Kaiser Health News
Nearly 600 front-line health care workers appear to have died of COVID-19, according to Lost on the Frontline, a project launched by The Guardian and KHN that aims to count, verify and memorialize every health care worker who dies during the pandemic.Special Reports COVID-19
By The Staffs of KHN and The Guardian Jun 5
America’s health care workers are dying from the coronavirus pandemic. These are some of the first tragic cases.
The tally includes doctors, nurses and paramedics, as well as crucial health care support staff such as hospital janitors, administrators and nursing home workers, who have put their own lives at risk during the pandemic to help care for others. Lost on the Frontline has now published the names and obituaries for more than 100 workers.
A majority of those documented were identified as people of color, mostly African American and Asian/Pacific Islander. Profiles of more victims, and an updated count, will be added to our news sites twice weekly going forward.
There is no other comprehensive accounting of U.S. health care workers’ deaths. The Centers for Disease Control and Prevention has counted 368 COVID deaths among health care workers, but acknowledges its tally is an undercount. The CDC does not identify individuals.
The Guardian and KHN are building an interactive, public-facing database that will also track factors such as race and ethnicity, age, profession, location and whether the workers had adequate access to protective gear. The database — to be released this summer — will offer insight into the workings and failings of the U.S. health care system during the pandemic.Email Sign-Up
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In addition to tracking deaths, Lost on the Frontline reports on the challenges health care workers are facing during the pandemic. Many were forced to reuse masks countless times amid widespread equipment shortages. Others had only trash bags for protection. Some deaths have been met with employers’ silence or denials that they were infected at work.
The number released today reflects the 586 names currently in the Lost on the Frontline internal database, which have been collected from family members, friends and colleagues of the deceased, health workers unions, media reports, unions, among other sources. Reporters at KHN and The Guardian are independently confirming each death by contacting family members, employers, medical examiners and others before publishing names and obituaries on our sites. More than a dozen journalists across two newsrooms — as well as student journalists ― are involved in the project.
Many of the health care workers included here studied physiology and anatomy for years. They steeled themselves against the long hours they’d endure. Emergency medical technicians raced by ambulance to help. Others did the cleanup, maintenance, security or transportation jobs needed to keep operations running smoothly.
They undertook their work with passion and dedication. They were also beloved spouses, parents, friends, military veterans and community activists.
None started 2020 knowing that simply showing up to work would expose them to a virus that would kill them.
This project aims to capture the human stories, compassion and heroism behind the statistics. Among those lost were Dr. Priya Khanna, a nephrologist, who continued to review her patients’ charts until she was put on a ventilator. Her father, a retired surgeon, succumbed to the disease just days after his daughter.
Susana Pabatao, one of thousands of Philippine health providers in the United States, became a nurse in her late 40s. Susana died just days after her husband, Alfredo, who was also infected with COVID-19.
Dr. James Goodrich, a renowned pediatric neurosurgeon, acclaimed for separating conjoined twins, was also remembered as a renaissance man who collected antique medical books, loved fine wines and played the didgeridoo.
Some of the first to die faced troubling conditions at work. Rose Harrison, 60, a registered nurse, wore no mask while taking care of a COVID-19 patient at an Alabama nursing home, according to her daughter. She felt pressured to work until the day she was hospitalized. The nursing home did not respond to requests for comment.
Thomas Soto, 59, a Brooklyn radiology clerk faced delays in accessing protective gear, including a mask, even as the hospital where he worked was overwhelmed with COVID-19 patients, his son said. The hospital did not respond to requests for comment.
The Lost on the Frontline team is documenting other worrying trends. Health care workers across the U.S. said failures in communication left them unaware they were working alongside people infected with the virus. And occupational safety experts raised alarms about CDC guidance permitting workers treating COVID patients to wear surgical masks ― which are far less protective than N95 masks.
The Occupational Safety and Health Administration, the federal agency responsible for protecting workers, has launched dozens of fatality investigations into health workers’ deaths. But recent agency memos raise doubts that many employers will be held responsible for negligence.
As public health guidelines have largely prevented traditional gatherings of mourners, survivors have found new ways to honor the dead: In Manhattan, a medical resident played a violin tribute for a fallen co-worker; a nurses union placed 88 pairs of shoes outside the White House commemorating those who had died among their ranks; fire departments have lined up trucks for funeral processions and held “last call” ceremonies for EMTs.
The Lost on the Frontline death toll includes only health care workers who were potentially exposed while caring for or supporting COVID-19 patients. It does not, for example, include retired doctors who died from the virus but were not working during the pandemic.
The number of reported deaths is expected to grow. But as reporters work to confirm each case, individual deaths may not meet our criteria for inclusion — and, therefore, may be removed from our count.
In nationwide demonstrations sparked by the killing of George Floyd in police custody, protesters have been frequently pepper-sprayed or enveloped in clouds of tear gas. These crowd-control weapons are rarely lethal, but in the middle of the coronavirus pandemic, there are strong calls for police to stop using these chemical irritants because they can damage the body in ways that can spread the coronavirus and increase the severity of COVID-19.
Even before the coronavirus pandemic, some experts said additional research was needed on the risks of tear gas — an umbrella term for several chemical “riot-control agents” used by law enforcement. It’s known that the chemicals can have both immediate and long-term health effects.
Their widespread use in recent weeks while an infectious disease — for which there is no vaccine — continues to spread across the U.S., has stunned experts and physicians. The coronavirus that causes the disease COVID-19 is highly contagious, spreads easily through the air via droplets, and can lead to severe or fatal respiratory illness. Deploying these corrosive, inhalable chemicals could harm people in several ways: exposing more people to the virus, compromising the body’s ability to fight off the infection and even causing mild infections to become more severe illnesses.
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Jordt refers to these chemicals as “pain gases” because they activate certain pain-sensing nerves on the skin and in the mucous membranes of the eyes, mouth and nose.
“You have this excruciating pain, sneezing, coughing, the production of a lot of mucus that obstructs breathing,” Jordt said.
People who have been exposed describe a burning and stinging sensation, even a sense of asphyxiation and drowning. Sometimes the chemicals cause vomiting or allergic reactions. In law enforcement, officers generally use two types of chemicals for crowd control: CS gas and pepper spray.
The active ingredient in pepper spray, called capsaicin, is derived from chiles. It is often sprayed from cans at close quarters or lobbed into crowds in the form of “pepper balls.”
CS gas (o‐chlorobenzylidene malononitrile) is a chlorinated, organic chemical that can induce “very strong inflammation” and “chemical injury” by burning the skin and airways when inhaled, Jordt said.
“Using it in the current situation with COVID-19 around is completely irresponsible,” he added. “There are sufficient data proving that tear gas can increase the susceptibility to pathogens, to viruses.”
Jordt said research on the harms of tear gas has not kept up with its escalating use in the U.S and around the world in recent years. Many of the safety studies that law enforcement officials rely on date to the 1950s and ’60s, he said.
But a 2014 study from the U.S. Army offers an alarming glimpse into how the chemical could escalate the pandemic. The study found that recruits who were exposed to tear gas as part of a training exercise were more likely to get sick with respiratory illnesses like the common cold and the flu.
“We have a lot of antiviral defenses that can inactivate viruses and prevent them from entering cells,” he said. “These are depleted by inhalation of tear gas and also compromised.”
The findings of the Army study led the U.S. military to significantly reduce how much recruits were being exposed to the chemical.
“Even the Army realized they had done something wrong and that this was more toxic than they thought before,” Jordt said.
Even though there is a limited amount of research on this new coronavirus, there are studies from China and Italy about how other irritants, such as smoking and air pollution, affect COVID-19. These studies indicate that tear gas could also make people more likely to develop severe illness, said Dr. John Balmes, a pulmonologist at the University of California-San Francisco and an expert with the American Thoracic Society.
“I actually think we could be promoting COVID-19 by tear-gassing protesters,” said Balmes. “It causes injury and inflammation to the lining of the airways.”
Balmes said this period of inflammation sets back the body’s defenses, and makes it more likely that someone who already harbors the virus will become sick.
“It’s adding fuel to the fire,” said Balmes. “These exposures to tear gas would increase the risk of progression from the asymptomatic infection, to a symptomatic disease.”
Growing evidence shows many people who have the coronavirus are asymptomatic and don’t know they are infected, or are “presymptomatic” — infected with the virus and able to infect others, but not yet showing symptoms.
With thousands of people jammed together at mass protests, the demonstrations are already primed to be “superspreading events,” which can lead to an explosion of new cases. Outdoor gatherings typically decrease the chance of spreading the coronavirus. But activities like singing and yelling can increase the risk.
Tear gas and pepper spray can also sow confusion and panic in a crowd. People may rip off their masks and touch their faces, leading to more contamination.
Dr. Amesh Adalja, with Johns Hopkins University, said the body’s reaction to the chemicals causes people to shed more of the virus.
“If they’re coughing, the particles actually emanate and are projectiles that travel about 6 feet or so and could land on other people,” said Adalja, who is also a spokesperson for the Infectious Diseases Society of America.
“This is a way to almost induce the virus to be expelled from people when they are exposed to these agents.”
Adalja anticipates the protests will inevitably lead to a spike in infections.
“We know that any kind of social unrest, especially in the midst of an outbreak, is only going to make things worse,” he said.
He said the most recent example would be bombings in Yemen that exacerbated a cholera outbreak.
Dr. Rohini Haar, an emergency physician in Oakland, California, has studied the use of riot-control agents around the world.
“These weapons don’t actually deescalate tensions in peaceful community policing,” said Haar who is a lecturer at the University of California-Berkeley.
Haar has also been treating COVID-19 patients. She recognizes there is a danger of spreading the virus at these gatherings, but she would not discourage people from attending the protests and exercising their right to free speech.
“It’s a really tough situation,” said Haar. “I think the irony is that people are rightfully and justifiably protesting police violence and are being met with violence that is worsening the pandemic conditions we’re living under right now.”
This week, more than a thousand physicians and health care professionals signed an open letter in support of the demonstrations.
Dr. Jade Pagkas-Bather, an infectious disease expert at the University of Chicago, is one of them. She said it will be difficult to determine whether any spike in cases was a direct result of the protests, because they’re happening at a time when many states are also allowing businesses to reopen.
“In everyday life, we weigh the risks and benefits of our actions. People who are going out to protests are clearly at a critical juncture where they are saying this state-sanctioned violence is unacceptable, and I am willing to put myself and others potentially at risk,” she said.
The open letter she signed recommends ways that protesters, police and local officials can reduce the transmission of the virus. Among the major recommendations: Police should not use tear gas or pepper spray.
Want to read the best and most provocative stories from the week? Welcome to the Friday Breeze, where we compile them all — so you’re set with your weekend reading.
Well, there is nothing like a militarily enforced curfew, complete with hovering choppers and redundant fencing, to guarantee some quality reading time.
Two big stories of the moment — racial justice and the pandemic — sadly converged in the autopsy of George Floyd, which found he had survived the coronavirus before being killed in the custody of the Minneapolis police.
The continuing protests over police brutality heightened concerns that the demonstrations could hasten the viral spread just as many areas of the country are reopening. It’s not merely being jammed together, singing and chanting: tear gas can also spread the virus, and mass arrests provide fertile ground for new cases. Atlanta’s mayor and the CDC director are among those encouraging protesters to get a COVID test. Unfortunately, many testing sites were closed because of the demonstrations.
At the New Yorker, Dhruv Khullar notes that, paradoxically, a spike in infected demonstrators may further exacerbate the existing racial disparity in COVID illness. “If the protests do cause a surge in infections, it will likely be centered in the very communities that are now demanding that their lives be valued equally by the state,” he writes.
In Politico, Dan Diamond dissects the turnaround by public health experts who insisted on extreme precautions against COVID infections as the economy collapsed but now are sanctioning mass protests that risk contagion. “I think what’s lost on people is that there have been real sacrifices made during lockdown,” a former GOP Hill staffer told Diamond. “People who couldn’t bury loved ones. Small businesses destroyed. How can a health expert look those people in the eye and say it was worth it now?”The Friday Breeze
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ProPublica had an absolutely bonkers story about coronavirus mask traders and other underground middlemen in the market for personal protective equipment. Highlights include a comedy writer and a former juicer salesman turned would-be entrepreneurs, a briefcase with $8,000 in cash and “proof of life” videos to demonstrate brokers actually have PPE to sell. “There are scandalous brokers out there,” one broker told J. David McSwane. “There are people that just make me want to take a Silkwood shower at the end of the day.”
Even the best mask shouldn’t be worn if you’ve been tear-gassed, writes Julia Scott at KQED. “In general we think that when masks become wet, that they are not as good at preventing the spread of virus,” a UC-Berkeley epidemiology professor says. (Another health risk of modern-day protests: rubber bullets.)
Meanwhile, marring what is an otherwise consistently pleasant experience, some dentists are charging $10 or $20 “infection control fees” to cover the costs of masks, gowns and other PPE, reports KHN’s Phil Galewitz. Will this be the oral version of the facility fee?
One underappreciated downside of mandated mask-wearing, according to Brian Brooks, the new acting head of the Office of the Comptroller of the Currency: Masks “create the very real risk of increases in bank robberies.” Hopefully, aspiring felons will not be monopolizing N95 and respirator masks when there are so many other options.
Running On Empty
On Thursday, the Centers for Medicare & Medicaid Services released a long-awaited dataset containing the number of coronavirus cases and deaths at more than 12,000 skilled nursing facilities. The deaths reached nearly 32,000, and more than 2,000 nursing homes reported a shortage of nurses or aides and thousands of others are on the brink of running out of gowns, masks and other protective gear. The data was more than a bit messy, with some facilities listed as having more COVID deaths than COVID cases. Some homes disputed the death totals for their facilities, although the government said the information was reported directly by the homes. The Wall Street Journal calculated a 10% drop in nursing home occupancy since the end of last year.
Testing, 1, 2, 3 …
Over at NPR, Sasha Pfeiffer and Tim Mak checked the status of the president’s promise that big retailers would be providing ubiquitous COVID testing and found a dearth that brings back memories of the worst of the Days of No Toilet Paper. Walgreens, Kroger, Rite Aid, Walmart and CVS combined have just 1,300 testing sites at 32,000 stores, about 4%. Most testing sites were at CVS, which is good news as you can simultaneously grab one of their notoriously long receipts to substitute for certain hard-to-find paper products.
In the What Else Are Law Enforcement Officers Up to These Days? Department, The Wall Street Journal follows a sergeant in the Broward County Sheriff’s Office who hunts iguanas in his free time. (Yes, of course this is Florida, and no, The Breeze doesn’t usually cover reptilian health, but today we make an exception.) Joe Harris started hunting iguanas with a slingshot, then upgraded to pellet guns and now uses a 4-foot blowgun with a 6-inch dart attached to a rod and reel, presumably sold separately. “It requires more skill and gives the animal more of a chance,” Harris tells John Clarke. One such lucky iguana was turned into hors d’oeuvres for Harris’ colleagues.
‘Watched With Glee’
Finally, after all this downbeat news, we end on an up note: the self-explanatory #docswhorock performances on Twitter that began way back when we were all staying at home. This week’s covers are from the ’60s, while previous weeks’ themes included soundtracks and the cheesy ’80s. Highlights include Dr. Parag Majmudar singing “Stand By Me,” a duet of “Homeward Bound” between Dr. Atul Grover and Dr. Maylyn Martinez, and Dr. Pete DeBalli operating on “Sympathy for the Devil.” Next week is the ’00s. Now, if physicians could just provide some tolerable waiting room music without adding an “ambiance control fee,” we’d happily deploy our “well-learned politesse” when they are running behind.
Have a good weekend — and with many restaurants offering outdoor service, we encourage you to try the iguana.
Thousands of protesters thronged the streets in recent days to express their anger over the killing of an African American man, George Floyd, in police custody in Minneapolis. The mostly peaceful rallies have turned violent at times, with police using batons, tear gas and rubber bullets that caused serious injuries.
That led to online social media postings that health plans might deny coverage for medical treatment of injured protesters, some suggesting it might be better for protesters not to tell providers how they got hurt.
i DO NOT recommend telling healthcare providers you were at a protest if you need care. many insurance plans can deny coverage for participation in “civil unrest or riots” https://t.co/YhHq1S466r
— BLACK TRANS LIVES MATTER (@tipptipphorray) May 31, 2020
reminder that covid-19 has a 2-14 day incubation period so for anyone needing medical attention do not mention you were at a protest. many insurance plans can deny coverage for participation in “civil unrest or riots” medical racism is real and you may not be treated bc of this.
— Mike Wizowski (@lickgoatnuts) June 2, 2020
Plans do sometimes have exclusions for coverage related to “illegal acts” that could leave people on the hook for at least part of their medical costs. But health policy experts said it’s unclear how common these clauses are or when they’re used to deny coverage.
In addition, even if a plan denies those claims, protesters would generally have strong grounds for appeal, the experts said. Success would hinge on the policy language and the circumstances around the protesters’ involvement.
“There’s a strong argument to be made that someone was participating in a civil protest, and that’s not illegal,” said Karen Pollitz, a senior fellow at KFF (the Kaiser Family Foundation). (KHN is an editorially independent program of the foundation.)Email Sign-Up
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America’s Health Insurance Plans, a trade group, played down the concerns that have been mentioned on social media. “We are not aware of any blanket exclusions that would deny coverage for injuries or illnesses received during a protest,” said David Allen, a spokesperson for the group.
In general, health plans have broad leeway to exclude certain things from coverage, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.
For example, plans may note that they won’t cover injuries from certain dangerous activities, such as skydiving or bungee jumping. Some states allow insurers to refuse to pay claims related to drug or alcohol use.
Likewise, people who commit felonies or other illegal acts might have their claims denied. And if a lawful protest turned violent, insurers might consider it an illegal riot and deny medical coverage.
But that exclusion has to be part of the insurance contract, not something the company decides after receiving a claim.
“These exclusions need to be written down in your policy document,” Corlette said. “The plan description is supposed to outline all the things it won’t cover, in very specific language.”
Most people don’t read their policy’s fine print, but the document is generally available from insurers or employers.
Exclusion examples are not that hard to find. A sample benefits handbook for Florida Blue large group policies, for instance, specifically excludes treatment for injuries that result from “your participation in, or commission of, any act punishable by law as a misdemeanor or felony, or which constitutes riot, or rebellion.” A Cigna plan says it wouldn’t pay for care for “a Member participating in an insurrection, rebellion, or riot.”
All Florida Blue plans incorporate that exclusion language, said spokesperson Ilyssa Drumm. The company is not aware of any instances in which it has denied coverage for injuries specifically related to a riot or protest, she said.
“[We] would not apply this to someone who was injured when peacefully protesting and the actions of others led to their injury,” Drumm said.
Cigna did not reply to a request for comment.
It’s unclear the extent to which employers and insurers exclude coverage for injuries from dangerous or illegal activities or reject related claims, experts said. Researchers in at least one state have looked into this. A 2016 analysis by the Connecticut General Assembly Office of Legislative Research said the state insurance department found no coverage exclusions related to illegal acts among major medical or HMO forms filed by major carriers in the state.
The analysis noted that the National Conference of State Legislatures says that at least 18 states have laws related to coverage exclusions for “illegal acts.” Some prohibit such exclusions, while others allow them, the Connecticut study said. NCSL could not be reached to confirm the number. (State laws apply to state-regulated insurance policies, but federal laws regulate employer plans that are self-funded, meaning the company pays employee claims itself rather than buying insurance for that purpose.)
If a health plan did have an exclusion for medical services related to rioting, for example, determining how that applied to an individual policyholder’s claims would depend on specific details. How does the policy define “riot”? What does it mean to “participate” in one? Does the policy differentiate between “riot” and “protest”? Did the injured policyholder plan to attend a peaceful protest that subsequently got out of hand?
“There are probably a lot of fact-based questions that would need to be answered,” said Corlette.
Sometimes language in a policy may be very broad, allowing insurers to deny coverage for injuries sustained in the “commission of a crime,” for example, said Phyllis Borzi, a former assistant secretary of Labor who headed the Employee Benefits Security Administration and is now a consultant.
That kind of language could trip up protesters who have been arrested for offenses such as violating curfew or failing to leave the street when ordered to do so by police.
“These exclusions are designed to make sure that the plan isn’t going to be responsible if you go off and do things that are unwise and illegal and as a result you get injured,” Borzi said. “If you do get arrested, it’s just another little indicia of the fact that maybe it wasn’t just a benign activity on your part.”
Lying about how an injury occurred probably isn’t a good idea, said Borzi.
“You don’t have to volunteer the information, but if they ask you and you don’t tell them or lie, they could not just exclude the coverage but prosecute you under an insurance fraud argument,” she said.
Medicaid, the federal-state health program for low-income people, doesn’t typically have these types of provisions, said Sara Rosenbaum, professor of health law and policy at George Washington University.
Medicare, the insurance program for people age 65 and older and people with disabilities, doesn’t have these exclusions either.
The sight of crowds of protesters giving full-throated, generally unmasked, voice to their grievances has raised the specter of a resurgence of COVID-19. But insurers would be unlikely to deny coverage for treatment of the virus if someone gets sick after going to a rally, experts say.
“The employer would have to prove that the protest was the cause” of the infection, said Borzi, and given how widespread the coronavirus is, that would be practically impossible.
CHULA VISTA, Calif. — Even as most California hospitals have avoided an incapacitating surge in coronavirus patients, some facilities near the Mexican border have been overwhelmed. They include El Centro Regional Medical Center in Imperial County and Scripps Mercy Hospital Chula Vista in San Diego County, which link the spike in COVID-19 patients to their communities’ cross-border lifestyle.
Some U.S. citizens and legal residents who live in Mexico are crossing the border from Tijuana and Mexicali into the U.S. for treatment. Dr. Juan Tovar, an emergency physician and chief operations executive for Scripps Mercy Hospital Chula Vista, said 48% of COVID-positive patients who visited the emergency room between May 24 and May 30 said they had recently traveled to Mexico. That figure jumped to 60% between May 31 and June 2. The hospital is about 10 miles from the San Ysidro Port of Entry, the busiest land border crossing in the Western Hemisphere.
Only about 5% of COVID-19 patients reported they’d recently been to Mexico at Scripps’ three other emergency rooms farther north, he said.Email Sign-Up
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“We are now transferring COVID-19 patients out of Chula Vista to other Scripps hospitals farther north on a fairly regular basis — 21 over the last week — to help decompress our hospital here,” Tovar said.
About two hours east, El Centro Regional Medical Center was so overwhelmed by COVID-19 patients it had to divert some to health care facilities in San Diego, National City and elsewhere. There have been more than 2,025 confirmed cases in Imperial County, which has the highest COVID-19 hospitalization rate in the state, said Andrea Bowers, special projects coordinator for the county health department.
“We know that our community has family on both sides of the border, so we’re relating the uptick to Mother’s Day weekend,” said Suzanne Martinez, assistant chief nursing officer at the medical center. “That means more risk as people travel back and forth over the border.”
KHN’s Heidi de Marco visited the intensive care units at both hospitals and documented the efforts to keep patients alive.
As Montana plows forward with its reopening, including throwing open the doors to tourism on June 1, the outlook is starkly different for members of the state’s Native American nations, which have approached the coronavirus with greater caution and stricter controls.
For members of the state’s far-flung tribes, who make up nearly 7% of Montana’s population of roughly 1 million, protective attitudes toward elders and cultural heritage have shaped a pandemic response around defending the most vulnerable rather than prioritizing economics. Tribal leaders across the state say reservation shutdowns and stay-at-home orders will continue for now, as widespread, proactive testing for the virus on reservations gets underway.More From The Mountain States View More
“For the most part, in general, wider society has put more value on the young, not so much on elderly and the information and experience and knowledge,” said Sharon Stewart-Peregoy, a Democratic state legislator and member of the Crow Nation. “Whereas with tribes, the acknowledgment and respect of elders as the carriers of the cultures has always been there.”
The stakes are high for the Crow and other tribes. Even with strict protective measures, ramped-up testing has already revealed a number of positive cases among the Crow, and members are braced for more.
For these Native American nations, losing an elder to the coronavirus, or any untimely death, is no small matter. Elders are often the bearers of vanishing languages, history and important cultural knowledge. The Indigenous populations here are small — fewer than 80,000 people in this state combined — so any losses would be significant.
“When an elder dies, there’s a whole history, a whole line of information that we lose,” Stewart-Peregoy said. “It’s like the library burning down.”Email Sign-Up
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Several tribal leaders have pointed southwest to the deadly outbreak in the Navajo Nation as evidence of the need for strict measures to ward off outbreaks. There, in the reservation that covers a swath of Utah, Arizona and New Mexico, more than 5,300 people had tested positive for the virus and at least 246 had died through Sunday. So far, none of Montana’s tribes has had an outsize virus outbreak, but small clusters have left many wary.
“We’re very concerned that we’re going to lose the last of those with the history of the people, the ceremonies and the traditions,” said Rae Peppers, a Crow member who lives on the Northern Cheyenne reservation in eastern Montana. “That’s what we’re really protecting.”
Montana is home to seven reservations and the Little Shell Chippewa Tribe, a landless nation granted federal recognition a few months ago. Across the state, where new positive cases have been relatively rare in recent weeks and testing has been made more widely available, nation leaders plan to continue their stronger stance as the rest of Montana shifts into something closer to normal life. Montana adopted stay-at-home orders early on and cases have remained relatively low — 539 confirmed cases and 17 deaths through Wednesday, one of the lowest rates in the country.
But already a handful of new positive cases have emerged in recent days on the Crow reservation with the wide availability of testing. Big Horn County, which includes the Crow and part of the Northern Cheyenne reservations, has ticked up to more than 30 positive cases.
When an elder dies, there’s a whole history, a whole line of information that we lose. It’s like the library burning down.Sharon Stewart-Peregoy
In the state’s northwest corner, the Blackfeet Nation announced plans to test everyone living on the reservation and opened drive-thru facilities with free swab tests. In a letter to members earlier in May, Robert DesRosier, the tribe’s emergency response manager, urged people to continue to abide by lockdown orders, saying, “Blackfeet are being inconvenienced, not oppressed!”
Some people fear that the state’s reopening to tourism without mandatory quarantine or testing for visitors will set up more conflicts with Indigenous nations that have chosen to keep their borders closed. The Confederated Salish and Kootenai Tribes of the Flathead reservation, located in the heart of one of the state’s most popular vacation regions, has suspended all nonresident recreation on reservation land and urged residents to report infractions to tribal authorities.
Already, tribes have dealt with people taking flight from pandemic hot spots, attempting to shelter on reservations that have no active cases. On the Northern Cheyenne reservation, Peppers said tribal leaders have kicked out a handful of nonresidents camping, believing it to be a haven from pandemic hot spots.
A major concern for the Northern Cheyenne is a highway that brings heavy truck and tourist traffic from the Dakotas into Montana. The tribe has set up checkpoints to make sure those visitors do not try to shelter on the reservation, putting tribal members at potential risk.
“Everybody comes through here, and all we’re asking is they keep moving through,” Peppers said.
Democratic Gov. Steve Bullock has urged respect for the tribes’ decisions to follow their specific protocols — and even supported the Blackfeet’s decision to close access to the eastern entrances of Glacier National Park, which draws millions of visitors each year. That’s a far different response than in neighboring South Dakota. There, Republican Gov. Kristi Noem demanded that the Cheyenne River Sioux Tribe and the Oglala Sioux Tribe remove checkpoints from state and federal highways through their reservations. Her hard-line response to the tribes’ protective measures has raised concerns over the governor’s respect for tribal sovereignty.
In Montana, meanwhile, some tribal officials said they are mostly satisfied with Bullock’s caution to let tribes set their own rules amid the pandemic. But Native nations fear the potential incoming surge of tourists when restrictions are lifted will set up conflict and new dangers.
“It’s unfortunate because what the Crow Tribe is trying to do is protect its own for public health and safety, and you wind up with people coming in just for recreation,” said Stewart-Peregoy.
For the Little Shell, the country’s newest recognized tribe, the situation is different still. Because the tribe has no reservation and no Indian Health Service Clinic, protecting elders is more challenging. Little Shell tribal chairman Gerald Gray said members are taking the virus threat seriously, but the situation is confusing.
“It’s one of those things, for us it’s really hard to tell where things are at, because we don’t have a clinic or a service unit to help our members,” said Gray.
The tribe has secured testing supplies for members, however, and offered free tests from the state at a drive-thru facility in Great Falls.
Across Indian Country in Montana, there have been no protests in favor of reopening or organized calls for getting back to business as usual. Instead, Peppers said, the scattered protests from some non-Indigenous people against stay-at-home closures have been puzzling.
“It’s such a lack of respect for the situation, it’s silly that they’re protesting it,” she said. “Maybe it’s because they’ve never experienced trauma.”
Can’t see the audio player? Click here to listen on SoundCloud.Julie Rovner
Kaiser Health NewsRead Julie's Stories Mary Agnes Carey
Kaiser Health NewsRead Mary Agnes' Stories Joanne Kenen
PoliticoRead Joanne's Stories Alice Miranda Ollstein
PoliticoRead Alice's Stories
Following the death of George Floyd while in custody in Minneapolis, protests have mushroomed around the U.S. to decry police violence, raising concerns among public health officials about the potential for further spread of the coronavirus.
Meanwhile, the economic toll of the continuing pandemic is prompting some states to cancel or scale back plans to expand health coverage to more of their residents.
And President Donald Trump said he will withdraw the United States from the World Health Organization. But it seems he lacks the legal authority to do that on his own.
This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Mary Agnes Carey of KHN and Joanne Kenen of Politico.
Among the takeaways from this week’s podcast:
- Although public health officials are warning about the dangers of a resurgence of COVID-19 caused by the mass gatherings to protest Floyd’s death, if cases do spike, it may be hard to separate out that effect from the general reopening of the economy occurring about the same time.
- The concerns about racial inequalities highlighted by the massive demonstrations include health disparities that have taken a big toll on minority communities. But fixing those inequities would be very expensive, and it’s not clear given the current economic downturn how federal or state officials would come up with funding to tackle those issues.
- Also, as they observe the demonstrations, many experts are noting that racism and violence are public health issues, too.
- Trump’s decision to pull out of the World Health Organization hampers U.S. efforts to play a role in pivotal decisions around the globe, especially on issues such as HIV/AIDS, malaria, flu and Ebola. Those are areas in which the WHO is seen as a leader on policy and research.
- The sudden slowdown in the economy is causing some states such as Kansas and California to put the brakes on plans to help more people get coverage, especially efforts to expand Medicaid programs that serve low-income residents.
- In a surprise opinion late last week, Chief Justice John Roberts sided with liberals on the Supreme Court to uphold California and Illinois regulations limiting church services to help curb the risk of COVID-19 infections. Roberts based his opinion on public health issues. Yet unknown is whether this signals how he might rule on a bigger case coming to the court in the fall over the fate of the Affordable Care Act.
Also this week, Rovner interviews Jonathan Oberlander, professor of health policy at the University of North Carolina-Chapel Hill and editor of the Journal of Health Policy, Politics and Law. The journal has released several articles examining the nexus between COVID-19, health inequities and social determinants of health. Those articles are temporarily free for the public to read, here.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:
Julie Rovner: The New York Times’ “The C.D.C. Waited ‘Its Entire Existence for This Moment.’ What Went Wrong?” by Eric Lipton, Abby Goodnough, Michael D. Shear, Megan Twohey, Apoorva Mandavilli, Sheri Fink and Mark Walker
Joanne Kenen: ProPublica’s “Senior Citizens in Subsidized Housing Have Been Dying Alone at Home, Unnoticed Because of Coronavirus Distancing,” by Mick Dumke and Haru Coryne
Alice Miranda Ollstein: Politico’s “States Brace for Disasters As Pandemic Collides With Hurricane Season,” by Dan Goldberg and Brianna Ehley
Mary Agnes Carey: Kaiser Health News’ “Police Using Rubber Bullets On Protesters That Can Kill, Blind Or Maim For Life,” by Liz Szabo
To hear all our podcasts, click here.
U.S. public health officials are closer to identifying a road map for curbing the rising rates of syphilis infections in newborn babies, but with so many resources diverted to stopping the spread of COVID-19, many fear the rate of deadly infections will only get worse.
Congenital syphilis — the term used when a mother passes the infection to her baby during pregnancy — is often a devastating legacy, potentially leaving babies blind or in excruciating pain or with bone deformities, blood abnormalities or organ damage. It’s one of the most preventable infectious diseases, experts say. Prevention, which means treating Mom so she doesn’t pass it on to her baby, requires just a few shots of penicillin.
Yet rates of infection and death from congenital syphilis have been on the rise for years. In 2018, 1,306 babies acquired syphilis from their mothers, a 40% increase over 2017 and the largest number since 1995. Nearly 100 were stillborn or died soon after birth. Federal researchers say 2019 data will show yet another jump.
A new report, released Thursday by the federal Centers for Disease Control and Prevention, aims to pinpoint the reasons so many women aren’t getting the care they need. It found that nationally 28% of women who gave birth to a baby with syphilis in 2018 had no prenatal care and weren’t tested in time for treatment. Nearly a third of the mothers were diagnosed but didn’t receive timely or thorough treatment.Email Sign-Up
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How women slip through the cracks of the public health system varies by race and geography. Syphilis rates are highest in the South and West but have been rising across the nation, particularly in rural areas of the Midwest and West.
The burden of the disease falls disproportionately on African American women and families. Nearly 40% of moms who gave birth to babies with syphilis in 2018 were black, even though they made up about 15% of deliveries.
“That falls on public health as an institution,” said Matthew Prior, communications director for the National Coalition of STD Directors. “We need to think about why we do what we do, and we need to hear from the voices we are trying to serve.”
The CDC researchers identified four core reasons that mothers who gave birth to babies with syphilis weren’t treated: lack of prenatal care; prenatal care that did not include testing; improper treatment after a positive diagnosis; and getting infected during pregnancy.
In the South, a lack of prenatal care was the most common reason white women who gave birth to infected babies didn’t get treatment, while black women tended to have been diagnosed but not treated. In the West, 41% of women of all races who gave birth to infected babies had no prenatal care.
The CDC study provides clues for how to prevent infections, but taking advantage of that information will be a challenge for many local health departments. The COVID-19 pandemic has strained the nation’s frayed public health system.
In many communities, the same people who work on preventing the spread of sexually transmitted diseases such as syphilis have been called on to help prevent the spread of COVID-19. Departments are reporting mass interruptions in STD care and prevention services.
“COVID-19 is an obstacle to a lot of the interventions that we will try to roll out,” said Rebekah Horowitz, a senior program analyst with the National Association of County and City Health Officials (NACCHO).
In mid-March, the National Coalition of STD Directors surveyed a panel of its members; 83% of responding STD programs said they had deferred services. Nearly two-thirds said they cannot keep up with their HIV and syphilis caseloads.
“A lot of our enhancement projects have been scaled back,” said Amanda Reich, congenital syphilis coordinator for Texas. “Our staff are doing the best that they can do.”
Shuttered clinics and delayed prenatal care — yet another consequence of COVID-related shutdowns — are likely to exacerbate rates of congenital syphilis and sexually transmitted diseases in general. Testing for syphilis is key since there’s often a lag between contracting the disease and developing symptoms, said Dr. Anne Kimball, a pediatrician in the Epidemic Intelligence Service of the CDC and lead author of the study. “You can have it and give it to your unborn child without knowing you have it,” she said.
Because syphilis is so easy to test for, treat and prevent, it’s often seen as the canary in the coal mine, signaling a warning about what’s happening with other infectious diseases. Cases of syphilis, gonorrhea and chlamydia combined reached an all-time national high in 2018.
“It is a symptom of under-supporting public health and STD programs for decades,” Prior said. “It’s not surprising.”
Even before the global coronavirus pandemic, many health departments around the country were working with bare-bones staffing and aggressively tracking and treating syphilis only among pregnancy-age women. Men who have sex with men have the highest rate of the disease nationally.
Arkansas reorganized its disease investigation unit after a spike in cases in 2018, assigning one person to follow up with all pregnant women with syphilis, said Brandi Roberts, the state’s STD Prevention Program Manager. She said the reorganization has been successful, and even as resources have been redeployed to COVID-19, that employee’s assignment hasn’t changed. But like many states, Arkansas has seen a decrease in reported STD cases, which Roberts believes is likely a sign of reduced testing, not a drop in cases.
NACCHO and the CDC are helping to fund and evaluate programs at six health departments — ranging from New York City to rural Tulare County, California — that they hope will offer further clues for how to curb the spread of disease.
But their success will rely on resources, said Horowitz.
“This was true two years ago, it is true now, and it will be true in the future: These missed opportunities will continue as long as we are not investing in a robust way in our public health infrastructure,” she said.
It’s tough getting people to report for jury duty in normal times. It’s even harder during a pandemic.
The kidnapping and rape trial of Kenneth Weathersby Jr. opened Feb. 24 in Vallejo, California, but three weeks later two jurors refused to show up after the state ordered people to stay home. Then the state’s chief justice stopped jury trials for 60 days, later extending the suspension into June.
Eventually, Solano County Superior Court Judge Robert Bowers had had enough.
At 10:24 a.m. on May 20, Bowers called the jurors who were left ― 11, and an alternate ― into Courtroom 101. Bailiffs offered each of the six men and six women a squirt of hand sanitizer before showing them to their seats. Four were led into the jury box, the rest to the gallery, with yellow tape covering groups of three seats to enforce social distancing.
“Citizens have a right to trials,” the tall, furrow-browed Bowers told the jurors, pulling down his blue mask to speak. “We have to find a way going forward.”
Solano was the first California county to resume a jury trial. Three others — Contra Costa, Santa Clara and Monterey — have notified Chief Justice Tani Cantil-Sakauye that they are resuming trials in the coming weeks, despite rising COVID-19 infection rates in the state.Don't Miss A Story
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In reopening, judges are trying to balance the constitutional rights of the accused to a speedy trial against the safety of jurors, bailiffs, clerks, attorneys, court reporters and others who work in their courthouses.
But courtrooms can be snug. Jury rooms almost always are. It will be very hard for people to keep the recommended distance, even as they abstain from the usual buttonholing, emoting and hugging in courthouse hallways.
Judges are conferring with health departments to limit the risks. Some courts, but not all, are requiring masks. Some are checking people’s temperatures before allowing them to enter the courthouse. Others may install plexiglass or plastic barriers.
Gone, for now at least, are the days when jury duty began with scores of prospective jurors packed into halls and waiting rooms. Courthouses in Contra Costa and Monterey are staggering the times and days of the week when potential jurors report, and calling only 50 people at a time to prevent large groups from gathering. Some are adding temperature checks to their usual security screenings.
“If they have a temperature over 100, they won’t be allowed in,” said Barry Baskin, presiding judge for Contra Costa County.
All the courts resuming trials say they’ll allow people to delay jury duty if they have concerns about the coronavirus. “We’re doing everything we can for their protection,” Baskin said.
Forty-eight states and territories — all except Illinois, Nebraska, Nevada, Ohio, South Dakota, Texas, American Samoa and the U.S. Virgin Islands — have restricted jury trials, according to the National Center for State Courts. So far, 14 states have reported coordinated statewide plans to reopen. California isn’t one of them.
At the federal level, decisions to resume jury trials are made on a district-by-district basis. All federal courts moved hearings to videoconferencing on April 8.
Health concerns and the legal rights of the accused are bound to be in conflict sooner or later in every jurisdiction.
Under the U.S. Constitution’s Sixth Amendment, defendants have a right to confront their accusers in a speedy public trial by a jury of their peers. In California, trial is supposed to start within 60 days of arraignment for a felony case and within 45 days for a misdemeanor. The chief justice’s order can provide relief from those deadlines on a case-by-case basis in the interest of public safety.
Still, some counties are reluctant and want Cantil-Sakauye to delay trials into July. The chief justice’s ruling allows courts to reopen earlier if they can do so “in compliance with applicable health and safety laws, regulations, and orders, including through the use of remote technology, when appropriate.”
“The further we get away from the height of the pandemic, the more likely people are to show up,” said Alameda County District Attorney Nancy O’Malley, president of the California District Attorneys Association.
“We are still hoping and pressing that people will respond,” said Chris Ruhl, court executive officer for Monterey County. “Jurors are real heroes in these times.”
While health officials recommend masks to prevent the spread of the coronavirus, testifying while wearing one may violate the Sixth Amendment, which allows a defendant to literally face their accuser, Baskin said.
The U.S. Supreme Court determined in Coy v. Iowa in 1988 that witnesses can’t testify behind curtains or other visual obstructions. In the current pandemic, the Ohio Supreme Court ruled in April that witnesses must lower or remove their masks when testifying.
Courts are looking to erect plexiglass barriers around witness stands, or have attorneys and witnesses wear clear plastic face shields, so everyone in the courtroom can see and hear what is said.
But mandates for such measures will come on a county-by-county basis. That frustrates Oscar Bobrow, chief deputy public defender in Solano County and the president of the California Public Defenders Association. He wants a consistent state policy and notes that Ohio released a 93-page guide to resuming jury trials after consulting with people from across that state’s legal community.
Bobrow worries that fear of infection will result in juries with fewer African Americans and Hispanics, two groups that have suffered the brunt of the pandemic. People over 60 might also be reluctant to appear; some counties would exclude them from jury service, according to guidelines posted on various websites.
“The whole process is going to be slowed down, if it’s done right,” he said.
If courthouses don’t do enough to protect jurors from the virus, the panels may be unable to concentrate on testimony. “You’ll be more worried about someone sneezing than what’s being said to you,” Bobrow said.
When Weathersby’s trial resumed May 20, fewer than 25 people sat in the courtroom, which has a new maximum capacity of 53. Yellow tape over seats assured they sat at least 6 feet apart.
Masks were “strongly recommended” but not required — and four jurors declined the ones offered by bailiffs.
“We have a balance of personal freedoms and human protections,” Bowers told the jurors. “This is the new norm. This is what jury trials will look like in the future.”
The jury found Weathersby guilty on 10 counts, including forcible rape and kidnapping to commit rape. He faces multiple life terms at sentencing, scheduled for July 14.
Gavin Newsom knew it was a political gamble when, as the newly elected mayor of San Francisco, he promised to eradicate chronic homelessness.
“I recognize that I’m setting myself up. I’m not naive to that,” he told his hometown newspaper in 2003 as he embarked on a campaign to sell his controversial plan. It hinged on slashing welfare payments for homeless people and redirecting those funds to acquire single-room occupancy hotels, converting them into long-term housing with health and social services.
“I don’t want to over-promise, but I also don’t want to under-deliver,” he said.
Over-promise he did, and the venture ultimately failed. But that pledge by Newsom — who at the time was a young, politically connected wine shop owner relatively new to public office — previewed a brand of political leadership on full display today as the first-term governor confronts an unprecedented public health emergency that has decimated the state’s economy and killed more than 4,280 Californians.
The COVID-19 pandemic has catapulted the 52-year-old Democrat into greater national prominence, winning him praise and voter support for taking decisive action to control the spread of infection in the absence of strong federal leadership.
But it has also exposed his penchant for making ambitious, showy announcements — often broadcast to a national audience — that aren’t necessarily ready for prime time. His plans regularly lack detail and, in some cases, follow-through.
“This governor wants to get a lot done even if all the details aren’t quite there yet. It’s uniquely his approach,” said Democratic strategist Dana Williamson, longtime adviser to former Gov. Jerry Brown. “He isn’t afraid to go big. The upside is establishing yourself as a real leader and, in the case of COVID, saving lives. But the downside is it doesn’t always work out quite perfectly.”
Newsom has a long history of pushing big ideas before they become popular, including legalizing gay marriage and recreational marijuana use, halting death penalty executions and expanding free health care for undocumented immigrants. Since his entry into public life, he has cultivated the image of a political risk-taker willing to buck the Democratic Party establishment. And although he has demurred, there is widespread speculation that Newsom has presidential ambitions.Email Sign-Up
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Since the start of the pandemic, Newsom has been praised by public health experts and Democratic strategists for making politically courageous decisions such as enacting the nation’s first statewide stay-at-home order, preventing widespread sickness and death. He has dramatically expanded hospital capacity while seeking to attack major problems as they erupt, from dire shortages of protective gear for hospital workers to inadequate testing in rural towns and poor, inner-city neighborhoods.
But as the crisis wears on, the list of Newsom’s unfulfilled promises is growing:
- On April 7, he told MSNBC host Rachel Maddow that he had inked a deal securing “upwards” of 200 million protective masks per month, enough to “supply the needs of the state of California — potentially the needs of other Western states.” But nearly two months later, just 61 million surgical masks have arrived in California, while no higher-caliber N95 masks have been delivered, according to Brian Ferguson, spokesperson for the state Office of Emergency Services — despite Newsom’s promise that the deal included at least 150 million N95s. The $1 billion effort has been riddled with flaws, and the state so far has taken back nearly $250 million from the Chinese contractor, BYD Ltd. Co.
- Later that month, Newsom announced a deal with Motel 6 that would provide thousands of rooms for homeless people in need of shelter. At least 5,025 Motel 6 rooms at 47 sites would open their doors to homeless people, “effective immediately,” should counties opt in, he said. But to date, just 628 Motel 6 rooms are open to homeless people at six sites.
- Newsom also said in April that California must dramatically expand COVID-19 testing before it reopens to at least 60,000 — ideally 80,000 — tests per day. But the state still has not consistently reached 60,000 tests per day, even as it has allowed most counties to ease their stay-at-home restrictions.
In other cases, the governor has artfully avoided making specific promises. For instance, he has called the safety of nursing home patients and staff members a “top priority” without detailing plans, allowing him to dodge criticism even as more than half the deaths in California have occurred in long-term care facilities, according to state data.
Yet so far Newsom is showing strong support from Californians. Nearly 70% of likely voters say he’s doing a good job of handling the pandemic, according to a new poll released Wednesday by the Public Policy Institute of California. His overall approval rating has climbed by double digits since February, rising from 52% to 64%.
But his support could erode if the public begins to notice that his promises — and lofty rhetoric — do not match reality, said Mark Baldassare, president and CEO of the institute.
“People can be forgiving and give the governor the benefit of the doubt, but that can turn from positive to negative very quickly,” Baldassare said. “The risk is public opinion can shift very quickly if people get a sense that it’s not going well or according to expectations.”
Although Newsom himself has acknowledged criticism that the state is falling short on some fronts, his chief spokesperson Nathan Click defended the governor’s approach.
“When it’s your life or livelihood on the line, wouldn’t you want leaders who are moving aggressively to help people on every possible front?” Click said in a statement. “He’s not afraid to swing for the fences — especially in a time of massive need.”
Daniel Zingale, Newsom’s former chief adviser, who retired earlier this year, argued that the governor’s handling of the pandemic has saved countless lives while bolstering the social safety net for those at greatest risk of contracting the coronavirus.
“When you have a crisis like this that is unprecedented, there is no real playbook,” Zingale said. “I think Gavin Newsom was made for this moment. This is a situation where you want a governor who is high-energy, deeply earnest and prone to action rather than inaction.”
Newsom’s political career dates back to the late 1990s, when he was appointed to San Francisco’s parking and traffic commission by its then-mayor, Willie Brown. Soon thereafter, Brown tapped Newsom to fill an open seat on the San Francisco Board of Supervisors. Running as the incumbent in 1998, Newsom was elected that year to his first full term on the board.
During his early years in public life, he honed his approach to politics — aggressively seeking national media attention for first-in-the-country social and economic policies. In 2004, the year he took office as mayor, Newsom granted same-sex couples marriage licenses before it was legal, and in 2006 he signed into law the nation’s first universal health care program, which covered all city residents regardless of their immigration status or ability to pay.
Newsom, in his 2013 book “Citizenville,” described his leadership approach as “Ready, fire, aim.”
“I’m as proud of some of my failures in business and politics as I am of my successes,” he wrote. “Failure isn’t something to be embarrassed about; it’s just proof that you’re pushing your limits, trying new things, daring to innovate.”
Newsom believes strongly in setting “audacious goals,” even if he risks over-promising or alienating supporters, said Peter Ragone, who was press secretary for part of Newsom’s mayoral tenure.
“Gavin has always believed that if you show people you’re thinking big and trying hard, they will take that over timidity, even if you might fail,” said Ragone, who remains a close, informal adviser to Newsom and also advises New York City Mayor Bill de Blasio. “He wasn’t able to completely eradicate homelessness, but the voters were OK with that because they saw he was trying. Success doesn’t have to be an absolute policy triumph.”
Now Newsom is facing the biggest challenge of his political career, with several high-profile crises slamming California at once: A global public health emergency. Widespread civil unrest sparked by the killing of an African American man in Minnesota, George Floyd, at the hands of a white police officer, Derek Chauvin. Rising unemployment that could reach 30%. And another potentially devastating wildfire season.
The coronavirus pandemic, in particular, could have long-lasting consequences for Newsom’s future, said Dr. Leonard Marcus, co-director of the National Preparedness Leadership Initiative, a joint program of the Harvard T.H. Chan School of Public Health and the Harvard Kennedy School of Government.
“The politics of crisis leadership are high-consequence,” Marcus said. “For every political leader, a crisis like this is going to make or break their career.”
Davis resident Simon Chin has grown disillusioned with Newsom since the start of the crisis.
Chin’s father, 80-year-old George Chin, lived in Stollwood Convalescent Hospital in nearby Woodland. Chin regularly tuned into Newsom’s public briefings on the crisis to hear the governor say he was committed to preventing infections in nursing homes and protecting staff members and residents.
But infections in senior care homes continued to rise. And although Newsom has called for universal testing of residents and staffers, the state hasn’t provided the resources to make that happen, said Jason Belden, emergency preparedness director for the California Association of Health Facilities, which represents California’s roughly 1,200 state-regulated nursing homes.
State Health and Human Services Secretary Mark Ghaly said it’s the responsibility of nursing homes, not the state, to test.
“It’s not what we’re doing, and it’s, in our view, not feasible,” Ghaly said in an interview, noting that across the state, there are about 119,000 nursing home beds and about 90,000 staff members.
Newsom’s rhetoric at times has given the public a false sense of hope, said Dr. Michael Wasserman, president of the California Association of Long Term Care Medicine.
“When it comes to vulnerable older adults in California, all this governor has been doing is saying he’s going to act, he’s going to help them, but he hasn’t actually taken action,” Wasserman said. “People are dying because of it.”
Newsom’s reassuring statements during his public briefings made Chin feel like the state was doing more to prevent widespread infections, he said.
But Chin’s father died of COVID-19 on April 22. State records show 15 residents — roughly half of the nursing home’s capacity — died of the disease.
“We had no idea that there were such big problems in skilled nursing facilities based on what the governor was saying,” Chin said. “By the time we found out, it was too late.”
In late March, Marcell’s girlfriend took him to the emergency room at Henry Ford Wyandotte Hospital, about 11 miles south of Detroit.
“I had [acute] paranoia and depression off the roof,” said Marcell, 46, who asked to be identified only by his first name because he wanted to maintain confidentiality about some aspects of his illness.
Marcell’s depression was so profound, he said, he didn’t want to move and was considering suicide.
“Things were getting overwhelming and really rough. I wanted to end it,” he said.
Marcell, diagnosed with schizoaffective disorder seven years ago, had been this route before but never during a pandemic. The Detroit area was a coronavirus hot spot, slamming hospitals, attracting concerns from federal public health officials and recording more than 1,000 deaths in Wayne County as of May 28. Michigan ranks fourth among states for deaths from COVID-19.Email Sign-Up
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The crisis enveloping the hospitals had a ripple effect on mental health programs and facilities. The emergency room was trying to get non-COVID patients out as soon as possible because the risk of infection in the hospital was high, said Jaime White, director of clinical development and crisis services for Hegira Health, a nonprofit group offering mental health and substance abuse treatment programs. But the options were limited.
Still, the number of people waiting for beds at Detroit’s crisis centers swelled. Twenty-three people in crisis had to instead be cared for in a hospital.
This situation was hardly unique. Although mental health services continued largely uninterrupted in areas with low levels of the coronavirus, behavioral health care workers in areas hit hard by COVID-19 were overburdened. Mobile crisis teams, residential programs and call centers, especially in pandemic hot spots, had to reduce or close services. Some programs were plagued by shortages of staff and protective supplies for workers.
At the same time, people battling mental health disorders became more stressed and anxious.
“For people with preexisting mental health conditions, their routines and ability to access support is super important. Whenever additional barriers are placed on them, it could be challenging and can contribute to an increase in symptoms,” said White.
After eight hours in the emergency room, Marcell was transferred to COPE, a community outreach program for psychiatric emergencies for Wayne County Medicaid patients.
“We try to get patients like him into the lowest care possible with the least restrictive environment,” White said. “The quicker we could get him out, the better.”
Marcell was stabilized at COPE over the next three days, but his behavioral health care team couldn’t get him a bed in one of two local residential crisis centers operated by Hegira. Social distancing orders had reduced the beds from 20 to 14, so Marcell was discharged home with a series of scheduled services and assigned a service provider to check on him.
However, Marcell’s symptoms ― suicidal thoughts, depression, anxiety, auditory hallucinations, poor impulse control and judgment ― persisted. He was not able to meet face-to-face with his scheduled psychiatrist due to the pandemic and lack of telehealth access. So, he returned to COPE three days later. This time, the staff was able to find him a bed immediately at a Hegira residential treatment program, Boulevard Crisis Residential in Detroit.
Residents typically stay for six to eight days. Once they are stabilized, they are referred elsewhere for more treatment, if needed.
Marcell ended up staying for more than 30 days. “He got caught in the pandemic here along with a few other people,” said Sherron Powers, program manager. “It was a huge problem. There was nowhere for him to go.”
Marcell couldn’t live with his girlfriend anymore. Homeless shelters were closed and substance abuse programs had no available beds.
“The big problem here is that all crisis services are connected to each other. If any part of that system is disrupted you can’t divert a patient properly,” said Travis Atkinson, a behavioral consultant with TBD Solutions, which collaborated on a survey of providers with the American Association of Suicidology, the Crisis Residential Association and the National Association of Crisis Organization Directors.
White said the crisis took a big toll on her operations. She stopped her mobile crisis team on March 14 because, she said, “we wanted to make sure that we were keeping our staff safe and our community safe.”
Her staff assessed hospital patients, including Marcell, by telephone with the help of a social worker from the emergency room.
People like Marcell have struggled during the coronavirus crisis and continue to face hurdles because emergency preparedness measures didn’t provide enough training, funds or thought about the acute mental health issues that could develop during a pandemic and its aftermath, said experts.
“The system isn’t set up to accommodate that kind of demand,” said Dr. Brian Hepburn, a psychiatrist and executive director of the National Association of State Mental Health Program Directors.
“In Detroit and other hard-hit states, if you didn’t have enough protective equipment you can’t expect people to take a risk. People going to work can’t be thinking ‘I’m going to die,’” said Hepburn.
For Marcell, “it was bad timing to have a mental health crisis,” said White, the director at Hegira.
At one time Marcell, an African American man with a huge grin and a carefully trimmed goatee and mustache, had a family and a “pretty good job,” White said. Then “it got rough.” Marcell made some bad decisions and choices. He lost his job and got divorced. Then he began self-medicating with cocaine, marijuana and alcohol.
By the time he reached the residential center in Detroit on April 1, he was at a low point. “Schizoaffective disorder comes out more when you’re kicked out of the house and it increases depression,” said Powers, the program manager who along with White was authorized by Marcell to talk about his care. Marcell didn’t always take his medications and his use of illicit drugs magnified his hallucinations, she said.
While in the crisis center voluntarily, Marcell restarted his prescription medications and went to group and individual therapy. “It is a really good program,” he said while at the center in early May. “It’s been one of the best 30 days.”
Hepburn said the best mental health programs are flexible, which allows them more opportunities to respond to problems such as the pandemic. Not all programs would have been able to authorize such a long stay in residential care.
Marcell was finally discharged on May 8 to a substance abuse addiction program. “I felt good about having him do better and better. He had improved self-esteem to get the help he needed to get back to his regular life,” Powers said.
But Marcell left the addiction program after only four days.
“The [recovery] process is so individualized and, oftentimes, we only see them at one point in their journey. But, recovering from mental health and substance use disorders is possible. It can just be a winding and difficult path for some,” said White.
If you or someone you know is in immediate danger, call 911. Below are other resources for those needing help:
— National Helpline: 1-800-662-HELP (4357) or https://findtreatment.samhsa.gov.
— National Suicide Prevention Lifeline: 1-800-273-TALK (8255).
— Disaster Distress Helpline: 1-800-985-5990 or text TalkWithUs to 66746.
En ciudades de todo el país, los departamentos de policía han tratado de frenar los disturbios provocados por la muerte de George Floyd disparando balas de goma a las multitudes, a pesar de que cinco décadas de evidencia muestran que estas armas pueden incapacitar, desfigurar e incluso matar.
Además de las balas de goma, que generalmente tienen un núcleo de metal, la policía ha usado gases lacrimógenos, granadas explosivas, gas pimienta y proyectiles para controlar a las multitudes de manifestantes que demandan justicia para George Floyd, de 46 años, quien murió después que un oficial de policía de Minneapolis se arrodillara sobre su cuello, mientras otros oficiales lo sostenían.
Algunas manifestaciones pacíficas se han vuelto violentas, con personas rompiendo ventanas, incendiando edificios y saqueando tiendas.
El uso de balas de goma por parte de la policía ha provocado indignación, con imágenes gráficas en las redes sociales mostrando a personas que perdieron un ojo o sufrieron otras lesiones después de recibir el impacto.
Un estudio publicado en 2017 en el British Medical Journal encontró que el 3% de las personas impactadas por balas de goma murieron a causa de la lesión. El 15% de las 1,984 personas analizadas sufrieron lesiones permanentes por estas, también conocidas como “proyectiles de impacto cinético”.
Las balas de goma deben usarse solo para controlar “una multitud extremadamente peligrosa”, dijo Brian Higgins, ex jefe de policía del condado de Bergen, Nueva Jersey.
“Dispararlas en multitudes abiertas es imprudente y peligroso”, dijo el doctor Douglas Lazzaro, profesor y experto en trauma ocular en la NYU Langone Health.
La última semana de mayo, una abuela en La Mesa, California, fue hospitalizada en una unidad de terapia intensiva después de recibir el impacto de una bala de goma entre los ojos. El actor Kendrick Sampson dijo que sufrió el impacto de siete balas de goma en una protesta en Los Ángeles.
En Washington, DC, la Guardia Nacional supuestamente disparó balas de goma el lunes 1 de junio para dispersar a los manifestantes pacíficos cerca de una iglesia histórica donde el presidente Donald Trump después se sacó una foto.
En una declaración, el Fiscal General William Barr defendió las acciones de los agentes de la ley locales y federales en Washington, diciendo que habían “hecho un progreso significativo restaurando el orden en la capital de la nación”.
Barr no mencionó el uso de gas lacrimógeno o balas de goma.
La fotógrafa independiente Linda Tirado dijo que fue cegada por una bala de goma en una protesta en Minneapolis.
En un correo electrónico, el vocero del Departamento de Policía de Minneapolis, John Elder, dijo: “Utilizamos balas de espuma menos letales, de 40 mm. No usamos balas de goma”.
Elder no mencionó la marca de estas balas de espuma. Pero un sitio web las describe como proyectiles que son “una solución excelente si necesita incapacitar a un solo sujeto o controlar una multitud”.
Nadie sabe con qué frecuencia la policía usa balas de goma, o cuántas personas sufren daños cada año, dijo el doctor Rohini Haar, profesor de la Escuela de Salud Pública de la Universidad de California-Berkeley y experto médico de Physicians for Human Rights. Muchas víctimas no van al hospital.
La policía no está obligada a documentar su uso, por lo que no hay datos nacionales que muestren con qué frecuencia se usan, dijo Higgins, ahora profesor adjunto en el John Jay College of Criminal Justice en Nueva York. No existen estándares nacionales para su uso.
Cuando apuntan a las piernas, las balas de goma pueden evitar que una persona peligrosa o una multitud se acerque a un oficial de policía, dijo Lazzaro.
Pero cuando se dispara a corta distancia, pueden penetrar en la piel, romper huesos, fracturar el cráneo y hacer explotar el globo ocular, dijo. Las balas de goma pueden causar lesiones cerebrales traumáticas y “heridas abdominales graves, incluidas lesiones en el bazo y el intestino junto con los principales vasos sanguíneos”, dijo el doctor Robert Glatter, médico de emergencias en la ciudad de Nueva York y vocero del Colegio Estadounidense de Médicos de Emergencia.
Disparar balas de goma a distancia disminuye tanto su fuerza como su precisión, lo que aumenta el riesgo de disparar a las personas en la cara o impactar en los transeúntes, dijo Lazzaro.
Physicians for Human Rights, un grupo de defensa sin fines de lucro con sede en Nueva York, ha pedido que se prohíban las balas de goma.
El ejército británico desarrolló balas de goma hace 50 años para controlar a los manifestantes nacionalistas en Irlanda del Norte, aunque el Reino Unido dejó de usarlas hace décadas.
Las fuerzas de seguridad israelíes utilizan balas de goma contra manifestantes palestinos. La policía francesa fue criticada por usar balas de goma el año pasado después que docenas de manifestantes resultaran heridos.
“Las balas de goma se usan casi todos los días en algún lugar del mundo”, dijo Haar. “Usarlas contra civiles desarmados es una gran violación de los derechos humanos”.
Según Physicians for Human Rights, muchas armas policiales consideradas “menos que letales” pueden causar graves daños.
- Las armas acústicas, como los cañones que hacen ruidos muy fuertes, pueden dañar la audición.
- El gas lacrimógeno puede dificultar la visión y la respiración.
- El spray de pimienta, aunque es doloroso e irritante, no causa daños permanentes, dijo Lazzaro.
- Las bolas de spray de pimienta, que se han utilizado para sofocar protestas recientes, pueden ser mortales cuando se usan incorrectamente. En 2004, una mujer de Boston de 21 años fue golpeada en el ojo y asesinada por un gránulo de gas pimienta disparado por la policía para dispersar a las multitudes que celebraban la victoria de la Serie Mundial de la ciudad.
- Los dispositivos de desorientación que crean ruidos fuertes y luces brillantes, conocidos como granadas de conmoción cerebral o explosiones repentinas, pueden causar quemaduras graves y lesiones, incluido daño al tímpano. Las multitudes que corren por pánico pueden causar lesiones por aplastamiento.
- Los cañones de agua pueden causar lesiones internas, caídas e incluso congelación si el clima es frío.
- La fuerza física, como golpear a alguien para controlarlo, hace que aproximadamente 1 de cada 3 personas sean hospitalizadas, dijo el doctor Howie Mell, vocero del Colegio Americano de Médicos de Emergencia y ex médico táctico, que trabajó con los equipos SWAT.
Las balas de goma son menos dañinas que someter a las personas por “fuerza física o balas normales”, dijo Mell. “Pero en estos días se están disparando mucho más de lo que se suelen disparar”.
“Save your business while saving lives,” reads the website of Because Health, a Seattle tech startup selling two types of tests to employers willing to pay $350 a pop to learn whether their workers have been infected with COVID-19.
The “Workplace Health” plan includes not only nasal swab tests to detect infection, but also blood tests aimed at indicating whether workers have developed antibodies to the virus — and, possibly, future protection.
“There’s a tremendous consumer demand,” said Dr. Lars Boman, the Boston-based medical director for the firm. “Can they return to work? Can they return to life?”
What the website does not make clear, however, is that public health officials have explicitly warned that antibody tests should not be used to make decisions about workplace staffing.Email Sign-Up
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“This is a personal choice of the business, of the consumer,” Boman said.
Across America, untold numbers of employers, employees and ordinary citizens are turning to a slew of sometimes pricey new COVID-19 blood tests. Knowing who’s already been infected could have important implications for understanding the spread of the disease, scientists say. But serious questions about the accuracy of some of the serology tests — and the usefulness of the results they provide — have prompted the federal Food and Drug Administration to try to rein in what several infectious disease experts described as “the wild, wild West” of antibody testing.
“It does look as if companies sprang up overnight both importing these tests and distributing them,” said Dr. Michael Busch, director of the nonprofit Vitalant Research Institute in San Francisco. “It’s outrageous that people were trying to make money off of this fear.”
More than 200 tests have flooded the market in a matter of weeks, promising to detect antibodies, which are proteins that develop in the blood as part of the body’s immune response to an invading virus. These are different from the molecular tests, typically done with nasal swabs, used to diagnose infection.
As of June 1, only 15 antibody tests had received FDA “emergency-use authorizations,” which allow tests that haven’t been fully vetted to be used in a crisis. Even that standard has become a selling point for some large companies, such as LabCorp and Quest Diagnostics, which emphasize that they rely on tests that have received the FDA nod.
In late May, the FDA removed more than 30 serology tests from a list of commercially available kits, saying they “should not be distributed” for sale. Removal could result from a manufacturer not submitting an emergency-use authorization request within a “reasonable period of time,” or if the test shows “significant problems” that cannot be or have not been addressed in a timely manner, the agency said. The manner of enforcement remains unclear.
Last month, the CDC issued new guidelines warning that, given the low prevalence of the virus in the general population, even the most accurate tests could be wrong half of the time.
“Serologic test results should not be used to make decisions about grouping persons residing in or being admitted to congregate settings, such as schools, dormitories, or correctional facilities,” the guidelines state. “Serologic test results should not be used to make decisions about returning persons to the workplace.”
Such tests are most useful for understanding the epidemiology of the virus, not for making individual decisions, said Dr. Mary Hayden, director of the division of clinical microbiology at Rush Medical Laboratories in Chicago. Even the best tests can’t yet answer the crucial question about whether antibodies confer immunity from future COVID infections, Hayden said.
“The best possible scenario is that people get infected and they have protective immunity for a long time,” she said. “That would be awesome. But we just don’t have that right now.”
But a plethora of tests being pitched to consumers explicitly promise results aimed at allowing a return to work, school and other social arenas.
The tests offered by Because Health are among hundreds churned out since March, ranging from those offered by commercial labs and academic research centers to small developers seeking a toehold in the lucrative market spurred by a global pandemic. Because Health is using two antibody tests in tandem, one of which received emergency-use authorization on May 29; the other is still pending.
Anders Boman, the son of the medical director and co-founder of Because Health, said that until the COVID crisis occurred, the company, which launched in Seattle last year, was focused on “a niche of integrative care and sexual health,” including hormone treatments for men and women.
“Consumers are not concerned about sexual health right now,” Boman said, explaining the change in focus. “They’re concerned about how to get back to work, how to return to normal and are they safe?”
The FDA normally follows a stringent approval process for tests to detect diseases, often a costly effort that can take months or years. That typically requires independent validation of the accuracy of the tests. But after being criticized for the fumbled rollout of diagnostic tests during the start of a global pandemic, the FDA swung hard in the other direction, waiving its usual requirements and letting firms rush self-validated tests into the market.
“They sort of relaxed all regulatory oversight,” Hayden said.
Several experts interviewed by Kaiser Health News said the FDA faced tremendous political pressure to make antibody tests available.
“It was really a single pressure — and that was the fact that the original inability to get a [diagnostic] test on the market in the U.S. as the outbreak escalated means they were trying to do basically everything they could to get these out,” said Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
The relaxed rules drew concern from Congress, where a subcommittee of the Committee on Oversight and Reform detailed the FDA’s failure to “police the test market.” Groups such as the Association of Public Health Laboratories also raised questions. Scott Becker, the APHL’s chief executive, said he spoke to top officials at the U.S. Department of Health and Human Services in early April.
“We just let loose and we said, ‘This is a really bad policy,’” Becker said. “‘We’re going to get flooded and we’re going to lose control of quality. We’re not going to know what to do with the results.’”
That’s exactly what has happened, said Osterholm. “The FDA needs to bring much more discipline to this area and they need to articulate it clearly,” he said.
A key issue is the accuracy of the tests, which rely on measures known as sensitivity and specificity. A highly sensitive test will capture all true positive results. A highly specific test would identify all true negative results.
In April, researchers at the University of California-San Francisco, led by immunologist Dr. Alexander Marson, analyzed 14 COVID-19 serology tests on the market and found that all but one turned up false-positive results, indicating that someone had antibodies to the coronavirus when they actually did not. False-positive rates reached as high as 16% in the study, which has not yet been peer-reviewed.
Unreliable results worry Dr. Jeff Duchin, the public health officer for Seattle and King County, Washington, where the first surge of COVID cases emerged in the U.S. A person who tests positive for antibodies that don’t exist may mistakenly believe he or she is free to ignore guidance about preventing infection, potentially spreading the disease. “Regardless of whether you test positive or negative, the workplace still needs to take steps,” he said. “They shouldn’t think a testing program in any way relieves them of that responsibility.”
FDA officials said they’re working now with the National Cancer Institute to independently validate serology tests on the market. Until that list is public, users must rely on the relatively few that have received the emergency-use authorizations to date. More than 190 others have asked for that authorization, pending FDA review.
But consumers may have little control, because they are most likely getting tests from their employers or doctors, with little understanding of why those products were chosen.
“There isn’t a national standard, there isn’t a one-stop shop or a Consumer Reports for antibody tests,” Becker said. “I don’t expect a member of the public is going to be able to figure this out.”
Even savvy physicians can have trouble. US Acute Care Solutions, a physician-owned medical services group, was trying out a Chinese-made test supplied by Minneapolis-based Premier Biotech, with plans to test its staff of more than 3,500 doctors and employees, said the group’s chief medical officer, Dr. Amer Aldeen. That test has been widely used, including in recent controversial serology surveys conducted by Stanford University and the University of Southern California.
When USACS used it, the Premier test failed to detect antibodies in several employees who had been ill and tested positive for the coronavirus on diagnostic tests, Aldeen said. The results could have been caused by faulty instructions rather than flaws in the test itself, he said. Still, the Premier test has not received FDA authorization and the results gave him pause.
“It does no good to select a test that isn’t FDA-approved,” he said.
In a statement, Premier Biotech officials said they anticipate exceeding FDA standards, which call for tests that are at least 90% accurate in identifying positive antibodies in a sample and 95% accurate in identifying samples that contain no antibody.
Some might ask why the FDA didn’t just identify several reliable antibody tests and require their use to avoid the chaos. An FDA official said making that type of choice would be outside the scope of the agency’s responsibilities.
“FDA’s lane is to review these tests and make sure that they are safe and accurate for the American people,” said spokesperson Emma Spaulding. “It wouldn’t be within our lane to say which test must be used.”
Although health officials understand the desire for a test that could provide comfort amid the uncertainty of COVID-19, Duchin advised employers and consumers to wait a little longer.
“There are costs to testing with unvalidated tests that might outweigh the benefits of satisfying your curiosity,” he said.
Doctors are fighting not only to save lives from COVID-19, but also to protect patients’ brains.
Although COVID-19 is best known for damaging the lungs, it also increases the risk of life-threatening brain injuries — from mental confusion to hallucinations, seizures, coma, stroke and paralysis. The virus may invade the brain, as well as starve the organ of oxygen by damaging the lungs. To fight the infection, the immune system sometimes overreacts, battering the brain and other organs it normally protects.
Yet the pandemic has severely limited the ability of doctors and nurses to prevent and treat neurological complications. The severity of the disease and the heightened risk of infection have forced medical teams to abandon many of the practices that help them protect patients from delirium, a common side effect of mechanical ventilators and intensive care.Email Sign-Up
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And while COVID-19 increases the risk of strokes, the pandemic has made it harder to diagnose them.
When doctors suspect a stroke, they usually order a brain MRI — a sophisticated type of scan. But many patients hospitalized with COVID-19 are too sick or unstable to be wheeled across the hospital to a scanner, said Dr. Kevin Sheth, a professor of neurology and neurosurgery at the Yale School of Medicine.
Many doctors also hesitate to request MRIs for fear that patients will contaminate the scanner and infect other patients and staff members.
“Our hands are much more tied right now than before the pandemic,” said Dr. Sherry Chou, an associate professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh School of Medicine.
In many cases, doctors can’t even examine patients’ reflexes and coordination because patients are so heavily sedated.
“We may not know if they’ve had a stroke,” Sheth said.
A study from Wuhan, China — where the first COVID-19 cases were detected — found 36% of patients had neurological symptoms, including headaches, changes in consciousness, strokes and lack of muscle coordination.
A smaller, French study observed such symptoms in 84% of patients, many of which persisted after people left the hospital.
Some hospitals are trying to get around these problems by using new technology to monitor and image the brain.
New York’s Northwell Health is using a mobile MRI machine for COVID patients, said Dr. Richard Temes, the health system’s director of neurocritical care. The scanner uses a low-field magnet, so it can be wheeled into hospital rooms and take pictures of the brain while patients are in bed.
Staffers at Northwell were also concerned about the infection risk from performing EEGs, tests that measure the brain’s electrical activity and help diagnose seizures, Temes said. Typically, technicians spend 30 to 40 minutes in close contact with patients in order to place electrodes around their skulls.
To reduce the risk of infection, Northwell is using a headband covered in electrodes, which can be placed on patients in just a couple of minutes, he said.
The Brain Under Attack
“Right now, we actually don’t know enough to say definitely how COVID-19 affects the brain and nervous system,” said Chou, who is leading an international study of neurological effects of the virus. “Until we can answer some of the most fundamental questions, it would be too early to speculate on treatments.”
Answering those questions is complicated by the limited data from patient autopsies, said Lena Al-Harthi, a professor and the chair of the microbial pathogens and immunity department at Rush Medical College in Chicago.
Authors of a recent study from Germany found the novel coronavirus in patients’ brains.
But many neuropathologists are unwilling or unable to perform brain autopsies, Al-Harthi said.
That’s because performing autopsies on patients who died of COVID-19 carries special risks, such as the aerosolization of the virus during brain removal. Pathologists need specialized facilities and equipment to conduct an autopsy safely.
Some of the best-known symptoms of COVID-19 might be caused by the virus invading the brain, said Dr. Robert Stevens, an associate professor of anesthesiology and critical care medicine at Johns Hopkins University.
Research shows that the coronavirus may enter a cell through a gateway known as the ACE-2 receptor. These receptors are found not only in the lung, but also on organs throughout the body, including many parts of the brain.
In a recent study, Japanese researchers reported finding the novel coronavirus in the cerebrospinal fluid that surrounds the brain and spinal cord.
Some of the most surprising symptoms of COVID-19 ― the loss of the senses of smell and taste ― remain incompletely understood, but may be related to the brain, Stevens said.
A study from Europe published in May found that 87% of patients with mild or moderate COVID-19 lost their sense of smell. Patients’ loss of smell couldn’t be explained by inflammation or nasal congestion, the study said. Stevens said it’s possible that the coronavirus interacts with nerve pathways from the nose to the brain, potentially affecting systems involved with processing scent.
A new study in JAMA provides additional evidence that the coronavirus invades the brain. Italian researchers found abnormalities in an MRI of the brain of a COVID-19 patient who lost her sense of smell.
Many COVID patients develop “silent hypoxia,” in which they are unaware that their oxygen levels have plummeted dangerously low, Stevens added.
When hypoxia occurs, regulatory centers in the brain stem — which control respiration — signal to the diaphragm and the muscles of the chest wall to work harder and faster to get more oxygen into the body and force out more carbon dioxide, Stevens said. The lack of this response in some patients with COVID-19 could indicate the brain stem is impaired.
Scientists suspect the virus is infecting the brain stem, preventing it from sending these signals, Temes said.
Well-intentioned efforts to save lives can also cause serious complications.
Many doctors put patients who are on mechanical ventilators into a deep sleep to prevent them from pulling out their breathing tubes, which would kill them, said Dr. Pratik Pandharipande, chief of anesthesiology and critical care medicine at Vanderbilt University School of Medicine in Nashville, Tennessee.
Both the disease itself and the use of sedatives can cause hallucinations, delirium and memory problems, said Dr. Jaspal Singh, a pulmonologist and critical care specialist at Atrium Health in Charlotte, North Carolina.
Many sedated patients experience terrifying hallucinations, which may return in recovery as nightmares and post-traumatic stress disorder.
Research shows 70% to 75% of patients on ventilators traditionally develop delirium. Delirious patients often “don’t realize they’re in the hospital,” Singh said. “They don’t recognize their family.”
In the French study in the New England Journal of Medicine, one-third of discharged COVID-19 patients suffered from “dysexecutive syndrome,” which can be characterized by inattention, disorientation or poorly organized movements in response to commands.
Research shows that patients who develop delirium — which can be an early sign of brain injury — are more likely to die than others. Those who survive often endure lengthy hospitalizations and are more likely to develop a long-term disability.
Under normal circumstances, hospitals would invite family members into the ICU to reassure patients and keep them grounded, said Dr. Carla Sevin, director of the ICU Recovery Center, also at Vanderbilt.
Just allowing a family member to hold a patient’s hand can help, according to Dr. Lee Fleisher, chair of an American Society of Anesthesiologists committee on brain health. Nurses normally spend considerable time each day orienting patients by talking to them, reminding them where they are and why they’re in the hospital.
“You can decrease the need for some of these drugs just by talking to patients and providing light touch and comfort,” Fleisher said.
Hospitals have banned visitors, however, to avoid spreading the virus. That leaves COVID-19 patients to suffer alone, even though it’s well known that isolation increases the risk of delirium, Fleisher said.
Although many hospitals offer patients tablets or smartphones to allow them to videoconference with family, these devices provide limited comfort and companionship.
Doctors are also positioning patients with COVID-19 on their stomachs, rather than their backs, because a prone position seems to help clear the lungs and let patients breathe more comfortably.
But a prone position also can be uncomfortable, so that patients need more medication, Pandharipande said.
All of these factors make COVID-19 patients extremely vulnerable to delirium. In a recent article in Critical Care, researchers said the intensive care unit has become a “delirium factory.”
“The way we’re having to care for patients right now is probably contributing to more mortality and bad outcomes than the virus itself,” said Dr. Sharon Inouye, a geriatrician at Harvard Medical School and Hebrew SeniorLife, a long-term care facility in Boston. “A lot of the things we’d like to do are just very difficult.”
After nearly two months at home due to the COVID-19 pandemic, Erica Schoenradt was making plans in May to see her dentist for a checkup.
Then she received a notice from Swish Dental that the cost of her next visit would include a new $20 “infection control fee” that would likely not be covered by her insurer.
“I was surprised and then annoyed,” said Schoenradt, 28, of Austin, Texas. She thought it made no sense for her dentist to charge her for keeping the office clean since the practice should be doing that anyway. She canceled the appointment for now.
Swish Dental is just one of a growing number of dental practices nationwide that in the past month have begun charging patients an infection control fee between $10 and $20.Don't Miss A Story
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Swish and others say they need the extra money to cover the cost of masks, face shields, gowns and air purifiers to help keep their offices free of the coronavirus. The price of equipment has risen dramatically because of unprecedented demand from health workers.
Dentists say they struggle to pay these extra costs particularly after most states shut down dental offices in March and April for all but emergency care to reserve personal protective equipment for hospital use. They are also seeing fewer patients than before the pandemic because some fear going back to the dentist and at the same time dentists need to space out appointments to keep the waiting room uncrowded.
Nearly two-thirds of dental offices across the country have reopened for routine care, according to the American Dental Association.
The association, which sets industry standards, says dentists who opt to charge the extra infection control fee should disclose it to patients ahead of each visit, a spokesperson said.
“The infection control fee is helping us mitigate the costs of the extra expenses,” said Michael Scialabba, a dentist and vice president of 42 North Dental, whose 75 dental offices in New England are charging an extra $10.
Why don’t dentists just raise prices instead? Dentists said they have little or no leverage with large insurance companies to force them to raise their reimbursement rates. The ADA asked insurers to take into account additional COVID costs dentists face and many insurers responded by agreeing to pay extra fees.
For example, Harrisburg, Pennyslvania-based United Concordia Dental agreed to pay dentists $10 per patient per visit in May and June to offset their PPE expenses for all fully insured clients. The company has more than 9 million members nationwide.
The new infection control fee upsets some patients, although most understand that the cost of dentistry has increased, said Rishi Desai, director of operations and finance at Swish Dental, which has eight locations in the Austin area. “We are just as frustrated with all of these, too, but as a small business we had to reassess things.”
Desai, whose wife, Viraj, is a dentist and the founder of the dental chain, said the extra money will help the practice survive. “We are not making money off this,” he said. “This is just to sustain us so we are not bleeding out cash.”
He noted that last year Swish was paying about $6 for a box of 20 face masks. Today, $6 buys a single mask. The dental office has installed sneeze guards, staffers are wearing face shields over their masks, and the offices have added air filtration systems and hired additional sanitation staff members to clean their offices every day.
He estimates the offices are working at only about half capacity since reopening in mid-May. In weighing how to handle the extra costs, Swish was reluctant to cut employee wages, he said. “Everyone is trying to figure this out,” he added.
Kim Hartlage, office manager of Klein Dental Group in Louisville, Kentucky, said insurers recommended the office add an infection control fee. The insurers balked at raising their reimbursement rates.
She said the small office has had to buy many more disposable masks and gloves. “We’ve had to step up our game,” she said. So far, she hasn’t heard any feedback on the $10 fee. “We have very understanding clients,” she said.
Tamar Lasky, an epidemiologist, said she likes her Owings Mills, Maryland, dentist and was glad the office was communicating the many precautions it was taking to prevent the spread of COVID-19. But she was stunned when informed by email that a $15 “infection control charge” would be added to her bill.
“I can readily imagine there are a range of additional expenses, as well as a loss of revenue associated with the pandemic, but infection control is not an extra service. It is part of the practice of dentistry,” Lasky said.
“I’m not sure what is the best solution to the increased costs of tighter infection control, but this new charge may not be covered by insurance, and that passes all the burden to the patient.”
In cities across the country, police departments have attempted to quell unrest spurred by the death of George Floyd by firing rubber bullets into crowds, even though five decades of evidence shows such weapons can disable, disfigure and even kill.
In addition to rubber bullets — which often have a metal core — police have used tear gas, flash grenades, pepper spray gas and projectiles to control crowds of demonstrators demanding justice for 46-year-old George Floyd, who died after a Minneapolis police officer knelt on his neck, while other officers restrained his body. Some peaceful demonstrations have turned violent, with people smashing windows, setting buildings afire and looting stores.
The use by police of rubber bullets has provoked outrage, as graphic images have flashed on social media showing people who have lost an eye or suffered other injuries after being hit.
I just got hit by a rubber bullet near the bottom of my throat. I had just interviewed a man with my phone at 3rd and Pine and a police officer aimed and shot me in the throat, I saw the bullet bounce onto the street @LAist @kpcc OK, that’s one way to stop me, for a while pic.twitter.com/9C2u5KmscG
— Adolfo Guzman-Lopez (@AGuzmanLopez) June 1, 2020
A study published in 2017 in the BMJ found that 3% of people hit by rubber bullets died of the injury. Fifteen percent of the 1,984 people studied were permanently injured by the rubber bullets, also known as “kinetic impact projectiles.”
Rubber bullets should be used only to control “an extremely dangerous crowd,” said Brian Higgins, the former police chief of Bergen County, New Jersey.Email Sign-Up
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“Shooting them into open crowds is reckless and dangerous,” said Dr. Douglas Lazzaro, a professor and expert in eye trauma at NYU Langone Health.
In the past week, a grandmother in La Mesa, California, was hospitalized in an intensive care unit after being hit between the eyes with a rubber bullet. Actor Kendrick Sampson said he was hit by rubber bullets seven times at a Los Angeles protest.
In Washington, D.C., the National Guard allegedly fired rubber bullets Monday to disperse peaceful protesters near a historic church where President Donald Trump was subsequently photographed.
In a statement, Attorney General William Barr defended the actions of local and federal law enforcement officers in Washington, saying they had “made significant progress in restoring order to the nation’s capital.”
Barr did not mention the use of tear gas or rubber bullets.
In case you are wondering, this is the size of a rubber bullet. I saw these all over the ground in LA. pic.twitter.com/hbHX33WBIO
— Tamara Dhia (@tamaradhia) June 1, 2020
Freelance photographer Linda Tirado said she was blinded by a rubber bullet at a protest in Minneapolis.
In an email, Minneapolis Police Department spokesperson John Elder said, “We use 40 mm less-lethal foam marking rounds. We do not use rubber bullets.”
No one knows how often police use rubber bullets, or how many people are harmed every year, said Dr. Rohini Haar, a lecturer at the University of California-Berkeley School of Public Health and medical expert with Physicians for Human Rights. Many victims don’t go to the hospital.
Police are not required to document their use of rubber bullets, so there is no national data to show how often they’re used, said Higgins, now an adjunct professor at the John Jay College of Criminal Justice in New York. There are no nationally agreed-upon standards for their use.
When aimed at the legs, rubber bullets can stop a dangerous person or crowd from getting closer to a police officer, Lazzaro said.
But when fired at close range, rubber bullets can penetrate the skin, break bones, fracture the skull and explode the eyeball, he said. Rubber bullets can cause traumatic brain injuries and “serious abdominal injury, including injuries to the spleen and bowel along with major blood vessels,” said Dr. Robert Glatter, an emergency physician at New York’s Lenox Hill Hospital and a spokesperson for the American College of Emergency Physicians.
Firing rubber bullets from a distance decreases both their force and their accuracy, increasing the risk of shooting people in the face or hitting bystanders, Lazzaro said.
Physicians for Human Rights, a nonprofit advocacy group based in New York, has called for rubber bullets to be banned.
The British military developed rubber bullets 50 years ago to control nationalist rioters in Northern Ireland, although the United Kingdom stopped using them decades ago. Rubber bullets are used by Israeli security forces against Palestinian demonstrators. French police were criticized for using rubber bullets last year after dozens of “yellow jacket” demonstrators were blinded and hundreds were injured.
“Rubber bullets are used almost every day somewhere in the world,” Haar said. “Using them against unarmed civilians is a huge violation of human rights.”
Many “less than lethal” police weapons can cause serious harm, according to Physicians for Human Rights.
- Acoustic weapons, such as sound cannons that make painfully loud noises, can damage hearing.
- Tear gas can make it difficult to see and breathe.
- Pepper spray, while painful and irritating, doesn’t cause permanent damage, Lazzaro said.
- Pepper spray balls, which have been used to quell recent protests, can be deadly when used incorrectly. In 2004, a 21-year-old Boston woman was hit in the eye and killed by a pepper spray pellet fired by police to disperse crowds celebrating the city’s World Series win.
- Disorientation devices that create loud noises and bright lights, known as concussion grenade or flash-bangs, can cause severe burns and blast injuries, including damage to the ear drum. Panicked crowds can cause crush injuries.
- Water cannons can cause internal injuries, falls and even frostbite during cold weather.
- Physical force, such as hitting someone to subdue them, causes about 1 in 3 people to be hospitalized, said Dr. Howie Mell, a spokesperson for the American College of Emergency Physicians and former tactical physician, who worked with SWAT teams.
Rubber bullets are less harmful than subduing people by “physical force or regular bullets, Mell said. “But we’re firing a lot more of them this week than we usually do.”
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Como rastreadora de contactos, a Teresa Ayala-Castillo a veces le preguntan si los tés de hierbas y el Vicks VapoRub pueden tratar a COVID-19.
Estas terapias no son exactamente una guía oficial de salud, pero Ayala-Castillo no se sorprende. Escucha y luego sugiere otras ideas, como descansar y beber mucho líquido.
Forma parte del grupo de Facebook de Kaiser Health News en español “KHN-Hablemos de Salud”.KHN-Hablemos de Salud
“No quiero decirles que son cuentos, porque estos remedios son cosas con las que estoy 100% familiarizada ya que mi mamá los usó conmigo”, dijo Ayala-Castillo, una ecuatoriana-estadounidense bilingüe, de primera generación, que trabaja para la ciudad de Long Beach, California.
Los departamentos de salud de los Estados Unidos trabajan a un ritmo frenético para dotar de personal a sus “ejércitos” de rastreadores de contactos para controlar la propagación del coronavirus que causa COVID-19.
Los expertos estiman que los departamentos de salud locales y estatales tendrán que agregar entre 100.000 y 300.000 personas para que la economía vuelva a funcionar.
Mientras organizan estos grupos, muchos estados y localidades quieren contratar a personas de minorías raciales y étnicas más afectadas por el virus. Entienden la necesidad de contar con rastreadores capacitados y culturalmente competentes que puedan convertir a contactos desconfiados o renuentes en participantes entusiastas en la campaña para erradicar el virus.
Las actividades de rastreo del virus varían según el estado. La mayoría han creado planes para añadir rastreadores de contactos mediante la contratación o el voluntariado, pero los más ricos —incluidos California, Connecticut, Massachusetts, Nueva Jersey, Nueva York y Washington— llevan ventaja, aseguró Marcus Plescia, director médico de la Asociación de Funcionarios de Salud Estatales y Territoriales.
Delaware, cuya meta es comenzar las contrataciones en un mes, dará prioridad a personas de comunidades vulnerables y que sean bilingües. Y Minnesota contrata personal con cuotas de diversidad que coinciden con la demografía de los casos de COVID-19 del estado.
“No hay una fórmula mágica que asegure el éxito de esa llamada y establezca una conversación productiva”, señaló Chris Elvrum, del Departamento de Salud de Minnesota. “Tenemos que entender que existen diferentes maneras de abordar el tema para las diferentes comunidades”.
El rastreo de la enfermedad funciona así: luego que alguien da positivo para COVID-19, un investigador del departamento de salud local llama al paciente para hacerle preguntas específicas sobre su salud, sus movimientos y con quién interactuó durante un cierto período de tiempo.
Luego, un rastreador llama a las personas identificadas por el paciente para hacerles saber que estuvieron potencialmente expuestos al virus. A estos contactos se les pide permanecer en casa por 14 días. Si viven con otras personas, la recomendación puede extenderse a esos individuos.
Si se siguen las órdenes de permanecer en casa, resulta relativamente fácil averiguar quién puede haber estado expuesto a la enfermedad, dicen funcionarios de salud.
Las personas infectadas por lo general sólo han estado con familiares o amigos cercanos y a menudo advierten a los contactos que esperen una llamada del departamento de salud, explicó Emily Holman, quien maneja el área enfermedades contagiosas de Long Beach.
Pero en algunos casos se puede requerir la presencia de trabajadores de campo, indicó la doctora Kara Odom Walker, secretaria del Departamento de Salud y Servicios Sociales de Delaware.
“Hay algunas comunidades que no van a responder a una llamada telefónica, a un mensaje de texto o a una carta”, dijo Walker. “Eso podría deberse a una falta de cultura de la salud, al miedo, o al estatus migratorio”.
Hasta ahora, la mayoría sigue las instrucciones, aseguran los funcionarios. Holman estima que menos del 1% de los contactados en Long Beach se negaron a participar.
Pero surgen problemas, especialmente entre quienes no pueden trabajar desde casa o son el único sustento de sus hijos, apuntó Elvrum.
Las personas notificadas sobre su contacto con alguien con COVID pueden pensar que la llamada es parte de un fraude, o preocuparse de que la información sea compartida con las autoridades de inmigración o que les cueste su trabajo.
Los departamentos de salud no tienen que entregar la información recopilada con fines médicos a las autoridades federales de inmigración, pero se necesita un rastreador de contactos sensible, empático y conocedor de la cultura para explicar esto.
“Necesitas a alguien que sea un agente cultural para decir, no sólo que estas medidas son para protegerte, sino para decir que confíes en mí y que todo irá bien”, comentó Walker. “Yo voy a asegurarme personalmente de que tienes lo que necesitas para una cuarentena segura”.
Minnesota pondrá a 1,400 empleados a trabajar en la localización de contactos para julio, informó Elvrum. Los contratos estipulan que buscan a personas de grupos raciales y étnicos proporcionales a su número en el estado o al porcentaje de casos positivos de COVID-19 en esos grupos. Lo que sea más alto.
Se contrata a personas que hablen hmong, somalí y español, según Kou Thao, quien dirige el Centro para la Equidad en la Salud del Departamento de Salud de Minnesota.
Un 23% de los casos positivos del estado se registran entre personas de raza negra, que constituye sólo el 7% de la población total del estado. Los hispanos constituyen el 19% de los casos y el 6% de la población. Sin embargo, alrededor del 22% de los casos son desconocidos.
Virginia, que cuenta con 200 rastreadores de contactos y espera contratar un total de 1,300 empleados para apoyar el esfuerzo, busca personas que hablen de mandarín, criollo haitiano, español y bengalí, según Mona Bector, comisionada del Departamento de Salud del estado.
Virginia ha recibido más de 6,000 curriculums para estos puestos, dijo Bector.
Long Beach se enorgullece de una fuerza laboral diversa que refleja la población de la ciudad. Los funcionarios sacaron a sus rastreadores de contactos e intérpretes, incluyendo a Ayala-Castillo, de los miembros del personal municipal que hablan samoano, jemer, tagalo, español, vietnamita, mandarín y otros idiomas para crear una plantilla de 60 personas. Su objetivo es tener 200 personas entrenadas y listas para ser desplegadas cuando sea necesario.
Tener trabajadores que puedan hablar con los contactos en el idioma que prefieran es un paso importante, expresó Crystal Watson, del Centro de Seguridad Sanitaria de Johns Hopkins. Ser capaz de extraer información mientras se es sensible a las preocupaciones y desconfianzas de los pacientes es primordial, añadió.
El sargento Jairo Paulino, de 38 años, miembro de la Guardia Nacional de Delaware, es uno de los militares bilingües que se ofrecen a ayudar con las llamadas a los contactos de COVID-19. Cuando empezó el trabajo a mediados de mayo, notó que había un “gran atraso” en la lista de nombres porque el estado no tenía suficientes hispanohablantes para contactarlos a todos con rapidez.
Paulino nació en la República Dominicana y llegó a Nueva York de niño. Creció traduciendo para su padre y asistiendo a la iglesia; ambas referencias ayudan a construir la confianza en la comunidad latina, dijo.
El escaso acceso a Internet también plantea un desafío. En Tulare, un condado rural en el centro de California, los trabajadores de la salud piden a los pacientes que utilicen un portal en línea para ayudar a agilizar la recopilación de datos de sus contactos. Sin embargo, entre el 5% y el 10% de las personas no pueden conectarse a Internet, explicó Tiffany Swarthout, del departamento de salud del condado. En esos casos, los trabajadores de la salud hablarán con el paciente por teléfono.
Las preocupaciones laborales representan otra área de dificultad para los rastreadores de contactos. Algunas personas son reacias a quedarse en casa porque no tienen ingresos, especialmente si la pandemia ha dejado a miembros de la familia sin trabajo, señaló Jody Menick, una enfermera que supervisa la localización de contactos en el condado de Montgomery, Maryland, en las afueras de Washington, D.C.
Algunos empleadores solicitan pruebas de que los pacientes y sus contactos pueden regresar con seguridad después de la cuarentena, y algunas jurisdicciones proporcionan cartas oficiales que especifican el período de cuarentena del trabajador.
Pero los trabajadores indocumentados, que cuentan con menos protecciones que los empleados con estatus legal, han sido presionados para que se presenten a trabajar, contó Menick, poniéndoles en una situación muy difícil.
“¿Voy a conseguir dinero para comprar comida para mi familia, o me voy a quedar en casa?”
As a contact tracer, Teresa Ayala-Castillo is sometimes asked whether herbal teas and Vicks VapoRub can treat COVID-19. These therapies aren’t exactly official health guidance, but Ayala-Castillo isn’t fazed. She listens and then suggests other ideas — like getting rest and drinking plenty of fluids.
“I don’t want to call them old wives’ tales, but these remedies are things that I’m 100% familiar with because my mom used them on me,” said Ayala-Castillo, a bilingual first-generation Ecuadorian American who works for the city of Long Beach, California.
Health departments across the U.S. are working at a furious pace to staff their armies of contact tracers to control the spread of the coronavirus that causes COVID-19. Experts estimate local and state health departments will have to add 100,000 to 300,000 people to get the economy back on track.
As they build these forces, many states and localities are trying hard to hire from the racial and ethnic minority communities hit hardest by the virus. They’re anticipating a need for skilled, culturally competent tracers who can convert suspicious or hesitant contacts into enthusiastic, willing participants in the drive to stamp out the virus.Don't Miss A Story
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Virus-tracking activities vary by state. Most states have created plans to add contact tracers through hiring or volunteering, but wealthier ones — including California, Connecticut, Massachusetts, New Jersey, New York and Washington — are further along than others, said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials.
Delaware, which aims to begin hiring in a month, plans to prioritize hires from vulnerable communities with bilingual language skills. Minnesota is hammering out staffing contracts with diversity quotas that match the demographics of the state’s COVID-19 cases.
“One size does not fit all for making that first call and being successful in having them pick up the phone and have a good conversation,” said Chris Elvrum, a deputy incident manager at the Minnesota Department of Health. “We need to recognize that we have to approach it in different ways for different cultural communities in the state.”
Tracking the disease works like this: After someone tests positive for COVID-19, a case investigator from the local health department calls the patient to ask detailed questions about her health, movements and whom she interacted with over a certain time frame. A contact tracer then calls everyone the patient named to let them know they were potentially exposed to the virus. These contacts are instructed to stay home and self-quarantine for 14 days after the exposure. If they live with other people, the recommendation may extend to those individuals.
Under stay-at-home orders, it’s often relatively easy to figure out who may have been exposed to the disease, health officials say. Infected people usually have been around only family or close friends and will often warn contacts to expect a call from the health department, said Emily Holman, communicable disease controller for Long Beach.
But shoe-leather fieldworkers may be required in some instances, said Dr. Kara Odom Walker, secretary of the Delaware Department of Health and Social Services. “There are some communities that aren’t going to respond to a phone call, a text message or a letter,” said Walker. “That could be due to health literacy issues, which could be due to fear, or documentation status.”
So far, most people are following instructions, say officials. Holman estimates that fewer than 1% of those contacted in Long Beach refused to participate.
But some defiance is likely, especially among those who cannot work from home or are the only provider for their children, Elvrum said. People being notified about contacts with a COVID-positive patient might think the call is a scam, or worry the information will be shared with immigration authorities or cost them their job. Health departments do not have to turn information collected for medical purposes over to federal immigration enforcement, but it takes a sensitive, empathetic and knowledgeable contact tracer to explain this.
“You need someone to be a cultural broker to say, not only are these policies in place to protect you, but I’m telling you to trust me that this will be OK,” Walker said. “I’m going to make sure you have what you need to safely quarantine.”
Minnesota plans to dedicate 1,400 staffers to contact tracing by July, Elvrum said. Contracts with two companies involved in the hiring stipulate that they bring on people of racial and ethnic groups proportional to their numbers in the state or the percentage of positive COVID-19 cases in those groups — whichever is higher.
They’re seeking hires who speak Hmong, Somali and Spanish, said Kou Thao, director of the Center for Health Equity in the Minnesota Department of Health.
About 23% of the state’s positive cases are among black people, who make up only 7% of the state population. Hispanics make up 19% of cases — and 6% of the population. However, about 22% of the cases are unknown.
Virginia, which has 200 contact tracers and hopes to hire a total of 1,300 staff to support the effort, is looking for speakers of Mandarin, Haitian Creole, Spanish and Bengali, said Mona Bector, deputy commissioner for administration at the Virginia Department of Health.
The state has received more than 6,000 résumés for these positions, Bector said.
Long Beach prides itself on a diverse workforce that reflects the city’s population. Officials pulled their contact tracers and interpreters, including Ayala-Castillo, from municipal staff members who speak Samoan, Khmer, Tagalog, Spanish, Vietnamese, Mandarin and other languages to create a staff of 60. Their goal is to have 200 people trained and ready to deploy as needed.
Having workers who can speak to contacts in the language they prefer is a step forward, said Crystal Watson, a senior scholar from the Johns Hopkins Center for Health Security. Being able to extract information while being sensitive to patients’ concerns and mistrust is paramount, she added.
Sgt. Jairo Paulino, a 38-year-old member of the Delaware National Guard, is one of several bilingual guardsmen volunteering to help call COVID-19 contacts. When he started the job in mid-May, he noticed there was a “major backlog” of names because the state didn’t have enough Spanish speakers to reach out to everyone quickly.
Paulino was born in the Dominican Republic and moved to New York as a boy. He grew up translating for his father and attending church — both elements that help build trust in the Latino community, he said.
Poor access to the internet also poses a challenge. In Tulare, a rural county in central California, health workers ask patients to use an online portal to help streamline data collection of their contacts. However, 5% to 10% of people cannot get online, said Tiffany Swarthout, an administrative specialist at the county health department. In those cases, health workers will speak to the patient on the phone.
Employment concerns represent another tricky area for contact tracers. Some people they reach out to may hesitate to stay home because they are strapped for cash, especially if the pandemic has left members of the family without work, said Jody Menick, a nurse who supervises contact tracing in Montgomery County, Maryland, just outside Washington, D.C.
Some employers are requesting proof that patients and contacts were safe to return after quarantine, and some areas provide official letters that specify the worker’s quarantine period.
But undocumented workers — who have fewer protections than employees with legal status — have been pressured to show up to work in her area, Menick said, leaving them with a difficult decision.
“Am I going to have money to buy food for my family, or am I going to stay home?”
Before Philadelphia shut down to slow the spread of the coronavirus, Ed had a routine: most mornings he would head to a nearby McDonald’s to brush his teeth, wash his face and — when he had the money — buy a cup of coffee. He would bounce between homeless shelters and try to get a shower. But since businesses closed and many shelters stopped taking new admissions, Ed has been mostly shut off from that routine.
He’s still living on the streets.
“I’ll be honest, I don’t really sleep too much,” said Ed, who’s 51 and struggling with addiction. “Every four or five days I get a couple hours.”
KHN agreed not to use his last name because he uses illegal drugs.
Philadelphia has the highest overdose rate of any big city in America — in 2019, more than three people a day died of drug overdoses there, on average. Before the coronavirus began spreading across the United States, the opioid overdose epidemic was the biggest health crisis on the minds of many city officials and public health experts. The coronavirus pandemic has largely eclipsed the conversation around the opioid crisis. But the crisis still rages on despite business closures, the cancellation of in-person treatment appointments and the strain on many addiction resources in the city.Email Sign-Up
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When his usual shelter wasn’t an option anymore, Ed tried to get into residential drug treatment. He figured that would be a good way to try to get back on his feet and, if nothing else, get a few good nights of rest. But he had contracted pinkeye, a symptom thought to be associated with the virus that leads to COVID-19, so the evaluation center didn’t want to place him in an inpatient facility until he’d gotten the pinkeye checked out. But he couldn’t see a doctor because he didn’t have a phone for a telehealth appointment.
“I got myself stuck, and I’m trying to pull everything back together before it totally blows up,” he said.
Rosalind Pichardo wants to help people in Ed’s situation. Before the pandemic, Pichardo would hit the streets of her neighborhood, Kensington, which has the highest drug overdose rate in Philadelphia. She’d head out with a bag full of snack bars, cookies and Narcan, the opioid overdose reversal drug.
She’d hand Narcan out to people using drugs, and people selling drugs — anyone who wanted it. Pichardo started her own organization, Operation Save Our City, which initially set out to work with survivors of gun violence in the neighborhood. When she realized that overdoses were killing people too, she began getting more involved with the harm reduction movement and started handing out Narcan through the city’s syringe exchange.
When Pennsylvania’s stay-at-home order went into effect, Pichardo and others worried that more people might start using drugs alone, and that fewer first responders would be patrolling the streets or nearby and able to revive them if they overdosed.
So, Pichardo and other harm reduction activists gave out even more Narcan. A representative for Prevention Point Philadelphia, the group that operates a large syringe exchange program in the city, said that during the first month of the city’s stay-at-home order, they handed out almost twice as much Narcan as usual.
After the lockdowns and social distancing began, Pichardo worried that more people would be using drugs alone, leading to more overdoses. But Philadelphia’s fatal overdose rate during the pandemic remains about the same as it was this time last year. Pichardo said she thinks that’s evidence that flooding the streets with Narcan is working — that people are continuing to use drugs, and maybe even using more drugs, but that users are utilizing Narcan more often and administering it to one another.
That is the hope. But Pichardo said users don’t always have a buddy to keep watch, and during the pandemic first responders have seemed much more hesitant to intervene. For example, she recently administered Narcan to three people in Kensington who overdosed near a subway station, while two police officers stood by and watched. Before the pandemic, they would often be right there with her, helping.
To reverse the overdoses, Pichardo crouched over the people who she said had started turning blue as their oxygen levels dropped. She injected the Narcan into their noses, using a disposable plastic applicator. Normally, she would perform rescue breathing, too, but since the pandemic began she has started carrying an Ambu bag, which pumps air into a person’s lungs and avoids mouth-to-mouth resuscitation. Among the three people, she said, it took six doses of Narcan to revive them. The police officers didn’t step in to help but did toss several overdose-reversal doses toward Pichardo as she worked.
“I don’t expect ’em to give ’em rescue breaths if they don’t want to, but at least administer the lifesaving drug,” Pichardo said.
In her work as a volunteer, she has reversed almost 400 overdoses, she estimated.
“There’s social distancing — to a limit,” Pichardo said, “I think when someone’s life is in jeopardy, they’re worth saving. You just can’t watch people die.”
Even before Philadelphia officially issued its stay-at-home order, city police announced they would stop making low-level arrests, including for narcotics. The idea was to reduce contact overall, help keep the jail population low and reduce the risk of the virus getting passed around inside. But Pichardo and other community activists said the decreased law enforcement emboldened drug dealers in the Kensington neighborhood, where open-air drug sales and use are common.
“You can tell they have everything down pat, from the lookout to the corner boys to the one actually holding the product — the one holding the product’s got some good PPE gear,” said Pichardo.
More dealers working openly on the street has led to more fights over territory, she added, which in turn has meant more violence. While overall crime in Philadelphia and other major cities has declined during the pandemic, gun violence has spiked.
Police resumed arrests at the beginning of May.
Now when she goes out to offer relief and hand out Narcan, Pichardo packs a few extra things in her bag of supplies: face masks, gloves and gun locks.
“It’s like the survival kit of the ’hood,” she said.
For those struggling with addiction who are ready to start recovery, newly relaxed federal restrictions have made it easier to get medications that curb opioid cravings and stem withdrawal. Several efforts are underway among Philadelphia-based public health groups and criminal justice advocacy organizations to give cellphones to people who are homeless or coming out of jail, so they can make a telehealth appointment and get quicker access to a prescription for those medicines.
During the pandemic, people taking medication-assisted treatment can renew their prescription every month instead of every week, which helps decrease trips to the pharmacy. It is too soon to know if more people are taking advantage of the new rules, and accessing medication-assisted treatment via telehealth, but if that turns out to be the case, many addiction medicine specialists argue the new rules should become permanent, even after the pandemic ends.
“If we find that these relaxed restrictions are bringing more people to the table, that presents enormous ethical questions about whether or not the DEA should reinstate these restrictive policies that they had going in the first place,” said Dr. Ben Cocchiaro, a physician who treats people with substance-use disorder.
Cocchiaro said the whole point of addiction treatment is to facilitate help as soon as someone is ready for it. He hopes if access to recovery can be made simpler during a pandemic, it can remain that way afterward.
California’s health care industry has a consolidation problem.
Independent physician practices, outpatient clinics and hospitals are merging or getting gobbled up by private equity firms or large health care systems. A single company can dominate an entire community, and in some cases, vast swaths of the state.
Such dominance can inflate prices, and consumers end up facing higher insurance premiums, more expensive outpatient services and bigger out-of-pocket costs to see specialists.
Now that COVID-19 has slammed the health care industry, especially the small practices that are barely seeing patients, the trend is likely to accelerate.
“I don’t see anything that’s going to stop this wave of consolidations amongst docs,” said Glenn Melnick, a health care economist at the University of Southern California.
“If this thing goes on a long time,” he said of the coronavirus, “then it becomes a tsunami.”
California Attorney General Xavier Becerra has made battling health care consolidation a signature issue since he took office in 2017. With the additional pressure that COVID-19 is putting on vulnerable practices and facilities, Becerra is now pressing the state legislature to expand his authority to slow health care mergers.
“We find that in these times of crisis, economic and health crisis, that the smaller health care players and stakeholders are oftentimes most at risk of being swallowed up by the big fish,” Becerra told California Healthline.Email Sign-Up
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His success would fundamentally change how the health care industry merges and grows in California.
When a health care system, private equity firm or hedge fund plans to merge with or acquire another practice or facility — whether that means buying a small practice or joining a multistate hospital chain — Becerra wants to know about it. He wants written notice, and the ability to deny any sale that doesn’t deliver better access, cost or quality health care to Californians.
Becerra already can regulate mergers among nonprofit health care facilities. Under SB-977, a collaboration between Becerra’s office and the legislature, he would get the ability to regulate the for-profit sector as well.
“Certainly it would put California where it’s accustomed to being,” Becerra said. “At the head of the pack.”
The bill has support from organized labor and consumer advocacy groups. Gov. Gavin Newsom has come out against health care consolidation in the past but hasn’t taken an official stance on the bill.
Yet Becerra isn’t convinced passage will be smooth.
“The biggest concern I have is the legislation will be killed by the industry,” he said. “We’ll end up seeing over-consolidation because decent practices that got on the edge could not swim with sharks.”
Indeed, health care industry players are already lining up against the bill. Alex Hawthorne, a lobbyist for the California Hospital Association, said that hospitals are stretched thin because of the pandemic, and that now isn’t the time for Becerra to be meddling in routine agreements between practices.
“It bestows absolute and arbitrary discretion on the office of the attorney general,” Hawthorne said at a budget hearing in May.
In 2010, about 25% of California physicians worked in a practice owned by a hospital. By 2016, more than 40% of doctors worked in hospital-owned practices, according to research published in the journal Health Affairs in 2018.
There’s evidence that consolidation can hurt consumers. A separate 2018 study found that the cost of medical procedures in highly consolidated Northern California was 20% to 30% higher than in Southern California.
Since 2018, California’s attorney general has had the authority to regulate mergers among nonprofit health care systems, which Becerra exercised the same year when considering a merger between two health care giants: Dignity Health and Catholic Health Initiatives. He said he would approve the deal only if the systems agreed to certain requirements, such as starting a homelessness program.
Later that year, Becerra joined a suit against Sutter Health for using its market power to drive up health care costs in Northern California.
The lawsuit alleged that Sutter, which has 24 hospitals and 34 surgery centers, had spent years buying up practices and facilities, giving insurers little choice but to include them in their networks and agree to higher rates for services.
In October 2019, Becerra secured a $575 million settlement against Sutter, which has yet to be finalized or paid out, that requires Sutter to change how it charges insurance companies and give patients more information about prices.
Sutter Health opposes SB-977, which was introduced in February by state Sen. Bill Monning (D-Carmel). The measure is intended to address some of the challenges Becerra encountered with the Sutter case, Becerra said.
“The best way to prevent problems from occurring in a merger is just to prevent the merger altogether,” said Jaime King, associate dean at UC Hastings College of the Law in San Francisco. “It’s really hard to unwind a merger after you’ve already done it.”
Under the measure, the attorney general must be notified before a system, hedge fund or private equity firm attempts to enter into a merger, acquisition or another kind of affiliation change with another practice or facility. The bill defines a health care system as one with two or more hospitals in multiple counties, or three or more hospitals within one county.
That would trigger a public review process allowing supporters and opponents to make their cases to a review board. The board would assess the transaction, using criteria to determine whether it would improve access, quality and price.
The bill also would make it illegal for systems to act anti-competitively and give the attorney general the power to bring a civil suit against monopolistic systems.
The Senate Health Committee approved the bill, which is expected to be heard in another committee this week.
“Maybe it does mean consolidation should occur, but only because we’ve done the oversight to make sure it’s because of quality and access,” Becerra said. “Not because a big fish wants to make bigger profit.”
The measure includes waivers for rural practices and a fast-track review process for transactions under $500,000.
The California Chamber of Commerce opposes the bill, as does the California Medical Association, which represents doctors. While the California Medical Association is concerned about the survival of small physician practices, it believes the bill is too broad and should focus more tightly on hospital consolidation, said spokesperson Anthony York.
“This approach will only further force smaller providers out of business,” especially as the health systems respond to the COVID-19 emergency, the group’s legislative advocate, Amy Durbin, wrote in a letter of opposition.
For many independent practices struggling for survival, the debate over Becerra’s powers is academic.
Dr. Sarah Azad, who owns a women’s health practice in Mountain View, California, said at least three independent practices in her area have started the process to merge or sell since March because of dramatically lower patient volume.
Her practice is fine for now, despite the fact that her patient volume was only about 30% of normal in March and 60% of normal in April. Azad received a loan from the federal Paycheck Protection Program for small businesses so she could pay her five doctors in May.
“If you catch me on a bad month, I feel like we’re one disaster away from bankruptcy,” Azad said.