These are fraught times with exponential growth of COVID-19 and many of us under lockdown conditions. But pandemics are not new. It is just that most of us alive have not experienced anything like this. Infection-induced holocausts have wiped out large shares of the population at various times. Think of smallpox and other infections among indigenous Americans or consider the horrific Black Plague of the mid-14th century and the Plague of Justinian in the sixth century. Our predecessors did the best they could with limited success at containment or treatment. Epidemiologists have been working overtime to forecast how this epidemic will unfold. Containment measures can be effective as we have seen in China and South Korea. This slows the outbreak and gives our woefully unprepared health system time to provide testing and surge capacity with more hospital beds, ventilators, supplies, and staff. Civilian and military stockpiles will help as will ramped up production. But time is of the essence and we have yet to see how overwhelmed our hospital capacity will become. We are lucky that COVID-19, while quite infectious, is not particularly deadly compared to many other threats. It has an estimated mortality rate ranging from 0.5% to 3.0%. This exceeds the mortality rate of 0.1% or maybe 0.2% for the common flu. Left unchecked, COVID-19 is expected to add perhaps 1 or 2 million deaths in the United States to the 3 million or so that we would otherwise experience from all causes. These numbers are too high if we do not have an accurate assessment of the mortality rate, because large numbers of asymptomatic persons are not accounted for in the denominator of estimated mortality rates. In either case, many of the deaths will occur among older Americans, but younger ones will die, too. It is also possible that improved therapeutics will reduce mortality without resorting to dire public health measures. Health care professionals are some of the brightest, most hardworking, and dedicated people we have. But they do have a blind spot. They are trained in the spirit of Hippocrates and are sworn to help the sick as much as possible. There is little, if any, emphasis in their training or culture to help determine when health expenditures are excessive. Yet, there is often opportunity cost to health-related decisions. Today's opportunity costs are of almost incomprehensible proportions. Do we shut down much of the economy to avert, or at least delay mass mortality? How much is too much? Unlike health care providers, economists and the business community are accustomed to weighing economic costs and benefits. There is growing concern in these circles and many question our approach going forward. The public relies on elected and unelected officials to make such judgments. Not all of them are from medical and public health communities and values clash. American politicians have been adept at avoiding decisions about costs and health. We are very squeamish about use of cost-effectiveness criteria, much more so than in other countries. Our health system is shaped by institutions that obfuscate decisions about the costs and benefits of health-related intervention. Some of this is about to end. Like an oncoming train, at some point soon, political and public health leaders will clash about economic versus health interests. An ethical balance must be found to best mitigate health and economic damage. Whatever happens may set precedent for decades or more. Perhaps some solace can be found in silver linings. Economic downturns are always an opportunity for regeneration. Some of our abrupt change will endure and improve the productivity of American workers. This in turn will lead to higher wages. Greater remote employment, more online education, and advances in artificial intelligence, for example, are here to stay. Rural economies will see dividends as more work from home. Telemedicine is being catalyzed with a rapid shift to online health care visits. This is particularly beneficial for rural regions. The huge injection of funds to boost health and public health capacity as part of fiscal stimulus will be of great benefit to the rural health sector and nearby communities. New job opportunities will be created. There will also be environmental dividends that markedly improve sustainability. This crisis shall pass. We will have better treatments and hopefully vaccines in a year. The future remains bright. But in the meantime, our leaders have difficult ethics-laden decisions to make and must explicitly face economic and health trade-offs that our society has long sought to evade.