Dr. Jeffrey Klausner, a primary care physician in Los Angeles, has treated gay men for decades. Since the start of the coronavirus pandemic, he said, many patients have so dramatically changed their sexual behavior that they shrug off the need for routine screenings for sexually transmitted diseases.
“They say, ‘I haven’t had any contact since I saw you last, so there’s no need to do any STD tests,’” said Klausner, an adjunct professor of epidemiology and infectious diseases at UCLA.
But attitudes among these patients are shifting, Klausner has noticed, now that California and other states are loosening policies on social distancing. “People are starting to think about a return to engaging [in sex],” he said, “and are asking me, are there ways they can remain safe” from COVID-19?
Concerns about sexual intimacy during an epidemic are universal and not limited to gay men, of course. Public health experts, including those long involved in HIV prevention, recognize that a proportion of all people are likely to ignore or reject categorical mandates about sexual behavior — whether they involve using condoms or limiting contact because of social distancing norms.Don't Miss A Story
Subscribe to KHN’s free Weekly Edition newsletter, delivered every Friday.Sign Up Please confirm your email address below: Sign Up
“It didn’t work when we had to deal with HIV, and it won’t work in dealing with COVID,” said Pierre-Cédric Crouch, a clinical nurse researcher at the University of California-San Francisco, and an expert in HIV prevention.
The coronavirus is known to spread through oral and nasal secretions but not specifically through sexual intercourse. In New York City, the health department issued sex and coronavirus guidelines that counsel against sex with those outside your household but advise those who choose otherwise to “have as few partners as possible.”
The guidelines, which note that “kissing can easily pass the virus,” suggest that people “make it [sex] a little kinky” by being “creative with sexual positions and physical barriers, like walls, that allow sexual contact while preventing close face to face contact.” In the Netherlands, the government has advised single people considering sex to find a symptom-free sexual partner.
For many gay men, especially in urban areas, sexual exploration with multiple partners is a way of life, whether single or not. Many committed male couples maintain open relationships.
Research supports the notion that gay men tend to have more sexual partners than do heterosexuals. A 2012 review of surveys among adults ages 18 to 39 noted that men who have sex with men (a phrase often used in scientific studies that focus on sexual behavior rather than sexual identity) “reported significantly more lifetime partners than heterosexual men and women at all ages.” In the 35-39 age group, the median lifetime number of sexual partners reported by men who have sex with men was 67, compared with 10 for heterosexuals, according to the study.
Damon Jacobs, a therapist with many gay clients, lives alone in Brooklyn and remained celibate for the first month of the lockdown. At that point, he said, he reached out to a regular and trusted sexual partner.
“He’d also been alone for four weeks except for going outside for groceries, and he also had zero symptoms,” said Jacobs, 49.
“So we got together and started hanging out again,” Jacobs added. More recently, he has met up with several other partners after asking about their social distancing practices. He has also found many of his clients dealing with similar issues after months of being on their own.
“Human beings can cope with certain levels of pain and suffering for a specific amount of time if they perceive an ending,” said Jacobs. After more than two months, he added, people who have been physically isolated are “starved for touch.”
A mid-April survey of more than 1,000 men who have sex with men provided a snapshot of how the coronavirus had affected sexual behavior. While about half reported fewer sexual partners than before the pandemic, only 1% reported more, with 48% reporting no change. (The survey did not ask about the number of partners or whether sex was with a household member.)
Many gay men remain cautious. Lewis Nightingale, a retired graphic designer in San Francisco who lived in New York during the early years of the AIDS epidemic, said he had spent much more time using online apps such as Grindr and Scruff to flirt and sext with other men.
He has received, and turned down, occasional invitations to meet up in person, he said. As an older man, he knows he is in a higher risk group for coronavirus complications. But refraining has been challenging, he said, since expressing himself sexually has played such a big part in his life. “For a lot of gay men, sex is pretty essential for a feeling of connection, for excitement, for validation,” said Nightingale, who has been in a relationship for 16 years.
Last month, Eric, a 42-year-old male escort in Manhattan who asked that his last name not be used, began weighing when and how to return to work. A former occupational therapist whose husband is a physician, he shut down business in mid-March and finally started seeing clients again earlier this month.
For now, he plans to limit scheduled appointments. He intends to see only those he knows well enough to believe they are truthful about routinely wearing masks and being symptom-free. And he is meeting people at his home rather than in a hotel room or their place. “I figure if I have people coming here, I’m only exposed to that person’s germs,” he said.
Eric also plans for now to avoid clients who have attended recent protests against police brutality. “I support the protests 1,000%, but I think they are probably pretty good breeding ground for the virus,” he said. “I don’t want to take that risk.”
In advising his gay patients about sexual activity, Klausner, the Los Angeles physician, said he tries to put the risk in context. The majority of coronavirus cases, he noted, have emerged from workplace and residential settings, such as meatpacking plants and nursing homes, as well as big indoor gatherings, such as concerts and religious services. Although the virus can be transmitted one-to-one in more intimate contexts, he said, “individual risk is really driven by people’s potential exposure to these crowded settings.”
A common misperception — that actions can be clearly defined as risky or not risky — can hamper understanding of other people’s actions, said Julia Marcus, a Harvard epidemiologist and HIV prevention expert. As restrictions on social distancing relax, she said, almost everyone will be making choices and engaging in activities that involve some level of risk — yet will likely be judged by various standards.
“There are very few zero-risk situations,” she said. Unfortunately, she added, “the gay guys are going to be shamed for hooking up, while the straight people having dinner together are less likely to be shamed.”
Join Julie Rovner, chief Washington correspondent for Kaiser Health News, along with top health policy reporters from The New York Times, The Washington Post, Politico and other media outlets to discuss the latest news and explain what the health is going on here in Washington.
Although the coronavirus pandemic shut down many organizations and businesses across the nation, KHN has never been busier ― and health coverage has never been more vital. We’ve revamped our Behind The Byline YouTube series and brought it to Instagram TV.
Journalists and producers from across KHN’s newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts — all while staying safe.
Julie Rovner – ‘Everybody Hit Record’
What happens when KHN’s podcast “What The Health?” goes from an in-person studio production to essentially a super-long Zoom meeting? Chief Washington Correspondent — and podcast host — Julie Rovner has some behind-the-screens advice: Turn off that noisy air conditioner and that bubbling fish tank, politely ask your quarantine crew to quiet down, and everybody hit record — at the same time if possible. The smartest health care podcast in the business: KHN’s “What The Health?” posts on Thursdays.
Former Vice President Joe Biden during a campaign speech in Lancaster, Pennsylvania, June 25, 2020
This story was produced in partnership with PolitiFact.This story can be republished for free (details). The same day the Trump administration reaffirmed its support of a lawsuit that would invalidate all of the Affordable Care Act, Joe Biden sharply warned that the suit endangers millions of Americans.
The presumptive Democratic presidential nominee said the law is even more important now, more than a decade after it was enacted, as the COVID-19 epidemic sweeps the U.S. The virus has killed more than 130,000, and Biden noted that some who survive may have long-lasting health problems.
His speech in the battleground state of Pennsylvania focused on a legal challenge headed to the Supreme Court and the fallout if the court upholds a 2018 U.S. District Court decision that struck down the entire ACA, including preexisting condition protections that bar insurers from rejecting people with medical problems or charging them more.
“And perhaps most cruelly of all, if Donald Trump has his way, complications from COVID-19 could become a new preexisting condition,” Biden said.
But would a decision against the health law affect COVID-19 patients in the way Biden described?Email Sign-Up
Subscribe to KHN’s free Morning Briefing.Sign Up Please confirm your email address below: Sign Up
We decided to check because it’s likely to come up a lot in the presidential electioneering. We reached out to the Biden campaign to find out the basis for his statement. A campaign spokesperson responded by reiterating the points made by the former vice president in his speech and sharing various news stories about COVID-19 and the preexisting condition coverage issue.
Several law and health policy experts noted that Biden is on fairly firm ground, though the issue — like many others in health care — is complicated.
First, A Little History
Before the ACA went into effect in 2014, insurers on the private market could reject applicants for coverage if they had any number of medical conditions, such as cancer, depression, heart disease — even high blood pressure, acne or plantar fasciitis. Consumers had to fill out forms listing their medical conditions when applying for coverage. An estimated 54 million Americans have a preexisting condition that could have led to a denial under pre-ACA rules, researchers estimate.
Also, at the time, some consumers had coverage cancelled retroactively once they fell ill with a serious or costly disease, as insurers would then comb through years of medical records looking for anything the consumer had failed to report as preexisting, even if it seemed to have little or nothing to do with the patient’s current medical concern.
Those rejections and cancellations mainly affected people who bought their own coverage, not those who got insurance through their jobs.
Job-based coverage, which is the main way most insured people get their plans, had some protections prior to the passage of the ACA. For example, the federal Health Insurance Portability and Accountability Act of 1996 said people who held health insurance continuously for at least a year could not face preexisting condition limits when they enrolled in a new employer plan, as long as they didn’t go uninsured for more than 63 days.
Those who didn’t meet that yearlong coverage requirement or went uninsured between jobs could find their medical conditions excluded for up to a year in a new group plan.
Before the ACA, insurers broadly defined preexisting conditions. Many included any condition for which a patient had received treatment, or even undiagnosed conditions for which a reasonable person should have sought treatment.
The ACA changed that. Among other things, it barred insurers from rejecting applicants based on their health, excluding coverage of preexisting medical conditions and charging sick people more than healthier ones. It also ended annual or lifetime dollar limits on coverage and said employers that offer insurance can’t make new workers wait more than 90 days for coverage to kick in.
Could COVID-19 Become A Preexisting Condition?
Biden’s comment raises the question of whether COVID-19 would be considered a preexisting condition in a future without the sweeping health law on the books.
Because the virus is so new, there’s no definitive answer on its long-term health effects.
Researchers are now starting to follow patients to track long-term effects.
Given insurers’ history, it’s certainly reasonable to assume they would put what are now cropping up as potential COVID complications in the preexisting-condition category, said Sabrina Corlette, who studies the individual insurance market as co-director of the Center on Health Insurance Reforms at Georgetown University.
“There is a real concern that if those preexisting condition protections are overruled or taken down by the Supreme Court, people who have COVID-19 could be medically underwritten, charged more or be denied a policy,” said Corlette.
That is possible, said Joe Antos, resident scholar in health policy at the conservative American Enterprise Institute. But many of the people most likely to suffer complications from the coronavirus likely already had conditions like diabetes, asthma or heart disease that would already have put them in danger of being rejected for coverage under pre-ACA business practices, he added.
In other words, COVID-19 could simply find a place on a long list of other conditions that could disqualify consumers from obtaining insurance.
And even if the high court tossed out the ACA, insurers might choose to keep offering coverage to people with health problems, say some analysts, including Antos.
But this take triggers skepticism.
“Insurance companies have an obligation to shareholders, and that obligation is to maximize profits,” Corlette said. “They don’t do that by covering a lot of sick people when competitors are not doing it.”
The Biggest UnknownSources
Telephone interview with Joe Antos, Wilson H. Taylor resident scholar in health care and retirement policy at the American Enterprise Institute, July 6, 2020
Telephone interview with Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University, July 6, 2020
Telephone interview with private practice attorney Christopher Condeluci, who served as tax and benefit counsel to the Senate Finance Committee when the ACA was drafted, July 6, 2020
“My Remarks on the Affordable Care Act in Lancaster, Pennsylvania,” Joe Biden, June 25, 2020
“Texas Judge Strikes Down Obama’s Affordable Care Act as Unconstitutional,” New York Times, Dec. 14, 2018
“Administration Challenges ACA’s Preexisting Conditions Protection In Court,” Kaiser Health News, June 8, 2018
“Supreme Court Won’t Fast-Track Obamacare Case ,” Politico, Jan. 21, 2020
“Nearly 54 Million Americans Have Pre-Existing Conditions That Would Make Them Uninsurable in the Individual Market Without the ACA,” Kaiser Family Foundation, Oct. 4, 2019
“The Emerging Long-Term Complications of Covid-19, Explained,” Vox, June 12, 2020
“What We Know (So Far) About the Long-Term Health Effects of Covid-19,” Advisory Board, June 2, 2020
“Looking Forward: Understanding the Long-Term Effects of Covid-19,” National Heart, Lung and Blood Institute, June 3, 2020
“Did The ACA Create Preexisting Condition Protections for People in Employer Plans?” Kaiser Health News and PolitiFact, May 21, 2019
Just how would Congress and the president react if the ACA is struck down?
Under a Biden presidency, coupled with Democrats holding the House and possibly winning the Senate, the ACA would definitely be replaced, the experts all agreed.
Under a second-term Trump administration, Republicans would face a dilemma because — even though the party has called for the law’s repeal since its enactment –— they have been unable to agree on how to replace it. Yet polls have consistently shown that parts of the law, especially the preexisting condition protections, are very popular with a wide swath of voters.
“They don’t want to come across as coming up hard against people who have health conditions,” said Antos.
Private practice attorney Christopher Condeluci, who served as tax and benefit counsel to the Senate Finance Committee when the ACA was drafted, agreed. He thinks Congress or the president would act to save the preexisting condition protections at least.
But how to do so is problematic. That provision is intricately tied with many other parts of the ACA, those aimed at getting as many healthy people to enroll as possible in order to spread costs out among the many, rather than the few.
The ACA did that partly by requiring most Americans to carry insurance coverage — the provision at the heart of the Texas lawsuit seeking to overturn the legislation. Restoring that requirement might be tricky, so the path forward for a split Congress or a second-term Trump presidency to come up with a solution quickly — or at all — if the Supreme Court tosses the entire law is a difficult one.
Biden said that if Trump had his way, COVID complications could become a preexisting condition. He said this while discussing what might happen if the ACA is overturned by the Supreme Court. Though the statement can’t be definitively proven, there’s a lot of evidence backing it up.
First, some patients are showing at least short-term aftereffects of COVID-19, some of which could be costly. Some may prove long-term.
Second, insurers dislike costly medical conditions. Their business model is designed to have enough healthy enrollees to offset those with costly conditions. Before the ACA, they did that by rejecting people with medical conditions, charging them more or excluding coverage for those conditions. Some also temporarily delayed coverage for specific conditions in group plans offered by employers. Without the ACA, no federal law would prevent them from returning to these practices when selling plans on the individual market.
We rate Biden’s statement Mostly True.
Worried about the high cost of the copayment for the shingles vaccine, Jacky Felder, a Medicare beneficiary, opted against getting immunized last year.
Last month, the Green Bay, Wisconsin, woman developed the disease, which left a painful, itchy rash across her abdomen. “Luckily, I’ve had a relatively mild case, but it’s been a week and half with a lot of pain,” said Felder, 69.
Felder is far from alone. Nationally, about 35% of people 60 and older were vaccinated for shingles by 2018, up from about 7% in 2008, according to a report released Thursday by the federal Centers for Disease Control and Prevention.Don't Miss A Story
Subscribe to KHN’s free Weekly Edition newsletter.Sign Up Please confirm your email address below: Sign Up
The report also shows low-income adults and those who are Black or Hispanic are far less likely to get vaccinated than whites. About 39% of non-Hispanic white adults were vaccinated for shingles by 2018, compared with about 19% of Hispanic and Black adults, the report found.
Those findings are consistent with disparities for other adult vaccines.
Adults with incomes under the federal poverty level ($12,760 for an individual) were only half as likely to get immunized as those with annual incomes of more than $25,000, the report said.
Cara James, CEO of the nonprofit Grantmakers in Health and former director of the Office of Minority Health at the Centers for Medicare & Medicaid Services, said Blacks and Hispanics are more likely than whites not to have health insurance or a regular health provider, which may help account for their lower vaccination rates. They are also likely to have less income to afford the shot.
The lower vaccination rates for Blacks and Hispanics have implications for when and if a vaccine is developed for COVID-19, she said. Even though they are more likely to have the coronavirus and experience more severe cases of COVID-19, Blacks and Hispanics may not be at the front of the line to get vaccinated because of costs and other factors.
Shingles is caused by the same virus that causes chickenpox, which can remain in the body inactive for years. For about a third of adults, it can reactivate as shingles, often presenting as a painful rash anywhere on the body.
The drugmaker Merck offered the first shingles vaccine, Zostavax, in the U.S. in 2006. In late 2017, a newer and more effective vaccine, Shingrix, was approved by the Food and Drug Administration, and this month Merck stopped selling its product.
Shingrix, made by GlaxoSmithKline, is 97% effective in preventing the disease in adults ages 50 to 69, compared with about 51% for Zostavax. The CDC recommends that everyone over 50 — including those who were vaccinated with Zostavax — get Shingrix. No prescription is required.
The Affordable Care Act required that preventive health services, including vaccines, be provided to people with private health insurance with no out-of-pocket costs. But people with Medicare were excluded.
While Medicare beneficiaries get free vaccinations for the flu and pneumonia, they often have to pay for other vaccines, including the shingle shots. The payments are set by their Medicare drug plan.
Dr. William Schaffner, an infectious disease expert at Vanderbilt University in Nashville, said he recommends his patients get the Shingrix vaccine before they turn 65 and enroll in Medicare. He faults Congress for adding costs for Medicare enrollees to get vaccinated.
“We’ve seen a substantial portion of the population receive the vaccine, but it is far from the goal of 100%,” Schaffner said.
GlaxoSmithKline said the average Medicare enrollee pays $50 for each of two doses of the vaccine, which are typically given a few months apart.
For people without insurance, Shingrix costs about $300 for the two doses.
Besides cost, another factor that may play into the low rate of vaccinations is access. Demand for Shingrix led to a shortage of the vaccine shortly after its launch, but GlaxoSmithKline officials say they now have plenty to distribute.
About 17 million people have received at least one dose of Shingrix, although the shots are recommended for more than 100 million people, spokesperson Sean Clements said. In comparison, he said between 20 million and 25 million people received Zostavax after 14 years on the market.
Dr. Anjali Mahoney, a family physician in Los Angeles and vice chair for clinical affairs at the University of Southern California’s Keck School of Medicine, said she was pleased to hear about the big increase in people getting the vaccine.
“About 1 in 3 people get shingles in their lifetime, and that is not something you want to get,” she said. Complications and pain from shingles, she added, can last for years, long after the rash has disappeared.
But she said that the cost barriers to vaccination for Medicare beneficiaries are keeping the numbers lower than they should be.
Felder, whose income is limited to her Social Security payments, said even $50 per dose would be too much for her to pay for the shingles vaccine. She hopes to get vaccinated if she receives another federal stimulus check.
“It isn’t right that people on Medicare have to pay for this, because for a lot of people, shingles can make them very sick,” Felder said.
The rate of positive tests, new daily COVID-19 cases and daily deaths in long-term care facilities are all now showing declines from earlier in the pandemic, according to a state presentation.
The method uses small molecules called "micro-RNAs," delivered by a virus into the spinal fluid, to block a gene key in the fatal nerve disease ALS, also known as Lou Gehrig's disease.
Cuando le dije a mi hija de 18 años, Caroline, que pronto podría descargar una aplicación para alertarla si se había estado recientemente en una situación de riesgo cerca de alguien con COVID-19, y que los funcionarios de salud pública esperaban combatir la pandemia con esas apps, su respuesta fue tajante.
“OK, pero nadie las va a usar”, respondió.
El pesimismo de mi hija, una joven adicta a los teléfonos inteligentes, es el reto que enfrentan los tecnólogos de todo el país al tratar de desarrollar e implementar aplicaciones para rastrear la pandemia en un momento en el que resurge en la mayoría de los estados.
A los que desarrollan aplicaciones, y a los expertos en salud pública que los observan de cerca, les preocupa que si no involucran a suficientes personas, las aplicaciones no lograrán captar un número significativo de infecciones, y de personas en riesgo de infección.
Su éxito depende de un alto nivel de cumplimiento y competencia en salud pública, algo de lo que los Estados Unidos ha carecido durante la crisis de COVID.
“Ni siquiera podemos hacer que la gente use máscaras en este país”, dijo el doctor Eric Topol, director del Scripps Research Translational Institute en San Diego. “¿Cómo vamos a hacer que sean diligentes en el uso de sus teléfonos para ayudar en el rastreo de contactos?”
Las aplicaciones de rastreo, un puñado de las cuales se han puesto a disposición del público en los Estados Unidos, permiten a los teléfonos celulares enviarse señales entre sí cuando están cerca, y si están equipados con la misma aplicación, o una compatible.
Los dispositivos mantienen un registro de todos sus encuentros digitales y, más tarde, alertan a los usuarios cuando alguien con quien estuvieron en proximidad física da positivo para COVID.
Para que una aplicación detenga un brote en una comunidad determinada, el 60% de la población tendría que utilizarla, aunque una tasa de participación menor podría reducir el número de casos y muertes, según un estudio reciente. Algunos dicen que una tasa de adopción tan baja como del 10% podría proporcionar beneficios.
En algunos lugares donde se han ofrecido este tipo de aplicaciones, el uso no ha alcanzado ni siquiera ese bajo umbral. En Francia, menos del 3% de la población había activado la aplicación respaldada por el gobierno, StopCovid, a fines de junio. La aplicación de Italia había atraído a alrededor del 6% de la población.
El porcentaje de residentes que han descargado la aplicación respaldada por Dakota del Norte y del Sur, Care19, está por debajo del 10%.
Una excepción es Alemania, donde más del 14% de la población descargó la Corona Warn App en la primera semana después de su lanzamiento.
Las aplicaciones para COVID-19 están generalmente destinadas a complementar el trabajo de los rastreadores de contactos, que hacen un seguimiento de las personas que han dado positivo en las pruebas del virus, preguntándoles dónde han estado y con quién.
Los rastreadores se ponen en contacto con los individuos potencialmente expuestos y les aconsejan qué hacer, como hacerse la prueba o la autocuarentena.
Hasta ahora, en los Estados Unidos el rastreo de contactos, lento y laborioso en en el mejor de los casos, ha sido un fracaso: se ha desplegado un número insuficiente de personas, a veces mal entrenadas, y las personas infectadas a las cuales han contactado a menudo no cooperan.
Las perspectivas del rastreo digital no parecen mejores. “Idealmente, debía existir una forma digital de complementar el rastreo de contactos”, explicó Topol. Pero “no hay ningún lugar aún a nivel mundial donde haya pruebas de que esta idea pueda ayudar realmente a la gente”.
Cerca de 20 aplicaciones de rastreo están en uso o en desarrollo en los Estados Unidos.
Un número creciente de desarrolladores de aplicaciones del país apuntan a las agencias de salud estatales porque Google, el fabricante de software para teléfonos móviles Android, y el fabricante de iPhone Apple no permiten que una aplicación utilice su plataforma conjunta sin el respaldo de un estado. La tecnología de Google-Apple, a pesar de su uso muy limitado hasta ahora, es considerada por muchos como la plataforma más prometedora.
Sin embargo, a muchos estados no les interesa tanto la tecnología de Google-Apple, ni del rastreo de contactos digitales en general. En una encuesta de Business Insider publicada en junio, sólo tres estados dijeron que se habían comprometido con el modelo de Google-Apple, mientras que 19 de ellos, incluída California, no se comprometieron. Diecisiete estados no tenían planes para ningun sistema de rastreo basado en teléfonos inteligentes. Los 11 restantes no respondieron o no fueron claros en cuanto a sus planes.
En abril, el gobernador de California, Gavin Newsom, dijo que su oficina estaba trabajando con Apple y Google para hacer que esta tecnología formara parte del plan del estado para salir de la orden de quedarse en casa. Dos meses más tarde, el Estado Dorado parece haberse retractado de la idea.
En su lugar, está capacitando a 20,000 rastreadores de contactos con la esperanza de que se pongan en marcha este mes. El Departamento de Salud Pública del estado dijo a California Healthline, en un correo electrónico, que la mayoría de los rastreos de contacto “se pueden hacer por teléfono, texto, correo electrónico y chat”.
La confianza es importante
Entre los múltiples obstáculos que impiden el uso satisfactorio de las aplicaciones de rastreo digital figura la indiferencia o la hostilidad a las medidas anti-COVID. Algunas personas ni siquiera usan máscaras o desconfían de otros esfuerzos de salud pública.
Además, en la medida en que las personas adopten el rastreo telefónico, podría pasar por alto los posibles brotes entre las poblaciones más afectadas: los adultos mayores y las personas de bajos ingresos, que suelen tener menos acceso a los teléfonos inteligentes.
“Si el uso es alto entre las personas de 20 años y bajo entre las personas mayores y en las residencias, no queremos que los mayores y las residencias pierdan la atención que deberían recibir a través de los esfuerzos de rastreo de contactos”, señaló Greg Nojeim, director del Proyecto de Libertad, Seguridad y Tecnología del Center for Technology and Democracy en Washington, D.C.
Los desafíos técnológicos no resueltos también podrían obstaculizar la eficacia de las aplicaciones.
Para captar los encuentros cercanos de riesgo entre usuarios, algunas aplicaciones emplean el GPS para rastrear su ubicación. Otras usan Bluetooth, que mide la proximidad de dos teléfonos celulares entre sí sin revelar su paradero.
Ninguno de los dos enfoques es perfecto para medir la distancia, y ambos podrían evaluar incorrectamente una amenaza de COVID para los usuarios. El GPS puede decir si dos personas están en la misma dirección, pero no si están en diferentes pisos de un edificio.
El Bluetooth determina la distancia basándose en la fuerza de la señal de un teléfono. Pero la fuerza de la señal puede distorsionarse si un teléfono está en el bolso o en el bolsillo de alguien, y los objetos metálicos también pueden interferir con ella.
La mayor barrera para la aceptación pública es la cuestión de la privacidad. Los defensores del sistema Google-Apple, que utiliza Bluetooth, dicen que las dos compañías mejoraron las perspectivas de aceptación al abordar preocupaciones fundamentales de privacidad.
Google-Apple no permitirá que las aplicaciones rastreen la ubicación de los usuarios de teléfonos inteligentes y garantiza que todos los contactos rastreados se almacenen en los teléfonos de las personas, y no en una base de datos centralizada que daría a las autoridades de salud pública un mayor acceso a la información.
Esto significa que cada decisión basada en los datos de rastreo depende de los usuarios de los teléfonos inteligentes. Ellos deciden si notifican a otros usuarios de la aplicación si contraen el virus o si siguen el consejo —de ponerse en cuarentena y contactar con las autoridades de salud pública— que acompañaría a una alerta de posible exposición.
El sistema Google-Apple facilita la comunicación entre las aplicaciones que lo utilizan, lo que podría ser especialmente importante en regiones multiestatales —el área metropolitana de Washington, por ejemplo— donde cada estado podría tener una aplicación diferente y la gente suele viajar de un lado a otro de las fronteras estatales.
Pero los desarrolladores de aplicaciones que no utilizan la plataforma Google-Apple tendrán dificultades para sincronizarse con ella, especialmente si sus aplicaciones rastrean lugares o utilizan un servidor centralizado.
Entre ellas se encuentran la aplicación Care19 en las Dakotas y Healthy Together, la aplicación de Utah, que utilizan tanto el GPS como la Wi-Fi para rastrear ubicaciones. Healthy Together también permite a los funcionarios de salud pública ver los nombres, números de teléfono e historial de ubicación de las personas.
Estos modelos son un anatema para los defensores de la privacidad, lo que podría limitar su uso. De hecho, Dakota del Norte ha anunciado que está planeando una segunda aplicación basada en la tecnología de Google-Apple.
Sin embargo, algunos expertos en salud pública advierten que el fuerte enfoque de privacidad de Google-Apple, con exclusión de otros factores importantes, puede limitar el valor de las aplicaciones para hacer frente a la pandemia.
“Apple-Google, al asociarse, ha definido de forma bastante estrecha lo que es aceptable”, indicó Jeffrey Kahn, director del Instituto Berman de Bioética de la Universidad Johns Hopkins. “Si estas cosas van a funcionar como todo el mundo espera, tenemos que tener una discusión más completa y pormenorizada sobre todas las cuestiones importantes”.
Las apps no te alertan en tiempo real necessariamente. Puede ser hasta 2 semanas después. Depende de cuándo la otra persona se entere que ha contraído el virus. Los teléfonos “recuerdan” todos los encuentros de cierta distancia ppor hasta unas dos semanas.
The increased testing will be available in Chelsea, Everett, Fall River, Lawrence, Lowell, Lynn, Marlborough, and New Bedford.
The Supreme Court Wednesday settled — at least for now — a decade’s worth of litigation over the women’s health provisions of the Affordable Care Act, ruling 7-2 that employers with a “religious or moral objection” to providing contraceptive coverage to their employees may opt out without penalty.
The Trump administration was within its rights to exempt religious nonprofit agencies, like the lead plaintiff in the case – the Catholic order Little Sisters of the Poor – from having to participate in any way from facilitating contraceptive coverage for their employees. Wrote Justice Clarence Thomas in the majority opinion, “We hold today that the Departments had the statutory authority to craft that exemption, as well as the contemporaneously issued moral exemption
Women’s health groups were quick to decry the ruling – even though liberal Justices Stephen Breyer and Elena Kagan agreed with the outcome.
“The Supreme Court just ruled that your boss or your university can, based on their own objections, take away your birth control coverage,” tweeted Planned Parenthood Action Fund, the political arm of Planned Parenthood. “The fact that the Court allowed this attack birth control coverage under the ACA in 2020 — and which has benefitted over 62 million people — shows the war on our reproductive health care isn’t just about access to abortion. It’s everything.Email Sign-Up
Subscribe to KHN’s free Morning Briefing.Sign Up Please confirm your email address below: Sign Up
The ACA itself did not require that contraceptives be covered. Rather, it called for preventive health services for women to be included in most insurance plans and left it to the Department of Health and Human Services to figure out which ones. In the Obama administration, HHS asked the Institute of Medicine (now the National Academy of Medicine) to recommend which services had enough scientific evidence backing them to be added, and FDA-approved methods of contraception were named by the institute.
That spurred bitter controversy, with some religious groups and business owners who object to certain types of contraceptives arguing that they should not be forced to provide the services to workers.
The Supreme Court ruled in 2014 that “closely held corporations” like the craft chain Hobby Lobby did not have to abide by the contraceptive coverage requirement. But that did not settle the issue completely.
From the start, the Obama administration exempted churches and other religious entities from the coverage requirement. Still, there was an outcry for relief from religious nonprofit groups such as hospitals and universities. And that battle has raged since Obama officials tried to find compromise after compromise, to no avail.
The last Obama rule allowed religious nonprofits to opt out of providing coverage directly by signing a form that would transfer the financial and administrative responsibility for coverage to their health insurer. But the organizations — including the Little Sisters of the Poor, which operates long-term care homes for low-income seniors — insist that the act of signing the form facilitates the coverage and makes them “complicit in sin.”
The Supreme Court took up the case — actually seven cases bundled together — in 2016. But with only eight justices on the bench following the death of Justice Antonin Scalia earlier that year, the court deadlocked 4-4 and sent the cases back to the lower courts, with orders to try to find a compromise that would allow employees to receive coverage without compromising the religious beliefs of the employers.
With the election of Donald Trump, the controversy continued, but in reverse. The Trump administration issued rules to give organizations with not just religious, but also moral, objections to birth control the ability to opt out. And it was sued by those who believe women should have the right to no-cost contraception, including state governments, whose leaders fear that if employers opt out, the states will end up paying more for state contraceptive programs and costs associated with unwanted pregnancies.
The addition of moral objection is a dramatic expansion, said Michael Fisher, who argued the case on behalf of Pennsylvania during the court’s oral arguments in May. Fisher said the provision was so broad that employers could deny contraceptive coverage because they morally object to women being in the workplace.
The decision is likely to have a political impact larger than its actual consequence – the loss of no-cost birth control for perhaps hundreds of thousands of women. While the court will not decide its broader case challenging the constitutionality of the Affordable Care Act before November’s election, it could boost the law’s fate back onto the electoral front burner.
HOUSTON — The Fourth of July was a little different this year here in Texas’ biggest city. Parades were canceled and some of the region’s beaches were closed. At the city’s biggest fireworks show, “Freedom Over Texas,” fireworks were shot higher in the air to make it easier to watch from a distance. Other fireworks displays encouraged people to stay in their cars.
After weeks of surging COVID-19 cases and dire warnings that Houston’s massive medical infrastructure would not be able to keep pace, Republican Gov. Greg Abbott issued an executive order on July 2 requiring Texans to wear masks in public, after previously reversing course on the state’s reopening by again closing bars and reducing restaurant capacity.
While most Houstonians appear to be taking heed, not everyone is on board. Small protests against the orders occurred over the holiday weekend. Lawsuits have been filed. At least one Houston-area law enforcement agency said it would not enforce the mask requirement. The State Republican Executive Committee plans to hold its mid-July convention downtown, drawing an expected 6,000 people from around the state.Don't Miss A Story
Subscribe to KHN’s free Weekly Edition newsletter.Sign Up Please confirm your email address below: Sign Up
Democratic Mayor Sylvester Turner said he and other local leaders sent a letter to GOP leaders asking them to convert the convention into a virtual event. But the party remains steadfast.
“There simply is no substitute for the in-person debate we value so strongly,” Texas GOP Chairman James Dickey said, adding that the party committee explicitly affirmed it would not voluntarily cancel the convention. He said there would be thermal scanners, social distancing, deep cleaning between meetings, hand sanitizer and thousands of donated masks available for those in attendance.
“My sincerest sympathies go out to anyone who is affected by any severe disease, including this one,” he said. “But on a per capita basis, Harris County, and Texas in general, are both dramatically better than most of the states in the United States.”
However, confirmed cases in Houston’s surrounding county, Harris, more than doubled in a month to reach more than 37,000 positive cases as of July 6. Hospitals in the Texas Medical Center had 2,261 COVID-positive patients that day in intensive care or medical-surgical units, up from 1,747 the week before, according to the center’s tracking website. All told, the nine-county Houston region has had more than 52,000 confirmed cases and 572 deaths.
The Texas Medical Center has predicted that unless the spread of the virus is mitigated, Houston hospitals could exceed existing capacity by mid-July. A federal assessment team came to Houston to determine how the federal government can help the city respond to the current surge.
Local officials had tried to protect Houston. Early in the pandemic, Harris County Judge Lina Hidalgo, a Democrat who serves as the county’s top elected leader, implemented business closures and stay-at-home and masking orders. But Lt. Gov. Dan Patrick and U.S. Rep. Dan Crenshaw, both Republicans, called them an “overreach” that “could lead to unjust tyranny.” On April 27, Abbott overruled the county guidance, and announced plans to reopen businesses and relax social distancing guidelines.
For those who live in Houston, it’s all meant lots of confusion.
“This whole thing has been a messaging nightmare from the beginning,” said Joe Garcia, 50, who works in data management. “When a flood happens, when a hurricane happens, nobody cares what side you’re on — blue, red, whatever else — all you know is it’s a disaster and everybody comes in and helps. That’s just the way things are. This wasn’t treated as a disaster.”
Public discourse about the pandemic has been disheartening, said Norma Ybarbo, 55, who avoids leaving home beyond socially distant visits with her father and attending a lightly populated early morning mass. She said the political arguments and conflicting communication from the Texas Medical Center in June about hospital capacity have made an already stressful situation worse.
“It’s worrisome, for sure,” Ybarbo said. “It’s really hard to determine what is right and what is true.”
Marine veteran S.D. Panter, 44, said it all has deepened his concern about bias in doctors and politicians who are advocating for businesses to be shut down. Panter, who doesn’t deny the virus is troublesome, said he prefers to do his own research because, for him, the dire picture being painted by those in the spotlight doesn’t make sense. He does wear a mask in public, even though he is not sure it is necessary.
“There’s just so much information. Just let me make my own decision, my own informed decision,” said Panter, who helps his parents and his wife’s parents stay socially isolated. “The older population should probably stay indoors, and let’s protect them the best we can.”
The state’s reopening this spring coincided with Mother’s Day, graduations, Memorial Day and Black Lives Matter protests. Once Texans were released from pandemic-induced restrictions, many happily took advantage of the chance to socialize.
Alyssa Guerra, 27, who lost her job when the store she managed closed, said she now knows people who have contracted the virus, and a few who have become sick or lost loved ones. She has friends who went to bars and social events, without masks, when the state reopened. She went out to eat once, but felt so uncomfortable she hasn’t done it since.
“It’s affecting us in greater numbers now because of the selfish decisions we are making,” said Guerra. “At some point, yes, we are going to have to start living our lives again, but we did it so quickly this time that people just had no care in the world.”
While the number of confirmed COVID-19 infections is rising in all age groups here, those seeing the most rapid growth in positive tests and hospitalizations are 20 to 40 years old. Dr. David Persse, public health authority with the Houston Health Department, said recently that 15% of COVID patients being admitted to the hospital are younger than 50, and 30% are younger than 60.
That could explain lower rates of death now than earlier in the pandemic, said Dr. Angela Shippy, chief medical and quality officer at Memorial Hermann Health System. Another reason for the lower death rates could be that providers have learned more effective treatments for the virus, using different respiratory and drug therapies to avoid intensive care units and intubation.
Still, Houston’s hospitals are being challenged by the rapid spike in COVID patients as a whole. Without taking steps to slow the spread of the virus, hospitals could become unable to manage the load. That has been the message from hospitals — including in multiple full-page ads in the Houston Chronicle advising people to stay home or wear a mask in public.
“We still have the ability to grow capacity, but there will come a limit to how much capacity you can grow,” said Roberta Schwartz, executive vice president, chief innovation officer and CEO of Houston Methodist Hospital.
The area’s public hospitals, which had been steadily handling COVID cases since March, have been transferring adult patients the past several weeks to private hospitals, including Texas Children’s Hospital, which had 29 COVID patients as of July 6. Houston Fire Chief Sam Peña said it has been taking an hour, in some cases, to transfer patients from ambulances to some emergency rooms — which Schwartz said have been “inundated.”
The fire and police departments have large numbers of staff in quarantine. Hospitals report staffers are testing positive, which they attribute to contracting the virus outside the hospital. Some area hospitals are bringing in traveling nurses to help.
“We encourage everyone to do their part and always wear a mask when leaving home, wash your hands often and maintain social distance,” Mark A. Wallace, president and CEO of Texas Children’s Hospital, said in an emailed statement. “This is the best way to protect yourself, your loved ones and our health care workers.”
Yes, of course, Americans’ health is priceless, and reining in a deadly virus that has trashed the economy would be invaluable.
But a COVID-19 vaccine will have an actual price tag. And given the prevailing business-centric model of American drug pricing, it could well be budget breaking, perhaps making it unavailable to many.
The last vaccine to quell a global viral scourge was the polio inoculation, which ended outbreaks that killed thousands and paralyzed tens of thousands each year in the United States. The March of Dimes Foundation covered the nominal drug cost for a free national vaccination program.
It came in the mid-1950s, before health insurance for outpatient care was common, before new drugs were protected by multiple patents, before medical research was regarded as a way to become rich. It was not patented because it was not considered patentable under the standards at the time.Email Sign-Up
Subscribe to KHN’s free Morning Briefing.Sign Up Please confirm your email address below: Sign Up
Now we are looking for viral deliverance when drug development is one of the world’s most lucrative businesses, ownership of drug patents is disputed in endless court battles, and monopoly power often lets manufacturers set any price, no matter how extraordinary. A new cancer treatment can cost a half-million dollars, and old staples like insulin have risen manifold in price to thousands of dollars annually.
And the American government has no effective way to fight back.
Recent vaccines targeting more limited populations, such as a meningitis B vaccine for college students and the shingles vaccine for older adults, have a retail cost of $300 to $400 for a full course.
If a COVID-19 vaccine yields a price of, say, $500 a course, vaccinating the entire population would bring a company over $150 billion, almost all of it profit.
Dr. Kevin Schulman, a physician-economist at the Stanford Graduate School of Business, called that amount “staggering.” But Katherine Baicker, dean of the University of Chicago Harris School of Public Policy, said that from society’s perspective “$150 billion might not be an unreasonable sum” to pay to tame an epidemic that has left millions unemployed and cost the economy trillions.
Every other developed country has evolved schemes to set or negotiate prices, while balancing cost, efficacy and social good. The United States instead has let business calculations drive drug price tags, forcing us to accept and absorb ever higher costs. That feels particularly galling for treatments and vaccines against COVID-19, whose development and production is being subsidized and incentivized with billions in federal investment.
When AZT, the first effective drug for combating the virus that causes AIDS, was introduced in 1992, it was priced at up to $10,000 a year or about $800 a month. It was the most expensive prescription drug in history, at that time. The price was widely denounced as “inhuman.” Today that price gets you some drugs for toenail fungus.
Investors already smell big money for a COVID-19 vaccine.
The market cap of Moderna, a small Boston-area company that has partnered with the National Institutes of Health in the vaccine race, has tripled since Feb. 20, to $23 billion from $7 billion, turning its chief executive into an overnight billionaire. While Moderna’s vaccine is regarded as a strong contender, the company has never brought a successful drug to market.
Manufacturers have traditionally claimed that only the lure of windfall profits would encourage them to take the necessary risks, since drug development is expensive and there’s no way of knowing whether they’re putting their money on a horse that will finish first, or scratch.
More recently they have justified high prices by comparing them with the costs they would prevent. Expensive hepatitis C drugs, they say, avoid the need for a $1 million liver transplant. No matter that the comparison being made is to the highly inflated costs of treating disease in American hospitals.
Such logic would be disastrous if it were applied to a successful COVID vaccine. COVID-19 has shut down countless businesses, creating record-high unemployment. And the medical consequences of severe COVID-19 mean weeks of highly expensive intensive care.
“Maybe the economic value of the COVID vaccine is a trillion — and even if the expense to the company was a billion, that’s 1,000 times return on investment,” said Schulman. “No economic theory would support that.”
In 2015, the Senate Finance Committee came up with a simpler explanation for high drug prices. After reviewing 20,000 pages of company documents, it found that Gilead Sciences had what the committee’s ranking Democratic member, Ron Wyden of Oregon, called “a calculated scheme for pricing and marketing its hepatitis C drug based on one primary goal, maximizing revenue.”
In setting prices, drugmakers rarely acknowledge the considerable federal funding and research that have helped develop their products; they have not offered taxpayer-investors financial payback.
The Biomedical Advanced Research and Development Authority, a federal agency known as BARDA, is giving Moderna up to $483 million for late-stage development of its vaccine.
The basic science that has allowed the small company to move so rapidly was developed with a huge prior infusion of federal money to come up with a treatment for diseases like Zika.
Francis Collins, the head of the National Institutes of Health, has said the government has some intellectual property rights. Moderna seems to dispute that view, saying it is “not aware of any I.P. that would prevent us from commercializing” a COVID-19 vaccine.
Likewise, AstraZeneca, a top competitor, has received a BARDA promise of up to $1.2 billion for commercializing a product derived from research at the University of Oxford.
There is no simple, direct mechanism for regulators or legislators to control pricing. Our laws, in fact, favor business: Medicare is not allowed to engage in price negotiations for medicines covered by its Part D drug plan. The Food and Drug Administration, which will have to approve the manufacturer’s vaccine for use as “safe and effective,” is not allowed to consider proposed cost. The panels that recommend approval of new drugs generally have no idea how they will be priced.
“The idea that we would allow ourselves to be held hostage in an emergency is mind-boggling,” said David Mitchell, head of Patients for Affordable Drugs, an advocacy group.
That’s why a bipartisan coalition in the House recently proposed two new bills to prevent “price gouging” for “taxpayer funded COVID-19 drugs” to ensure affordable pricing.
The exact mechanisms for enacting the provisions therein — such as requiring manufacturers to reveal their development costs — remain unclear. The industry has previously protected development data as a trade secret. The bills would also require “reasonable pricing clauses” be included in agreements between drug companies and agencies funding their work. They propose waiving exclusive licenses for COVID-19 drugs, allowing competitors to sell the same products as long as they pay the patent holder royalties.
Other countries, such as Britain, take a more head-on approach: a national body does a cost-benefit analysis regarding the price at which a new drug is worth being made available to its citizens. Health authorities then use that information to negotiate with a drugmaker on price and to develop a national reimbursement plan.
We could, too, but would need to consider mechanisms outside of our current box — at least for this national emergency.
The federal government could, for example, invoke a never-before-used power called “march-in rights,” through which it can override a patent holder’s rights if it doesn’t make its medicines “available to the public on reasonable terms.” (Unfortunately, in already-signed agreements with BARDA, some drugmakers have explicitly watered down or eliminated that proviso.)
We could, alternatively, allow Medicare to negotiate drug prices — a proposal that has been raised by politicians and beaten back by industry again and again. We would then need to restrict markup for a COVID-19 vaccine for the private market. Otherwise, we’d get the kinds of results emerging from the COVID testing industry, where Medicare pays $100 for the test but some labs charge insurers over $2,000.
There is already reason to worry that our deliverance from the coronavirus will cost us plenty. BARDA paid AztraZeneca up to $1.2 billion toward development, production and delivery of its candidate vaccine, in order to secure 300 million doses in October. Britain paid the equivalent of $80 million to secure 100 million doses in September — one-fifth of what the United States government agreed to pay per dose.
Baicker, the public policy school dean, thinks public scrutiny will prevent outrageous pricing. The industry has made various pledges, trying to balance corporate citizenship against making eager investors happy: Astra Zeneca has promised 1 billion doses for low- and middle-income countries. Johnson & Johnson says it would make the COVID-19 vaccine available on a “not for profit basis” at $10 for “emergency pandemic use.”
We’ve heard such offers before. Pharmaceutical companies routinely provide coupons to cover patient copayments for expensive drugs so that we don’t squawk when they charge our insurance company tens of thousands for the medicine, driving up premiums year after year. A naloxone injector to reverse heroin overdoses is given free to some clinics, but priced at thousands for the rest.
And it won’t feel like a bargain if we get free or cheap vaccines during a pandemic but pay dearly for annual COVID-19 shots thereafter.
Drug companies deserve a reasonable profit for taking on this urgent task of creating a COVID-19 vaccine. But we deserve a return, too.
So before these invaluable vaccines hit the market, we should talk about an actual price. Otherwise, we will be stuck paying dearly for shots that the rest of the world will get for much less.
The old men live in cramped spaces and breathe the same ventilated air. Many are frail, laboring with heart disease, liver and prostate cancer, tuberculosis, dementia. And now, with the coronavirus advancing through their ranks, they are falling one after the next.
This is not a nursing home, not in any traditional sense. It is California’s death row at San Quentin State Prison, north of San Francisco. Its 670 residents are serial killers, child murderers, men who killed for money and drugs, or shot their victims as part of their wasted gangster lives. Some have been there for decades, growing old behind bars. One is 90, and more than 100 are 65 or older.
Executions have been on hold in California since 2006, stalled by a series of legal challenges. And they won’t resume anytime soon: In 2019, two months after taking office, Gov. Gavin Newsom declared a moratorium on executions and ordered that San Quentin’s death chamber be dismantled. But death has come to San Quentin nonetheless.Email Sign-Up
Subscribe to KHN’s free Morning Briefing.Sign Up Please confirm your email address below: Sign Up
In recent days, five death row inmates have died after contracting COVID-19. Almost 200 others are thought to be ill with the virus, according to a Newsom administration official not authorized to speak publicly. Scores more are refusing to be tested. For now, there is no clear remedy and no end in sight.
“San Quentin’s staff — especially medical staff — is simply drowning among the chaos,” State Public Defender Mary McComb said in a letter last week to the state Senate Public Safety Committee. “San Quentin desperately needs a significant number of additional personnel, and quickly.”
Correctional officers are working double and even triple shifts. Doctors have been working 12-plus-hour days, seven days a week, for the past six weeks, McComb wrote: “Men (including some who have tested positive) report not having access to doctors, not receiving medication for symptoms such as coughs, and not receiving regular oxygen-level or blood pressure checks.”
San Quentin’s coronavirus outbreak could prove to be the worst at any prison in the nation. It began in mid-June, shortly after the California Department of Corrections and Rehabilitation transferred 121 inmates to San Quentin from the state prison in Chino, east of Los Angeles, in a failed effort to stem an outbreak there. At least 20 of the Chino transfers subsequently tested positive for the disease.
Now, more than 1,400 San Quentin inmates have the virus, or more than a third of the prison’s 4,000 inmates. And death row has been hit particularly hard. Of the six inmate deaths that prison authorities have formally attributed to the coronavirus, three were on death row. Two more death row inmates who died in recent days also tested positive for the virus, though the official cause of death is pending.
San Quentin, which opened in 1852, is renowned for its rehabilitative programs. Most San Quentin inmates are classified as minimum or medium security risks and will be released one day. They take college courses and participate in job-training programs. Some work on the prison’s award-winning podcast and newspaper.
An additional 670 at San Quentin are condemned, and ineligible for release, no matter how old or infirm.
About 500 of them are housed in East Block, a hangar-size structure that is five tiers high. They live one to a cell, 10.5 feet by 4.75 feet. The doors are steel mesh. They cannot help but breathe one another’s air. Sixty-four of the best-behaved inmates are housed on the traditional death row, known as North Seg. There’s a Mickey Mouse clock in the officers’ area emblazoned with the words “The Happiest Place on Earth.” North Seg, East Block and a third unit for condemned inmates, Donner, were built in 1934, 1930 and 1913, none with a pandemic in mind.
COVID-19 has infiltrated 20 of California’s 34 prisons, though it has been especially bad at nine. As of Tuesday, more than 5,300 inmates statewide had tested positive for the virus and 29 had died.
The plague raging inside San Quentin’s walls is spreading into the outside world. Dozens of San Quentin inmates are being treated in community hospitals, including at least 20 death row inmates as of last week. Each is guarded by two correctional officers round-the-clock.
The exact number of death row inmates who have the virus is not known. Complicating matters, about 40% have refused to be tested, McComb and others said. By law, they cannot be compelled to undergo the test unless they are deemed mentally incompetent.
McComb addressed the refusals in her letter, saying some of the condemned inmates worry they will be moved to a segregated unit typically reserved for discipline if they test positive, while others fear the procedure is unsafe.
“And third, a general hopelessness has set in among the population; there is no reason to be tested when medical staff, despite their best efforts, are stretched too thin to respond to those in need of care,” McComb wrote.
One who refused to be tested was Richard Stitely. He was found dead in his cell the night of June 24. The Marin County coroner found he was infected with the coronavirus, though the exact cause of death is still to be determined.
Stitely, 71, was sentenced to death in 1992 for the murder of Carol Unger, a 47-year-old mother. The two had met in a San Fernando Valley bar, and he offered to drive her home. Her body was found in the valley in January 1990.
Andrew R. Flier was a 28-year-old L.A. County deputy district attorney who prosecuted Stitely for the rape and murder of Unger, and for the previous rape of a 16-year-old girl. Now in private practice, Flier said evidence suggested Stitely could have choked Unger for five minutes, first with a cord and then with his hands. He sees Stitely’s apparent death from a disease that deprives victims of their breath as “poetic justice.”
“A terrible disease is infecting our world, and it found someone terrible to infect,” Flier said. “I shed no tears. Evil is evil, and I thought he was evil.”
Over the years, the California Supreme Court had upheld the death sentences of Stitely and the four other condemned inmates who died after contracting the virus. Two of the men had killed children, including a 75-year-old convicted of a 1979 murder. Three of the inmates were in their late 50s.
No matter their crimes, some people say, inmates don’t deserve to die of COVID-19, especially after it likely was introduced by the ill-fated decision to transfer infected inmates from Chino to San Quentin.
“It is the death penalty by other means. It is a miscarriage of justice,” said Assembly member Marc Levine, a Democrat whose district includes San Quentin.
In a hearing last week, U.S. District Court Judge Jon S. Tigar in San Francisco, presiding over a long-running suit challenging California prison conditions, urged the state to release elderly and infirm inmates who pose no public safety threat — and are not on death row — to free up cells so infected prisoners could be isolated and the COVID-19 spread slowed.
“These releases need to happen immediately. There simply is no time to wait,” Tigar said, directing his comments at Newsom.
On Monday, Newsom said San Quentin’s population would be reduced to about 3,000 in coming weeks. “We’ve been working on this every single day for the last three weeks,” he said.
Corrections spokesperson Terry Thornton said the department has installed six tents to treat San Quentin inmates and “is working closely with health care and public health experts on all isolation and quarantine protocols recommended by the Centers for Disease Control and Prevention to address COVID-19 in correctional settings.”
While the virus infects death row, California’s capital punishment law is in a state of limbo. With executions on hold, Levine last year introduced legislation to place a measure on the statewide ballot to abolish capital punishment. That measure has stalled.
Last month, the California Supreme Court indicated it is weighing the legality of one aspect of the state’s death penalty statute: Must jurors agree on aggravating factors that led them to recommend death? As it is, jurors need not be unanimous.
The justices posed the question based on a single case involving a 2004 killing, though a decision could set a precedent that would affect the sentences of scores of condemned inmates. Any decision is likely months away, presumably after the COVID-19 rampage has run its course on San Quentin’s death row.
My 18-year-old daughter, Caroline, responded quickly when I told her that she’d soon be able to download an app to alert her when she had been in risky proximity to someone with COVID-19, and that public health officials hoped to fight the pandemic with such apps.
“Yeah, but nobody will use them,” she replied.
My young smartphone addict’s dismissal sums up a burning question facing technologists around the country as they seek to develop and roll out apps to track the newly resurgent pandemic.
The app developers, and the public health experts who are watching closely, worry that if they do not engage enough people, the apps will fail to catch a significant number of infections and people at risk of infection. Their success relies on levels of compliance and public health competence that have been sorely lacking in the U.S. during the COVID crisis.
“We can’t even get people to wear masks in this country,” said Dr. Eric Topol, director of the Scripps Research Translational Institute in San Diego. “How are we going to get them to be diligent about using their phones to help with contact tracing?”Don't Miss A Story
Subscribe to KHN’s free Weekly Edition newsletter, delivered every Friday.Sign Up Please confirm your email address below: Sign Up
The tracking apps, a handful of which have already been launched in the U.S., enable cellphones to send signals to one another when they are nearby — and if they are equipped with the same app, or a compatible one. The devices keep a record of all their digital encounters, and later on, they alert users when someone with whom they were in physical proximity tests positive for the virus.
For an app to stop an outbreak in a given community, 60% of the population would have to use it, although a lower rate of participation could still reduce the number of cases and deaths, according to one recent study. Some say an adoption rate as low as 10% could provide benefits.
In many places where apps have been implemented so far, adoption has failed to reach even that lower threshold. In France, less than 3% of the population had activated the government-endorsed app, StopCovid, as of late June. Italy’s app had attracted about 6% of the population. The percentage of residents who have downloaded the app endorsed by North and South Dakota, Care19, is in the low single digits.
One exception is Germany, where more than 14% of the population downloaded the new Corona Warn App in the first week after its launch.
COVID-19 apps are generally intended to supplement the work of human contact tracers, who follow up with people who’ve tested positive for the virus, asking them where they’ve been and with whom they’ve been in contact. The tracers then contact those potentially exposed individuals and advise them on the next steps, such as testing or self-quarantine.
Human contact tracing, slow and laborious in the best of times, has been a notable failure in the United States so far: An insufficient number of sometimes inadequately trained people have been deployed, and the infected people they’ve contacted often won’t cooperate.
The prospects for digital tracing appear no better. “Ideally, we’d have a digital way to supplement the human contact tracing,” said Topol. But “there hasn’t been any place yet globally where there’s proof that it goes from a clever idea to really helping people.”
Close to 20 tracing apps are in use or under development in the U.S.
A growing number of U.S. app developers are targeting state health agencies because Google, the maker of Android cellphone software, and iPhone maker Apple won’t enable an app to use their joint platform without a state’s endorsement. The Google-Apple technology, despite very limited use so far, is considered by many the most promising platform.
However, many states are lukewarm to the Google-Apple technology — and to digital contact tracing more broadly. In a Business Insider survey published in June, only three states said they had committed to the Google-Apple model, while 19 — including California — were noncommittal. Seventeen states had no plans for a smartphone-based tracking system. The remaining 11 didn’t respond or gave unclear plans.
In April, California Gov. Gavin Newsom said his office was working with Apple and Google to make their technology a part of the state’s plan for easing out of the stay-at-home order. Two months later, the Golden State seems to have backed off the idea.
Instead, it is training 20,000 human contact tracers with the hope they will hit the ground running this month. The state’s Department of Public Health told California Healthline in an email that most contact tracing “can be done by phone, text, email and chat.”
Trust Is Important
The multiple obstacles to successful use of digital tracing apps include indifference or outright hostility to anti-COVID measures. Some people won’t even wear masks or are leery of other public health efforts.
Moreover, to the extent that people do adopt phone-based tracing, it might miss potential outbreaks among the hardest-hit populations — seniors and low-income people, who are less likely than others to engage with smartphones.
“If adoption is high among 20-year-olds and low among seniors and in nursing homes, we probably don’t want the result to be that seniors and nursing homes don’t get the attention they should get through contact-tracing efforts,” said Greg Nojeim, director of the Freedom, Security and Technology Project at the Center for Technology and Democracy in Washington, D.C.
Unresolved technical challenges could also hamper the effectiveness of the apps.
To capture risky close encounters between users, some apps employ GPS to track their location. Others use Bluetooth, which gauges the proximity of two cellphones to each other without revealing their whereabouts.
Neither approach is perfect at measuring distance, and either might incorrectly assess a COVID threat to users. GPS can tell if two people are at the same address, but not if they are on different floors of a building. Bluetooth determines distance based on the strength of a phone’s signal. But signal strength can be distorted if a phone is in somebody’s purse or pocket, and metal objects can also interfere with it.
The biggest barrier to public buy-in is the privacy question. Advocates of the Google-Apple system, which uses Bluetooth, say the two companies enhanced the prospects for wide adoption by addressing fundamental privacy concerns.
Google-Apple won’t allow apps to track the locations of smartphone users, and it ensures that all contacts traced are stored on the phones of individuals, not on a centralized database that would give public health authorities greater access to the information.
That means every decision based on the tracking data is up to the smartphone users. They decide whether to notify other app users if they contract the virus or whether to follow the advice — to self-quarantine and contact public health authorities — that would accompany an alert of possible exposure.
The Google-Apple system makes it easy for apps that use it to communicate with one another, which could be particularly important in multistate regions — the Washington metropolitan area, for example — where each state might have a different app and people frequently travel back and forth across state lines.
But developers of apps that don’t use the Google-Apple platform will struggle to sync with it, especially if their apps track locations or use a centralized server. Those include the Care19 app in the Dakotas and Healthy Together, Utah’s app, which both use GPS and Wi-Fi to track locations. Healthy Together also allows public health officials to see people’s names, phone numbers and location history.
These models are anathema to privacy-first app proponents, which might limit their uptake. In fact, North Dakota has announced it is planning a second app based on the Google-Apple technology.
Some public health experts, however, warn that the strong privacy focus of Google-Apple, to the exclusion of other important factors, may limit the value of the apps in tackling the pandemic.
“Apple-Google in their partnership have pretty narrowly defined what is acceptable,” said Jeffrey Kahn, director of Johns Hopkins University’s Berman Institute of Bioethics. “If these things are going to work as everyone hopes, we have to have a fuller and more soup-to-nuts discussion about all the parts that matter.”
Mosquitoes have already tested positive for EEE in the towns of Wendell and Orange in Franklin County, state Public Health Commissioner Monica Bharel said as officials discussed the state’s preparations for mosquito season in Plymouth.
When an employee told a group of 20-somethings they needed face masks to enter his fast-food restaurant, one woman fired off a stream of expletives. “Isn’t this Orange County?” snapped a man in the group. “We don’t have to wear masks!”
The curses came as a shock, but not really a surprise, to Nilu Patel, a certified registered nurse anesthetist at nearby University of California-Irvine Medical Center, who observed the conflict while waiting for takeout. Health care workers suffer these angry encounters daily as they move between treacherous hospital settings and their communities, where mixed messaging from politicians has muddied common-sense public health precautions.
“Health care workers are scared, but we show up to work every single day,” Patel said. Wearing masks, she said, “is a very small thing to ask.”
Patel administers anesthesia to patients in the operating room, and her husband is also a health care worker. They’ve suffered sleepless nights worrying about how to keep their two young children safe and schooled at home. The small but vocal chorus of people who view face coverings as a violation of their rights makes it all worse, she said.Email Sign-Up
Subscribe to KHN’s free Morning Briefing.Sign Up Please confirm your email address below: Sign Up
That resistance to the public health advice didn’t grow in a vacuum. Health care workers blame political leadership at all levels, from President Donald Trump on down, for issuing confusing and contradictory messages.
“Our leaders have not been pushing that this is something really serious,” said Jewell Harris Jordan, a 47-year-old registered nurse at the Kaiser Permanente Oakland Medical Center in Oakland, California. She’s distraught that some Americans see mandates for face coverings as an infringement upon their rights instead of a show of solidarity with health care workers. (Kaiser Health News produces California Healthline, is not affiliated with Kaiser Permanente.)
“If you come into the hospital and you’re sick, I’m going to take care of you,” Jordan said. “But damn, you would think you would want to try to protect the people that are trying to keep you safe.”
In Orange County, where Patel works, mask orders are particularly controversial. The county’s chief health officer, Dr. Nichole Quick, resigned June 8 after being threatened for requiring residents to wear them in public. Three days later, county officials rescinded the requirement. On June 18, a few days after Patel visited the restaurant, Gov. Gavin Newsom issued a statewide mandate.
Meanwhile, cases and hospitalizations continue to rise in Orange County.
The county’s flip-flop illustrates the national conflict over masks. When the coronavirus outbreak emerged in February, officials from the U.S. Centers for Disease Control and Prevention discouraged the public from buying masks, which were needed by health care workers. It wasn’t until April that federal officials began advising most everyone to wear cloth face coverings in public.
One recent study showed that masks can reduce the risk of coronavirus infection, especially in combination with physical distancing. Another study linked policies in 15 states and Washington, D.C., mandating community use of face coverings with a decline in the daily COVID-19 growth rate and estimated that as many as 450,000 cases had been prevented as of May 22.
But the use of masks has become politicized. Trump’s inconsistency and nonchalance about them sowed doubt in the minds of millions who respect him, said Jordan, the Oakland nurse. That has led to “very disheartening and really disrespectful” rejection of masks.
“They truly should have just made masks mandatory throughout the country, period,” said Jordan, 47. Out of fear of infecting her family with the virus, she hasn’t flown to see her mother or two adult children on the East Coast during the pandemic, Jordan said.
But a mandate doesn’t necessarily mean authorities have the ability or will to enforce it. In California, where the governor left enforcement up to local governments, some sheriff’s departments have said it would be inappropriate to penalize mask violations. This has prompted some health care workers to make personal appeals to the public.
After the Fresno County Sheriff-Coroner’s Office announced it didn’t have the resources to enforce Newsom’s mandate, Amy Arlund, a 45-year-old nurse at the COVID unit at the Kaiser Permanente Fresno Medical Center, took to her Facebook account to plead with friends and family about the need to wear masks.
“If I’m wrong, you wore a silly mask and you didn’t like it,” she posted on June 23. “If I’m right and you don’t wear a mask, you better pray that all the nurses aren’t already out sick or dead because people chose not to wear a mask. Please tell me my life is worth a LITTLE of your discomfort?”
To protect her family, Arlund lives in a “zone” of her house that no other member may enter. When she must interact with her 9-year-old daughter to help her with school assignments, they each wear masks and sit 3 feet apart.
Every negative interaction about masks stings in the light of her family’s sacrifices, said Arlund. She cites a woman who approached her husband at a local hardware store to say he looked “ridiculous” in the N95 mask he was wearing.
“It’s like mask-shaming, and we’re shaming in the wrong direction,” Arlund said. “He does it to protect you, you cranky hag!”
After seeing a Facebook comment alleging that face masks can cause low oxygen levels, Dr. Megan Hall decided to publish a small experiment. Hall, a pediatrician at the Conway Medical Center in Myrtle Beach, South Carolina, wore different kinds of medical masks for five minutes and then took photos of her oxygen saturation levels, as measured by her pulse oximeter. As she predicted, there was no appreciable difference in oxygen levels. She posted the photo collection on June 22, and it quickly went viral.
“Some of our officials and leaders have not taken the best precautions,” said Hall, who hopes for “a change of heart” about masks among local officials and the public. South Carolina Gov. Henry McMaster has urged residents to wear face coverings in public, but he said a statewide mandate was unenforceable.
In Florida, where Gov. Ron DeSantis has resisted calls for a statewide order on masks despite a massive surge of COVID-19 cases and hospitalizations, Cynthia Butler, 62, recently asked a young man at the register of a pet store why he wasn’t wearing a mask.
“His tone was more like, this whole mask thing is ridiculous,” said Butler, a registered nurse at Fawcett Memorial Hospital in Port Charlotte. She didn’t tell him that she had just recovered from a COVID-19 infection contracted at work. The exchange saddened her, but she hasn’t the time to lecture everyone she encounters without a mask — about three-quarters of her community, Butler estimated.
“They may think you’re stepping on their rights,” she said. “It’s not anything I want to get shot over.”
Fresh off a Caribbean cruise in early March, John Campbell developed a cough and fever of 104 degrees. He went to his primary care physician and got a flu test, which came up negative.
Then things got strange. Campbell said the doctor then turned to him and said, “I’ve called the ER next door, and you need to go there. This is a matter of public health. They’re expecting you.”Special Reports
Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills.
It was March 3, and no one had an inkling yet of just how bad the COVID-19 pandemic would become in the U.S.
At the JFK Medical Center near his home in Boynton Beach, Florida, staffers met him in protective gear, then ran a battery of tests — including bloodwork, a chest X-ray and an electrocardiogram — before sending him home. But because he had not traveled to China — a leading criterion at the time for coronavirus testing — Campbell was not swabbed for the virus.
A $2,777 bill for the emergency room visit came the next month.
Now Campbell, 52, is among those who say they were wrongly billed for the costs associated with seeking a COVID-19 diagnosis.
While most insurers have promised to cover the costs of testing and related services — and Congress passed legislation in mid-March enshrining that requirement — there’s a catch: The law requires the waiver of patient cost sharing only when a test is ordered or administered.
And therein lies the problem. In the early weeks of the pandemic and through mid-April in many places, testing was often limited to those with specific symptoms or situations, likely excluding thousands of people who had milder cases of the virus or had not traveled overseas.
“They do pay for the test, but I didn’t have the test,” said Campbell, who appealed the bill to his insurer, Florida Blue. More on how that turned out later.Don't Miss A Story
Subscribe to KHN’s free Weekly Edition newsletter.Sign Up Please confirm your email address below: Sign Up
“These loopholes exist,” said Wendell Potter, a former insurance industry executive who is now an industry critic. “We’re just relying on these companies to act in good faith.”
Exacerbating the problem: Many of these patients were directed to go to hospital emergency departments — the most expensive place to get care — which can result in huge bills for patients-deductible insurance.More From Our Bill Of The Month Series
Insurers say they fully cover costs when patients are tested for the coronavirus, but what happens with enrollees who sought a test — but were not given one — is less clear.
KHN asked nine national and regional insurers for specifics about how they are handling these situations.
Results were mixed. Three — UnitedHealthcare, Kaiser Permanente and Anthem — said they do some level of automatic review of potential COVID-related claims from earlier in the pandemic, while a fourth, Quartz, said it would investigate and waive cost sharing for suspected COVID patients if the member asks for a review. Humana said it is reviewing claims made in early March, but only those showing confirmed or suspected COVID. Florida Blue, similarly, said it is manually reviewing claims, but only those involving COVID tests or diagnoses. The remaining insurers pointed to other efforts, such as routine audits that look for all sorts of errors, along with efforts to train hospitals and doctors in the proper COVID billing codes to use to ensure patients aren’t incorrectly hit with cost sharing. Those were Blue Cross Blue Shield of Michigan, CIGNA and the Health Care Services Corp., which operates Blues plans in Illinois, Montana, New Mexico, Oklahoma and Texas.
All nine said patients should reach out to them or appeal a claim if they suspect an error.
To be sure, it would be a complex effort for insurers to go back over claims from March and April, looking for patients that might qualify for a more generous interpretation of the cost waiver because they were unable to get a coronavirus test. And there’s nothing in the CARES Act passed by Congress — or subsequent guidance from regulatory agencies — about what to do in such situations.
Still, insurers could review claims, for example, by looking for patients who received chest X-rays, and diagnoses of pneumonia or high fever and cough, checking to see if any might qualify as suspected COVID cases, even if they were not given a diagnostic test, said Potter.
One thing was clear from the responses: Much of the burden falls on patients who think they’ve been wrongly billed to call that to the attention of the insurer and the hospital, urgent care center or doctor’s office where they were treated.
Some states have broader mandates that could be read to require the waiver of cost sharing even if a COVID test was not ordered or administered, said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.
But no matter where you live, she said, patients who get bills they think are incorrect should contest them. “I’ve heard a lot of comments that claims are not coded properly,” said Corlette. “Insurers and providers are on a learning curve. If you get a bill, ask for a review.”
Scarce Tests, Rampant Virus
In some places, including the state of Indiana, the city of Los Angeles and St. Louis County, Missouri, a test is now offered to anyone who seeks one. Until recently, tests were scarce and essentially rationed, even though more comprehensive testing could have helped health officials battle the epidemic.
But even in the early weeks, when Campbell and many others sought a diagnosis, insurers nationwide were promising to cover the cost of testing and related services. That was good PR and good public health: Removing cost barriers to testing means more people will seek care and thus could prevent others from being infected. Currently, the majority of insurers offering job-based or Affordable Care Act insurance say they are fully waiving copays, deductibles and other fees for testing, as long as the claims are coded correctly. (The law does not require short-term plans to waive cost sharing.) Some insurers have even promised to fully cover the cost of treatment for COVID, including hospital care.
But getting stuck with a sizable bill has become commonplace. “I only went in because I was really sick and I thought I had it,” said Rayone Moyer, 63, of La Crosse, Wisconsin, who was extra concerned because she has diabetes. “I had a hard time breathing when I was doing stuff.”
On March 27, she went to Gundersen Lutheran Medical Center, which is in her Quartz insurance network, complaining of body aches and shortness of breath. Those symptoms could be COVID-related, but could also signal other conditions. While there, she was given an array of tests, including bloodwork, a chest X-ray and a CT scan.
She was billed in May: $2,421 by the hospital and more than $350 in doctor bills.
“My insurance applied the whole thing to my deductible,” she said. “Because they refused to test me, I’ve got to pay the bill. No one said, ‘Hey, we’ll give you $3,000 worth of tests instead of the $100 COVID test,’” she said.
Quartz spokesperson Christina Ott said patients with concerns like Moyer’s should call the insurance company’s customer service number and ask for an appeals specialist. The insurer, she wrote in response to KHN’s survey of insurers, will waive cost sharing for some members who sought a diagnosis.
“During the public health emergency, if the member presented with similar symptoms as COVID, but didn’t receive a COVID-19 test and received testing for other illnesses on an outpatient basis, then cost sharing would be waived,” she wrote.
Moyer said she has filed an appeal and was notified by the insurer of a review expected in mid-July. Back in Florida, Campbell filed an appeal of his bill with Florida Blue on April 22, but didn’t hear anything until the day after a KHN reporter called the insurer about his case in June.
Then, Campbell received phone calls from Florida Blue representatives. A supervisor apologized, saying the insurer should not have billed him and that 100% of his costs would be covered.
“Basically they said, ‘We’ve changed our minds,’” said Campbell. “Because I was there so early on, and the bill was coded incorrectly.”
Months into the coronavirus pandemic, older adults are having a hard time envisioning their “new normal.”
Many remain fearful of catching the virus and plan to follow strict precautions — social distancing, wearing masks and gloves, limiting excursions to public places — for the indefinite future.
Mortality is no longer an abstraction for those who have seen friends and relatives die of COVID-19. Death has an immediate presence as never before.Email Sign-Up
Subscribe to KHN’s free Morning Briefing.Sign Up Please confirm your email address below: Sign Up
Many people are grieving the loss of their old lives and would love nothing better than to pick up where they left off. Others are convinced their lives will never be the same.
“We’re at the cusp of a new world,” said Harry Hutson, 72, an organizational consultant and executive coach who lives in Baltimore.
He’s among nearly a dozen older adults who discussed the “new normal” in lengthy conversations. All acknowledged their vulnerability as states across the country lift stay-at-home orders. (Adults 65 and older are more likely to become critically ill if infected with the coronavirus.) Here’s some of what they said:
Willetha, 67, and Harold, 68, Barnette, of Durham, North Carolina. The Barnettes are an unusual couple: They divorced in 1995 but began living together again in 2014 when both Willetha and her elderly mother became ill and Harold returned to help.
For Willetha, who has Crohn’s disease and is immunocompromised, the “new normal” is characterized by vigilance — masks, gloves, disinfectants, social distancing, working remotely (she’s a development officer at a school).
“I’m not going to be comfortable freely moving around this world until they’re able to do reliable antibody testing and there is a vaccine,” she said. “Right now, I think we all have to learn to live smaller.”
Harold believes that self-reliance and local support networks are more important than ever. “To me, the pandemic reveals troubling things about the state of institutions in our society. The elder care system is rotten and the health care system full of neglect,” he said.
“I’m preparing myself for a different social order. I’m thinking that will be built on relationships with family and people near to us and we’ll all be helping each other out more.”
Patricia Griffin, 80, of Oxford, Pennsylvania. Griffin is a retired microbiologist who lives alone in a continuing care community and loves to travel. In March, as the coronavirus pandemic gathered steam, she was due to take a trip to the Amazon, which was canceled.
“I envision conditions for seniors being restrictive until we have a vaccine,” Griffin said. “That makes me angry because I don’t have that many years left. And I would like to do the things I want to do. At the moment, I’m leaning toward being cautious but not being completely a prisoner.”
A big frustration for Griffin is the lack of clear guidance for healthy older adults like her who do not have underlying medical conditions. “All we see are statistics that lump all of us together, the healthy with those that have multiple issues,” she said. I’m wondering what my odds of getting really sick from this virus are.”
Wilma Jenkins, 82, of South Fulton, Georgia. Jenkins, who has coped with depression most of her life and describes herself as an introvert, lives alone in a small house just outside Atlanta.
“I confess I’m going to be afraid for a while,” she said.
During the pandemic, her three adult children and grandchildren have created a new tradition: Zoom meetings every Sunday afternoon. Previously, the entire family got together once a year, at Thanksgiving. “It helps me a lot, and I think it will last because we have so much fun,” Jenkins said.
Before her life ground to a halt, Jenkins regularly gave presentations at senior centers across Atlanta on what it’s like to grow old. “My work is helping little old people like me,” she said, “and when I can get out again, I’ll be reminding them that we have reached a point when we can wear the crown of age and we should be doing that proudly.”
Marian and Ed Hollingsworth, 66 and 72, of La Mesa, California. Ed has a rare gastrointestinal cancer and is enrolled in a clinical trial of a new drug.
“My vision of the future is somewhat limited, given my age and my prognosis,” he said. “There’s a constant fear and uncertainty. I don’t see that changing anytime soon. We’ll be in the house a lot, cooking a lot, watching a lot of Netflix.”
“I’m looking at least a year or two of taking strong precautions,” said Marian, a patient safety advocate.
“I always was the person who was active and doing for others: Now I’m the one at home having to ask for help, and it feels so foreign,” she said. Her most immediate heartache: “We don’t know when we’ll see our [four] kids again.”
Richard Chady, 75, of Chapel Hill, North Carolina. Chady, a former journalist and public relations professional, lives in a retirement community and participates in the North Carolina Coalition on Aging.
“This pandemic has given me a greater appreciation of how precious family and friends are,” he said. “I think it will cause older people to examine their lives and their purpose a little more carefully.”
Chady is optimistic about the future. “I’ve been involved in progressive causes for a long time and I think we have a great opportunity now. With all that’s happened, there’s more acceptance of the idea that we need to do more to improve people’s lives.”
Edward Mosley, 62, of Atlanta. Mosley lives alone in Big Bethel Village, an affordable senior housing community. Disabled by serious heart disease, he relies on Supplemental Security Income and Medicaid. In the past year, he has had multiple hospitalizations.
“The pandemic, it affected me because they canceled my doctors’ appointments and I was in a bad way,” said Mosley, who had a pacemaker implanted in his chest before COVID-19 emerged. “But I’m doing better now. I can walk with a cane, though not very far.”
The hardest thing for Mosley is not being able to mingle with other people “because you don’t know where they’ve been or who they’ve been with. You feel like you’re in solitary confinement.”
Vicki Ellner, 68, of Glenwood Landing, New York. Ellner ran Senior Umbrella Network of Brooklyn for 20 years. Today she works as a consultant for an elder care attorney on Long Island.
Before the coronavirus upended life in and around New York City, Ellner and the attorney were planning to launch an initiative aimed at older women. Now, they’ve broadened it to include older men and address issues raised during the pandemic. The theme: “You’re not done yet.”
Ellner explains it this way: “Maybe you were on a path and had a vision of your life in mind. Then all of a sudden you have these challenges. Maybe you lost your job, or maybe things have happened in your family. What we want to help people understand is you’re not done yet. You still have the ability to redirect your life.”
In her personal life, Ellner, who lives with a “significant other,” is determined to keep fear at bay. “We tell ourselves we’re doing everything we can to stay vital and get through this. We try to turn that into a positive.”
Harry Hutson, 72, of Baltimore. Hutson, an organizational consultant and executive coach, is married and has five grown children. He believes “an enormous change in lifestyle” is occurring because of the pandemic.
“We’re all more careful, but we’re also more connected,” he said. “Older friends are coming out of the woodwork. Everyone is Zooming and making calls. People are more open and vulnerable and willing to share than before. We’re all trying to make meaning of this new world.”
“We’re all having a traumatic experience — an experience of collective trauma,” Hutson said. As the future unfolds, “the main thing is self-care and compassion. That’s the way forward for all of us.”
Annis Pratt, 83, of Birmingham, Michigan. A retired English professor, novelist and environmental activist, Pratt lives alone in a home in suburban Detroit.
“What I’m looking forward to is getting back to interacting with real people. Much of my human contact now is on Zoom, which I consider about 75% of a personal encounter,” she said. “But every day, I make myself go out and talk to someone — like taking a vitamin pill.”
Pratt now has a “do not put me on a ventilator” order in her front hallway, along with a “do not resuscitate” order. “I know it’s very likely that if I get to the point where I have to go to the hospital, I’ll probably die,” she said. “Of course, I’m going to die anyway: I’m 83. But somehow, this pandemic has brought it all home.”
Going forward, Pratt sees two possibilities. “Our moral imaginations will have grown because of what we’ve all gone through and we will do better. Or nothing will have changed.”
Most of all, she said, “I would like to get my wonderful, wonderful life back.”
With Massachusetts' reopening plans moving ahead, early survivors of COVID-19 in the state are hoping their experiences will convince others to be cautious.
While the decision to reopen further does falls in line with Massachusetts' low average positive test rate for COVID-19 -- just 1.8 percent -- the coronavirus reality in many other states is going from bad to worse.
Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.
To contact Judith Graham with a question or comment, click here.
Join the Navigating Aging Facebook Group.See All Columns
For months, Patricia Merryweather-Arges, a health care expert, has fielded questions about the coronavirus pandemic from fellow Rotary Club members in the Midwest.
Recently people have wondered “Is it safe for me to go see my doctor? Should I keep that appointment with my dentist? What about that knee replacement I put on hold: Should I go ahead with that?”
These are pressing concerns as hospitals, outpatient clinics and physicians’ practices have started providing elective medical procedures — services that had been suspended for several months.
Late last month, KFF reported that 48% of adults had skipped or postponed medical care because of the pandemic. Physicians are deeply concerned about the consequences, especially for people with serious illnesses or chronic medical conditions.Email Sign-Up
Subscribe to KHN’s free Morning Briefing.Sign Up Please confirm your email address below: Sign Up
To feel comfortable, patients need to take stock of the precautions providers are taking. This is especially true for older adults, who are particularly vulnerable to COVID-19. Here are suggestions that can help people think through concerns and decide whether to seek elective care:
Before you go in. Give yourself at least a week to learn about your medical provider’s preparations. “You want to know in advance what’s expected of you and what you can expect from your providers,” said Lisa McGiffert, co-founder of the Patient Safety Action Network.
Merryweather-Arges’ organization, Project Patient Care, has developed a guide with recommended questions. Among them: Will I be screened for COVID-19 upon arrival? Do I need to wear a mask and gloves? Are there any restrictions on what I can bring (a laptop, books, a change of clothing)? Are the areas I’ll visit cleaned and disinfected between patients?
Also ask whether patients known to have COVID are treated in the same areas you’ll use. Will the medical staffers who interact with you also see these patients?
If you’re getting care in a hospital, will you be tested for COVID-19 before your procedure? Is the staff being tested and, if so, under what circumstances?
Hospitals, medical clinics and physicians are offering this kind of information to varying degrees. In the New York City metropolitan area, Mount Sinai Health System has launched a comprehensive “Safety Hub” on its website featuring extensive information and videos.
Mount Sinai also encourages physicians to reach out to patients with messages tailored to their conditions. People “want to hear directly from their providers,” said Karen Wish, the system’s chief marketing officer.
Don’t hesitate to press for more details, said Dr. Allen Kachalia, senior vice president of patient safety and quality at Johns Hopkins Medicine: “Where people get in trouble is when they’re afraid to bring their concerns forward.”
Seeking care. Wendy Hayum-Gross, 57, a counselor who lives in Naperville, Illinois, had been waiting since mid-March to get blood tests that would help doctors diagnose the underlying cause of a new condition, a goiter. A few weeks ago, she decided it was time.
The hospital lab she went to, operated by Edward-Elmhurst Health, told Hayum-Gross to wear a mask and gave her a number to call when she arrived in the parking lot. Outside the front door, she was met by a staffer who took her temperature, asked several screening questions and gave her hand sanitizer.
“Once I passed that, a phlebotomist met me on the other side of the door and took me to a chair that was still wet with disinfectant. She wore a mask and gloves, and there was no one else around,” Hayum-Gross said. “When I saw the precautions they had put in place and the almost military precision with which they were carrying them out, I felt much better.”
Marjorie Helsel DeWert, 67, of Athens, Ohio, was similarly impressed when she visited her dentist recently and noticed circular yellow signs on the floor of the office, spaced 6 feet apart, indicating where people should stand. Staffers had even put pens used to fill out paperwork in individual containers and arranged to disinfect them after use.
DeWert, a learning scientist, came up with a patient safety checklist and distributed it to family and friends. Among her questions: Can necessary forms be completed online before a medical visit? Can I wait in the car outside until called? What kind of personal protective equipment is the staff using? And is the staff being checked for symptoms daily?
Bringing a caregiver. Some medical centers are allowing caregivers to accompany patients; others are not. Be sure to ask what policies are in place.
If you feel your presence is necessary — for instance, if you want to be there for a relative who is frail or cognitively compromised — be firm but also respectful, said Ilene Corina, president of the Pulse Center for Patient Safety Education & Advocacy.
Be prepared to wear a gown, gloves and mask. “You’re not there for yourself: You’re there to support the health care team and the patient,” said Corina, whose organization offers training to caregivers.
In Orland Park, Illinois, debi Ross, an interior designer, and her sister live with her 101-year-old mother. Eight years ago, when her mother had a tumor removed from her colon, Ross and her sister wiped down every electric socket, cord, surface and door handle in her mother’s hospital room.
“Unless Mom absolutely needs [medical] care, we’re not going to take her anywhere,” Ross said. “But I assure you, if she does have to go see somebody, we’re going to clean that place down from top to bottom, I don’t care what anybody says.”
If you are not allowed into a medical facility, get a phone number for the physician caring for a loved one and make sure they have your number as well, Merryweather-Arges said. Ask that you be contacted immediately if there are any complications.
Afterward. Patients leaving hospitals are fearful these days that they may have become infected with COVID-19, unwittingly. Ask your physician or a nurse what equipment you’ll need to monitor yourself. Will a pulse oximeter and a thermometer be necessary? Will you need masks and gloves at home if someone is coming in to help you out with the transition? Can someone provide that equipment?
“Family caregivers need instructions that are clear,” said Martin Hatlie, chief executive of Project Patient Care. “They need to know who to call 24/7 if they have a question. And they need clear guidance about infection control in the home.”
If home care is being ordered, ask the agency whether they have trained staff to recognize COVID symptoms. And have home care workers been tested for COVID-19 or had symptoms?
If follow-up care is being provided via telehealth, make sure the setup works before your loved one comes home. Ask your physician’s office what kind of equipment you will need, which service they use (Zoom? Skype?) and whether you can arrange a test in advance.
Finally, as you resume activities, help protect others against COVID-19 as well as yourself. When you go out into the world again, “mask up, socially distance and wash your hands,” said Kachalia of Johns Hopkins. “And if you’re sick or have symptoms, by all means, let your doctor’s office know before you come in for a checkup.”