where they live, except for work or emergencies. Restaurants, bars and all shops except foodstores and pharmacies were told to close entirely from March 12th. Europe has not seen controls on this scale since the second world war.

Other European countries have, for the moment, opted for less restrictive measures. Like Italy, several countries including France, Spain and Greece have closed schools and universities. Some have banned big public gatherings. In America variations on these themes are being imposed at county or state level. A growing number of universities, including Harvard and Princeton, are switching to remote teaching or simply sending their students home. But if these limitations fail to slow rapidly and substantially the rate at which infections are increasing, Italy may become a role model.

Italy’s national lockdown was prompted by its apparent success using comparable measures on a regional level. The government tested similar restrictions in two “red zones” around a handful of small towns in the northern part of the country where, in late February, it found its first big clusters of covid-19 cases. On March 8th Silvio Brusaferro, the president of Italy’s national public health institute, said the number of new infections in both areas was falling.

But that is no guarantee the national quarantine will lead to similar results. The efficacy of the shutdown depends on two things: the extent to which people comply with the rules; and the length of time the rules can be left in place, given their vast social and economic costs. For those watching Italy, the crucial question is whether they need to go to similar lengths, or whether a more modest set of restrictions will slow the epidemic.

Italy is following the example set by China, which got a raging covid-19 epidemic in Hubei province under control and prevented outbreaks elsewhere by imposing stringent mass quarantines. Millions have been mostly stuck inside for weeks. In some cities, such as Wuhan, where the outbreak began, people have been prevented from leaving their homes for more than a month. The lockdown has been strictly enforced by neighbourhood committees and building managers, though restrictions are now being loosened as China’s new cases have dwindled. In Italy, by contrast, the implementation of the travel restrictions depends on the public’s co-operation. Authorities and doctors are imploring people to stay at home. But at checkpoints drivers need only show a self-certified form stating their reasons for travelling.

So far Italians seem to be adhering to the new rules. There have been exceptions. A hospital porter who tested positive for the virus and should have been in self-quarantine was found shopping in a supermarket at Sciacca in Sicily. He risks being charged with spreading an epidemic, which carries a maximum penalty of 12 years in jail. People were still gathering in bars and clubs—in at least one case, to watch a football match—before the strictest measures came into effect. But in Caserta near Naples, where a handful of infractions were reported on the first full day of police checks, a senior officer said: “Members of the public are starting to be aware that it’s in the interests of their health to keep their movements to a minimum.”

The extent to which people continue to comply with demands that they keep their distance from friends, colleagues and the general public depends in large part on how long they are required to do so. Social-distancing measures work best when they are put in place early, before an epidemic takes off, says Elias Mossialos from the London School of Economics. In China cities that imposed restrictions on mass gatherings and transport before identifying their first covid-19 case had fewer infections in the first week after that milestone than places that acted later.

In Britain, however, the government is worried about introducing such restrictions too soon. The country, which is at an earlier stage of its covid-19 outbreak than many others, has not yet banned mass gatherings, nor has it closed schools or instructed people to work from home. The scientists advising the government are concerned that if such measures come now, compliance fatigue may set in just as the epidemic is taking off. But tougher restrictions are almost certainly on the way. Sometime in the next two weeks everyone with symptoms of a cold will be asked to stay at home for seven days because at that point many such cases will be assumed to be covid-19 infections.

The experience of South Korea, which has seen one of the largest outbreaks of covid-19, suggests that scientists in Britain may be right to worry. Outside the city of Daegu, where most of the country’s covid-19 cases have been identified, the government has not introduced any mandatory restrictions—hoping instead that people will voluntarily follow advice to stay at home and to take precautions during gatherings that they cannot avoid. In Gyeonggi province, which surrounds Seoul, mourners at funerals have been told to co-operate with temperature checks before writing their names in visitors’ books. They have also been ordered to minimise contact and conversation with others in attendance (including relatives of the deceased). Across the country guests attending weddings must wear masks—as must the happy couples, prompting many to postpone their nuptials.

Restaurants and bars in Seoul were noticeably quieter for a few days during the peak of the government’s official social-distancing campaign, which began in the capital on March 2nd. But that has changed in recent days. Seoul’s popular nightspots are once again seeing long queues forming. Trains are filling up and people are getting laxer about wearing masks. The shift is probably the result of officials saying that, based on a steep fall in new cases in recent days, they hope that the country has passed the peak of its epidemic.

But on March 11th a new cluster of infections was discovered in a call centre in an office building in Seoul that sits next to one of the city’s busiest subway interchanges. The outbreak may prompt people to stay at home once again. And the government may start enforcing its rules more strictly if the voluntary approach proves inadequate. On March 11th Park Won-soon, the mayor of Seoul, said that he may consider forcing call centres to shut down if they do not follow recommendations to keep their employees at a distance from each other.

As countries employ varying intensities of measures to battle their covid-19 epidemics, it should become clearer which work best—and whether the most drastic are the most effective. Gabriel Leung, an epidemiologist from Hong Kong University who was part of a World Health Organisation team that examined China’s efforts to contain its epidemic, says nobody knows yet what combination of controls works best against covid-19. “Do you need to do everything that the Chinese have done to control it?” he says, or is it enough to copy only certain elements. “That”, says Mr Leung, “is really the big question.”

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Abortions are becoming safer and easier to obtain—even where they are illegal

IN AMERICA ABORTION is a battleground. Pro-lifers urge the Supreme Court to overturn Roe v Wade, its convoluted ruling in 1973 that made abortion legal in all states. Pro-choice campaigners fret that, one day, they will succeed. Presidential elections hinge, in part, on the kind of judges each candidate vows to appoint. And test cases crop up regularly. This week the Supreme Court heard arguments for a law making it harder to run abortion clinics in Louisiana, which could lead to the closure of two of the three in that state.

Yet behind the headlines, abortion is becoming more widely available in most of the world. Between 2000 and 2017 some 27 countries made it easier for women to get abortions. Only Nicaragua made it harder. In the past two years Cyprus, the Republic of Ireland, Northern Ireland and North Macedonia have all loosened restrictions. Since last April, South Korea and Thailand’s constitutional courts have ruled that banning abortion is unconstitutional. Argentina will probably legalise it soon, though Colombia’s top court refused to do so on March 3rd. And in countries where ending a pregnancy is still illegal or tightly restricted, do-it-yourself abortions, which once involved back-alley butchery or wire coat-hangers, are becoming safer.

Reynosa, a city on Mexico’s border with America, is controlled by drug cartels and patrolled by heavily armed state police, their bulletproof vests bristling with spare magazines. The streets are lined with pharmacies which are visited regularly by Americans. Maria (not her real name), a pharmacist, says she sells the “abortion pill” to at least one “gringo” every day.

Misoprostol, the drug in question, is a stomach-ulcer drug which can also be used to cause abortions. It is tightly regulated in America. In Mexico, where abortion is mostly illegal, pharmacies stock it next to cough drops and painkillers. The generic version costs 990 pesos ($50). Some 15 miles away in McAllen in Texas, a state that is dogged in its efforts to stop women getting abortions, the region’s sole surviving abortion clinic charges $700 for treatment that includes the same drug. Some who cannot afford that take their chances with Reynosa’s guns and gangs. Others who dare not cross the Rio Grande buy misoprostol on the black market in America, where they risk getting fakes. Even if the medication is genuine, it is less effective without a second drug, mifepristone, which is much harder to get.

Now there is a third option. Last year Isis, an unemployed 20-year-old from Fort Worth in Texas, got an abortion. She consulted online a doctor in Austria who works for Aid Access, a non-profit that helps women who cannot otherwise get abortions. She paid the group $90. A pharmacy in India sent her seven pills. Isis never had to leave her home. Such abortions are increasingly available—even in countries where ending a pregnancy is illegal.

Bans and restrictions seem to do little to cut the number of abortions. In countries where it is mostly illegal, 37 in 1,000 women have an abortion each year compared with 34 in countries where it is widely available, estimates the Guttmacher Institute, a pro-choice research group. Abortion rates in America have declined steadily since the late 1980s, with no significant difference between states that have introduced new limits and those that have not.

Better access to contraception, by contrast, does make abortions rarer. Every year nearly half of pregnancies worldwide are unintended. That share has been falling for years, mostly thanks to the increased availability of effective contraceptives. In 1969 only 4% of women in the least-developed countries who wanted modern contraception got it; by 2019 that figure was 59%. In much of the rich world it is nearly 90%. Abortion was a prime form of birth control in the Soviet Union. Since communism’s collapse, contraceptive use in eastern Europe has risen sharply. Abortion rates there have halved since 1990. In Mozambique the share of women using contraception doubled between 2011 and 2018. The government is in the middle of making pills and condoms available in all secondary schools. Teenage pregnancies are down.

Delaware is a model of how to improve access to contraception quickly and effectively. From 2014 to 2019 it trained primary health-care workers regularly to ask each woman of childbearing age whether she was happy with her method of birth control or was thinking about having a baby. It also enabled women to get whichever kind of contraception they wanted that same day, explains Mark Edwards of Upstream, the non-profit which ran the programme. Births following unintended pregnancies fell by 25% between 2014 and 2017. The abortion rate dropped more sharply than in any other state in America.

Necessary but not sufficient

Yet effective birth control is not enough. Half of American women seeking an abortion said they used contraception in the month they got pregnant, reports the Guttmacher Institute. Just ask Gaby Ramirez, a 27-year-old cashier and single mother, whose contraception failed. The morning-after pill also let her down (few realise that it does not work after ovulation). “This”, she says as she nods to the faded-pink waiting area of the Whole Women’s Health clinic in McAllen, its walls enlivened by quotes from women such as Michelle Obama and Isabel Allende, “was a very difficult decision. But I just can’t have another baby.” After three hours of medical tests, state-mandated counselling and form-filling, she was sent home with an appointment to return the next day (Texas law requires two separate visits for abortions). Ms Ramirez opted for a medical abortion (using pills) because she can take them in private.

Brazilian women first discovered misoprostol could be used to terminate pregnancies in the 1980s. Women across Latin America told each other about “the pill that makes your period come back”, first in person and later through hotlines and online.

Since then the shift from surgical abortions to medical ones has been dramatic; in the Nordic countries over 90% of abortions are now drug-induced, in India 80% and in America a third. When taken with mifepristone, misoprostol ends 97% of pregnancies in the first ten weeks without complications. More women are seeking abortions earlier in their pregnancies. That is largely because of cheap at-home pregnancy tests, says Jasbir Ahluwalia, a doctor at the McAllen clinic: “The 98 cents test at Walmart has given women such power.” In most rich countries over two-thirds of terminations are carried out before nine weeks and 90% before 13 weeks.

Statistics on how many women take abortion pills without medical care are understandably patchy. Still less is known about how they fared. But a study in 2016 by Abigail Aiken of the University of Texas at Austin of 1,000 women in Ireland who managed their own abortions with the help of Women on Web, a non-profit which provides online advice and prescribes pills by post, found that 95% ended their pregnancies without any surgical intervention. Just 3% received medical help such as a blood transfusion or antibiotics. The organisation gets around 150,000 requests for help each year, many coming from Brazil, Poland, Thailand and (until abortion was legalised) Northern Ireland. Requests shoot up whenever the website is translated into a new language, says Rebecca Gomperts, the group’s founder.

Interest in self-induced abortion is keen, particularly in conservative places. In one month in 2017, there were 210,000 Google searches in America about it. In 2018 Dr Gomperts set up a separate organisation for Americans after a rise in requests by women in states where it is relatively hard to get abortions. In its first ten months Aid Access held over 11,000 consultations and prescribed abortion pills 2,600 times.

Other websites provide women with information on how to get the medication to induce abortions and how to take it safely. One such site, Plan C, regularly tests pills ordered from online pharmacies and rates providers on the quality of the tablets, price, shipping time and advice. It also answers questions about how to avoid getting in trouble with the law.

The Royal College of Obstetricians and Gynaecologists recently called on the British government to relax rules that require women to take the first pill in a doctor’s office. Were they to do so, abortions could be organised entirely by smartphone and post. Clinics in some parts of the world are already trying this.

The impact on women who live in countries where abortion is illegal is most dramatic. Backstreet abortions used to result in perforated uteruses and life-threatening infections and haemorrhages. Some still do. But globally such complications have become rarer. Since 1990 the number of women dying as a result of botched abortions—most of them illegal—has dropped by 42%, from 108 per 100,000 abortions (1990-94) to 63 (2010-14).

Even on its own, misoprostol is effective in around 85% of cases, and it is far less dangerous than other DIY methods. Countries where misoprostol has become most widely available saw the biggest decline in deaths as a result of unsafe abortions. The fall in unsafe terminations in Brazil, where abortion is illegal, has been dramatic (see chart). In Reynosa, Maria says she regularly sells pills to local women who send their husbands with “lousy excuses about stomach problems”. In Mozambique hospitals have seen many more incomplete abortions in recent years, but a dramatic drop in women coming in with perforated uteruses, says Diana Restrepo of the UN Population Fund. She believes this is due to informal use of misoprostol, which is increasingly easy to buy in pharmacies.

For 90m women in 26 countries abortion is still banned under all circumstances. In El Salvador women have been jailed after having miscarriages. Donald Trump’s administration is trying to extend its global “gag rule”, which bans government aid to foreign non-governmental organisations that “actively promote” abortion, by demanding that all UN aid meets the same criteria. Some American states, along with the Food and Drug Administration, are going after the providers and users of abortion pills.

“Ultimately, what are they going to do? Stop every package? Shut down the internet?” wonders Dr Aiken in a soft Irish-Texan accent. The practice has become too widespread to stop, she says. A recent survey found that nearly a third of patients at three Texan clinics already knew about self-managed abortion with pills. As she learned in Ireland, when governments introduce unreasonable laws and barriers, “you merely drive people to find ever more creative solutions.” Those solutions are, at least, becoming safer.

This article appeared in the International section of the print edition under the headline “From backstreet to mail-order”

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