On Sundays, Bishop Bruce Davis preached love. Through his Pentecostal ministry, he organized youth parades and gave computers, bicycles and food to families in need.
During the week, Bruce practiced what he preached, caring for prisoners at a Georgia hospital. On March 27 he began coughing, and on April 1 he was hospitalized. He’d tested positive for covid-19. The virus swept through his household, infecting his wife and daughter and hospitalizing their disabled son. Ten days after landing in the hospital, Bruce died.
But when Gwendolyn Davis received her husband’s death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.
“He wouldn’t have had kidney failure if he didn’t have covid,” Gwendolyn said.
After Bruce died, his wife applied to two pandemic relief programs seeking help with $1,500 in missed payments on a truck and an electricity bill. But, she said, she was denied because his death certificate didn’t mention covid-19.
“I think it’s wrong,” Gwendolyn said. “It’s almost like we didn’t count.”
The count has profound implications for families and the country. Omitting covid-19 on death certificates threatens to undercount the toll of the pandemic nationwide. For Davis’ family and others, it can pile financial hardship onto emotional despair, as death benefits and other covid-19 relief programs are withheld. Interviews with families across the U.S. shed light on reasons covid deaths are being undercounted — and the consequences loved ones have endured.
When covid patients die, the “immediate” cause of death is always something else, such as respiratory failure or cardiac arrest. Residents, doctors, medical examiners and coroners make the call on whether covid was an underlying factor, or “contributory cause.” If so, the diagnosis should be included on the death certificate, according to the Centers for Disease Control and Prevention.
Even beyond the pandemic, there is wide variation in how certifiers describe causes of death: “There’s just no such thing as an objective measure of cause of death,” said Lee Anne Flagg, a statistician at the CDC’s National Center for Health Statistics.
Partly because of a lack of training in how to fill them out, “the quality of the death certificates is not good,” said Dr. James Gill, vice president of the National Association of Medical Examiners. And in cases in which people had other chronic conditions, it can be difficult to determine whether covid was a contributing cause of death, he said. That was especially true early on, when reliable testing was not widely available.
Since early in the pandemic, the CDC has encouraged certifiers who suspect covid as a cause of death to list it on the death certificate as “probable” or “likely.”
Still, some clinicians are “reluctant to certify a death as a covid death without a test in hand,” Gill said.
It’s not clear how Bruce Davis’ case slipped under the radar. His death was certified by William Ken Garland, deputy coroner in Baldwin County. Reached by phone, Garland said the causes of death were provided by Dr. Joseph Coppiano, a medical resident who pronounced Davis dead at Augusta University Medical Center, about 90 miles away. No autopsy was done.
“I did certify the record, but that’s about all I did,” Garland said.
Hospital spokesperson Danielle Harris declined to comment on the case, citing patient privacy. She said the hospital follows Georgia Department of Public Health guidelines.
In the absence of certainty, the CDC has encouraged coroners to document the virus. “We’re not worried that we’re overcounting the number of [covid-19] deaths,” Farida Ahmad, epidemiologist and mortality surveillance team leader at NCHS, said in April.
Missed cases are one reason that experts agree covid deaths are being undercounted nationwide. As evidence for that, they point to the vast number of excess deaths — additional deaths compared to what would be expected based on prior-year numbers and demographic trends.
These excess deaths “tend to track pretty closely with covid cases, trailing by a couple of weeks,” said Daniel Weinberger, an epidemiologist at Yale School of Public Health who has published on this topic. “This strongly suggests that a large proportion of these uncounted deaths are due to covid but not recorded as such.”
We may never know how many covid deaths went uncounted: Postmortem tests can detect the virus, but it’s “unlikely that this type of testing will be performed at a [sufficient] scale,” Weinberger said. Early in the pandemic, especially in the Northeast, many of those who were treated clinically for covid and then died were not tested for the virus — so they never made it into the statistics.
Testing Troubles Affect Lawsuits, Hospital Bills
Inaccurate death certificates can make it harder to pursue a lawsuit or win a workers’ compensation case when a loved one dies after contracting covid on the job. Gwendolyn Davis did win workers’ compensation death benefits from Bruce’s employer, a state psychiatric facility in Milledgeville, by providing medical records. But problems with covid testing can complicate the process.
Bruce’s supervisor at work, Mark DeLong, also died after contracting covid, but it did not appear on his death certificate with the other causes: cardiopulmonary arrest, respiratory failure and diabetes.
The omission on DeLong’s certificate seemed to stem from a delay in test results: His covid-positive results didn’t arrive until three days after he died, according to his widow, Jan DeLong. She has asked the local coroner to correct the record.
In New Jersey, attorney Paul da Costa represents 75 family members who lost loved ones at veterans homes in Menlo Park and Paramus in April and May. He said he knows of at least five patients whose death certificates did not list covid-19 despite evidence suggesting it killed them.
The root problem, he said, was a “complete dearth of testing.” Patients were transferred to hospitals, or dying in the veterans facilities, without ever being tested, he said.
The gap between excess deaths and confirmed covid deaths has “narrowed over time as testing has increased,” Weinberger said.
Early testing inaccuracy may also have led to undercounting, which creates a different burden: hospital bills. Without a diagnosis, families can be on the hook for thousands of dollars in charges that otherwise would have been covered under the CARES Act.
Correcting the Record
In some cases, families have sought to have death certificates changed to reflect covid. Dorothy Payton, 95, who lived in the ManorCare nursing home in Denver, first showed covid symptoms April 5. Five days later, Payton — known as “Nana Dee” — tested positive for it. And on April 13, her husband, Edward Benjamin, received a call that she had died.
The death certificate offered a litany of causes: vascular dementia, atrial fibrillation, congestive heart failure, gait instability, difficulty swallowing and “failure to thrive.”
But not covid-19. So it “seemed logical to fight for listing her cause of death under her cause of death,” Benjamin said.
After a few calls, her husband was able to get the certificate amended. ManorCare could not be reached for comment.
For Benjamin, it wasn’t about public health statistics or financial considerations. It simply offers a sense of closure.
“I want her life and death remembered the way it was, and I’m glad we set the record straight,” he said. “It’s the first step towards moving on.”
This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.
Dr. Andrew Carroll — a family doctor in Chandler, Arizona — wants to help his patients get immunized against covid, so he paid more than $4,000 to buy an ultra-low-temperature freezer from eBay needed to store the Pfizer vaccine.
But he’s not sure he’ll get a chance to use it, given health officials have so far not said when private doctor’s offices will get vaccine.
“I’m really angry,” said Carroll.
Not only are doctors having trouble getting vaccine for patients, but many of the community-based physicians and medical staff that aren’t employed by hospitals or health systems also report mixed results in getting inoculated. Some have had their shots, yet others are still waiting, even though health workers providing direct care to patients are in the Centers for Disease Control and Prevention’s top-priority group.
Many of these doctors say they don’t know when — or if — they will get doses for their patients, which will soon become a bigger issue as states attempt to vaccinate more people.
“The reason that’s important is patients trust their doctors when it comes to the vaccine,” said Carroll, who has complained on social media that his county hasn’t yet released plans on how primary care doctors will be brought into the loop.
Collectively, physicians in the county could vaccinate thousands of patients a day, he said, and might draw some who would otherwise be hesitant if they had to go to a large hospital, a fairground or another central site.
His concern comes as, nationally, the rollout of the vaccine is off to a slower start than expected, lagging far behind the initial goal of giving 20 million doses before the new year.
But Dr. Jen Brull, a family practice doctor in Plainville, Kansas, said her rural area has made good progress on the first phase of vaccinations, crediting close working relationships formed well before the pandemic.
This fall, before any doses became available, the local hospital, the health department and physician offices coordinated a sign-up list for medical workers who wanted the vaccine. So, when their county, with a population of 5,000, got its first 70 doses, they were ready to go. Another 80 doses came a week later.
“We’ll be able to vaccinate almost all the health care-associated folks who wanted it in the county” Brull said recently
Gaps in the Rollout
But that’s not the case everywhere.
Dr. Jason Goldman, a family doctor in Coral Gables, Florida, said he was able to get vaccinated at a local hospital that received the bulk of vaccines in his county and oversaw distribution.
In the weeks since, however, he said several of his front-line staff members still “don’t have access to the vaccine.”
Additionally, “a tremendous number” of patients are calling his office because Florida has relaxed distribution guidelines to include anyone over age 65, Goldman said, asking when they can get the vaccine. He’s applied to officials about distributing the vaccines through his practice but has heard nothing back.
Patients “are frustrated that they do not have clear answers and that I am not being given clear answers to provide them,” he said. “We have no choice but to direct them to the health department and some of the hospital systems.”
Another troubling point for Goldman, who served as a liaison between the American Academy of Family Physicians and the expert panel drawing up the CDC distribution guidelines, is the tremendous variation in how those recommendations are being implemented in the states.
The CDC recommends several phases, with front-line health care workers and nursing home residents and staff in the initial group. Then, in the second part of that phase, come people over 75 and non-health care front-line workers, which could include first responders, teachers and other designated essential workers.
States have the flexibility to design their own rollout schedule and priority groups. Florida, for example, is offering doses to anyone 65 and up. In some counties, older folks were told vaccines were available on a first-come, first-served basis, a move that has resulted in long lines.
“To say right now, 65-plus, when you haven’t even appropriately vaccinated all the health care workers, is negating the phasing,” said Goldman. “There needs to be a national standard. We have those guidelines. We need to come up with some oversight.”
On Thursday, the American Hospital Association echoed that concern in a letter to Health and Human Services Secretary Alex Azar. Hospitals — along with health departments and large pharmacy chains — are doing the bulk of the vaccinations.
Calling for additional coordination by federal officials, the letter outlined what it would take to reach the goal of vaccinating 75% of Americans by the end of May: 1.8 million vaccinations every day. Noting there are 64 different rollout plans from states, cities and other jurisdictions, the letter asked whether HHS has “assessed whether these plans, taken as a whole, are capable of achieving this level of vaccination?”
Making It Work
Lack of direct national support or strategy means each county is essentially on its own, with success or failure affected by available resources and the experience of local officials. Most state and local health departments are underfunded and are under intense pressure because of the surging pandemic.
Still, the success of vaccination efforts depends on planning, preparation and clear communication.
In Lorain County, Ohio, population 310,000, local officials started practicing in October, said Mark Adams, deputy health commissioner. They set up mass vaccination clinics for influenza to study what would be needed for a covid vaccination effort. How many staff? What would the traffic flow be like? Could patients be kept 6 feet apart?
“That gave us an idea of what is good, what is bad and what needs to change,” said Adams, who has had previous experience coordinating mass vaccination efforts at a county level.
So, when the county got its first shipment of 500 doses Dec. 21, Adams had his plan ready. He called the fire chiefs to invite all emergency medical technicians and affiliated personnel to an ad hoc vaccination center set up at a large entertainment venue staffed by his health department. Upon arrival, people were greeted at the door and directed to spaced-apart “lanes” where they would get their shots, then to a monitoring area where they could wait for 15 minutes to make sure they didn’t have a reaction.
Right after Christmas, another 400 doses arrived — and the makeshift clinic opened again. This time, doses went to community-based physicians, dentists and other hands-on medical practitioners, 600 of whom had previously signed up. (Hospital workers and nursing home staff and residents are getting their vaccinations through their own institutions.)
As they move into the next phase — recipients include residents over 80, people with developmental disorders and school staff — the challenges will grow, he said. The county plans a multipronged approach to notify people when it’s their turn, including use of a website, the local media, churches, other organizations and word-of-mouth.
Adams shares the concerns of medical providers nationwide: He gets only two days’ notice of how many doses he’s going to receive and, at the current pace of 400 or 500 doses a week, it’s going to take a while before most residents in the county have a chance to get a shot, including the estimated 33,000 people 65 and older.
With 10 nurses, his clinic can inject about 1,200 people a day. But many other health professionals have volunteered to administer the shots if he gets more doses.
“If I were to run three clinics, five days a week, I could do 15,000 vaccinations a week,” Adams said. “With all the volunteers, I could do almost six clinics, or 30,000 a week.”
Still, for those in the last public group, those age 18 and up without underlying medical conditions, “it could be summer,” Adams said.
The CDC has engaged the California-based health system’s Vaccine Study Center to conduct an analysis of its Covid-19 vaccine data with the aim of pinpointing adverse events and reactions. The collaboration will continue for the next three years.
States will get some much needed support to roll out a coronavirus vaccine. Last week, the Department of Health and Human Services shared it would roll out $22 billion in funding to support state testing and vaccination efforts.
Workers at Garfield Medical Center in suburban Los Angeles were on edge as the pandemic ramped up in March and April. Staffers in a 30-patient unit were rationing a single tub of sanitizing wipes all day. A May memo from the CEO said N95 masks could be cleaned up to 20 times before replacement.
Patients showed up COVID-negative but some still developed symptoms a few days later. Contact tracing took the form of texts and whispers about exposures.
By summer, frustration gave way to fear. At least 60 staff members at the 210-bed community hospital caught COVID-19, according to records obtained by KHN and interviews with eight staff members and others familiar with hospital operations.
The first to die was Dawei Liang, 60, a quiet radiology technician who never said no when a colleague needed help. A cardiology technician became infected and changed his final wishes — agreeing to intubation — hoping for more years to dote on his grandchildren.
Few felt safe.
Ten months into the pandemic, it has become far clearer why tens of thousands of health care workers have been infected by the virus and why so many have died: dire PPE shortages. Limited COVID tests. Sparse tracking of viral spread. Layers of flawed policies handed down by health care executives and politicians, and lax enforcement by government regulators.
All of those breakdowns, across cities and states, have contributed to the deaths of more than 2,900 health care workers, a nine-month investigation by over 70 reporters at KHN and The Guardian has found. This number is far higher than that reported by the U.S. government, which does not have a comprehensive national count of health care workers who’ve died of COVID-19.
The fatalities have skewed young, with the majority of victims under age 60 in the cases for which there is age data. People of color have been disproportionately affected, accounting for about 65% of deaths in cases in which there is race and ethnicity data. After conducting interviews with relatives and friends of around 300 victims, KHN and The Guardian learned that one-third of the fatalities involved concerns over inadequate personal protective equipment.
Many of the deaths occurred in New York and New Jersey, and significant numbers also died in Southern and Western states as the pandemic wore on.
Workers at well-funded academic medical centers — hubs of policymaking clout and prestigious research — were largely spared. Those who died tended to work in less prestigious community hospitals like Garfield, nursing homes and other health centers in roles in which access to critical information was low and patient contact was high.
Garfield Medical Center and its parent company, AHMC Healthcare, did not respond to multiple calls or emails regarding workers’ concerns and circumstances leading to the worker deaths.
So as 2020 draws to a close, we ask: Did so many of the nation’s health care workers have to die?
New York’s Warning for the Nation
The seeds of the crisis can be found in New York and the surrounding cities and suburbs. It was the region where the profound risks facing medical staff became clear. And it was here where the most died.
As the pandemic began its U.S. surge, city paramedics were out in force, their sirens cutting through eerily empty streets as they rushed patients to hospitals. Carlos Lizcano, a blunt Queens native who had been with the New York City Fire Department (FDNY) for two decades, was one of them.
He was answering four to five cardiac arrest calls every shift. Normally he would have fielded that many in a month. He remembered being stretched so thin he had to enlist a dying man’s son to help with CPR. On another call, he did chest compressions on a 33-year-old woman as her two small children stood in the doorway of a small apartment.
“I just have this memory of those kids looking at us like, ‘What’s going on?’”
After the young woman died, Lizcano went outside and punched the ambulance in frustration and grief.
The personal risks paramedics faced were also grave.
More than 40% of emergency medical service workers in the FDNY went on leave for confirmed or suspected coronavirus during the first three months of the pandemic, according to a study by the department’s chief medical officer and others.
In fact, health care workers were three times more likely than the general public to get COVID-19, other researchers found. And the risks were not equally spread among medical professions. Initially, CDC guidelines were written to afford the highest protection to workers in a hospital’s COVID-19 unit.
Yet months later, it was clear that the doctors initially thought to be at most risk — anesthesiologists and those working in the intensive care unit — were among the least likely to die. This could be due to better personal protective equipment or patients being less infectious by the time they reach the ICU.
Instead, scientists discovered that “front door” health workers like paramedics and those in acute-care “receiving” roles — such as in the emergency room — were twice as likely as other health care workers to be hospitalized with COVID-19.
For FDNY’s first responders, part of the problem was having to ration and reuse masks. Workers were blind to an invisible threat that would be recognized months later: The virus spread rapidly from pre-symptomatic people and among those with no symptoms at all.
In mid-March, Lizcano was one of thousands of FDNY first responders infected with COVID-19.
At least four of them died, city records show. They were among the 679 health care workers who have died in New York and New Jersey to date, most at the height of the terrible first wave of the virus.
“Initially, we didn’t think it was this bad,” Lizcano said, recalling the confusion and chaos of the early pandemic. “This city wasn’t prepared.”
Neither was the rest of the country.
An Elusive Enemy
The virus continued to spread like a ghost through the nation and proved deadly to workers who were among the first to encounter sick patients in their hospital or nursing home. One government agency had a unique vantage point into the problem but did little to use its power to cite employers — or speak out about the hazards.
Health employers had a mandate to report worker deaths and hospitalizations to the Occupational Safety and Health Administration.
When they did so, the report went to an agency headed by Eugene Scalia, son of conservative Supreme Court Justice Antonin Scalia who died in 2016. The younger Scalia had spent part of his career as a corporate lawyer fighting the very agency he was charged with leading.
Its inspectors have documented instances in which some of the most vulnerable workers — those with low information and high patient contact — faced incredible hazards, but OSHA’s staff did little to hold employers to account.
Beaumont, Texas, a town near the Louisiana border, was largely untouched by the pandemic in early April.
That’s when a 56-year-old physical therapy assistant at Christus Health’s St. Elizabeth Hospital named Danny Marks called in sick with a fever and body aches, federal OSHA records show.
He told a human resources employee that he’d been in the room of a patient who was receiving a breathing treatment — the type known as the most hazardous to health workers. The CDC advises that N95 respirators be used by all in the room for the so-called aerosol-generating procedures. (A facility spokesperson said the patient was not known or suspected to have COVID at the time Marks entered the room.)
Marks went home to self-isolate. By April 17, he was dead.
The patient whose room Marks entered later tested positive for COVID-19. And an OSHA investigation into Marks’ death found there was no sign on the door to warn him that a potentially infected patient was inside, nor was there a cart outside the room where he could grab protective gear.
The facility did not have a universal masking policy in effect when Marks went in the room, and it was more than likely that he was not wearing any respiratory protection, according to a copy of the report obtained through a public records request. Twenty-one more employees contracted COVID by the time he died.
“He was a beloved gentleman and friend and he is missed very much,” Katy Kiser, Christus’ public relations director, told KHN.
OSHA did not issue a citation to the facility, instead recommending safety changes.
The agency logged nearly 8,700 complaints from health care workers in 2020. Yet Harvard researchers found that some of those desperate pleas for help, often decrying shortages of PPE, did little to forestall harm. In fact, they concluded that surges in those complaints preceded increases in deaths among working-age adults 16 days later.
One report author, Peg Seminario, blasted OSHA for failing to use its power to get employers’ attention about the danger facing health workers. She said issuing big fines in high-profile cases can have a broad impact — except OSHA has not done so.
“There’s no accountability for failing to protect workers from exposure to this deadly virus,” said Seminario, a former union health and safety official.
More ‘Lost on the Frontline’ Stories
Desperate for Safety Gear
There was little outward sign this summer that Garfield Medical Center was struggling to contain COVID-19. While Medicare has forced nursing homes to report staff infections and deaths, no such requirement applies to hospitals.
Yet as the focus of the pandemic moved from the East Coast in the spring to Southern and Western states, health care worker deaths climbed. And behind the scenes at Garfield, workers were dealing with a lack of equipment meant to keep them safe.
Complaints to state worker-safety officials filed in March and April said Garfield Medical Center workers were asked to reuse the same N95 respirator for a week. Another complaint said workers ran out of medical gowns and were directed to use less-protective gowns typically provided to patients.
Staffers were shaken by the death of Dawei Liang. And only after his death and a rash of infections did Garfield provide N95 masks to more workers and put up plastic tarps to block a COVID unit from an adjacent ward. Yet this may have been too late.
The coronavirus can easily spread to every corner of a hospital. Researchers in South Africa traced a single ER patient to 119 cases in a hospital — 80 among staff members. Those included 62 nurses from neurology, surgical and general medical units that typically would not have housed COVID patients.
By late July, Garfield cardiac and respiratory technician Thong Nguyen, 73, learned he was COVID-positive days after he collapsed at work. Nguyen loved his job and was typically not one to complain, said his youngest daughter, Dinh Kozuki. A 34-year veteran at the hospital, he was known for conducting medical tests in multiple languages. His colleagues teased him, saying he was never going to retire.
Kozuki said her father spoke up in March about the rationing of protective gear, but his concerns were not allayed.
The PPE problems at Garfield were a symptom of a broader problem. As the virus spread around the nation, chronic shortages of protective gear left many workers in community-based settings fatally exposed. Nearly 1 in 3 family members or friends of around 300 health care workers interviewed by KHN or The Guardian expressed concerns about a fallen workers’ PPE.
Health care workers’ labor unions asked for the more-protective N95 respirators when the pandemic began. But Centers for Disease Control and Prevention guidelines said the unfitted surgical masks worn by workers who feed, bathe and lift COVID patients were adequate amid supply shortages.
Mary Turner, an ICU nurse and president of the Minnesota Nurses Association, said she protested alongside nurses all summer demanding better protective gear, which she said was often kept from workers because of supply-chain shortages and the lack of political will to address them.
“It shouldn’t have to be that way,” Turner said. “We shouldn’t have to beg on the streets for protection during a pandemic.”
At Garfield, it was even hard to get tested. Critical care technician Tony Ramirez said he started feeling ill on July 12. He had an idea of how he might have been exposed: He’d cleaned up urine and feces of a patient suspected of having COVID-19 and worked alongside two staffers who also turned out to be COVID-positive. At the time, he’d been wearing a surgical mask and was worried it didn’t protect him.
Yet he was denied a free test at the hospital, and went on his own time to Dodger Stadium to get one. His positive result came back a few days later.
As Ramirez rested at home, he texted Alex Palomo, 44, a Garfield medical secretary who was also at home with COVID-19, to see how he was doing. Palomo was the kind of man who came to many family parties but would often slip away unseen. A cousin finally asked him about it: Palomo said he just hated to say goodbye.
Palomo would wear only a surgical mask when he would go into the rooms of patients with flashing call lights, chat with them and maybe bring them a refill of water, Ramirez said.
Ramirez said Palomo had no access to patient charts, so he would not have known which patients had COVID-19: “In essence, he was helping blindly.”
Palomo never answered the text. He died of COVID-19 on Aug. 14.
And Thong Nguyen had fared no better. His daughter, a hospital pharmacist in Fresno, had pressed him to go on a ventilator after seeing other patients survive with the treatment. It might mean he could retire and watch his grandkids grow up. But it made no difference.
“He definitely should not have passed [away],” Kozuki said.
Nursing Homes Devastated
During the summer, as nursing homes recovered from their spring surge, Heather Pagano got a new assignment. The Doctors Without Borders adviser on humanitarianism had been working in cholera clinics in Nigeria. In May, she arrived in southeastern Michigan to train nursing home staffers on optimal infection-control techniques.
Federal officials required worker death reports from nursing homes, which by December tallied more than 1,100 fatalities. Researchers in Minnesota found particular hazards for these health workers, concluding they were the ones most at risk of getting COVID-19.
Pagano learned that staffers were repurposing trash bin liners and going to the local Sherwin-Williams store for painting coveralls to backfill shortages of medical gowns. The least-trained clinical workers — nursing assistants — were doing the most hazardous jobs, turning and cleaning patients, and brushing their teeth.
She said nursing home leaders were shuffling reams of federal, state and local guidelines yet had little understanding of how to stop the virus from spreading.
“No one sent trainers to show people what to do, practically speaking,” she said.
As the pandemic wore on, nursing homes reported staff shortages getting worse by the week: Few wanted to put their lives on the line for $13 an hour, the wage for nursing assistants in many parts of the U.S.
The organization GetusPPE, formed by doctors to address shortages, saw almost all requests for help were coming from nursing homes, doctors’ offices and other non-hospital facilities. Only 12% of the requests could be fulfilled, its October report said.
And a pandemic-weary and science-wary public has fueled the virus’s spread. In fact, whether or not a nursing home was properly staffed played only a small role in determining its susceptibility to a lethal outbreak, University of Chicago public health professor Tamara Konetzka found. The crucial factor was whether there was widespread viral transmission in the surrounding community.
“In the end, the story has pretty much stayed the same,” Konetzka said. “Nursing homes in virus hot spots are at high risk and there’s very little they can do to keep the virus out.”
The Vaccine Arrives
From March through November, 40 complaints were filed about the Garfield Medical Center with the California Department of Public Health, nearly three times the statewide average for the time. State officials substantiated 11 complaints and said they are part of an ongoing inspection.
For Thanksgiving, AHMC Healthcare Chairman Jonathan Wu sent hospital staffers a letter thanking “frontline healthcare workers who continue to serve, selflessly exposing themselves to the virus so that others may cope, recover and survive.”
The letter made no mention of the workers who had died. “A lot of people were upset by that,” said critical care technician Melissa Ennis. “I was upset.”
By December, all workers were required to wear an N95 respirator in every corner of the hospital, she said. Ennis said she felt unnerved taking it off. She took breaks to eat and drink in her car.
Garfield said on its website that it is screening patients for the virus and will “implement infection prevention and control practices to protect our patients, visitors, and staff.”
On Dec. 9, Ennis received notice that the vaccine was on its way to Garfield. Nationwide, the vaccine brought health workers relief from months of tension. Nurses and doctors posted photos of themselves weeping and holding their small children.
At the same time, it proved too late for some. A new surge of deaths drove the toll among health workers to more than 2,900.
And before Ennis could get the shot, she learned she would have to wait at least a few more days, until she could get a COVID test.
She found out she’d been exposed to the virus by a colleague.
Shoshana Dubnow and Anna Sirianni contributed to this report.Video by Hannah NormanWeb production by Lydia Zuraw
This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.
The recent rollout of two newly authorized COVID-19 vaccines is a bright ray of hope at the pandemic’s darkest hour.
We now have a path that can lead us to happier times — even as we watch and suffer from the horrible onslaught of new infections, hospitalizations and deaths that mark the end of this regrettable year.
Health care workers and nursing home residents have already begun to get shots in the first phase of the rollout. Vaccinations should start to be available to the general public sometime in the first few months of next year.
The two vaccines — one developed by Pfizer and BioNTech, the other by Moderna — use the same novel genetic approach. Their development in under a year, shattering all records, is a marvel of science. It’s also a cause for concern for millions of Americans who fear the uncertainty of an unknown technology.
The clinical trial data for the Pfizer and Moderna vaccines show that when both shots of the dual-injection immunization are taken, three weeks to a month apart, they are about 95% effective — at least at preventing severe COVID illness.
However, “a vaccine that remains in the vial is 0% effective no matter what the data show,” says Dr. Walter Orenstein, a professor of infectious diseases at the Emory University School of Medicine in Atlanta and associate director of the Emory Vaccine Center.
Hence, the imperative of persuading millions of people, across racial, cultural, religious, political and generational lines, to get immunized when a vaccine becomes available to them. A survey published this month showed 45% of respondents are taking a wait-and-see approach to vaccination.
Because the vaccines were developed under duress as the coronavirus exacted its deadly toll, the premium was on speed — “warp speed.” So although the number of people in the trials is as large as or larger than in previous vaccine trials, some key questions won’t be answered until millions more are vaccinated.
For example, we don’t know to what extent the vaccines will keep us from transmitting or contracting the virus — though the protection from potentially fatal illness they are likely to confer is in itself something of a miracle.
We don’t know whether irreversible side effects might emerge, or who is at higher risk from them. And we don’t know whether we’ll need to get vaccinated every year, every three years, or never again.
These unknowns add to the challenges faced by the federal government, local health authorities, medical professionals and private sector entities as they seek to persuade people across the broadest possible swath of the population to get a vaccine.
Skepticism resides in many quarters, including among African Americans, many of whom have a long-standing mistrust of the medical world; the vocal “anti-vaxxers”; and people of all stripes with perfectly understandable doubts. Not to mention communities with language barriers and immigrants without documents — more than 2 million strong in California — who may fear coming forward.
Here are answers to some questions you might be asking yourself about the new vaccines:
Q: How can I be sure they’re safe?
There’s no ironclad guarantee. But the federal Food and Drug Administration, in authorizing the Moderna and Pfizer vaccines, determined that their benefits outweighed their risks.
The side effects observed in trial participants were common to other vaccines: pain at the injection site, fatigue, headache, muscle pain and chills. “Those are minor side effects, and the benefit is not dying from this disease,” says Dr. George Rutherford, a professor of epidemiology at the University of California-San Francisco.
It’s possible other unexpected adverse effects could pop up down the road. “The chances are low, but they are not zero,” says Orenstein. There’s not enough data yet to know if the vaccines pose an elevated risk to pregnant or lactating women, for example, or to immunocompromised people, such as those with HIV. And we know very little about the effects in children, who were not in the initial trials and for whom the vaccines are not authorized.
Q: Why should my family and I take it?
First of all, because you will protect yourselves from the possibility of severe illness or even death. Also, by getting vaccinated you will be doing your part to achieve a vaccination rate high enough to end the pandemic. Nobody knows exactly what percentage of the population needs to get inoculated for that to happen, but infectious disease experts put the number somewhere between 60% and 70% — perhaps even a little higher. Think of it as a civic duty to get your shots.
Q: So, when can I get mine?
It depends on your health status, age and work. In the first phase, already underway, health care workers and nursing home residents are getting vaccinated. The 40 million Moderna and Pfizer doses expected to be available by year’s end should immunize most of them.
Next in line are people 75 and older and essential workers in various public-facing jobs. They will be followed by people ages 65-74 and those under 65 with certain medical conditions that put them at high risk. Enough vaccine could be available for the rest of the population by late spring, but summer or even fall is more likely. Already, some distribution bottlenecks have developed.
Q: Once I’m vaccinated, can I finally stop wearing a mask and physical distancing?
No. Especially not early on, before a lot of people have been vaccinated. One reason for that is self-protection. The Moderna and Pfizer vaccines are 95% effective, but that means you still have a 5% chance of falling ill if you are exposed to someone who hasn’t been vaccinated — or who has been but is still transmitting the virus.
Another reason is to protect others, since you could be the one shedding virus despite the vaccination.
Q: I’ve already had COVID-19, so I don’t need the vaccine, right?
We don’t know for sure how long exposure to the virus protects you from reinfection. Protection probably lasts at least a few months, but public health experts say it’s a good idea to get vaccinated when your turn comes up — especially if it’s been many months since you tested positive.
There’s been some talk among health officials of pushing those who’ve been infected in the last 90 days or so toward the back of the line, to ensure adequate supply for those who might be at higher risk.
Q: How long before our lives get back to normal?
“If everything goes well, next Thanksgiving might be near normal, and we might be getting close to that by the summer,” says Dr. William Schaffner, a professor of infectious diseases at the Vanderbilt University School of Medicine in Nashville, Tennessee. ”But there would have to be substantial acceptance of the vaccine and data showing the virus moving in a downward direction.”
A year ago, while many Americans were finishing their holiday shopping and finalizing travel plans, doctors in Wuhan, China, were battling a mysterious outbreak of pneumonia with no known cause.
Chinese doctors began to fear they were witnessing the return of severe acute respiratory syndrome, or SARS, a coronavirus that emerged in China in late 2002 and spread to 8,000 people worldwide, killing almost 800.
Although the disease hasn’t been seen in 16 years, SARS cast a long shadow that colored how many nations — and U.S. scientists — reacted to its far more dangerous cousin, the novel coronavirus that causes COVID-19.
When Chinese officials revealed that their pneumonia outbreak was caused by another new coronavirus, Asian countries hit hard by SARS knew what they had to do, said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. Taiwan and South Korea had already learned the importance of a rapid response that included widespread testing, contact tracing and isolating infected people.
The U.S., by contrast, learned all the wrong lessons.
KHN’s in-depth examination of the year-long pandemic shows that many leading infectious disease specialists underestimated the fast-moving outbreak in its first weeks and months, assuming that the United States would again emerge largely unscathed. American hubris prevented the country from reacting as quickly and effectively as Asian nations, Adalja said.
During the first two decades of this century, “there were a lot of fire alarms with no fire, so people tended to ignore this one,” said Lawrence Gostin, director of Georgetown’s O’Neill Institute for National and Global Health Law, who acknowledges he underestimated the virus in its first few weeks.
In a Jan. 24 story, Dr. William Schaffner told KHN the real danger to Americans was the common flu, which can kill up to 61,000 Americans a year.
“Coronavirus will be a blip on the horizon in comparison,” said Schaffner, a professor of preventive medicine and health policy at Vanderbilt University Medical Center. “The risk is trivial.”
The same day, The Washington Post published a column by Dr. Howard Markel, who questioned China’s lockdown of millions of people. “It’s possible that this coronavirus may not be highly contagious, and it may not be all that deadly,” wrote Markel, director of the Center for the History of Medicine at the University of Michigan.
JAMA, one of the most prestigious medical journals in the world, published a podcast Feb. 18 titled, “The 2020 Influenza Epidemic — More Serious Than Coronavirus in the US.” A week later, JAMA published a large infographic illustrating the dangers of flu and minimizing the risks from the novel virus.
Dr. Paul Offit, who led development of a rotavirus vaccine, predicted that the coronavirus, like most respiratory bugs, would fade in the summer.
“I can’t imagine, frankly, that it would cause even one-tenth of the damage that influenza causes every year in the United States,” Offit told Christiane Amanpour in a March 2 appearance on PBS.
Caitlin Rivers, an epidemiologist and assistant professor at the Johns Hopkins Bloomberg School of Public Health, worried — and tweeted — about the novel coronavirus from the beginning. But she said public health officials try to balance those fears with the reality that most small outbreaks in other countries typically don’t become global threats.
New sitrep out from Wuhan pneumonia outbreak. 59 cases between 12/12 and 12/29. SARS ruled out, but no other etiology identified. Still no evidence of H2H. https://t.co/b8ZdEGIzyJ
“If you cry wolf too often, people will never pay attention,” said epidemiologist Mark Wilson, an emeritus professor at the University of Michigan School of Public Health.
Experts were hesitant to predict the novel coronavirus was the big pandemic they had long anticipated “for fear of seeming alarmist,” said Dr. Céline Gounder, an infectious disease specialist advising President-elect Joe Biden.
Many experts fell victim to wishful thinking or denial, said Dr. Nicole Lurie, who served as assistant secretary for preparedness and response during the Obama administration.
“It’s hard to think about the unthinkable,” Lurie said. “For people whose focus and fear was bioterrorism, they had a world view that Mother Nature could never be such a bad actor. If it wasn’t bioterrorism, then it couldn’t be so bad.”
Had more experts realized what was coming, the nation could have been far better prepared. The U.S. could have gotten a head start on manufacturing personal protective equipment, ventilators and other supplies, said Dr. Nicholas Christakis, author of “Apollo’s Arrow: The Profound and Enduring Impact of Coronavirus on the Way We Live.”
“Why did we waste two months that the Chinese essentially bought for us?” Christakis asked. “We could have gotten billions of dollars into testing. We could have had better public messaging that we were about to be invaded. … But we were not prepared.”
Dr. Fauci Doesn’t Cast Blame
Dr. Anthony Fauci, the nation’s top infectious disease official, isn’t so critical. In an interview, he said there was no way for scientists to predict how dangerous the coronavirus would become, given the limited information available in January.
“I wouldn’t criticize people who said there’s a pretty good chance that it’s going to turn out to be like SARS or MERS,” said Fauci, director of the National Institute of Allergy and Infectious Diseases, noting this was “a reasonable assumption.”
It’s so easy to go back with the retrospect-o-scope and say ‘You coulda, shoulda, woulda.’
— Dr. Anthony Fauci
Fauci noted that solutions are always clearer in hindsight, adding that public health authorities lose credibility if they respond to every new germ as if it’s a national disaster. He has repeatedly said scientists need to be humble enough to recognize how little we still don’t know about this new threat.
“It’s so easy to go back with the retrospect-o-scope and say ‘You coulda, shoulda, woulda,’” Fauci said. “You can say we should have shut things down much earlier because of silent spread in the community. But what would the average man or woman on the street have done if we said, ‘You’ve got to close down the country because of three or four cases?’”
Scientists largely have been willing to admit their errors and update their assessments when new data becomes available.
“If you’re going to be wrong, be wrong in front of millions of people,” Offit joked about his PBS interview. “Make a complete ass of yourself.”
Scientists say their response to the novel coronavirus would have been more aggressive if people had realized how easily it spreads, even before infected people develop symptoms — and that many people remain asymptomatic. “For a virus to have pandemic potential, that is one of the greatest assets it can have,” Adalja said.
Although COVID-19 has a lower death rate than SARS and MERS, its ability to spread silently throughout a community makes it more dangerous, said Dr. Kathleen Neuzil, director of the Center for Vaccine Development at the University of Maryland School of Medicine.
People infected with SARS and MERS are contagious only after they begin coughing and experiencing other symptoms; patients without symptoms don’t spread either disease.
With SARS and MERS, “when people got sick, they got sick pretty badly and went right to the hospital and weren’t walking around transmitting it,” Christakis said.
Because it’s possible to quarantine people with SARS and MERS before they begin spreading the virus, “it was easier to put a moat around them,” said Offit.
Based on their knowledge of SARS and MERS, doctors believed they could contain the novel coronavirus by telling sick people to stay home. In the first few months of the pandemic, there appeared to be no need for healthy people to wear masks. That led health officials, including U.S. Surgeon General Jerome Adams, to admonish Americans not to buy up limited supplies of face masks, which were desperately needed by hospitals.
Seriously people- STOP BUYING MASKS! They are NOT effective in preventing general public from catching #Coronavirus, but if healthcare providers can’t get them to care for sick patients, it puts them and our communities at risk! https://t.co/UxZRwxxKL9
“We are always fighting the last epidemic,” Markel said. “Our experiences with coronaviruses was that they kind of burn themselves out in warm weather and they didn’t have the capacity to spread as viciously as this one has.”
Many scientists were skeptical of early anecdotes of pre-symptomatic spread.
“It takes a lot to overturn established dogma,” Wilson said. “Jumping on an initial finding, without corroborating it, can be just as bad as missing a new finding.”
I continue to be baffled that we keep making the same mistakes. It’s almost like we’re doomed to repeat this cycle endlessly.
— Dr. Amesh Adalja
Adalja notes that the CDC’s earlier advice against wearing masks was based on research that found them to be ineffective against spreading influenza. New research, however, has shown masks reduce the transmission of the novel coronavirus, which spreads mainly through respiratory droplets but can travel in the air as tiny particles.
Adalja said the U.S. should have learned from its early stumbles. Yet in spite of abundant evidence, many communities still resist mandating masks or physical distancing.
“I continue to be baffled that we keep making the same mistakes,” Adalja said. “It’s almost like we’re doomed to repeat this cycle endlessly.”
“We had to immediately react as if this were going to hit every corner of the Earth,” said Adalja, who began blogging about the novel virus Jan. 20. It was clear “this was not a containable virus.”
Adalja led a 2018 project identifying the features that allow emerging viruses to become pandemic. In that prescient report, Adalja and his co-authors highlighted the threat of certain respiratory viruses that use RNA as their genetic material.
The more Adalja learned about the novel coronavirus, the more it seemed to embody the very type of threat he had warned about: one with “efficient human-to-human transmissibility, an appreciable case fatality rate, the absence of an effective or widely available medical countermeasure, an immunologically naïve population, virulence factors enabling immune system evasion, and respiratory mode of spread.”
Adalja and other experts dismissed some of the Trump administration’s early responses, such as quarantines and a travel ban on China, as “window dressing” that “squandered resources” and did little to contain the virus.
“There was political inertia about the public health actions that could have avoided lockdowns,” Adalja said. “We let this spill into hospitals … [and] if you give a virus a three-month head start, what do you expect?”
Lucey, adjunct professor of infectious diseases at Georgetown University Medical Center, notes that the international response was hampered by misinformation from Chinese officials. “The Chinese government said there was no person-to-person spread,” said Lucey, who traveled to China hoping to visit Wuhan. “That was a lie.”
When China revealed on Jan. 20 that 14 health workers had been infected, Lucey knew the virus would spread much farther. “To me, that was like Pandora’s box,” Lucey said. “I knew there would be more.”
Although his blog is read by thousands of infectious disease specialists, Lucey emailed a special warning to journalists and a dozen doctors and public health officials, hoping to alert influential leaders.
“I put this heartfelt commentary in my email and just got silence,” Lucey said.
Researchers had developed a vaccine against SARS, Fauci said, although the epidemic ended before researchers could widely test it in humans.
“We showed it was safe and induced an immune response,” Fauci said. “The cases of SARS disappeared, so we couldn’t test it. … We put the vaccine in cold storage. If SARS comes back, we will do a phase 3 [clinical] trial.”
“We jumped all over it,” Fauci said. “We had a meeting on Jan. 10 and five days later they started [working on] a vaccine.”
Although scientists knew the COVID outbreak might end before a vaccine was needed, “we couldn’t take the chance,” Fauci said.
“We said, ‘We have no idea what is going to happen, so why don’t we just go ahead and proceed with a vaccine anyway?’”
Although his team worried about finding the money to pay for it all, Fauci told them, “‘Don’t worry about the money. I’ll find it, you do it, if we really need it, I’m sure we’ll get it.’”
Health experts hope the U.S. will learn from its mistakes and be better prepared for the next threat.
Given how many novel viruses have emerged in the past two decades, it’s likely that “pandemics are going to become more frequent,” Gounder said, making it critical to be ready for the next one.
Of all the lessons learned during the pandemic, the most important is that “we can’t be this unprepared again,” said Dr. Tom Frieden, who directed the CDC during the Obama administration.
“To me, this should be the most teachable moment of our lifetime, in terms of the need to strengthen public health in the United States and globally,” Frieden said.
But Gounder notes that U.S. public health funding tends to follow a cycle of crisis and neglect. The U.S. increased spending on public health and emergency preparedness after the 9/11 and anthrax attacks in 2001, but that funding has declined sharply over the years.
“We tend to invest a lot in that moment of crisis,” Gounder said. “When the crisis fades, we cut the budget. That leads us to be really vulnerable.”
Imagine this: Your elderly mother, who has dementia, is in a nursing home and COVID-19 vaccines are due to arrive in a week or two.
You think she should be vaccinated, having heard the vaccine is effective in generating an immune response in older adults. Your brother disagrees. He worries that development of the vaccine was rushed and doesn’t want your mother to be among the first people to get it.
These kinds of conflicts are likely to arise as COVID vaccines are rolled out to long-term care facilities across the country.
“This is a highly politicized environment, not only with respect to vaccines but also over the existence of the virus itself,” said Michael Dark, a staff attorney with California Advocates for Nursing Home Reform. “It’s not hard to imagine disputes arising within families.”
About 3 million people — most of them elderly — live in nursing homes, assisted living centers and group homes, where more than 105,000 residents have died of COVID-19. They should be among the first Americans to receive vaccines, along with health care workers, according to recommendations from the Centers for Disease Control and Prevention and various state plans.
But long-term care residents’ participation in the fastest and most extensive vaccination effort in U.S. history is clouded by a significant complication: More than half have cognitive impairment or dementia.
This raises a number of questions. Will all older adults in long-term care understand the details of the vaccines and be able to consent to getting them? If individual consent isn’t possible, how will families and surrogate decision-makers get the information they need on a timely basis?
And what if surrogates don’t agree with the decision an elderly person has made and try to intervene?
“Imagine that the patient, who has some degree of cognitive impairment, says ‘yes’ to the vaccine but the surrogate says ‘no’ and tells the nursing home, ‘How dare you try to do this?” said Alta Charo, a professor of law and bioethics at the University of Wisconsin-Madison Law School.
Addressing these issues will occur against a backdrop of urgency. Deaths in long-term care facilities are rising dramatically, with new estimates suggesting that 19 residents die of COVID-19 every hour. With viral outbreaks increasing, already-overwhelmed staffers may not have much time to sit down with residents to answer questions or have conversations with families over the phone.
Meanwhile, CVS and Walgreens, the companies operating vaccine programs at most long-term care facilities, have aggressive timetables. Both companies have said the large-scale rollout of the Pfizer-BioNTech vaccine — the first one that the Food and Drug Administration has authorized — will begin on Dec. 21.But facilities in some states may get supplies earlier. Altogether, there are more than 15,000 nursing homes and nearly 29,000 assisted living residences in the U.S.
At a meeting of the federal Advisory Committee on Immunization Practices early this month, Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, acknowledged the agency was “very concerned” that information about vaccines be adequately explained to long-term care residents. “It’s very important for the frail elderly not only to ensure that they are understanding the vaccine that they’re getting but also that their family members do,” she said.
Each vaccine manufacturer will be required to prepare a fact sheet describing what’s known about benefits and risks associated with a vaccine, what’s not known, and making it clear that a vaccine has received “emergency use authorization” from the FDA — a conditional endorsement that falls short of full approval. A second vaccine, from Moderna, is poised to receive this kind of authorization after an FDA meeting on Thursday.
Something that will need to be made clear to residents: while vaccines have been tested on people age 65 and older, those tests did not include individuals living in long-term care, according to Dr. Sara Oliver, a CDC expert.
Some operators have crafted communication plans around the vaccines and already begun intensive outreach. Others may not be well prepared.
Juniper Communities operates 22 senior housing communities (a standalone nursing home, multiple memory care and assisted living facilities, and two continuing care retirement communities) in Colorado, New Jersey and Pennsylvania. This week, it is planning an hour-long town hall videoconferencing session for residents and families about coronavirus vaccines. Last week, it held a similar event for staffers.
Juniper has contracted with CVS, which is requiring that every resident and staff member fill out consent forms in triplicate before being inoculated. When written consent can’t be obtained directly, verbal consent, confirmed independently, may substitute. Walgreens has similar requirements.
For residents with memory impairment, two Juniper nurses will reach out by phone to whomever has decision-making authority. “One will ask questions and obtain verbal consent; the other will serve as a witness,” said Lynne Katzmann, Juniper’s founder and chief executive officer. Separately, emails, blog posts and prerecorded voice messages about the vaccines have gone out to Juniper residents and staffers, starting at the end of November.
A key message is “we’ve done this before, not at this scale, mind you, and not at this level of import, but we do flu vaccinations annually,” said Katzmann, who plans to be the first Juniper employee to get the Pfizer vaccine when it comes to New Jersey.
At Genesis Healthcare, crucial messages are “these vaccines have been studied thoroughly, tens of thousands of people have received them already, they’re very, very effective, and no steps have been skipped in the scientific process,” said Dr. Richard Feifer, executive vice president and chief medical officer. Genesis, the nation’s largest long-term care company, operates more than 380 nursing homes and assisted living residences in 26 states, with about 45,000 employees and more than 30,000 residents.
Medical directors at each Genesis facility have been scheduling video conferences with families, residents and staffers during the past few weeks to address concerns. They’ve also distributed a letter and a question-and-answer document prepared by the Society for Post-Acute and Long-Term Care Medicine, in addition to getting information out through closed-circuit TV channels and social media.
In partnership with Brown University researchers, the company will monitor daily the side effects that its long-term care residents experience after getting coronavirus vaccines. Most reactions are expected to be mild or moderate and resolve within a few days. They include fatigue, pain at the injection site, headaches, body aches, fever and, rarely, allergic responses.
Administering the vaccine will occur over three visits for all long-term care facilities. At the first, all Genesis residents and staffers will get inoculations. At the second, three to four weeks later, those same people will get a second dose, and new staffers and residents will get a first dose. At the third, those who still qualify for a second vaccine dose will get one.
What will happen if lots of people experience uncomfortable side effects and employees don’t come in for a couple of days while recovering? “It’s a very difficult problem and we’re making contingency plans to address it,” Feifer said.
And what about continuing care retirement communities — also known as “life plan communities” — where residents in skilled nursing, assisted living and independent living can reside in close proximity?
That’s the case at Bayview in Seattle, which houses 210 residents in a 10-story building. For the moment, independent living residents aren’t on the priority list but “I know there will be a contingent of residents and staff who won’t want to be vaccinated and we’ll see if we can use those vaccines for our independent living people instead,” said Joel Smith, Bayview’s health services administrator.
Logistical challenges are sure to arise, but many operators have an acute sense of mission. “It is critical that we lead the way out of this crisis,” Feifer of Genesis said. “Nursing homes need to go first and be the first ones to address vaccine hesitancy head-on and be successful at generating a high level of acceptance. There is no alternative, no Plan B right now. We have to be successful.”
A Florida taxi driver and his wife had seen enough conspiracy theories online to believe the virus was overblown, maybe even a hoax. So no masks for them. Then they got sick. She died. A college lecturer had trouble refilling her lupus drug after the president promoted it as a treatment for the new disease. A hospital nurse broke down when an ICU patient insisted his illness was nothing worse than the flu, oblivious to the silence in beds next door.
Lies infected America in 2020. The very worst were not just damaging, but deadly.
President Donald Trump fueled confusion and conspiracies from the earliest days of the coronavirus pandemic. He embraced theories that COVID-19 accounted for only a small fraction of the thousands upon thousands of deaths. He undermined public health guidance for wearing masks and cast Dr. Anthony Fauci as an unreliable flip-flopper.
But the infodemic was not the work of a single person.
Anonymous bad actors offered up junk science. Online skeptics made bogus accusations that hospitals padded their coronavirus case numbers to generate bonus payments. Influential TV and radio opinion hosts told millions of viewers that physical distancing was a joke and that states had all of the personal protective equipment they needed (when they didn’t).
It was a symphony of counter-narrative, and Trump was the conductor, if not the composer. The message: The threat to your health was overhyped to hurt the political fortunes of the president.
Every year, PolitiFact editors review the year’s most inaccurate statements to elevate one as the Lie of the Year. The “award” goes to a statement, or a collection of claims, that prove to be of substantive consequence in undermining reality.
It has become harder and harder to choose when cynical pundits and politicians don’t pay much of a price for saying things that aren’t true. For the past month, unproven claims of massive election fraud have tested democratic institutions and certainly qualify as historic and dangerously baldfaced. Fortunately, the constitutional foundations that undergird American democracy are holding.
Meanwhile, the coronavirus has killed more than300,000 in the United States, a crisis exacerbated by the reckless spread of falsehoods.
PolitiFact’s 2020 Lie of the Year: claims that deny, downplay or disinform about COVID-19.
‘I Wanted to Always Play It Down’
On Feb. 7, Trump leveled with book author Bob Woodward about the dangers of the new virus that was spreading across the world, originating in central China. He told the legendary reporter that the virus was airborne, tricky and “more deadly than even your strenuous flus.”
Trump told the public something else. On Feb. 26, the president appeared with his coronavirus task force in the crowded White House briefing room. A reporter asked if he was telling healthy Americans not to change their behavior.
“Wash your hands, stay clean. You don’t have to necessarily grab every handrail unless you have to,” he said, the room chuckling. “I mean, view this the same as the flu.”
Three weeks later, March 19, he acknowledged to Woodward: “To be honest with you, I wanted to always play it down. I still like playing it down. Because I don’t want to create a panic.”
His acolytes in politics and the media were on the same page. Rush Limbaugh told his audience of about 15 million on Feb. 24 that the coronavirus was being weaponized against Trump when it was just “the common cold, folks.” That’s wrong — even in the early weeks, it was clear the virus had a higher fatality rate than the common cold, with worse potential side effects, too.
As the virus was spreading, so was the message to downplay it.
“There are lots of sources of misinformation, and there are lots of elected officials besides Trump that have not taken the virus seriously or promoted misinformation,” said Brendan Nyhan, a government professor at Dartmouth College. “It’s not solely a Trump story — and it’s important to not take everyone else’s role out of the narrative.”
The skeptics cited Centers for Disease Control and Prevention data to claim that only 6% of COVID-19 deaths could actually be attributed to the virus. On Aug. 24, BlazeTV host Steve Deace amplified it on Facebook.
“Here’s the percentage of people who died OF or FROM Covid with no underlying comorbidity,” he said to his 120,000 followers. “According to CDC, that is just 6% of the deaths WITH Covid so far.”
That misrepresented the reality of coronavirus deaths. The CDC had always said people with underlying health problems — comorbidities — were most vulnerable if they caught COVID-19. The report was noting that 6% died even without being at obvious risk.
But for those skeptical of COVID-19, the narrative confirmed their beliefs. Facebook users copied and pasted language from influencers like Amiri King, who had 2.2 million Facebook followers before he was banned. The Gateway Pundit called it a “SHOCK REPORT.”
“I saw a statistic come out the other day, talking about only 6% of the people actually died from COVID, which is very interesting — that they died from other reasons,” Trump told Fox News host Laura Ingraham on Sept. 1.
Fauci, director of the National Institute of Allergy and Infectious Diseases, addressed the claim on “Good Morning America” the same day.
“The point that the CDC was trying to make was that a certain percentage of them had nothing else but just COVID,” he said. “That does not mean that someone who has hypertension or diabetes who dies of COVID didn’t die of COVID-19 — they did.”
False information moved between social media, Trump and TV, creating its own feedback loop.
“It’s an echo effect of sorts, where Donald Trump is certainly looking for information that resonates with his audiences and that supports his political objectives. And his audiences are looking to be amplified, so they’re incentivized to get him their information,” said Kate Starbird, an associate professor and misinformation expert at the University of Washington.
Weakening the Armor: Misleading on Masks
At the start of the pandemic, the CDC told healthy people not to wear masks, saying they were needed for health care providers on the front lines. But on April 3 the agency changed its guidelines, saying every American should wear non-medical cloth masks in public.
Trump announced the CDC’s guidance, then gutted it.
“So it’s voluntary. You don’t have to do it. They suggested for a period of time, but this is voluntary,” Trump said at a press briefing. “I don’t think I’m going to be doing it.”
Rather than an advance in best practices on coronavirus prevention, face masks turned into a dividing line between Trump’s political calculations and his decision-making as president. Americans didn’t see Trump wearing a mask until a July visit to Walter Reed National Military Medical Center.
In September, the CDC reported a correlation between people who went to bars and restaurants, where masks can’t consistently be worn, and positive COVID-19 test results. Bloggers and skeptical news outlets countered with a misleading report about masks.
On Oct. 13, the story landed on Fox News’ flagship show, “Tucker Carlson Tonight.” During the show, Carlson claimed “almost everyone — 85% — who got the coronavirus in July was wearing a mask.”
“So clearly [wearing a mask] doesn’t work the way they tell us it works,” Carlson said.
That’s wrong, and it misrepresented a small sample of people who tested positive.Public health officials and infectious disease experts have been consistent since April in saying that face masks are among the best ways to prevent the spread of COVID-19.
But two days later, Trump repeated the 85% stat during a rally and at a town hall with NBC’s Savannah Guthrie.
“I tell people, wear masks,” he said at the town hall. “But just the other day, they came out with a statement that 85% of the people that wear masks catch it.”
The Assault on Hospitals
On March 24, registered nurse Melissa Steiner worked her first shift in the new COVID-19 ICU of her southeastern Michigan hospital. After her 13-hour workday caring for two critically ill patients on ventilators, she posted a tearful video.
“Honestly, guys, it felt like I was working in a war zone,” Steiner said. “[I was] completely isolated from my team members, limited resources, limited supplies, limited responses from physicians because they’re just as overwhelmed.”
“I’m already breaking, so for f—’s sake, people, please take this seriously. This is so bad.”
Steiner’s post was one of manyemotionalpleas offered by overwhelmed hospital workers last spring urging people to take the threat seriously. The denialists mounted a counteroffensive.
On March 28, Todd Starnes, a conservative radio host and commentator, tweeted a video from outside Brooklyn Hospital Center. There were few people or cars in sight.
“This is the ‘war zone’ outside the hospital in my Brooklyn neighborhood,” Starnes said sarcastically. The video racked up more than 1.5 million views.
Starnes’ video was one of the first examples of #FilmYourHospital, a conspiratorial social media trend that pushed back on the idea that hospitals had been strained by a rapid influx of coronavirus patients.
Several internet personalities asked people to go out and shoot their own videos. The result: a series of user-generated clips taken outside hospitals, where the response to the pandemic was not easily seen. Over the course of a week, #FilmYourHospital videos were uploaded to YouTube and posted tens of thousands of times on Twitter and Facebook.
Nearly two weeks and more than 10,000 deaths later, Fox News featured a guest who opened a new misinformation assault on hospitals.
Dr. Scott Jensen, a Minnesota physician and Republican state senator, told Ingraham that, because hospitals were receiving more money for COVID-19 patients on Medicare — a result of a coronavirus stimulus bill — they were overcounting COVID-19 cases. He had no proof of fraud, but the cynical story took off.
Trump used the false report on the campaign trail to continue to minimize the death toll.
“Our doctors get more money if somebody dies from COVID,” Trump told supporters at a rally in Waterford, Michigan, on Oct. 30. “You know that, right? I mean, our doctors are very smart people. So what they do is they say, ‘I’m sorry, but, you know, everybody dies of COVID.’”
The Real Fake News: The Plandemic
The most viral disinformation of the pandemic was styled to look as if it had the blessing of people Americans trust: scientists and doctors.
In a 26-minute video called “Plandemic: The Hidden Agenda Behind COVID-19,” a former scientist at the National Cancer Institute claimed the virus was manipulated in a lab, hydroxychloroquine is effective against coronaviruses, and face masks make people sick.
Judy Mikovits’ conspiracies received more than 8 million views, partly credited to the online outrage machine — anti-vaccine activists, anti-lockdown groups and QAnon supporters — that push disinformation into the mainstream. The video was circulated in a coordinated effort to promote Mikovits’ book release.
Around the same time, a similar effort propelled another video of fact-averse doctors to millions of people in only a few hours.
On July 27, Breitbart publisheda clip of a press conference hosted by a group called America’s Frontline Doctors in front of the U.S. Supreme Court. Looking authoritative in white lab coats, these doctors discouraged mask-wearing and falsely said there was already a cure in hydroxychloroquine, a drug used to treat rheumatoid arthritis and lupus.
Trump, who had been talking up the drug since March and claimed to be taking it himself as a preventive measure in May, retweeted clips of the event before Twitter removed them as misinformation about COVID-19. He defended the “very respected doctors” in a July 28 press conference.
When Olga Lucia Torres, a lecturer at Columbia University, heard Trump touting the drug in March, she knew it didn’t bode well for her own prescription. Sure enough, the misinformation led to a run on hydroxychloroquine, creating a shortage for Americans like her who needed the drug for chronic conditions.
A lupus patient, she went to her local pharmacy to request a 90-day supply of the medication. But she was told they were granting only partial refills. It took her three weeks to get her medication through the mail.
“What about all the people who were silenced and just lost access to their staple medication because people ran to their doctors and begged to take it?” Torres said.
No Sickbed Conversion
On Sept. 26, Trump hosted a Rose Garden ceremony to announce his nominee to replace the late Ruth Bader Ginsburg on the U.S. Supreme Court. More than 150 people attended the event introducing Amy Coney Barrett. Few wore masks, and the chairs weren’t spaced out.
In the weeks afterward, more than two dozenpeople close to Trump and the White House became infected with COVID-19. Early on Oct. 2, Trump announced his positive test.
Those hoping the experience and Trump’s successful treatment at Walter Reed might inform his view of the coronavirus were disappointed. Trump snapped back into minimizing the threat during his first moments back at the White House. He yanked off his mask and recorded a video.
“Don’t let it dominate you. Don’t be afraid of it,” he said, describing experimental and mostly out-of-reach therapies he received. “You’re going to beat it.”
In Trump’s telling, his hospitalization was not the product of poor judgment about large gatherings like the Rose Garden event, but the consequence of leading with bravery. Plus, now, he claimed, he had immunity to the virus.
On the morning after he returned from Walter Reed, Trump tweeted a seasonal flu death count of 100,000 lives and added that COVID-19 was “far less lethal” for most populations. More false claims at odds with data — the U.S. average for flu deaths over the past decade is 36,000, and experts said COVID-19 is more deadly for each age group over 30.
When Trump left the hospital, the U.S. death toll from COVID-19 was more than 200,000. Today it is more than 300,000. Meanwhile, this month the president has gone ahead with a series of indoor holiday parties.
The Vaccine War
The vaccine disinformation campaign started in the spring but is still underway.
In April, blogs and social media users falsely claimed Democrats and powerful figures like Bill Gates wanted to use microchips to track which Americans had been vaccinated for the coronavirus. Now, false claims are taking aim at vaccines developed by Pfizer and BioNTech and other companies.
A blogger claimed Pfizer’s head of research said the coronavirus vaccine could cause female infertility. That’s false.
An alternative health website wrote that the vaccine could cause an array of life-threatening side effects, and that the FDA knew about it. The list included all possible — not confirmed— side effects.
Social media users speculated that the federal government would force Americans to receive the vaccine. Neither Trump nor President-elect Joe Biden has advocated for that, and the federal government doesn’t have the power to mandate vaccines, anyway.
As is often the case with disinformation, the strategy is to deliver it with a charade of certainty.
“People are anxious and scared right now,” said Dr. Seema Yasmin, director of research and education programs at the Stanford Health Communication Initiative. “They’re looking for a whole picture.”
Most polls have shown far from universal acceptance of vaccines, with only 50% to 70% of respondents willing to take the vaccine. Black and Hispanic Americans are even less likely to take it so far.
Meanwhile, the future course of the coronavirus in the U.S. depends on whether Americans take public health guidance to heart. The Institute for Health Metrics and Evaluation projected that, without mask mandates or a rapid vaccine rollout, the death toll could rise to more than 500,000 by April 2021.
“How can we come to terms with all that when people are living in separate informational realities?” Starbird said.
PolitiFact staff researcher Caryn Baird contributed to this report.
Note: Readers can find the detailed source list for this story, as well as PolitiFact’s related coverage, or vote in the Lie of the Year Readers’ Choice Poll at PolitiFact.com.
Si existe una cita con el destino, está escrita en el calendario del doctor Taison Bell.
Al mediodía del martes 15 de diciembre, Bell, especialista en cuidados intensivos del Sistema de Salud de la Universidad de Virginia será uno de los primeros en arremangarse para recibir la vacuna que lo protegerá del coronavirus.
Bell, de 37 años, se inscribió la semana pasada a través del correo electrónico del hospital para recibir la vacuna. “La historia de esta crisis es que cada semana se siente como un año. Esta es realmente la primera vez que hay una esperanza genuina de que podemos revertir esta situación”.
Por ahora, esa esperanza se limita a unos pocos elegidos. Bell atiende a algunos de los pacientes con COVID-19 más enfermos en el hospital UVA Health en Charlottesville, Virginia.
Bell es uno de los 12,000 trabajadores del hospital “que trabajan directo con estos pacientes”, que podrían ser elegibles para unas 3,000 primeras dosis de vacunas, dijo el doctor Costi Sifri, director de epidemiología del hospital.
“Estamos tratando de encontrar las categorías de mayor riesgo, aquellas que realmente pasan una cantidad significativa de tiempo cuidando a los pacientes”, dijo Sifri. “No se tiene en cuenta a todo el mundo”.
Incluso cuando la Administración de Alimentos y Medicamentos (FDA) participaba en intensas deliberaciones antes de la autorización del viernes de la vacuna contra COVID de Pfizer y BioNTech, y días antes de que se liberaran las 6.4 millones de dosis iniciales, los hospitales de todo el país ya estaban planeando cómo distribuir la primeras, y escasas, dosis.
Un comité asesor de los Centros para el Control y Prevención de Enfermedades (CDC) recomendó que la máxima prioridad sea para los hogares de adultos mayores de atención a largo plazo y para los trabajadores de atención médica de primera línea.
Pero se sabía que la primera tanda de vacunas no iba a cubrir toda la necesidad y que se iba a tener que hacer un proceso más selectivo, incluso entre los trabajadores críticos del hospital.
En general, se aconseja a los hospitales que cubran a los miembros de su fuerza laboral con mayor riesgo, pero las instituciones deben decidir exactamente quiénes serán, dijo Colin Milligan, vocero de la Asociación Estadounidense de Hospitales, en un correo electrónico.
“Está claro que los hospitales no recibirán lo suficiente en las primeras semanas para vacunar a todos los miembros de su personal, por lo que hubo que tomar decisiones”, escribió Milligan.
En Intermountain Healthcare, en Salt Lake City, Utah, las primeras inyecciones serán para los miembros del personal “con el mayor riesgo de contacto con pacientes COVID positivos o sus desechos”, dijo la doctora Kristin Dascomb, directora médica de prevención de infecciones y salud del personal. Dentro de ese grupo, los gerentes determinarán qué cuidadores son los primeros en la fila.
En la UW Medicine, en Seattle, Washington, que incluye el Harborview Medical Center, un plan temprano requería que el personal de alto riesgo fuera seleccionado al azar para recibir las primeras dosis, dijo la doctora Shireesha Dhanireddy, directora médica de la clínica de enfermedades infecciosas.
Pero el sistema hospitalario de la Universidad de Washington espera recibir dosis suficientes para vacunar a todas las personas en ese nivel de alto riesgo dentro de dos semanas, por lo que la selección aleatoria no ha sido necesaria por ahora.
“Permitimos que las mismas personas programen la cita”, dijo Dhanireddy, y alentamos al personal a vacunarse cerca del final de sus semanas laborales en caso de que tengan reacciones a la nueva vacuna.
Los resultados de los ensayos han demostrado que las inyecciones con frecuencia producen efectos secundarios que, aunque no debilitantes, podrían causar síntomas como fiebre, dolores musculares o fatiga que podrían mantener a alguien en casa por uno o dos días.
“Queremos asegurarnos de que no todo el mundo reciba la vacuna el mismo día para que, si hay algunos efectos secundarios, no acabemos quedando cortos de personal”, dijo Sifri, de UVA Health, y señaló que las directrices exigen que no más del 25% de cualquier unidad se vacune a la vez.
En UVA Health, una vez que se distribuyan las 3,000 dosis iniciales, el hospital planea confiar en lo que Sifri describió como “un código de honor muy estricto” para permitir que los miembros del personal decidan qué lugar ocupar en la fila. Se les ha pedido que consideren factores profesionales, como el tipo de trabajo que realizan, así como riesgos personales: la edad o afecciones subyacentes como la diabetes.
“Vamos a pedirles a los miembros del equipo, utilizando el código de honor, que determinen cuál es su riesgo de COVID y si necesitan tener una cita temprana para la vacuna o una fecha posterior”, explicó.
Se elaboró este plan después que el personal de atención médica rechazara rotundamente otras opciones. Por ejemplo, pocos favorecieron una propuesta para asignar dosis a través de una lotería, como el caótico sistema basado en la fecha de cumpleaños de la película “Contagion”, sobre una horrible pandemia.
Funcionarios del hospital también enfatizaron que están tratando de diseñar planes de distribución que garanticen que las vacunas se asignen de manera equitativa entre los trabajadores de salud, incluidos los grupos sociales, raciales y étnicos que han sido perjudicados de manera desproporcionada por COVID-19. Eso requiere pensar más allá de los médicos y enfermeras de primera línea.
Por ejemplo, en UVA Health, uno de los primeros grupos invitados a vacunarse será el de 17 trabajadores cuya tarea es limpiar cuartos en la unidad de patógenos especiales donde se tratan los casos graves de COVID.
“Reconocemos que todo el mundo está en riesgo de contraer COVID, todo el mundo merece una vacuna”, dijo Sifri.
En muchos casos, quedará claro quién debe ir primero. Por ejemplo, aunque Dhanireddy es doctora especialista en enfermedades infecciosas que consulta sobre casos de COVID, está feliz de esperar. “No me pondría en el primer grupo en absoluto”, dijo. “Creo que tenemos que proteger a nuestro personal que realmente está ahí con ellos la mayor parte del día, y esa no soy yo”.
Para algunos trabajadores de salud, no ser el primero en la fila para la vacunación está bien. Debido a que la vacuna inicialmente fue autorizada solo para uso de emergencia, los hospitales no requerirán que los empleados sean vacunados como parte de esta primera ronda. Entre el 70% y el 75% del personal de atención médica de UVA Health e Intermountain Health aceptaría una vacuna COVID, mostraron encuestas internas. El resto no está seguro o no está dispuesto.
“Hay algunos que aceptarán de inmediato y otros querrán observar y esperar”, dijo Dascomb.
Aún así, autoridades del hospital dicen que confían en que aquellos que quieran la vacuna no tengan que esperar mucho. Dosis suficientes para aproximadamente 21 millones del personal de atención médica deberían estar disponibles a principios de enero, según funcionarios de los CDC.
Bell, el médico de cuidados intensivos, dijo que está agradecido de estar entre los primeros en recibir la vacuna, especialmente después que sus padres, que viven en Boston, contrajeran COVID-19. Publicó sobre su próxima cita en Twitter y dijo que otros trabajadores de salud que se encuentran entre los primeros en la fila deberían hacer público el proceso.
“Serviremos como ejemplo de que esta es una vacuna segura y eficaz”, dijo. “La estamos dejando entrar en nuestros cuerpos. Deberías dejar que entre en el tuyo también”.
If there’s such a thing as a date with destiny, it’s marked on Dr. Taison Bell’s calendar.
At noon Tuesday, Bell, a critical care physician, is scheduled to be one of the first health care workers at the University of Virginia Health System to roll up his sleeve for a shot to ward off the coronavirus.
“This is a long time coming,” said Bell, 37, who signed up via hospital email last week. “The story of this crisis is that each week feels like a year. This is really the first time that there’s genuine hope that we can turn the corner on this.”
For now, that hope is limited to a chosen few. Bell provides direct care to some of the sickest COVID-19 patients at the UVA Health hospital in Charlottesville, Virginia. But he is among some 12,000 “patient-facing” workers at his hospital who could be eligible for about 3,000 early doses of vaccine, said Dr. Costi Sifri, director of hospital epidemiology.
“We’re trying to come up with the highest-risk categories, those who really spend a significant amount of time taking care of patients,” Sifri said. “It doesn’t account for everybody.”
Even as the federal Food and Drug Administration engaged in intense deliberations ahead of Friday’s authorization of the Pfizer and BioNTech COVID vaccine, and days before the initial 6.4 million doses were to be released, hospitals across the country have been grappling with how to distribute the first scarce shots.
An advisory committee of the Centers for Disease Control and Prevention has recommended that top priority go to long-term care facilities and front-line health care workers, but the early allocation was always expected to fall far short of the need and require selective screening even among critical hospital workers.
Hospitals in general are advised to target the members of their workforce at highest risk, but the institutions are left on their own to decide exactly who that will be, Colin Milligan, a spokesperson for the American Hospital Association, said in an email.
“It is clear that the hospitals will not receive enough in the first weeks to vaccinate everyone on their staff, so decisions had to be made,” Milligan wrote.
At Intermountain Healthcare in Salt Lake City, the first shots will go to staff members “with the highest risk of contact with COVID-positive patients or their waste,” said Dr. Kristin Dascomb, medical director of infection prevention and employee health. Within that group, managers will determine which caregivers are first in line.
At UW Medicine in Seattle, which includes Harborview Medical Center, one early plan called for high-risk staff to be selected randomly to receive first doses, said Dr. Shireesha Dhanireddy, medical director of the infectious disease clinic. But the University of Washington hospital system expects to receive enough doses to vaccinate everyone in that high-risk tier within two weeks, so randomization isn’t necessary — for now.
“We are allowing people to schedule themselves,” Dhanireddy said, and encouraging staffers to be vaccinated near the end of their workweeks in case they have reactions to the new vaccine.
Trial results have shown the shots frequently produce side effects that, while not debilitating, could cause symptoms such as fever, muscle aches or fatigue that might keep someone home for a day or two.
“We want to make sure that not everybody has the vaccine on the same day so that if there are some side effects, we don’t end up being short-staffed,” said Sifri, of UVA Health, noting that guidelines call for no more than 25% of any unit to be vaccinated at once.
At UVA Health, once the initial 3,000 doses are distributed, the hospital plans to rely on what Sifri described as “a very strong honor code” to allow staff members to decide where they should be in line. They’ve been asked to consider professional factors, like the type of work they do, as well as personal risks, such as age or underlying conditions like diabetes.
“We’re going to ask team members, using the honor code, to determine what their risk is for COVID and to determine whether they need to have an early vaccine sign-up time or a later vaccine sign-up time,” he said.
That plan was chosen after health care staff members soundly rejected other options. For instance, few favored a proposal to allocate dosages via a lottery, like the chaotic birthday-based system depicted in the 2011 pandemic horror film “Contagion.” “That was the biggest loser,” he said.
Hospital officials also stressed they are trying to devise distribution plans that ensure vaccines are allocated equitably among health care workers, including the social, racial and ethnic groups that have been disproportionately harmed by COVID-19 infections. That requires thinking beyond front-line doctors and nurses.
At UVA Health, for example, one of the first groups invited to get shots will be 17 workers whose job is to clean rooms in the special pathogens unit where severe COVID cases are treated.
“We acknowledge that everybody is at risk for COVID, everybody is deserving of a vaccine,” Sifri said.
In many cases, it will be clear who should go first. For instance, although Dhanireddy is an infectious disease doctor who consults on COVID cases, she is happy to wait to be vaccinated. “I wouldn’t put myself in the first group at all,” she said. “I think that we need to protect our staff that are really right there with them most of the day — and that’s not me.”
But hospitals must remain vigilant about relying on workers to prioritize their own access, Dhanireddy cautioned. “Sometimes, self-selection works more for self-advocacy,” she said. “It’s great that some individuals say they would defer to others, but sometimes that’s not actually the case.”
For some health care workers, not being first in line for vaccination is fine. Because the vaccine initially has been authorized only for emergency use, hospitals won’t require employees to be inoculated as part of this first round. Between 70% and 75% of health care staff at UVA Health and Intermountain Health would accept a COVID vaccine, internal surveys showed. The rest are unsure — or unwilling.
“There are some that will be immediate acceptors and some who will want to watch and wait,” Dascomb said.
Still, hospital officials say they’re confident that those who want the vaccine won’t have to wait long. Enough doses for roughly 21 million health care personnel should be available by early January, according to CDC officials.
Bell, the critical care doctor, said he’s grateful to be among the first to receive the vaccine, especially after his parents, who live in Boston, both contracted COVID-19. He has posted about his upcoming appointment on Twitter and said he and other health care workers who are among the first in line should be public about the process.
“We’ll serve as an example that this is a safe and effective vaccine,” he said. “We’re letting it go into our bodies. You should let it go into yours, too.”
Vivek Kaliraman, que vive en Los Angeles, ha celebrado todas las navidades desde 2002 con su mejor amigo, que vive en Houston. Pero, este año, por el riesgo de COVID, en lugar de ir en avión, manejó y piensa quedarse varias semanas.
El viaje, que le llevaría 24 horas, era demasiado largo para hacerlo en un día, así que Kaliraman llamó a siete hoteles en Las Cruces, Nuevo México —que está a medio camino— para preguntar cuántas habitaciones ofrecían y cuáles eran sus protocolos de limpieza y entrega de alimentos.
“Llamaba por la noche y hablaba con una persona de la recepción y luego volvía a llamar durante el día”, dijo Kaliraman, de 51 años, que es empresario en el sector de la salud digital. “Quería estar seguro de que las dos personas me dieran la misma respuesta”.
Cuando llegó al hotel elegido, pidió una habitación que hubiera estado desocupada la noche anterior. Y aunque esa noche hacía frío, dejó la ventana abierta.
Precauciones por estadísticas aterradoras
Muchos estadounidenses, como Kaliraman, que finalmente llegó a Houston, todavía piensan viajar en diciembre, a pesar de que las cifras de coronavirus en el país empeoran día a día.
La primera semana de diciembre, los Centros para el Control y Prevención de Enfermedades (CDC) informaron que la tasa de hospitalización semanal por COVID estaba en su punto más alto desde el comienzo de la pandemia.
Más de 283,000 estadounidenses han muerto a causa de COVID-19. Los funcionarios de salud pública se preparan para un aumento de casos como resultado de los millones de personas que, desoyendo el consejo de los CDC, viajaron para celebrar el Día de Acción de Gracias, incluyendo los 9 millones que pasaron por los aeropuertos del 20 al 29 de noviembre.
Los hospitales están colmados. Por eso, de nuevo, expertos en salud recomiendan a los estadounidenses que se queden en casa durante las fiestas.
Para muchos, sin embargo, los viajes se reducen a una cuestión de riesgo-beneficio.
Según David Ropeik, autor del libro “How Risky Is It, Really?” y experto en psicología de la percepción de riesgos, es importante recordar que lo que está en juego en este tipo de situaciones no puede ser cuantificado con exactitud.
Nuestro cerebro percibe el riesgo al observar primero la amenaza —en este caso, contraer o transmitir COVID-19— y luego el contexto de nuestra propia vida, que a menudo involucra emociones, explicó.
Si conoces personalmente a alguien que murió por COVID-19, eso es un contexto emocional agregado. Si quieres asistir a una boda, es escenario.
“Piensa en ello como una balanza. A un lado están todos los datos sobre COVID-19, como el número de muertes”, dijo Ropeik. “Y del otro lado están todos los factores emocionales. Las vacaciones son un gran peso en el lado emocional”.
Las personas que entrevistamos para esta historia dijeron que entienden el riesgo que implica. Y sus razones para viajar difieren. Kaliraman comparó su viaje para ver a su amigo con un ritual importante: no se ha perdido esta visita en 19 años.
Lo que está claro es que muchos no se toman la decisión de viajar a la ligera.
Para Annette Olson, de 56 años, el riesgo de volar desde Washington, D.C., a Tyler, Texas, valía la pena porque necesitaba ayudar a cuidar de sus padres, ya muy mayores, durante las vacaciones.
“Desde mi punto de vista, yo represento un riesgo menor para ellos que el que supondría tener a una enfermera viniendo a la casa, que entra y sale, y va a otras casas”, comentó Olson. “En cuanto llego yo, estoy en cuarentena”.
Ahora que está con sus padres, lleva una máscara facial en las zonas comunes de la casa hasta que reciba los resultados de la prueba de COVID.
Otros piensan ponerse en cuarentena semanas antes de ver a sus familiares; aunque, como en el caso de Chelsea Toledo, la familia que va a visitar esté a sólo una hora en auto.
Toledo, de 35 años, vive en Clarkston, Georgia, y trabaja desde su casa. Sacó a su hija, de 6 años, de la escuela en persona después del Día de Acción de Gracias, con la esperanza de ver a su mamá y a su padrastro en Navidad.
Madre e hija harán cuarentena durante varias semanas y pedirá que les envíen las compras del mercado para no entrar en contacto con nadie antes del viaje. Toledo no sabe si seguirá con este plan. Todo puede cambiar basado en base a los casos de COVID en su área.
“Estamos tomando las cosas semana a semana, o realmente día a día”, contó Toledo. “No hay un plan para ver a mi madre; está la esperanza de verla”.
Para los jóvenes adultos que viven solos, ver a los padres en las fiestas es una recarga de energía en este año difícil. Rebecca, de 27 años, vive en Washington, D.C., y condujo con una amiga con la que vive, a Nueva York para ver a sus padres y a su abuelo en Hanukkah. (Rebecca le pidió a KHN que no publicara su apellido porque temía que la publicidad pudiera afectar negativamente su trabajo, que es en la salud pública).
“Estoy bien, pero creo que tener una ilusión ayuda. No quería cancelar mi viaje”, dijo Rebecca. “Soy la única hija y nieta que no tiene hijos. Puedo controlar, más que nadie, lo que hago y con quién entro en contacto”.
Ella, y las dos amigas con las que vive, estuvieron en cuarentena durante dos semanas antes del viaje y se hicieron la prueba de COVID-19 dos veces durante ese tiempo. Ahora que Rebecca está en Nueva York, se ha puesto en auto cuarentena durante 10 días y se hará la prueba de nuevo antes de ver a su familia.
“Creo que, con lo que he hecho, voy segura”, comentó Rebecca. “Aunque sé que lo más seguro es no verlos, así que me siento un poco nerviosa”.
Porque el mejor plan siempre puede fallar. Las pruebas pueden dar falsos negativos y los familiares pueden pasar por alto la posible exposición o no creer en la gravedad de la situación.
Para entender mejor las consecuencias potenciales del riesgo que se está corriendo, Ropeik aconseja tener pensamientos “personales y viscerales” sobre lo peor que podría pasar.
“Imagina que la abuela se enferma y muere” o “que la abuela está en la cama del hospital y no puedes visitarla”, dijo Ropeik. Eso equilibrará la atracción emocional positiva de las fiestas y te ayudará a tomar una decisión más fundamentada.
¿Reducción de daños?
Todos los entrevistados para esta historia reconocieron que muchas de las precauciones que están tomando son posibles sólo porque disfrutan de ciertos privilegios, incluyendo la posibilidad de trabajar desde casa, poder aislarse o hacer que les envíen los comestibles; opciones que pueden no estar al alcance de todos, incluyendo los trabajadores esenciales y aquellos con bajos ingresos.
Aun así, los estadounidenses viajarán durante las vacaciones de diciembre.
En primer lugar, Gonsenhauser aconseja observar los números de casos de COVID en tu área, considerar si viajas de una comunidad de alto riesgo a una de bajo riesgo y hablar con tus familiares sobre los riesgos. Además, comprueba si el estado al que viajas tiene requisitos de cuarentena o de pruebas que debes hacerte al llegar.
Y ponte en cuarentena antes del viaje, las recomendaciones van de siete a 14 días.
Otra cosa que hay que recordar, dijo Gonsenhauser, es que una prueba de COVID negativa antes de viajar no es una garantía, y sólo funciona si se hace en combinación con el período de cuarentena.
Por último, una vez que hayas llegado a tu destino, prepárate para lo que podría ser la parte más difícil: continuar el distanciamiento físico, usar máscara y lavarte las manos. “Es fácil bajar la guardia durante las vacaciones, pero hay que mantenerse alerta”, concluyó Gonsenhauser.
Vivek Kaliraman, who lives in Los Angeles, has celebrated every Christmas since 2002 with his best friend, who lives in Houston. But, this year, instead of boarding an airplane, which felt too risky during the COVID pandemic, he took a car and plans to stay with his friend for several weeks.
The trip — a 24-hour drive — was too much for one day, though, so Kaliraman called seven hotels in Las Cruces, New Mexico — which is about halfway — to ask how many rooms they were filling and what their cleaning and food-delivery protocols were.
“I would call at nighttime and talk to one front desk person and then call again at daytime,” said Kaliraman, 51, a digital health entrepreneur. “I would make sure the two different front desk people I talked to gave the same answer.”
Once he arrived at the hotel he’d chosen, he asked for a room that had been unoccupied the night before. And even though it got cold that night, he left the window open.
Scary Statistics Trigger Strict Precautions
Many Americans, like Kaliraman, who did ultimately make it to Houston, are still planning to travel for the December holidays, despite the nation’s worsening coronavirus numbers.
Last week, the Centers for Disease Control and Prevention reported that the weekly COVID hospitalization rate was at its highest point since the beginning of the pandemic. More than 283,000 Americans have died of COVID-19. Public health officials are bracing for an additional surge in cases resulting from the millions who, despite CDC advice, traveled home for Thanksgiving, including the 9 million who passed through airports Nov. 20-29. Hospital wards are quickly reaching capacity. In light of all this, health experts are again urging Americans to stay home for the holidays.
For many, though, travel comes down to a risk-benefit analysis.
According to David Ropeik, author of the book “How Risky Is It, Really?” and an expert in risk perception psychology, it’s important to remember that what’s at stake in this type of situation cannot be exactly quantified.
Our brains perceive risk by looking at the facts of the threat — in this case, contracting or transmitting COVID-19 — and then at the context of our own lives, which often involves emotions, he said. If you personally know someone who died of COVID-19, that’s an added emotional context. If you want to attend a wedding of loved family members, that’s another kind of context.
“Think about it like a seesaw. On one side are all the facts about COVID-19, like the number of deaths,” said Ropeik. “And then on the other side are all the emotional factors. Holidays are a huge weight on the emotional side of that seesaw.”
The people we interviewed for this story said they understand the risk involved. And their reasons for going home differed. Kaliraman likened his journey to see his friend as an important ritual — he hasn’t missed this visit in 19 years.
What’s clear is that many aren’t making the decision to travel lightly.
For Annette Olson, 56, the risk of flying from Washington, D.C., to Tyler, Texas, felt worth it because she needed to help take care of her elderly parents over the holidays.
“In my calculations, I would be less of a risk to them than for them to get a rotating nurse that comes to the house, who has probably worked somewhere else as well and is repeatedly coming and going,” said Olson. “Once I’m here, I’m quarantined.”
Now that she’s with her parents, she’s wearing a mask in common areas of the house until she gets her COVID test results back.
Others plan on quarantining for several weeks before seeing family members — even if, as in Chelsea Toledo’s situation, the family she hopes to see is only an hour’s drive away.
Toledo, 35, lives in Clarkston, Georgia, and works from home. She pulled her 6-year-old daughter out of her in-person learning program after Thanksgiving, in hopes of seeing her mom and stepdad over Christmas. They plan to quarantine for several weeks and get groceries delivered so they won’t be exposed to others before the trip. But whether Toledo goes through with it is still up in the air, and may change based on COVID case rates in their area.
“We’re taking things week by week, or really day by day,” said Toledo. “There is not a plan to see my mom; there is a hope to see my mom.”
And for young adults without families of their own, seeing parents at the holidays feels like a needed mood booster after a difficult year. Rebecca, a 27-year-old who lives in Washington, D.C., drove up with a roommate to New York City to see her parents and grandfather for Hanukkah. (Rebecca asked KHN not to publish her last name because she feared that publicity could negatively affect her job, which is in public health.)
“I’m doing fine, but I think having something to look forward to is really useful. I didn’t want to cancel my trip completely,” said Rebecca. “I’m the only child and grandchild who doesn’t have children. I can control my actions and exposures more than anyone else can.”
She and her two roommates quarantined for two weeks before the drive and also got tested for COVID-19 twice during that time. Now that Rebecca is in New York, she’s also quarantining alone for 10 days and getting tested again before she sees her family.
“I think, based on what I’ve done, it does feel safe,” said Rebecca. “I know the safest thing to do is not to see them, so I do feel a little bit nervous about that.”
But the best-laid plan can still go awry. Tests can return false-negative results and relatives may overlook possible exposure or not buy into the seriousness of the situation. To better understand the potential consequences of the risk you’re taking, Ropeik advises coming up with “personal, visceral” thoughts of the worst thing that could happen.
“Envision Grandma getting sick and dying” or “Grandma in bed and in the hospital and not being able to visit her,” said Ropeik. That will balance the positive emotional pull of the holidays and help you to make a more grounded decision.
All of those interviewed for this story acknowledged that many of the precautions they’re taking are possible only because they enjoy certain privileges, including the ability to work from home, isolate or get groceries delivered — options that may not be available to many, including essential workers and those with low incomes.
Still, Americans are bound to travel over the December holidays. And much like teaching safe-sex practices in schools rather than an abstinence-only approach, it’s important to give out risk mitigation strategies so that “if you’re going to do it, you think about how to do it safely,” said Dr. Iahn Gonsenhauser, chief quality and patient safety officer at the Ohio State University Wexner Medical Center.
First, Gonsenhauser advises that you look at the COVID case numbers in your area, consider whether you are traveling from a higher-risk community to a lower-risk community, and talk to family members about the risks. Also, check whether the state you’re traveling to has quarantine or testing requirements you need to adhere to when you arrive.
Also, make sure you quarantine before your trip — recommendations range from seven to 14 days.
Another thing to remember, Gonsenhauser said, is that a negative COVID test before traveling is not a free pass, and it works only if done in combination with the quarantine period.
Finally, once you’ve arrived at your destination, prepare for what might be the most difficult part: to continue physical distancing, wearing masks and washing your hands. “It’s easy to let our guard down during the holidays, but you need to stay vigilant,” said Gonsenhauser.
Americans have made no secret of their skepticism of COVID-19 vaccines this year, with fears of political interference and a “warp speed” timeline blunting confidence in the shots. As recently as September, nearly half of U.S. adults said they didn’t intend to be inoculated.
But with two promising vaccines primed for release, likely within weeks, experts in ethics and immunization behavior say they expect attitudes to shift quickly from widespread hesitancy to urgent, even heated demand.
“People talk about the anti-vaccine people being able to kind of squelch uptake. I don’t see that happening,” Dr. Paul Offit, a vaccinologist with Children’s Hospital of Philadelphia, told viewers of a recent JAMA Network webinar. “This, to me, is more like the Beanie Baby phenomenon. The attractiveness of a limited edition.”
Reports that vaccines produced by drugmakers Pfizer and BioNTech and Moderna appear to be safe and effective, along with the deliberate emphasis on science-based guidance from the incoming Biden administration, are likely to reverse uncertainty in a big way, said Arthur Caplan, director of the division of medical ethics at New York University School of Medicine.
“I think that’s going to flip the trust issue,” he said.
The shift is already apparent. A new poll by the Pew Research Center found that by the end of November 60% of Americans said they would get a vaccine for the coronavirus. This month, even as a federal advisory group met to hash out guidelines for vaccine distribution, a long list of advocacy groups — from those representing home-based health workers and community health centers to patients with kidney disease — were lobbying state and federal officials in hopes their constituents would be prioritized for the first scarce doses.
“As we get closer to the vaccine being a reality, there’s a lot of jockeying, to be sure,” said Katie Smith Sloan, chief executive of LeadingAge, a nonprofit organization pushing for staff and patients at long-term care centers to be included in the highest-priority category.
Certainly, some consumers remain wary, said Rupali Limaye, a social and behavioral health scientist at the Johns Hopkins Bloomberg School of Public Health. Fears that drugmakers and regulators might cut corners to speed a vaccine linger, even as details of the trials become public and the review process is made more transparent. Some health care workers, who are at the front of the line for the shots, are not eager to go first.
“There will be people who will say, ‘I will wait a little bit more for safety data,” Limaye said.
But those doubts likely will recede once the vaccines are approved for use and begin to circulate broadly, said Offit, who sits on the FDA advisory panel set to review the requests for emergency authorization Pfizer and Moderna have submitted.
He predicted demand for the COVID vaccines could rival the clamor that occurred in 2004, when production problems caused a severe shortage of flu shots just as influenza season began. That led to long lines, rationed doses and ethical debates over distribution.
“That was a highly desired vaccine,” Offit said. “I think in many ways that might happen here.”
Initially, vaccine supplies will be tight, with federal officials planning to ship 6.4 million doses within 24 hours of FDA authorization and up to 40 million doses by the end of the year. The CDC panel recommended that the first shots go to the 21 million health care workers in the U.S. and 3 million nursing home staff and residents, before being rolled out to other groups based on a hierarchy of risk factors.
Even before any vaccine is available, some people are trying to boost their chances of access, said Dr. Allison Kempe, a professor of pediatrics at the University of Colorado School of Medicine and expert in vaccine dissemination. “People have called me and said, ‘How can I get the vaccine?’” she said. “I think that not everyone will be happy to wait, that’s for sure. I don’t think there will be rioting in the streets, but there may be pressure brought to bear.”
That likely will include emotional debates over how, when and to whom next doses should be distributed, said Caplan. Under the CDC recommendations, vulnerable groups next in line include 87 million workers whose jobs are deemed “essential” — a broad and ill-defined category — as well as 53 million adults age 65 and older.
“We’re going to have some fights about high-risk groups,” said Caplan of NYU.
The conversations will be complicated. Should prisoners, who have little control over their COVID exposure, get vaccine priority? How about professional sports teams, whose performance could bolster society’s overall morale? And what about residents of facilities providing care for people with intellectual and developmental disabilities, who are three times more likely to die from COVID-19 than the general population?
Control over vaccination allocation rests with the states, so that’s where the biggest conflicts will occur, Caplan said. “It’s a short fight, I hope, in the sense in which it gets done in a few months, but I think it will be pretty vocal.”
Once vaccine supplies become more plentiful, perhaps by May or June, another consideration is sure to boost demand: requirements for proof of COVID vaccination for work and travel.
“It’s inevitable that you’re going to see immunity passports or that you’re required to show a certificate on the train, airplane, bus or subway,” Caplan predicted. “Probably also to enter certain hospitals, probably to enter certain restaurants and government facilities.”
But with a grueling winter surge ahead, and new predictions that COVID-19 will fell as many as 450,000 Americans by February, the tragic reality of the disease will no doubt fuel ample demand for vaccination.
“People now know someone who has gotten COVID, who has been hospitalized or has unfortunately died,” Limaye said.
“We’re all seeing this now,” said Kempe. “Even deniers are beginning to see what this illness can do.”
A number of national home-based care advocacy organizations have come together to address the CDC’s Advisory Committee on Immunization Practices (ACIP). In a new letter penned to ACIP Chairman Dr. José Romero, the group called for the inclusion of in-home caregivers when it comes to priority access to the COVID-19 vaccine.
The letter was born out of a collaboration between seven organizations, including the Home Care Association of America (HCAOA), the National Association for Home Care & Hospice (NAHC), the Partnership for Medicaid Home-Based Care (PMHC) and the Partnership for Quality Home Healthcare (PQHH).
“I’m really thrilled that all of the home care associations got together and are speaking in one voice on such an important issue as vaccines,” Vicki Hoak, executive director of HCAOA, told Home Health Care News.
Last week, ACIP specified which groups should be granted priority access for Phase 1 of vaccine distribution.
ACIP determined that health care workers and residents of nursing homes should be on the list. The CDC committee also said that essential workers, older adults and individuals with underlying medical conditions should also be granted priority access to a vaccine.
During a Tuesday meeting, ACIP voted 13 to 1 in favor of those recommendations.
Vaccine distribution has garnered national attention since last month’s news that COVID-19 vaccine manufacturers Pfizer and Moderna filed for emergency use authorization with the Food and Drug Administration (FDA). Oxford and AstraZeneca are also close to rolling out a vaccine.
In their letter, the national home-based care advocacy organizations commended ACIP’s recommendations but urged the committee to be specific in its definition of health care workers in order to ensure that all caregivers are included. That includes home health aides, hospice aides, personal care aides, home care workers, direct support professionals and others.
“Our concern is that under the most recent CDC COVID-19 Vaccination Program Interim Playbook for COVID-19 Vaccination Program Jurisdiction Operations, home care workers, specifically personal care aides and home health aides, are not explicitly mentioned as Phase 1 or Phase 1A critical populations for vaccinations,” PMHC Chairman David Totaro told HHCN in an email.
The distinction is important because caregivers working on the non-medical side of home-based care are sometimes overlooked when it comes to federal policy, according to Hoak.
“Sometimes when you think of COVID, you think ‘medical,’ and a personal care aide helping people with activities of daily living doesn’t always come to mind,” she said. “But they are just as critical, especially during this pandemic.”
In the letter, the group also stated that the home care population should be afforded high-priority status for access to the vaccine.
The letter also stressed the importance of the adoption of these recommendations at the state and local levels. ACIP recommendations will serve as a guideline, but ultimately the decisions happen at a state level.
In Massachusetts, for example, physicians and community leaders on the Massachusetts COVID-19 Vaccine Advisory Group have expressed that front-line workers such as caregivers should be early recipients of the vaccine.
“What we’re doing next is encouraging all of our members to send letters to their various state officials who are developing these plans,” Hoak said. “Now that we have tried to encourage the federal agency to adopt our recommendations — making sure that they’re all-inclusive — the next step is to advocate at the state levels to make sure that same message is carried forward.”
In addition to the previously mentioned organizations, the American Network of Community Options and Resources; the Council of State Home Care & Hospice Associations; and the National Hospice and Palliative Care Organization also signed the letter.
Combined, the seven organizations represent in-home care providers caring for over 12 million individuals annually. Collectively, those home-based care providers have served “tens of thousands of patients with active COVID-19 infections,” according to the letter.
Over 60% of home care and hospice providers are currently reporting COVID-19-infected patients on service, with many of those patients often living in facility-based settings.
“We want to emphasize that the individuals we serve often have complex service needs and are
at high risk for COVID-19,” The letter reads. “While we recognize the need for vaccinations for those that live in long-term care facilities, it is important to remember that our workforce, on a daily basis, frequently goes to multiple homes. They also provide care in other health care settings, including nursing homes, assisted living facilities and in-patient hospice facilities. The greater protection that both the workforce and individuals receive, the less likely there will be a community spread of the virus.”
U.S. nursing homes are experiencing the worst outbreak of weekly new COVID-19 cases since last spring due to community spread among the general population, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) announced on Tuesday.
Nursing home cases have officially surpassed the previous peaks since the Centers for Medicare & Medicaid Services (CMS) started tracking cases in nursing homes.
“Our worst fears have come true, as COVID runs rampant among the general population and long-term care facilities are powerless to fully prevent it from entering due to its asymptomatic and pre-symptomatic spread,” Mark Parkinson, president and CEO of AHCA/NCAL, said in a statement.
Dr. Jacqueline Chu considered the man with a negative coronavirus test on the other end of the phone, and knew, her heart dropping, that the test result was not enough to clear him for work.
The man was a grocery store clerk — an essential worker — and the sole earner for his family. A 14-day isolation period would put him at risk of getting fired or not having enough money to make rent that month. But he had just developed classic COVID-19 symptoms, and many others around him in Chelsea, Massachusetts, had confirmed cases. Even with the negative test, his chances of having the disease were too high to dismiss.
For many Americans, including clinicians like Chu, who specializes in primary care and infectious disease at Massachusetts General Hospital, the pandemic has forced difficult conversations about the limits of medical tests. It has also revealed the catastrophic harms of failing to recognize those limits.
“People think a positive test equals disease and a negative test equals not disease,” said Dr. Deborah Korenstein, who heads the general medicine division at Memorial Sloan Kettering Cancer Center in New York City. “We’ve seen the damage of that in so many ways with COVID.”
National COVID test shortages have emphasized testing’s critical role in containing and mitigating the pandemic, but these inconvenient truths remain: A test result is rarely a definitive answer, but instead a single clue at one point in time, to be appraised alongside other clues like symptoms and exposure to those with confirmed cases. The result itself may be falsely positive or negative, or may show an abnormality that doesn’t matter. And even an accurate, meaningful test result is useless (or worse) unless it’s acted on appropriately.
These lessons are not unique to COVID-19.
Last year, David Albanese logged in to the online patient portal for his primary care doctor’s office and discovered that his routine screening test for the hepatitis C virus showed a positive result.
“I never considered myself somebody who’s in a high-risk category,” said the 34-year-old Boston-area college administrator and adjunct history professor. “But I just know that for a couple of days, I was really, really anxious about this test. I didn’t know if I should be behaving differently based on it.”
Within days, a confirmatory test showed Albanese did not actually have the potentially severe yet curable liver infection. Still, the memory of that false positive result gave him a new perspective on testing writ large. He had been skeptical of recommendations shifting breast cancer screening to older ages to reduce the psychological toll of false positives, but he said they made more sense after his own testing drama.
“‘Isn’t it better to do the screening regardless?’” he said he used to think. “Now I realize it is a little more complicated.”
These false positives are especially common for screening tests like hepatitis C antibody tests and mammograms that look for medical problems in healthy people without symptoms. They are designed to cast a wide net that catches more people with the disease, known as the test’s sensitivity, but also risks catching some without it, which lowers what is known as the test’s specificity.
Though some degree of uncertainty is inherent in all medical decisions, clinicians often fail to share this with patients because it’s complicated to explain and unsettling and leaves doctors vulnerable to seeming uninformed, said Korenstein. What’s more, doctors are trained to seek definitive answers and can themselves struggle to think in probabilities.
“High-tech diagnostic testing has led to this mirage of certainty,” said Korenstein. “Back in the day before there were MRIs and what not, I think, doctors were more cognizant of how often they were uncertain.”
Enter COVID. Coupled with genuine uncertainty about an emerging disease and a political environment that has sown misinformation and rendered science partisan, the nuances of testing are too often lost at a time when they are particularly crucial to convey.
Dr. Jasmine Marcelin, who specializes in infectious disease at the University of Nebraska Medical Center, was concerned to see Nebraskans tested at statewide facilities get “inconsistent results without a lot of guidance or explanation about what these results might mean.” When she offers COVID testing, she said, she approaches it as she does any other medical decision, starting with a simple question: “What do you want to learn from this test?”
To answer this, it helps to know something about how coronavirus tests work and how well they do their jobs.
Many of the available tests are meant to tell you if you’re infected right now. For example, polymerase chain reaction tests like the one Chu’s patient received detect small traces of genetic material from the virus. But by some estimates, those tests have a false negative rate of up to 30%, meaning 3 out of 10 people who truly have the infection will test negative. This rate also varies based on who collects the sample, from which part of the body and when in the course of a possible infection.
Antigen tests look for viral proteins and are faster to analyze than the PCR, but also less accurate.
To know if you’ve already had COVID-19, the closest you can get is the COVID antibody test. But the too-common interpretation is black and white: I had COVID, or I didn’t. Here, again, the reality is more nuanced. The test checks your blood for antibodies — your immune system’s soldiers in the fight against the coronavirus. A negative antibody test could mean you were never infected with SARS-CoV-2, or it could mean that you’re currently infected but haven’t yet built up that army, or that these defenses have already faded away.
A positive test, on the other hand, may have mistakenly detected antibodies to another, similar-looking virus. And even if the test correctly shows you had COVID-19, it’s not yet clear if this means you’re protected from reinfection.
Yet, these shades of gray are difficult to internalize. Roy Avellaneda, the 49-year-old president of the Chelsea City Council, got the antibody test out of curiosity and could not help but see his positive result as what he called an immunity pass. “I can act a little bit cavalier with it now,” he said. “Yes, I’ll continue to wear a mask and so forth, but the fear is gone.”
Korenstein said that’s a common though worrisome reaction. “It’s really hard to expect the public to have a more nuanced understanding when even doctors don’t,” she said.
Some of the uncertainty around COVID testing has abated as researchers learn more about the new disease. Early in the pandemic, health care providers retested patients with confirmed cases, looking for a negative PCR test to prove they were no longer infectious. But soon, epidemiologists discovered that a COVID patient rarely infected others 10 or more days after first developing symptoms (or 20, in severe cases), even if the PCR test was picking up traces of the — presumably dead — virus weeks or even months after initial infection. So the Centers for Disease Control and Prevention and health systems adjusted their policies to clear patients on the basis of time rather than a negative test.
But while the desire for certainty in coronavirus testing is magnified by the rampant uncertainty in other facets of pandemic life, this is simply not something most medical tests can provide.
Don’t expect any turkey recipes from the CDC, but the do advise a fair amount of caution during this Thanksgiving holiday.
More than 1 million COVID-19 cases were reported in the United States over the last 7 days. As cases continue to increase rapidly across the United States, the safest way to celebrate Thanksgiving is to celebrate at home with the people you live with. Gatherings with family and friends who do not live with you can increase the chances of getting or spreading COVID-19 or the flu.
If you do need to travel, be sure to always wear a mask in public settings, follow social distancing guidelines (remain 6 feet apart from anyone you don’t live with), and wash your hands often (or use hand sanitizer).
See the CDC’s full Celebrating Thanksgiving recommendations here.
Pfizer, Moderna and the University of Oxford are among the organizations to tout highly effective COVID-19 vaccines this month. With “the cavalry coming,” the focus is now shifting to how, when and where vaccines should be distributed.
In September, the American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) urged state leaders to prioritize nursing homes and assisted living communities for vaccine distribution, pointing to the tragic deaths among both residents and staff. In-home care advocates and other aging services stakeholders have made similar overtures.
Early policies out of Texas suggest those outreach efforts are paying off.
Workers in long-term care settings serving high-risk, vulnerable populations should be part of the first group to receive COVID-19 vaccines, according to new recommendations from Texas’ COVID-19 Expert Vaccine Allocation Panel. That includes home health workers.
“These guiding principles established by the Expert Vaccine Allocation Panel will ensure that the State of Texas swiftly distributes the COVID-19 vaccine to Texans who voluntarily choose to be immunized,” Governor Greg Abbott, a Republican, said in a statement.
In addition to long-term care workers, hospital staff members and emergency medical responders directly caring for COVID-19 patients will likewise receive early access to a vaccine.
Specifically, home health workers are included in Texas’ “Tier 1” prioritization category, along with hospice staff. “Tier 2” includes outpatient settings where health care providers are treating patients exhibiting COVID-19 symptoms.
Nearly 3,700 health care providers and institutions in Texas have signed up to receive vaccine shipments, The Dallas Morning News reported, attributing the information to a spokesman from the Department of State Health Services.
“This foundation for the allocation process will help us mitigate the spread of COVID-19 in our communities, protect the most vulnerable Texans, and safeguard crucial state resources,” Abbott’s statement continued.
While Texas is one of the only states so far to directly call out home health workers, others have broadly identified “health care workers” as early vaccine recipients.
In California’s framework unveiled Monday, for example, state officials said the goal is to first vaccinate the state’s 2.4 million health care workers, including first responders and those who work in congregate care settings.
Full Phase 1 distribution recommendation will be ready by Dec. 1, according to Democratic Governor Gavin Newsom, who recently had to quarantine with his family after his children were exposed to the coronavirus.
“The first tranche of vaccinations will be extraordinarily limited,” Newsom clarified.
Considering the developments in Texas, it’s likely that even more states will focus on in-home care workers in days to come. Doing so certainly makes sense from a numbers standpoint, as home health and hospice agencies employ millions of workers who deliver care to even more high-risk individuals each year.
In 2018, the country’s network of roughly 11,500 home health agencies cared to 3.4 million Medicare beneficiaries, according to the Medicare Payment Advisory Commission (MedPAC). In doing so, they delivered roughly 6.3 million visits.
Most of those beneficiaries suffered from multiple chronic conditions and had trouble eating, bathing or dressing.
In 2019, home health agencies employed an estimated 1.5 million workers, according to the Alliance for Home Health Quality and Innovation’s 2020 Chartbook, produced in conjunction with Avalere Health.
While Texas is clearly prioritizing home health and hospice workers, it is unclear whether “health care workers” also includes front-line professionals in the non-medical home care field.
Even if states prioritize home health and home care agencies for a COVID-19 vaccine, it’s not a guarantee that workers will opt for one, especially with all the unknowns and potentially unpleasant side effects.
Participants in Moderna and Pfizer’s coronavirus vaccine trials told CNBC in September, for instance, that they experienced “high fever, body aches, bad headaches, daylong exhaustion and other symptoms” after receiving the shots.
For the 2019-2020 flu, vaccination coverage among health care personnel was 80.6%, according to the U.S. Centers for Disease Control and Prevention (CDC). By occupation, flu vaccination coverage was highest among physicians, nurses, pharmacists, nurse practitioners and physician assistants.
Flu vaccination coverage was lowest among health care aides and non-clinical personnel, the CDC notes.
The holidays are approaching just as COVID-19 case rates nationwide are increasing at a record-breaking pace, leading to dire warnings from public health experts.
The Centers for Disease Control and Prevention has issued cautions and updated guidelines related to family gatherings. Dr. Anthony Fauci, a White House coronavirus adviser and director of the National Institute of Allergy and Infectious Diseases, said in interviews that his kids won’t be coming home for Thanksgiving because of coronavirus risks. “Relatives getting on a plane, being exposed in an airport,” he told CBS News. “And then walking in the door and saying ‘Happy Thanksgiving’ — that you have to be concerned about.”
Are Americans listening? Maybe not. Especially as airlines, reeling from major revenue blows since the pandemic took hold in March, tell passengers they can travel with peace of mind and sweeten the deal with special holiday fares.
The airlines argue more is now known about the virus and recent industry-sponsored studies show flying is just as safe as regular daily activities. They also tout policies such as mask mandates and enhanced cleaning to protect travelers from the coronavirus.
Time for a reality check.
Americans who do choose to fly will be subject to evolving COVID safety policies that vary by airline, a result of the continuing lack of a unified federal strategy. Under the Trump administration, government agencies such as the Federal Aviation Administration and the Centers for Disease Control and Prevention have failed to issue and enforce any national directives for air travel.
And, though President-elect Joe Biden has signaled he will take a more robust federal approach to addressing COVID-19, which may result in such actions, the Trump administration remains in charge during the upcoming holiday season.
Here’s what you need to know before you book.
Airlines Say It’s Safe to Fly During the Pandemic. Is it?
The airline industry pins its safety clearance to a study funded by its leading trade group, Airlines for America, and conducted by Harvard University researchers, as well as one headed by the Department of Defense, with assistance from United Airlines.
Both reports modeled disease transmission on a plane, assuming all individuals were masked and the airplane’s highly effective air filtration systems were working. The Harvard report concluded the risk of in-flight COVID-19 transmission was “below that of other routine activities during the pandemic, such as grocery shopping or eating out,” while the DOD study concluded an individual would need to, hypothetically, sit for 54 straight hours on an airplane to catch COVID-19 from another passenger.
But these studies’ assumptions have limitations.
Despite airlines’ ramped-up enforcement of mask-wearing, reports of noncompliance among passengers continue. Most airlines say passengers who outright refuse to wear masks will not only be refused boarding, but will also be putting their future travel privileges at risk. Recent press reports indicate Delta has placed hundreds of these passengers on a no-fly list. Some passengers may still try to skirt around the rule by removing their mask to eat or drink for an extended time on the flight, and flight attendants may or may not feel they can stop them.
And though public health experts agree that airplanes do have highly effective filtration systems spaced throughout the cabin that filter and circulate the air every couple of minutes, if someone who unknowingly has COVID-19 takes off their mask to eat or drink, there is still time for viral particles to reach others seated nearby before they get sucked up by the filter.
Public health experts said comparing time on an airplane with time at the grocery store is apples and oranges.
Even if you wear a mask in both places, said Dr. Henry Wu, director of Emory TravelWell Center and associate professor of infectious diseases at Emory University School of Medicine, the duration of contact in both locales can be very different.
“If it’s a long flight and you are in that situation for several hours, then you are accumulating exposure over time. So a one-hour flight is 1/10 the risk of a 10-hour flight,” said Wu. “Whereas most people don’t spend more than an hour in the grocery store.”
Also, both studies analyzed only one aspect of a travel itinerary — risk on board the aircraft. Neither considered the related risks involved in air travel, such as getting to the airport or waiting in security lines. And public health experts say those activities pose opportunities for COVID exposure.
“Between when you arrive in the airport and you get into a plane seat, there is a lot of interaction that happens,” said Lisa Lee, a former CDC official and associate vice president for research and innovation at Virginia Tech.
And while Wu said he agrees that an airplane cabin is likely safer than other environments, with high rates of COVID-19 in communities across the U.S., “there is no doubt people are flying when they’re sick, whether they know it or not.”
Another data point touted by the airline industry has been that out of the estimated 1.2 billion people who have flown so far in 2020, only 44 cases of COVID-19 have been associated with air travel, according to data from the International Air Transport Association, a worldwide trade group.
But this number reflects only case reports published in the academic literature and isn’t likely capturing the true picture of how many COVID cases are associated with flights, experts said.
“It’s very difficult to prove, if you get sick after a trip, where exactly you got exposed,” said Wu.
The low count could also stem from systemic contact-tracing inconsistencies after a person with COVID-19 has traveled on a flight. In a recent case, a woman infected with the coronavirus died during a flight and fellow passengers weren’t notified of their exposure.
That may be due to the decentralized public health system the U.S. has in place, said Lee, the former CDC official, since contact tracing is done through state and local health departments. The CDC will step in to help with contact tracing only if there is interstate travel, which is likely during a flight — but, during the pandemic, the agency has “been less consistently effective than in the past,” said Lee.
“Let’s say there is a case of COVID on a flight. The question is, who is supposed to deal with that? The state that [the flight] started in? That it ended in? The CDC? It’s not clear,” said Lee.
Is Now the Time to Fly?
Most airlines have implemented safety measures beyond requiring masks, such as asking passengers to fill out health questionnaires, enhancing cleaning on planes, reducing interactions between crew members and passengers, and installing plexiglass stations and touchless check-in at service desks.
But many have also stepped back from other efforts, such as pledging to block middle seats. United relaxed its social distancing policy for allowing empty middle seats between customers at the end of May, though there were complaints from customers before then about flights being full. American Airlines stopped blocking middle seats in July. Other airlines plan to fill seats after the Thanksgiving holiday, with Southwest stopping the practice of blocking middle seats starting Dec. 1, and JetBlue planning to increase capacity to 85% on Dec. 2. In January, Alaska Airlines plans to stop blocking middle seats and JetBlue will fly at full capacity. Delta announced this week that it will continue to block the middle seat until March 30.
This policy change is a result of airlines’ lack of cash on hand, said Robert Mann, an aviation analyst. It also reflects a rising demand from consumers who feel increasingly comfortable traveling again, especially as holiday gatherings beckon.
“It was easy to keep middle seats empty when there wasn’t much demand,” said Mann.
Now, they’re instead hoping that new COVID-era services will calm passengers’ fears.
American, United, Alaskan and Hawaiian, among others, offer some form of preflight COVID test for customers traveling to Hawaii or specific foreign destinations that also require a negative test or quarantine upon arrival. JetBlue recently partnered with a company to offer at-home COVID tests that give rapid results for those traveling to Aruba.
Airlines are likely to expand their preflight COVID testing options in the next couple of months. “This is the new dimension of airline competition,” said Mann.
But is it a new dimension of travel safety?
Emory’s Wu said there is certainly a risk of catching the coronavirus if you travel by plane, and travelers should have a higher threshold in making the decision to travel home for the holidays than they would in years past.
After all, COVID case rates are surging nationwide.
“I think the less folks crowding the airports, the less movement in general around the country, will help us control the epidemic,” said Wu. “We are worried things will get worse with the colder weather.”
President-elect Joe Biden made COVID-19 a linchpin of his campaign, criticizing President Donald Trump’s leadership on everything from masks and packed campaign rallies to vaccines.
That was the easy part. Biden now has the urgent job of filling top health care positions in his administration to help restore public trust in science-driven institutions Trump repeatedly undermined, and oversee the rollout of several coronavirus vaccines to a skeptical public who fear they were rushed for political expediency.
At the top of that list is a new commissioner of the Food and Drug Administration, an agency where Biden faces immense pressure to move faster than any other modern president as the pandemic rages and COVID deaths are expected to surge through the winter. That agency and its beleaguered personnel will be relied on to give the green light to vaccines and therapeutics to fight the COVID pandemic.
Biden is expected to swiftly announce his choices to lead the FDA and the Centers for Disease Control and Prevention, given their importance in informing the federal government’s COVID strategy, according to interviews with Biden advisers, former agency officials and Democrats with knowledge of the transition team’s inner workings. But how soon they’ll be able to begin work after Biden’s Jan. 20 inauguration is unclear.
The CDC director does not need Senate confirmation, avoiding a hurdle that could slow that process. That is not the case for the FDA commissioner, who now appears increasingly likely to face a Republican-controlled Senate that may not be as keen as Democrats to swiftly clear Biden’s nominees. As a result, even if Biden moves at breakneck speed to replace outgoing Commissioner Stephen Hahn, it could be weeks after Biden is in the White House before his pick could get to work.
In the meantime, the FDA will face critical decisions about vaccines needed to help put the nation on its path out of the pandemic. Biden will have to rely on a temporary head of the FDA to steer the 17,000-employee agency during one of the most challenging times in its history.
“It’s not ideal timing, for sure,” a former FDA official said. “It’s a huge job.”
The transition of power will occur at one of the most high-profile times for the FDA, as it vets multiple coronavirus vaccine candidates that could reach the public before the inauguration. The Trump administration could oversee emergency authorizations of initial vaccines from two front-runners, Pfizer and Moderna, that would be prioritized for health care workers and other groups at higher risk of severe COVID complications. But other companies’ vaccines that could be available for many more Americans — such as teachers, adults at lower risk of severe health consequences if they get sick, and children — are all but certain to fall under Biden’s FDA for review because the data on safety and efficacy isn’t expected until next year.
FDA’s credibility in vetting the safety and benefits of COVID products has been in question for months, fueled by Hahn’s inaccurate statements about certain treatments for sick patients. Further, infighting between officials there and political appointees at the White House and the Department of Health and Human Services persisted even in the weeks leading up to the election, with HHS Secretary Alex Azar openly plotting Hahn’s removal because of disagreements over vaccine standards, Politico reported in October.
In September, eight senior FDA officials who have served in multiple administrations took the extraordinary step of publishing an op-ed in USA Today stating they would work with agency leadership “to maintain FDA’s steadfast commitment to ensuring our decisions will continue to be guided by the best science.”
“Protecting the FDA’s independence is essential if we are to do the best possible job of protecting public health and saving lives,” the officials wrote.
“Trust has eroded so significantly in these institutions that have undermined public confidence, especially on vaccines,” a Biden adviser said of the FDA and CDC. “Change in leadership is critical.”
Getting new people into the federal government — where Biden is charged with filling roughly 4,000 jobs held by political appointees — is a mammoth slog on its own, let alone while moving to take over the U.S. pandemic response. Former President Barack Obama set the record for presidential appointments in the first 100 days, securing Senate confirmation for 69 appointees. The FDA commissioner wasn’t among them — Dr. Margaret Hamburg was not nominated until March 2009 and became commissioner that May. A similar timeline held for Trump’s first FDA commissioner, Dr. Scott Gottlieb, who began in May 2017.
“It is a difficult period because you’re going to have a lot of folks who need to get into place,” said Max Stier, CEO of the Partnership for Public Service, which advises presidential candidates and their teams installing new administrations. “The track record has not been good on getting people in quickly.”
At the outset of the Biden administration, it’s expected there will be a fair number of “acting” agency heads rather than Senate-confirmed appointees, Stier said. Biden has said he’ll trust the government’s scientists on COVID vaccines. Former FDA officials said in interviews that if there’s an acting official in charge when a specific vaccine is under review, it should not make a difference because the agency’s longtime scientists conduct the necessary scientific evaluations.
Where it could make a difference is in messaging and accountability, not just to the new president but to the public: The traditionally lower profile and temporary nature of an acting FDA commissioner is at odds with the highly visible role the commissioner is expected to play during a public health emergency, particularly in convincing people that vaccines are safe.
“An agency needs a face, and it’s hard for an ‘acting’ to be the face of the agency,” a former senior agency official said. “The work could be done, but the communication is always better if there’s an FDA commissioner who’s willing to take responsibility.”
The messaging role has taken on extraordinary importance since public confidence in a coronavirus vaccine has eroded significantly. A September Pew Research Center poll found that only 51% of U.S. adults would definitely or probably get a vaccine to prevent COVID-19 if it were available, a drop of 21 percentage points since May.
“Things can only be better,” said Michael Carome, director of the health research group at Public Citizen, a left-leaning group that advocates for consumer interests. “I think an acting commissioner under a Biden administration will be far more trusted than the current FDA commissioner, who has been kowtowed by the White House.”
FDA staffing policy outlines who should be the agency’s acting head in the event there isn’t a permanent commissioner. The most recent version, from 2016, says the position is delegated to the deputy commissioner for foods and veterinary medicine, a title that has since been recast as deputy commissioner for food policy and response. The job is currently held by Frank Yiannas, a longtime food safety expert who joined the agency in 2018 after the retirement of Stephen Ostroff, a veteran FDA scientist who served as acting commissioner twice. The FDA did not respond to questions about whether it had a new staffing policy.
Some administrations, however, have ignored that policy. The Trump administration, for example, briefly installed senior HHS official Brett Giroir, a political appointee, as acting FDA commissioner, a move criticized by Democrats in Congress.
But critical decisions await the new appointee.
The earliest officials would know whether COVID vaccines from Johnson & Johnson and AstraZeneca work is January or February, said Moncef Slaoui, the top scientific adviser for Operation Warp Speed, which is funding multiple coronavirus vaccines and treatments. Other efficacy trials won’t be completed until spring, he said in October.
Safety will take even longer to assess — Johnson & Johnson’s and AstraZeneca’s late-stage clinical trials were already paused earlier this year for safety reasons —and companies will seek emergency authorization or FDA approval only once both metrics are known.
After four years of politicization of the science agency, a Biden adviser said, most important was having a “trusted, credible voice to restore trust in a vaccine.”
In the waning days of the campaign, President Donald Trump complained repeatedly about how the United States tracks the number of people who have died from COVID-19, claiming, “This country and its reporting systems are just not doing it right.”
He went on to blame those reporting systems for inflating the number of deaths, pointing a finger at medical professionals, who he said benefit financially.
All that feeds into the swirling political doubts that surround the pandemic, and raises questions about how deaths are reported and tallied.
We asked experts to explain how it’s done and to discuss whether the current figure — an estimated 231,000 deaths since the pandemic began — is in the ballpark.
Dismissing Conspiracy Theories, Profit Motives
Trump’s recent assertions have fueled conspiracy theories on Facebook and elsewhere that doctors and hospitals are fudging numbers to get paid more. They’ve also triggered anger from the medical community.
“The suggestion that doctors — in the midst of a public health crisis — are overcounting COVID-19 patients or lying to line their pockets is a malicious, outrageous, and completely misguided charge,” Dr. Susan R. Bailey, American Medical Association president, said in a press release.
Hospitals are paid for COVID treatment the same as for any other care, though generally, the more serious the problem, the more hospitals are paid. So, treating a ventilator patient — with COVID-19 or any other illness — would mean higher payment to a hospital than treating one who didn’t require a ventilator, reflecting the extra cost.
There is one financial difference. Medicare, the government health program for the elderly and disabled, pays 20% on top of its ordinary reimbursement for COVID patients — a result of the CARES Act, the federal stimulus bill that passed in the spring.
That additional payment applies only to Medicare patients.
Experts say there is simply no evidence that physicians or hospitals are labeling patients as having COVID-19 simply to collect that additional payment. Rick Pollack, president and CEO of the American Hospital Association, wrote an opinion piece in September addressing what he called the “myths” surrounding the add-on payments. While many hospitals are struggling financially, he wrote, they are not inflating the number of cases — and there are serious disincentives to do so.
“The COVID-19 code for Medicare claims is reserved for confirmed cases,” he wrote, and using it inappropriately can result in criminal penalties or a hospital being kicked out of the Medicare program.
Public health officials and others also pushed back.
Said Jeff Engel, senior adviser for COVID-19 at the Council of State and Territorial Epidemiologists: “Public health is charged with the duty to collect accurate, timely and complete data. We’re not incentivized to overcount or undercount for any political or funding reason.”
And what about medical examiners? Are they part of a concerted effort to overcount deaths to reap financial rewards?
“Medical examiners and coroners in the U.S. are not organized enough to have a conspiracy. There are 2,300 jurisdictions,” said Dr. Sally Aiken, president of the National Association of Medical Examiners. “That’s not happening.”
Still, there’s an ongoing debate about which mortalities should be considered COVID deaths.
States have leeway to decide how to gather and report data. Many rely on death certificates, which list the cause of death, along with contributing factors. They are considered very accurate but can take one to two weeks to be finalized because of the processes involved in filling them out, reviewing and filing them. These reports generally lag behind testing and hospitalization data.
The other way deaths get reported is through what’s known as the case classification method, which reports deaths of people with previously identified cases of COVID, whether listed as confirmed or probable. Confirmed COVID deaths are affirmed by a positive test result. Probable COVID deaths are classified by using medical record evidence, suspected exposure or serology tests for COVID antibodies. The case classification method is faster than using death certificates and makes the data available in a more real-time fashion. Epidemiologists say this information can be helpful in gaining an understanding in the midst of an outbreak of how many people are dying and where.
Some experts point out that, while both methods have their virtues, each shows a different mortality count at a different time, so the best practice is to gather both sets of information.
The federal government, though, has offered conflicting guidance. The National Center for Health Statistics, an arm of the CDC, recommends primarily using death certificate data to count COVID deaths. But in April, the CDC asked jurisdictions to start tracking mortality based on probable and confirmed case classifications. Most states now gather data only one of the two ways, though a couple use both.
This patchwork approach does lead to conflicting data on total deaths.
Why Is the Count So Hard?
For the most part, public health researchers and medical examiners agree that COVID deaths are likely being undercounted.
“It’s very hard in a situation moving as rapidly as this one, and at such a large scale, to be able to count accurately,” said Sabrina McCormick, an associate professor in environmental and occupational health at George Washington University.
For one thing, the processes for certifying deaths vary widely, as does who fills out the death certificates. While physicians certify most death certificates, coroners, medical examiners and other local law enforcement officials can also do so.
Aiken, the medical examiner of Spokane County, Washington, said any time someone in her area dies at home and may have had COVID symptoms, the deceased person will automatically be tested for the disease.
But that doesn’t happen everywhere, she added, which means some who die at home could be omitted from the count.
It’s also unknown how accurate post-mortem COVID testing is, because there haven’t yet been any research studies on the practice — which could lead to missed cases.
Another wrinkle: Doctors in hospitals might not always be trained in the best practices for filling out death certificates, Aiken said.
“These folks are dealing with ERs and ICUs that are crowded. Death certificates are not their priority,” she said.
Emergency room doctors acknowledged the challenges, noting they don’t always have the resources that coroners and medical examiners do to perform autopsies.
“Much of the time, we don’t have an answer as to the final reason that a person died, so we are often stuck with the old cardiopulmonary arrest, which coroners and certifiers hate,” said Dr. Ryan Stanton, a Lexington, Kentucky, ER doctor and board member of the American College of Emergency Physicians.
That gets to how complex it is to determine what, exactly, caused a death — and what some say is a confusion between who died “with” COVID-19 (but may have had other underlying conditions that caused their death) and who died directly “of” COVID-19.
John Fudenberg, the former coroner for Clark County, Nevada, which surrounds Las Vegas, said including some of those who died with COVID-19 could result in an overcount.
“As a general rule, if someone dies with COVID, it’s going to be on the death certificate, but it doesn’t mean they died from COVID,” said Fudenberg, now executive director of the International Association of Coroners and Medical Examiners. For example, “if somebody has end-stage pancreatic cancer and COVID, did they die with COVID or from COVID?”
That question has proven controversial, and Trump has claimed that counting those who died “with COVID” has led to an inflation of the numbers. But most public health experts agree that if COVID-19 caused someone to die earlier than they normally would have, then it certainly contributed to their death. Additionally, those who certify death certificates say they list only contributing factors that are certain.
“Doctors don’t put things on death certificates that have nothing to do with the death,” said Dr. Amesh Adalja, senior scholar at the Johns Hopkins Center for Health Security.
COVID-19 can directly lead to death in someone with cancer or heart problems, even if those conditions were also serious or even expected to be fatal, he said.
And the claim that some states are counting people who die in car accidents, but also test positive for COVID-19, as COVID deaths is just plain unfounded, experts said.
“I can’t imagine a scenario where a medical examiner would test someone for COVID who died in a motor vehicle accident or a homicide,” said Engel, at the epidemiologists council. “I think that’s been greatly exaggerated on the internet.”
An additional approach to determining the pandemic’s scope has emerged, and many experts increasingly point to this measure as a useful indicator.
It relies on a concept known as “excess deaths,” which involves comparing the total number of deaths from all causes in a given period with the same period in previous years.
A CDC study estimated that almost 300,000 more people died in the U.S. this year from late January through Oct. 3 than in previous years. Some of those excess deaths were no doubt COVID cases, while others may have been people who avoided medical care because of the pandemic and then died from another cause.
These excess deaths are “the best evidence” that undercounting is ongoing, said Dr. Jeremy Faust, an ER doctor at Brigham and Women’s Hospital in Boston. “The timing of the excess deaths exactly parallels the COVID deaths, so when COVID deaths spike, all causes of deaths spike. They are hugging each other like parallel train tracks on a graph.”
Faust believes the majority of the excess deaths should be attributed in some way to COVID-19.
Even so, it’s unclear if we’ll ever get an accurate count.
Aiken said it is possible but could take years. “I think eventually, when this is said and done, we’ll have a pretty good count,” she said.
McCormick, of George Washington University, isn’t as sure, mostly because the number has become a flashpoint.
“It will always be a controversy, especially because it’s going to be so politically charged,” she said. “I don’t think we’ll come to a final number.”
In August, Robert Pettigrew was working a series of odd jobs. While washing the windows of a cellphone store he saw a sign, one that he believes the “good Lord” placed there for him.
“Facing eviction?” the sign read. “You could be eligible for up to $3,000 in rent assistance. Apply today.”
It seemed a hopeful omen after a series of financial and health blows. In March, Pettigrew, 52, learned he has an invasive mass on his lung that restricts his breathing. His doctor told him his condition puts him at high risk of developing deadly complications from COVID-19 and advised him to stop working as a night auditor at a Motel 6, where he manned the front desk. Reluctantly, he had to leave that job and start piecing together other work.
With pay coming in less steadily, Pettigrew and his wife, Stephanie, fell behind on the rent. Eventually, they were many months late, and the couple’s landlord filed to evict them.
Then Pettigrew saw the rental assistance sign.
“There were nights I would lay in bed and my wife would be asleep, and all I could do was say, ‘God, you need to help me. We need you,’” Pettigrew said. “And here he came. He showed himself to us.”
As many as 40 million Americans faced a looming eviction risk in August, according to a report authored by 10 national housing and eviction experts. The Centers for Disease Control and Prevention cited that estimate in early September when it ordered an unprecedented, nationwide eviction moratorium through the end of 2020.
That move — a moratorium from the country’s top public health agency — spotlights a message experts have preached for years without prompting much policy action: Housing stability and health are intertwined.
The CDC is now citing stable housing as a vital tool to control the coronavirus, which has killed more than 200,000 Americans. Home is where people isolate themselves to avoid transmitting the virus or becoming infected. When local governments issue stay-at-home orders in the name of public health, they presume that residents have a home. For people who have the virus, home is often where they recover from COVID-19’s fever, chills and dry cough — in lieu of, or after, a hospital stay.
But the moratorium is not automatic. Renters have to submit a declaration form to their landlord, agreeing to a series of statements under threat of perjury, including “my housing provider may require payment in full for all payments not made prior to and during the temporary halt, and failure to pay may make me subject to eviction pursuant to state and local laws.”
Princeton University is tracking eviction filings in 17 U.S. cities during the pandemic. As of Sept. 19, landlords in those cities have filed for more than 50,000 evictions since March 15. The tally includes about 11,900 in Houston, 10,900 in Phoenix and 4,100 in Milwaukee.
It’s an incomplete snapshot that excludes some major American cities such as Indianapolis, where local housing advocates said court cases are difficult to track, but landlords have sought to evict thousands of renters.
Children raised in unstable housing are more prone to hospitalization than those with stable housing. Homelessness is associated with delayed childhood development, and mothers in families that lose homes to eviction show higher rates of depression and other health challenges.
Mountingresearch illustrates that even the threat of eviction can exact a physical and mental toll from tenants.
Nicole MacMillan, 38, lost her job managing vacation rentals in Fort Myers, Florida, in March when the pandemic shut down businesses. Later, she also lost the apartment where she had been living with her two children.
“I actually contacted a doctor, because I thought, mentally, I can’t handle this anymore,” MacMillan said. “I don’t know what I’m going to do or where I’m going to go. And maybe some medication can help me for a little bit.”
But the doctor she reached out to wasn’t accepting new patients.
With few options, MacMillan moved north to live with her grandparents in Grayslake, Illinois. Her children are staying with their fathers while she gets back on her feet. She recently started driving for Uber Eats in the Chicagoland area.
“I need a home for my kids again,” MacMillan said, fighting back tears. The pandemic “has ripped my whole life apart.”
Searching for Assistance to Stay at Home
That store window sign? It directed Pettigrew to Community Advocates, a Milwaukee nonprofit that received $7 million in federal pandemic stimulus funds to help administer a local rental aid program. More than 3,800 applications for assistance have flooded the agency, said Deborah Heffner, its housing strategy director, while tens of thousands more applications have flowed to a separate agency administering the state’s rental relief program in Milwaukee.
Persistence helped the Pettigrews break through the backlog.
“I blew their phone up,” said Stephanie Pettigrew, with a smile.
She qualifies for federal Social Security Disability Insurance, which sends her $400 to $900 in monthly assistance. That income has become increasingly vital since March when Robert left his motel job.
He has since pursued a host of odd jobs to keep food on the table — such as the window-washing he was doing when he saw the rental assistance sign — work where he can limit his exposure to the virus. He brings home $40 on a good day, he said, $10 on a bad one. Before they qualified for rent assistance, February had been the last time the Pettigrews could fully pay their $600 monthly rent bill.
Just as their finances tightened and their housing situation became less stable, the couple welcomed more family members. Heavenly, Robert’s adult daughter, arrived in May from St. Louis after the child care center where she worked shut down because of concerns over the coronavirus. She brought along her 3-year-old son.
Through its order, the CDC hopes to curtail evictions, which can add family members and friends to already stressed households. The federal order notes that “household contacts are estimated to be 6 times more likely to become infected by [a person with] COVID-19 than other close contacts.”
“That’s where that couch surfing issue comes up — people going from place to place every few nights, not trying to burden anybody in particular, but possibly at risk of spreading around the risk of coronavirus,” said Andrew Bradley of Prosperity Indiana, a nonprofit focusing on community development.
The Pettigrews’ Milwaukee apartment — a kitchen, a front room, two bedrooms and one bathroom — is tight for the three generations now sharing it.
“But it’s our home,” Robert said. “We’ve got a roof over our head. I can’t complain.”
Housing Loss Hits Black and Latino Communities
A U.S. Census Bureau survey conducted before the federal eviction moratorium was announced found that 5.5 million of American adults feared they were either somewhat or very likely to face eviction or foreclosure in the next two months.
State and local governments nationwide are offering a patchwork of help for those people.
In Massachusetts, the governor extended the state’s pause on evictions and foreclosures until Oct. 17. Landlords are challenging that move both in state and federal court, but both courts have let the ban stand while the lawsuits proceed.
“Access to stable housing is a crucial component of containing COVID-19 for every citizen of Massachusetts,” Judge Paul Wilson wrote in a state court ruling. “The balance of harms and the public interest favor upholding the law to protect the public health and economic well-being of tenants and the public in general during this health and economic emergency.”
The cases from Massachusetts may offer a glimpse of how federal challenges to the CDC order could play out.
By contrast, in Wisconsin, Gov. Tony Evers was one of the first governors to lift a state moratorium on evictions during the pandemic — thereby enabling about 8,000 eviction filings from late May to early September, according to a search of an online database of Wisconsin circuit courts.
In other states, housing advocates note similar disparities.
“Poor neighborhoods, neighborhoods of color, have higher rates of asthma and blood pressure — which, of course, are all health issues that the COVID pandemic is then being impacted by,” said Amy Nelson, executive director of the Fair Housing Center of Central Indiana.
“This deadly virus is killing people disproportionately in Black and brown communities at alarming rates,” said Dee Ross, founder of the Indianapolis Tenants Rights Union. “And disproportionately, Black and brown people are the ones being evicted at the highest rate in Indiana.”
Across the country, officials at various levels of government have set aside millions in federal pandemic aid for housing assistance for struggling renters and homeowners. That includes $240 million earmarked in Florida, between state and county governments, $100 million in Los Angeles County and $18 million in Mississippi.
In Wisconsin, residents report that a range of barriers — from application backlogs to onerous paperwork requirements — have limited their access to aid.
In Indiana, more than 36,000 people applied for that state’s $40 million rental assistance program before the application deadline. Marion County, home to Indianapolis, had a separate $25 million program, but it cut off applications after just three days because of overwhelming demand. About 25,000 people sat on the county’s waiting list in late August.
Of that massive need, Bradley, who works in economic development in Indiana, said: “We’re not confident that the people who need the help most even know about the program — that there’s been enough proactive outreach to get to the households that are most impacted.”
After Milwaukeean Robert Pettigrew saw that sign in the store window and reached out to the nonprofit Community Advocates, the group covered more than $4,700 of the Pettigrews’ rental payments, late charges, utility bills and court fees. The nonprofit also referred the couple to a pro-bono lawyer, who helped seal their eviction case — that means it can’t hurt the Pettigrews’ ability to rent in the future, and ensures the family will have housing at least through September. The CDC moratorium has added to that security.
“It’s protecting 30 to 40 million adults and children from eviction and the downward spiral that it causes in long-term, poor health outcomes,” she said.
Doctor: Evictions Akin to ‘Toxic Exposure’
Megan Sandel, a pediatrician at Boston Medical Center, said at least a third of the 14,000 families with children that seek treatment at her medical center have fallen behind on their rent, a figure mirrored in national reports.
Hospital officials worry that evictions during the pandemic will trigger a surge of homeless patients — and patients who lack homes are more challenging and expensive to treat. One study from 2016 found that stable housing reduced Medicaid spending by 12% — and not because members stopped going to the doctor. Primary care use increased 20%, while more expensive emergency room visits dropped by 18%.
A year ago, Boston Medical Center and two area hospitals collaborated to invest $3 million in emergency housing assistance as community organizing focused on affordable housing policies and development. Now the hospitals are looking for additional emergency funds, trying to boost legal resources to prevent evictions and work more closely with public housing authorities and state rental assistance programs.
“We are a safety-net hospital. We don’t have unlimited resources,” Sandel said. “But being able to avert an eviction is like avoiding a toxic exposure.”
Sandel said the real remedy for avoiding an eviction crisis is to offer Americans substantially more emergency rental assistance, along the lines of the $100 billion included in a package proposed by House Democrats in May and dubbed the Heroes Act. Boston Medical Center is among the 26 health care associations and systems that signed a letter urging congressional leaders to agree on rental and homeless assistance as well as a national moratorium on evictions for the entire pandemic.
“Without action from Congress, we are going to see a tsunami of evictions,” the letter stated, “and its fallout will directly impact the health care system and harm the health of families and individuals for years to come.”
Groups representing landlords urge passage of rental assistance, too, although some oppose the CDC order. They point out that property owners must pay bills as well and may lose apartments where renters can’t or won’t pay.
In Milwaukee, Community Advocates is helping the Pettigrews look for a more affordable apartment. Robert Pettigrew continues attending doctors’ appointments for his lungs, searching for safe work. He looks to the future with a sense of resolve — and a request that no one pity his family.
“Life just kicks you in the butt sometimes,” he said. “But I’m the type of person — I’m gonna kick life’s ass back.”
Thousands of minks at Utah fur farms have died because of the coronavirus in the past 10 days, forcing nine sites in three counties to quarantine, but the state veterinarian said people don’t appear to be at risk from the outbreak.
The COVID-19 infections likely were spread from workers at the mink ranches to the animals, with no sign so far that the animals are spreading it to humans, said Dr. Dean Taylor, the state veterinarian, who is investigating the outbreak.
“We genuinely don’t feel like there is much of a risk going from the mink to the people,” he said Thursday.
Between 7,000 and 8,000 minks have died since the disease swept through the ranches that produce the animals, valued for their luxurious pelts. So far, no animals in Utah have been euthanized because of the disease, and it doesn’t appear to be necessary, Taylor said.
Fur from the dead infected animals will be processed to remove any traces of the virus and then used for coats and other garments, according to Fur Commission USA, a mink farming trade group. The U.S. produces more than 3 million mink pelts each year.
Taylor declined to name the farms or the counties where the affected minks were found.
With minks, as with humans, COVID-19 is less deadly for the young.
“It’s going through the breeding colonies and wiping out the older mink and leaving the younger mink unscathed,” Taylor said. Most of the deaths have been in minks between the ages of 1 and 4 years.
In addition to the minks, more than 50 animals in the U.S. had tested positive for the coronavirus as of Sept. 2, according to the U.S. Department of Agriculture. The infections have been detected in pet cats and dogs, as well as lions and tigers at a New York zoo.
Minks seem particularly susceptible to COVID-19, likely because of a protein in their lungs, the ACE2 receptor, which binds to the virus and appears to predict vulnerability to the infection, according to Wageningen University & Research in the Netherlands. Humans also have this protein in their lungs.
The COVID outbreak in Utah has surged since mid-August, when the first cases of the disease in the animals were confirmed by the USDA.
Minks were discovered to be susceptible to the SARS-CoV-2 virus, which causes COVID-19, in April, after outbreaks at several farms in the Netherlands, followed by outbreaks in Denmark and Spain. More than 1 million animals were culled in those countries, according to the Associated Press.
Several workers at the Utah mink farms have tested positive for COVID-19, including some who had no symptoms.
“Some of our mink ranchers have more than one facility, and that’s probably how it spread,” Taylor said.
A study in the Netherlands found that the virus appeared to jump back and forth between people and minks, but the data so far remains limited.
After the initial U.S. cases were confirmed, mink farms across Utah and the rest of the country implemented strict measures to prevent the disease from spreading, such as restricting access, conducting health checks on workers and disinfecting surfaces. The USDA and the Centers for Disease Control and Prevention have issued guidelines for farmed minks and other mustelids, a family of animals that also includes weasels and badgers.
“Obviously, it’s very concerning to have a species that is this susceptible with this high of a death rate,” Taylor said.
The outbreak has led to the quarantine of a quarter of Utah’s three dozen mink ranches and raised concerns across the state, said Clayton Beckstead, regional manager for the Utah Farm Bureau and a fourth-generation mink farmer.
“We’re certainly worried, but I think everybody’s taking pretty extreme biosecurity measures,” said Beckstead, whose own farm has not been affected.
Utah is one of the nation’s top mink producers. Overall, there are 245 fur farms in 22 states, part of an industry valued at $82.6 million a year, according to Fur Commission USA.
Investigating an outbreak of a novel virus in a new species is “daunting,” Taylor said.
“We’re learning as quick as we can,” he said. “We’re scrambling to help these animals and protect this industry.”
“Children in approximately 4 million households in the United States are being exposed to high levels of lead.” As I discuss in my video The Effects of Low-Level Lead Exposure in Adults, “Despite the dramatic decline in children’s blood-lead concentrations over the decades, lead toxicity remains a major public health problem”—and not just for children. Yes, lead is “a devastating neurotoxin,” with learning disabilities and attention deficits in children beginning around blood lead levels of 10 mg/dL, which is when you start seeing high blood pressure and nerve damage in adults, as you can see at 0:41 in my video. But, the blood levels in American adults these days are down around 1 mg/dL, not 10 mg/dL, unless you work or play in an indoor firing range, where the lead levels in the air are so high that more than half of recreational target shooters have levels over 10 mg/dL or even 25 mg/dL.
In fact, even open-air outdoor ranges can be a problem. Spending just two days a month at such a range may quadruple blood lead levels and push them up into the danger zone. What if you don’t use firearms yourself but live in a house with someone who does? The lead levels can be so high that the Centers for Disease Control and Prevention advises those who go to shooting ranges to take “measures to prevent take-home exposure including showering and changing into clean clothes after shooting…, storing clean clothes in a separate bin from contaminated clothing, laundering of non disposable outer protective clothing…and leaving at the range shoes worn inside the firing range,” among other actions. Even if none of that applies and your blood levels are under 10 mg/dL, there is still some evidence of increased risk of hand tremors, high blood pressure, kidney damage, and other issues, as you can see at 1:44 in my video. But what if you’re down around a blood lead level of 1 mg/dL, like most people?
“Blood lead levels in the range currently considered acceptable are associated with increased prevalence of gout,” a painful arthritis. In fact, researchers found that blood levels as low as approximately 1.2 mg/dL, which is close to the current American average, can be associated with increased prevalence of gout. So, this means that “very low levels of lead may still be associated with health risks,” suggesting “there is no such thing as a ‘safe’ level of exposure to lead.”
Where is the lead even coming from? Lead only circulates in the body for about a month, so if you have lead in your bloodstream, it’s from some ongoing exposure. Most adults don’t eat peeling paint chips, though, and autos aren’t fueled by leaded gas anymore. There are specific foods, supplements, and cosmetics that are contaminated with lead (and I have videos on all those topics), but for most adults, the source of ongoing lead exposure is from our own skeleton. I just mentioned that lead only circulates in the body for about a month. Well, where does it go after that? It can get deposited in our bones. “More than 90% of the total body lead content resides in the bone, where the half-life is decades long,” not just a month. So, half or more of the lead in our blood represents lead from past exposures just now leaching out of our bones back into our bloodstream, and this “gradual release of lead from the bone serves as a persistent source of toxicity long after cessation of external exposure,” that is, long after leaded gasoline was removed from the pumps for those of us that who were around back before the 1980s.
So, the answer to where the lead comes from is like Pogo’s We’ve met the enemy and he is us or that classic horror movie scene where the call is coming from inside the house.
The amount of lead in our bones can actually be measured, and research shows higher levels are associated with some of our leading causes of death and disability, from tooth decay and miscarriages to cognitive decline and cataracts. “Much of the lead found in adults today was deposited decades ago. Thus, regulations enacted in the 1970s were too late” for many of us, but at least things are going in the right direction now. The “dramatic societal decreases” in blood lead in the United States since the 1970s have been associated with a four- to five-point increase in the average IQs of American adults. Given that, a “particularly provocative question is whether the whole country suffered brain damage prior to the 1980 decreases in blood lead. Was ‘the best generation’ really the brain damaged generation?”
I’m such a sucker for science documentaries, and my favorite episode of Cosmos: A Spacetime Odyssey was The Clean Room, which dealt with this very issue. Trivia: Carl Sagan was my next-door neighbor when I was at Cornell!
La temporada de influenza se verá diferente este año, ya que los Estados Unidos se enfrentan a una pandemia de coronavirus que ya ha matado a más de 176.000 personas.
Muchos estadounidenses son reacios a ir al médico y los funcionarios de salud pública temen que las personas eviten vacunarse.
Aunque a veces se considera incorrectamente como un resfriado, la gripe también mata a decenas de miles de personas en el país cada año. Los más vulnerables son los niños pequeños, los adultos mayores y las personas con enfermedades subyacentes. Cuando se combina con los efectos de COVID-19, los expertos en salud pública dicen que es más importante que nunca vacunarse contra la gripe.
Si una cantidad suficiente de la población se vacuna, más del 45% lo hizo la temporada de gripe pasada, podría ayudar a evitar un escenario de pesadilla este invierno, con hospitales llenos de pacientes con COVID-19 y los que sufren los efectos graves de la influenza.
Además de la posible carga para los hospitales, existe la posibilidad de que las personas contraigan ambos virus y “nadie sabe qué sucede si se contrae influenza y COVID simultáneamente porque nunca sucedió antes”, dijo la doctora Rachel Levine, secretaria de Salud de Pennsylvania, a reporteros.
En respuesta, este año los fabricantes están produciendo más suministros de vacunas, entre 194 y 198 millones de dosis, unas 20 millones más de las que se distribuyeron la temporada pasada, según los Centros para el Control y Prevención de Enfermedades (CDC).
Mientras se acerca la temporada de gripe, aquí hay algunas respuestas a preguntas frecuentes:
P: ¿Cuándo debo vacunarme contra la gripe?
La publicidad ya ha comenzado y algunas farmacias y clínicas ya tienen sus suministros. Pero, debido a que la efectividad de la vacuna puede disminuir con el tiempo, los CDC recomiendan no recibir la dosis en agosto.
Muchas farmacias y clínicas comenzarán las inmunizaciones a principios de septiembre. Generalmente, los virus de la influenza comienzan a circular a mediados o fines de octubre, pero se expanden masivamente más tarde, en el invierno. Se necesitan aproximadamente dos semanas después de recibir la inyección para que los anticuerpos, que circulan en la sangre y frustran las infecciones, se acumulen.
“Las personas jóvenes y sanas pueden comenzar a vacunarse contra la gripe en septiembre, y las personas mayores y otras poblaciones vulnerables pueden hacerlo en octubre”, dijo el doctor Steve Miller, director clínico de la aseguradora Cigna.
Los CDC recomiendan que las personas “se vacunen contra la influenza a fines de octubre”, pero señalaron que se puede recibir la vacuna más tarde porque “aún puede ser beneficiosas y la vacunación debe ofrecerse a lo largo de toda la temporada de influenza”.
Aun así, algunos expertos recomiendan no esperar demasiado este año, no solo por COVID-19, sino también en caso de que haya escasez debido a la abrumadora demanda.
P: ¿Cuáles son las razones por las que las que debería ofrecer mi brazo para vacunarme?
Hay que vacunarse porque brinda protección contra la gripe y, por lo tanto, contra la propagación a otras personas, lo que puede ayudar a disminuir la carga para los hospitales y el personal médico.
Y hay otro mensaje que puede resonar en estos tiempos extraños.
“Le da a la gente la sensación de que hay algunas cosas que pueden controlar”, dijo Eduardo Sánchez, director médico de prevención de la American Heart Association.
Si bien una vacuna contra la gripe no evitará COVID-19, recibirla podría ayudar al médico a diferenciar entre las dos enfermedades si se desarrolla algún síntoma (fiebre, tos, dolor de garganta) que ambas infecciones comparten, explicó Sánchez.
Y aunque las vacunas contra la gripe no evitarán todos los casos de gripe, vacunarse puede reducir la gravedad si la persona se enferma, dijo.
Todas las personas elegibles, especialmente los trabajadores esenciales, los que sufren de afecciones subyacentes y aquellos en mayor riesgo, incluidos los niños muy pequeños y las mujeres embarazadas, deben buscar protección, dijeron los CDC. La entidad recomienda la vacunación a partir de los 6 meses.
P: ¿Qué sabemos sobre la efectividad de la vacuna de este año?
Se deben producir nuevas vacunas contra la gripe cada año, porque el virus muta y la efectividad de la vacuna varía, dependiendo de qué tan bien coincida con el virus circulante.
Se calculó que la formulación del año pasado tuvo una eficacia de aproximadamente un 45% para prevenir la gripe en general, con una efectividad de aproximadamente un 55% en los niños. Las vacunas disponibles en el país este año tienen como objetivo prevenir al menos tres cepas diferentes del virus, y la mayoría cubre cuatro.
Todavía no se sabe qué tan bien coincidirá el suministro de este año con las cepas que circularán en los Estados Unidos. Las primeras indicaciones del hemisferio sur, que atraviesa su temporada de gripe durante nuestro verano, son alentadoras. Allí, las personas practicaron el distanciamiento social, usaron máscaras y se vacunaron en mayor número este año, y los niveles mundiales de gripe son más bajos de lo esperado. Sin embargo, expertos advierten que no se debe contar con una temporada igual de suave en los Estados Unidos, en parte porque los esfuerzos por usar mascara facial y de distanciamiento social varían ampliamente.
P: ¿Qué están haciendo diferente los seguros y sistemas de salud este año?
Las aseguradoras y los sistemas de salud contactados por KHN dicen que seguirán las pautas de los CDC, que exigen limitar y espaciar la cantidad de personas que esperan en las filas y las áreas de vacunación. Algunos están programando citas para vacunas contra la gripe para ayudar a controlar el flujo.
Health Fitness Concepts, una compañía que trabaja con UnitedHealth Group y otras empresas para establecer clínicas de vacunación contra la gripe en el noreste del país, dijo que está “fomentando eventos más pequeños y frecuentes para apoyar el distanciamiento social” y “exigiendo que se completen todos los formularios y arremangarse las camisas antes de entrar al área de vacunación contra la influenza”.
Se requerirá que todos usen máscaras.
Además, a nivel nacional, algunos grupos médicos contratados por UnitedHealth instalarán carpas, para que las inyecciones se puedan administrar al aire libre, dijo un vocero.
Kaiser Permanente planifica las vacunas directamente en autos en algunos de sus centros médicos y está probando los procedimientos de detección y registro sin contacto en algunos lugares.
Geisinger Health, un proveedor de salud regional en Pennsylvania y Nueva Jersey, dijo que también tendría programas de vacunación contra la influenza al aire libre en sus instalaciones.
Además, “Geisinger exige que todos los empleados reciban la vacuna contra la influenza este año”, dijo Mark Shelly, director de prevención y control de infecciones del sistema. “Al dar este paso, esperamos transmitir a nuestros vecinos la importancia de la vacuna contra la influenza para todos”.
P: Por lo general, me vacunan contra la gripe en el trabajo. ¿Seguirá siendo una opción este año?
Con el objetivo de evitar riesgosas reuniones en interiores, muchos empleadores se muestran reacios a patrocinar las clínicas de gripe en oficinas como han ofrecido en años anteriores. Y con tanta gente que sigue trabajando desde casa, hay menos necesidad de llevar las vacunas contra la gripe al lugar de trabajo. En cambio, muchos empleadores están alentando a los trabajadores a que reciban vacunas de sus médicos de atención primaria, en farmacias u otros entornos comunitarios. El seguro generalmente cubrirá el costo de la vacuna.
Algunos empleadores están considerando ofrecer cupones para vacunas contra la gripe a sus trabajadores sin seguro o a aquellos que no participan en el plan médico de la compañía, dijo Julie Stone, directora general de salud y beneficios de Willis Towers Watson, una firma consultora.
Estos cupones podrían, por ejemplo, permitir a los trabajadores obtener la vacuna en un laboratorio en particular sin costo.
Algunos empleadores están comenzando a pensar en cómo podrían usar sus estacionamientos para administrar vacunas contra la gripe enlos autos, dijo el doctor David Zieg, líder de servicios clínicos para el consultor de beneficios Mercer.
Aunque la ley federal permite a los empleadores exigir a los empleados que se vacunen contra la gripe, ese paso generalmente lo toman solo los centros de atención médica y algunas universidades donde las personas viven y trabajan en estrecha colaboración, dijo Zieg.
Pero sucede. El mes pasado, el sistema de la Universidad de California emitió una orden ejecutiva que requiere que todos los estudiantes, profesores y personal se vacunen contra la gripe antes del 1 de noviembre, con limitadas excepciones.
P: ¿Qué están haciendo las farmacias para alentar a las personas a vacunarse contra la gripe?
Algunas farmacias están haciendo un esfuerzo adicional para salir a la comunidad y ofrecer vacunas contra la gripe.
Walgreens, que tiene casi 9,100 farmacias en todo el país, continúa una asociación iniciada en 2015 con organizaciones comunitarias, iglesias y empleadores que ha ofrecido alrededor de 150,000 clínicas de gripe móviles hasta la fecha.
El programa pone especial énfasis en trabajar con poblaciones vulnerables y en áreas desatendidas, dijo el doctor Kevin Ban, director médico de la cadena de farmacias.
Tanto Walgreens como CVS están estimulando a las personas a programar citas y hacer trámites en línea este año para minimizar el tiempo que pasan en los locales.
En los CVS MinuteClinic, una vez que los pacientes se han registrado para recibir la vacuna contra la gripe, deben esperar afuera o en su automóvil, ya que las áreas de espera interiores ahora están cerradas.
“No tenemos un arsenal contra COVID”, dijo Ban, de Walgreens. “Pero quitar la presión del sistema de atención médica proporcionando vacunas por adelantado es algo que sí podemos hacer”.
Flu season will look different this year, as the country grapples with a coronavirus pandemic that has killed more than 172,000 people. Many Americans are reluctant to visit a doctor’s office and public health officials worry people will shy away from being immunized.
Although sometimes incorrectly regarded as just another bad cold, flu also kills tens of thousands of people in the U.S. each year, with the very young, the elderly and those with underlying conditions the most vulnerable. When coupled with the effects of COVID-19, public health experts say it’s more important than ever to get a flu shot.
If enough of the U.S. population gets vaccinated — more than the 45% who did last flu season — it could help head off a nightmare scenario in the coming winter of hospitals stuffed with both COVID-19 patients and those suffering from severe effects of influenza.
Aside from the potential burden on hospitals, there’s the possibility people could get both viruses — and “no one knows what happens if you get influenza and COVID [simultaneously] because it’s never happened before,” Dr. Rachel Levine, Pennsylvania’s secretary of health, told reporters this month.
In response, manufacturers are producing more vaccine supply this year, between 194 million and 198 million doses, or about 20 million more than they distributed last season, according to the Centers for Disease Control and Prevention.
As flu season approaches, here are some answers to a few common questions:
Q: When should I get my flu shot?
Advertising has already begun, and some pharmacies and clinics have their supplies now. But, because the effectiveness of the vaccine can wane over time, the CDC recommends against a shot in August.
Many pharmacies and clinics will start immunizations in early September. Generally, influenza viruses start circulating in mid- to late October but become more widespread later, in the winter. It takes about two weeks after getting a shot for antibodies — which circulate in the blood and thwart infections — to build up. “Young, healthy people can begin getting their flu shots in September, and elderly people and other vulnerable populations can begin in October,” said Dr. Steve Miller, chief clinical officer for insurer Cigna.
The CDC has recommended that people “get a flu vaccine by the end of October,” but noted it’s not too late to get one after that because shots “can still be beneficial and vaccination should be offered throughout the flu season.”
Even so, some experts say not to wait too long this year — not only because of COVID-19, but also in case a shortage develops because of overwhelming demand.
Q: What are the reasons I should roll up my sleeve for this?
Get a shot because it protects you from catching the flu and spreading it to others, which may help lessen the burden on hospitals and medical staffs.
And there’s another message that may resonate in this strange time.
“It gives people a sense that there are some things you can control,” said Eduardo Sanchez, chief medical officer for prevention at the American Heart Association.
While a flu shot won’t prevent COVID-19, he said, getting one could help your doctors differentiate between the diseases if you develop any symptoms — fever, cough, sore throat — they share.
And even though flu shots won’t prevent all cases of the flu, getting vaccinated can lessen the severity if you do fall ill, he said.
You cannot get influenza from having a flu vaccine.
All eligible people, especially essential workers, those with underlying conditions and those at higher risk — including very young children and pregnant women — should seek protection, the CDC said. It recommends that children over 6 months old get vaccinated.
Q: What do we know about the effectiveness of this year’s vaccine?
Flu vaccines — which must be developed anew each year because influenza viruses mutate — range in effectiveness annually, depending on how well they match the circulating virus. Last year’s formulation was estimated to be about 45% effective in preventing the flu overall, with about a 55% effectiveness in children. The vaccines available in the U.S. this year are aimed at preventing at least three strains of the virus, and most cover four.
It isn’t yet known how well this year’s supply will match the strains that will circulate in the U.S. Early indications from the Southern Hemisphere, which goes through its flu season during our summer, are encouraging. There, people practiced social distancing, wore masks and got vaccinated in greater numbers this year — and global flu levels are lower than expected. Experts caution, however, not to count on a similarly mild season in the U.S., in part because masking and social distancing efforts vary widely.
Q: What are insurance plans and health systems doing differently this year?
Insurers and health systems contacted by KHN say they will follow CDC guidelines, which call for limiting and spacing out the number of people waiting in lines and vaccination areas. Some are setting appointments for flu shots to help manage the flow.
Health Fitness Concepts, a company that works with UnitedHealth Group and other businesses to set up flu shot clinics in the Northeast, said it is “encouraging smaller, more frequent events to support social distancing” and “requiring all forms to be completed and shirtsleeves rolled up before entering the flu shot area.” Everyone will be required to wear masks.
Also, nationally, some physician groups contracted with UnitedHealth will set up tent areas so shots can be given outdoors, a spokesperson said.
Kaiser Permanente plans drive-thru vaccinations at some of its medical facilities and is testing touch-free screening and check-in procedures at some locations. (KHN is not affiliated with Kaiser Permanente.)
Geisinger Health, a regional health provider in Pennsylvania and New Jersey, said it, too, would have outdoor flu vaccination programs at its facilities.
Additionally, “Geisinger is making it mandatory for all employees to receive the flu vaccine this year,” said Mark Shelly, the system’s director of infection prevention and control. “By taking this step, we hope to convey to our neighbors the importance of the flu vaccine for everyone.”
Q: Usually I get a flu shot at work. Will that be an option this year?
Aiming to avoid risky indoor gatherings, many employers are reluctant to sponsor the on-site flu clinics they’ve offered in years past. And with so many people continuing to work from home, there’s less need to bring flu shots to employees on the job. Instead, many employers are encouraging workers to get shots from their primary care doctors, at pharmacies or in other community settings. Insurance will generally cover the cost of the vaccine.
Some employers are considering offering vouchers for flu shots to their uninsured workers or those who don’t participate in the company plan, said Julie Stone, managing director for health and benefits at Willis Towers Watson, a consulting firm. The vouchers could allow workers to get the shot at a particular lab at no cost, for example.
Some employers are starting to think about how they might use their parking lots for administering drive-thru flu shots, said Dr. David Zieg, clinical services leader for benefits consultant Mercer.
Although federal law allows employers to require employees to get flu shots, that step is typically taken only by health care facilities and some universities where people live and work closely together, Zieg said.
Q: What are pharmacies doing to encourage people to get flu shots?
Some pharmacies are making an extra push to get out into the community to offer flu shots.
Walgreens, which has nearly 9,100 pharmacies nationwide, is continuing a partnership begun in 2015 with community organizations, churches and employers that has offered about 150,000 off-site and mobile flu clinics to date.
The program places a special emphasis on working with vulnerable populations and in underserved areas, said Dr. Kevin Ban, chief medical officer for the drugstore chain.
New rules by the Center for Medicare and Medicaid Services would penalize hospitals and laboratories that report Covid-19 data. Hospitals would be required to report the number of confirmed or suspected Covid-19 patient, occupied beds, and availability of ventilators and other critical supplies.
Detective Ryan Holets, whose personal story includes the adoption of an infant born to a drug-addicted mother, addressed the Republican National Convention on its second night.
He praised President Donald Trump’s efforts in addressing drug and opioid abuse and noted “drug overdose deaths decreased in 2018 for the first time in 30 years.”
The detective has worked for the Albuquerque, New Mexico, police department for nine years and was invited by Trump to the 2018 State of the Union address. The year before, Holets promised an addicted mom that he and his wife would adopt her baby — and they did.
Holets has seen the results of the nation’s drug crisis both professionally and personally. We reached out to the Albuquerque Police Department for the source of Holets’ data, but did not get a response.
The nation’s opioid crisis has been a talking point in Trump’s campaign since 2016 – and his administration has touted efforts it has made to provide money to states for treatment and other programs, so we decided to look into it.
Did the death rate mark the decline in 2018 that Holets noted? Yes, but that’s not the whole story.
Two-thirds of those drug overdose deaths involved some type of opioid, including those given by prescription or those purchased illicitly, such as heroin.
The CDC cites a rise in opioid deaths as coming in three “waves.”
The origin of the first wave came after doctors began prescribing more opioids for pain relief in the 1990s, with data showing a rise in deaths emerging around 1999, the CDC said.
Another wave began in 2010, this one was fueled by deaths involving the illegal use of heroin. That was followed quickly by the third wave, starting in 2013, with increases in deaths associated with synthetic opioids, particularly illicitly manufactured fentanyl.
Despite the rising number of deaths, opioid prescribing continued to rise, fueled in part by marketing campaigns aimed at physicians by drug manufacturers. The total number of prescriptions peaked in 2012 at more than 81 prescriptions per 100 people in the U.S., according to CDC data.
To combat that, a growing number of prescribing recommendations have been issued by physician and hospital groups, aimed at reducing the number of pills per prescription and the total number of prescriptions.
The overall prescribing rate fell to 51 prescriptions per 100 people by 2018, according to the CDC.
Still, Americans are more likely to fill a prescription painkiller than patients in other countries and the rate of opioid prescriptions in the U.S. remains among the highest in the world.
Deaths associated with all types of opioid use — from prescriptions to street use — are a lagging indicator of the number of people dependent or addicted to the drugs, said experts. Death rates can be affected by improved access to treatments to help people quit, as well as increased use of overdose reversal treatments, such as naloxone.
The Trump administration has continued and expanded funding efforts, some of which began under President Barack Obama, to help provide treatment, research and other services.
Yet the administration is also actively seeking to end the Affordable Care Act, which includes a provision requiring insurers to offer substance abuse treatment and has expanded access to treatment through Medicaid in the majority of states that fully implemented the law.
So What Happened With Drug Overdose Deaths?
Drug overdose deaths did decrease from 2017 to 2018, dropping by about 4.1%, according to the CDC. Still, the agency notes that the crisis is far from over, as the number of overdose deaths was four times higher in 2018 than in 1999.
Parsing those numbers further, the decrease in deaths in 2018 came in three categories, with prescription-involved opioid deaths falling the most at a 13.5% decrease, followed by heroin deaths, down 4%.
Conversely, deaths associated with the use of synthetic man-made opioids, such as fentanyl, rose by 10%.
So Holets was correct to say drug overdose deaths fell in 2018.
But that statistic doesn’t put the issue in perspective.
“It did decrease slightly, meaning it went from 134 deaths a day to 130 deaths a day,” noted Chad Brummett, a director of the Michigan Opioid Prescribing Engagement Network, a collaboration of physicians that makes recommendations on prescribing.
“It’s disingenuous to pretend that was a huge win,” said Amy Bohnert, associate professor at the University of Michigan. “As someone who does research on this, I would be reluctant to consider a change of that scale to be clearly a sign of a real change as opposed to random error.”
Brandeis University professor Andrew Kolodny said it was the first overall downtick in drug overdoses in 30 years, but he would parse it a bit for opioids, saying it was the first decline in 25 years.
However, a bigger issue for Kolodny is that the speaker failed to mention that drug overdose numbers went up again last year.
“It is misleading to point to a slight reduction in 2018, when deaths went up again in 2019 and we remain at record high levels of opioid deaths,” said Kolodny, medical director for the Opioid Research Collaborative at the Heller School for Social Policy and Management.
The CDC says preliminary data shows reported overdose deaths went up 6% in the 12 months ending in January 2020.
Holets is correct in saying that overall drug overdose deaths ticked down in 2018, although a small category of deaths — those related to fentanyl — actually rose. And it’s pretty close to 30 years since there was a decline.
Still, Holets failed to mention that drug overdose deaths went up again last year, according to preliminary data from the CDC. Also left unsaid were all the factors that may be going into the rising or falling drug death rates — and what that may say about the underlying level of dependence or addiction.
Even as his state is a hotbed for COVID-19, Florida Gov. Ron DeSantis has been pushing schools to reopen so parents have the choice of sending children back to the classroom or keeping them home to learn virtually.
The Republican governor has said children without any underlying health conditions would benefit from in-person learning and the stimulation and companionship of being among other young people. He has also made clear that he thinks these benefits far outweigh what he considers to be minimal risks.
“The fact is, in terms of the risk to schoolkids, this is lower risk than seasonal influenza,” DeSantis said, during an Aug. 10 televised roundtable discussion on education.
DeSantis’ assertion got us wondering, so we asked the governor’s office what evidence it had to back up the claim.
Looking at the Numbers
A spokesperson responded with data from the Florida Department of Health showing the state’s COVID-19 mortality rate is 0.02% for people 24 and younger. That’s the same as the influenza mortality rate for this age group.
But for children 14 and younger, the spokesperson said, Florida’s COVID-19 mortality rate is 0.009%, far below the 0.01% for flu for that age group.
And the risk of death is not the only concern children face if infected by the COVID-19 virus. They can develop complications that require hospitalization.
“The risk of complications for healthy children is higher for flu compared to COVID-19,” according to the Centers for Disease Control and Prevention. “However, infants and children with underlying medical conditions are at increased risk for both flu and COVID-19.”
The CDC estimates there were 480 deaths among U.S. children due to flu in the 2018-19 season, including 136 cases in which the virus was confirmed by laboratory testing.
As of mid-August, 90 children died of COVID-19 in the United States, according to the American Academy of Pediatrics.
More than 46,000 children were hospitalized for flu in that 2018-19 period. The hospitalization rate among children 5 to 17 was 39.2 children per 100,000 children.
The hospitalization rate for COVID-19 is six per 100,000 children for those ages 5 to 17, according to the CDC.
The number and rate of COVID cases in children in the United States steadily increased from March to July. “The true incidence of SARS-CoV-2 infection in children is not known due to lack of widespread testing and the prioritization of testing for adults and those with severe illness,” the CDC wrote recently.
While children have lower rates of using a ventilator than adults, 1 in 3 children hospitalized with COVID-19 in the United States were admitted to the intensive care unit, the same rate as for adults, the CDC said.
Dr. Chad Vercio, chair of pediatrics at Riverside University Health System in California, said DeSantis’ statement is partly true, with many caveats. Children’s risk from COVID-19 “entirely depends on how widespread COVID is in any area,” he said.
Data Reflects a Snapshot in Time
U.S. hospitalization rates for children with COVID are lower than for those with flu, Vercio said. But that could be due to parents keeping children home and schools being closed since March, he added. “It is unknown if these COVID hospitalization rates would rise when we open schools,” he said.
About two-thirds of Florida school districts have opened in the past two weeks with the rest planning to resume by Aug. 31. Most districts are offering in-person classes while giving parents the option to keep students home for virtual learning. In South Florida, where the pandemic has hit hardest, districts are planning, at least initially, to offer only virtual teaching.
Hillsborough County, which includes Tampa, had initially planned to reopen classrooms but reversed itself after doctors warned that school closures were likely to ensue. The county revised its plan to limit classes to online-only instruction, but the state’s education commissioner rejected that approach, saying it denies parents the option of sending their children back to school. Fearing the loss of millions of dollars in state funding, the district now plans to begin virtual learning for all students on Aug. 24, and, on Aug. 31, begin offering students the option to return to the classroom.
“The direct impact of COVID-19 on children is currently small in comparison with other risks and … the main reason we are keeping children at home is to protect adults,” concluded a report in the British Medical Journal published in June. Still, health authorities say parents should make sure children practice good hygiene and limit playtime with other children.
Based on data from February through mid-May, the report found 44 deaths from COVID-19 for people 19 and younger in France, Germany, Italy, Korea, Spain, England and the United States. In a typical three-month period, there would be 308 deaths from lower respiratory tract infections, including flu, in those countries.
“At this stage of the pandemic, COVID appears to be less dangerous for children than influenza,” said Sunil Bhopal, a co-author of the report and an academic clinical lecturer at Newcastle University in England.
“We don’t need to wait for a whole season because, even at its peak in most countries, COVID killed a smaller number of children than estimated influenza deaths averaged from across a year,” Bhopal said.
“While flu is likely to have caused more deaths than COVID, this may change as the pandemic progresses and major caution is necessary to ensure this doesn’t change,” said Bhopal, an honorary assistant professor at the London School of Hygiene and Tropical Medicine.
Dr. Sean O’Leary, professor of pediatrics at the University of Colorado Anschutz Medical Campus, said the growing number of U.S. deaths could be another reason to think about COVID-19 and children.
“We do know for sure that schoolchildren are major drivers of influenza epidemics in the community and, though that is not as much the case with COVID, it doesn’t mean they can’t spread it,” he said.
DeSantis also maintained that kids are less likely to spread COVID-19 than they are the influenza virus. However, experts cautioned that there’s still a lot that is unknown about children’s ability to transmit the virus to the people they interact with — parents, grandparents and even teachers. The perceived risk for teachers, for instance, is at the root of a lawsuit between the state’s largest teachers union and the DeSantis administration. The Florida Education Association wants a Leon County judge to stop the state’s order forcing school districts to open classrooms for in-person learning by the end of August.
Dr. Gabriela Andujar Vazquez, an infectious disease specialist at Tufts Medical Center in Boston, said children are more likely to have zero or mild symptoms from COVID-19 compared with adults.
“The bottom line is kids can get infected and they tend to have less severe disease,” she said. But the concern over reopening school is that children could spread the disease to others, including adults who are more likely to develop complications.
“Because schools are tied to the community — they are not in a bubble — and if community spread is not controlled in the community, it’s likely the school will reflect that,” she said. One factor that can determine if the disease is out of control is if positivity rates for people getting tested for COVID are over 5%. Many Florida counties have been well above that mark since June, although the rates have been dropping this month.
Back-to-school risks will be handicapped based on the ability of the school to adopt physical distancing measures and enforce wearing of face masks, said Dr. Andrew Pavia, a pediatric infectious disease specialist at the University of Utah Health and Intermountain Primary Children’s Hospital.
“This fall, we may see a lot of kids get infected as schools reopen, and those could be just the tip of the iceberg,” he said. “Even though most kids have mild or asymptomatic cases, what I worry about is just how big is the tip of the iceberg,” Pavia said.
He also noted there is a vaccine for flu — which about 50% to 70% of children receive. “The vaccine is not perfect but does reduce the impact of the disease, and with COVID everyone is at risk and susceptible,” Pavia said.
Dr. Vidya Mony, an infectious disease expert with Santa Clara Valley Medical Center in San Jose, California, said data suggests COVID-19 is not as bad for children as flu and that children are not the main driver of the pandemic. But, she said, there isn’t enough data yet to say indisputably that the COVID-19 risk is lower. “We are learning something every day with this.”
DeSantis said that COVID-19 is a lower risk for schoolchildren than is seasonal influenza.
Studies show the numbers of COVID-related deaths and hospitalizations among children are lower than the average rates for flu. Still, it’s uncertain if these lower rates among children were partly because schools were closed since March and whether those rates will rise as classrooms reopen this fall. It’s also unclear whether opening schools — particularly in communities with a high number of people testing positive — will lead to more spread of the disease.
The third night of the Democratic National Convention was all about one thing: Sen. Kamala Harris of California becoming the first Black and Indian American woman to accept a major political party’s vice presidential nomination.
But key Democratic criticisms — many rooted in health care issues and the COVID-19 pandemic — were repeated throughout the evening.
Hillary Clinton took an early swipe at President Donald Trump’s coronavirus response, describing how he has fallen short despite coming in “with so much set up for him,” such as “plans for managing crises — including a pandemic.”
House Speaker Nancy Pelosi reupped another criticism of Trump and his fellow Republicans: “Instead of crushing the virus, they’re trying to crush the Affordable Care Act and its preexisting conditions benefit,” she said.
During her acceptance speech, Harris issued her harsh rebuke: “Donald Trump’s failure of leadership has cost lives and livelihoods.”
Our partners at PolitiFact did a thorough rundown on many of the evening’s claims. Here’s one of our favorites:
“And while this virus touches us all, we’ve got to be honest: It is not an equal opportunity offender. Black, Latino and Indigenous people are suffering and dying disproportionately.” — Democratic vice presidential nominee Kamala Harris
This is true, based on available data.
The Centers for Disease Control and Prevention has broken down some COVID data by race and ethnicity; however, not all cases reported include demographic information. Of the cases that do, Hispanic/Latino people have represented 31% of cases and 16.9% of deaths. Black people account for 19.8% of cases and 22.3% of deaths. And American Indians and Alaska Natives make up 1.2% of cases and 0.8% of deaths.
This data isn’t balanced against what proportion of the population fits into each group. Other sources have attempted to provide such context.
The COVID Racial Data Tracker has asked every state to report complete data by race and ethnicity. These data sets are then analyzed against Census Bureau demographic statistics. According to the tracker’s website, Black people nationwide are dying from COVID-19 at 2.4 times the rate of white people. In May, NPR analyzed data from the COVID Racial Data Tracker and reported that in 42 states and Washington, D.C., Hispanics and Latinos make up a greater share of COVID-19 confirmed cases than their share of the population. White deaths from COVID-19 were found to be lower than their share of the population in 37 states and Washington, D.C.
In addition, The New York Times has analyzed CDC data by race and ethnicity. According to its July analysis, the Times found that Latinos and African Americans in the U.S. are three times as likely to become infected with COVID-19 as white people. And Blacks and Latinos are also twice as likely to die from COVID-19 as white people.
The New York Times also analyzed limited data from state and local health agencies on COVID-19’s impact on the Native American community in July. In its analysis, the rate of known cases in eight counties with the largest populations of Native Americans is nearly double the national average. There were also smaller counties with large Native American populations that had high COVID-19 case rates.
By 1926, lead poisoning was already “of relatively frequent occurrence in children,” yet “the United States continued to allow the use of lead-based paint until 1978.” In contrast, in Europe, many countries said, Hmm, poisoning children? No, thanks. and “banned the use of lead-based paint as early as 1909.”
“The delay in banning lead-based paint in the United States was due largely to the marketing and lobbying efforts of the lead industry,” profiting from the poison. It knew it couldn’t hold off forever, but the industry boasted that its “victories have been in the deferral of implementation of…regulations.”
And now, “peeling paint turns into poisonous dust,” and guess where it ends up? As a Mount Sinai dean and a Harvard neurology professor put it: “Lead is a devastating poison. It damages children’s brains, erodes intelligence, diminishes creativity…” and judgment and language. Yet, despite the accumulating evidence, the lead industry didn’t just fail to warn people—“it engaged in an energetic promotion of lead paint.” After all, a can of pure white lead paint had huge amounts of lead, which meant huge profits for the industry.
But, as you can see in an old advertisement featured at 1:55 in my video, “[t]here is no cause for worry” if your toddler rubs up against lead paint, because those “fingerprint smudges or dirt spots” can be removed “easily without harming the paint.” Wouldn’t want to harm the paint. After all, “painted walls are sanitary…”
The director of the Lead Industry Association blamed the victims: “Childhood lead poisoning is essentially a problem of slum dwellings and relatively ignorant parents.”
“It seems that no amount of evidence, no health statistics, no public outrage could get industry to care that their lead paint was killing and poisoning children,” but how much public outrage was there really?
“It goes without saying that lead is a devastating, debilitating poison” and that “literally millions of children have been diagnosed with varying degrees of elevated blood lead levels…” Compare that to polio, for example. “In the 1950s, for example, fewer than sixty thousand new cases of polio per year created a near-panic among American parents and a national mobilization that led to vaccination campaigns that virtually wiped out the disease within a decade.” In contrast, despite “many millions of children [who have] had their lives altered for the worse by exposure to lead…[a]t no point in the past hundred years has there been a similar national mobilization over lead.” Today, after literally a century, the Centers for Disease Control and Prevention estimates over five hundred thousand children still suffer from “elevated blood-lead levels.”
The good news is that blood lead levels are in decline, which is celebrated as one of our great public health achievements. But, given what we knew, and for how long we knew, “it is presumptuous to declare the decline in childhood lead poisoning a public health victory.” Indeed, “even if we were victorious…it would be a victory diminished by our failure to learn from the epidemic and take steps to dramatically reduce exposures to other confirmed and suspected environmental toxicants as well as chemicals of uncertain toxicity.”
That’s one of the reasons I wanted to do this series on lead. We need to learn from our history so the next time some industry wants to sell something to our kids, we’ll stick to the science. And, of course, lead levels aren’t declining for everyone.
As the whistle-blowing pediatrician who helped expose the Flint drinking water crisis explained, “The people in Flint have a 20-year lower life expectancy than people in a neighboring suburb. We were already struggling with every barrier to our children’s success. Then we gave them lead.”
Her research showed that the switch in water supplies from the Great Lakes to the polluted Flint River “created a perfect storm” for lead contamination, doubling the percentage of kids with elevated lead levels in their blood, as you can see at 0:42 in my video How the Leaded Gas Industry Got Away with It, whereas out in the suburbs, where the water supply remained unchanged, children’s lead levels stayed about the same. That’s how she knew it was the switch in water supplies. That’s what broke the story of the Flint crisis: a doubling of elevated lead levels.
But wait a moment: Even before the switch from Lake Huron to the polluted Flint River, when everyone was getting the same water, lead levels in children in Flint were twice that of the suburbs. There was already a doubling in elevated lead levels in Flint and other poor communities around the country, but where have all the crisis headlines been? Indeed, even with all the bottled water in the world, the children in Flint will continue to live in a lead-polluted environment.
Many have pointed out the irony that the new water from the Flint River was “so corrosive” that the nearby General Motors plant switched back to a clean water source when it started noticing rust spots on its new parts, all while water quality complaints from Flint residents were being ignored. But, there is an additional irony: General Motors is a major reason why the world is so contaminated with lead in the first place, as GM invented leaded gasoline. “Shortly after manufacture began, workers…began to become floridly psychotic and die.”
“In the wake of blaring headlines” about the lead-poisoned workers, public health leaders “warned of the potential for damage to broad swaths of the population” posed by putting this “well established toxin” into gasoline, “into the daily lives of millions of people. Yet, despite these warnings, millions…were harmed…and this entirely preventable poisoning still occurs today.”
“Virtually all the lead in the environment is there as a result of human activity.” Because we put it there. It used to be locked away, deep underground or under the ocean, but that was before we drove it around the Earth. “In the early 1970s, 200,000 tons of lead was emitted from automobiles in the United States each year, mostly in urban areas.” Had lead not been added to gasoline, the industry would have had to use higher-octane gas, which is less profitable. So, the “oil and lead industries…successfully thwarted government efforts to limit lead in gasoline for 50 years.” But, how were they able to do that? “Early public health warnings were not heeded because the industry assured the scientific community and the public that there was no danger.” I could see how a gullible public might be swayed by slick PR, but how do you manipulate the scientific community? By manipulating the science.
“The lead industry was able to achieve its influence in large part by being the primary supporter of research on health effects of lead,” and it got the best science money could buy. “Long before Big Tobacco, the lead industry understood the inestimable value of purchasing ‘good science.’”
“Consequently, the vast majority of relevant studies of lead in gasoline published [for decades]…were favorable to the lead industries.” What’s more, they “even sent a delegation to try to convince the U.S. EPA administrator that the lead regulation was not necessary because they alleged lead was an essential mineral required for optimum growth and development.”
Of course, the exact opposite is true. Lead is toxic to development. There are, however, nutritional interventions that can help alleviate lead toxicity. For example, there are food components that can help decrease the absorption of lead and help flush it out of your body. I’ve produced a series of three videos on specific dietary interventions, such as particular foods to eat, but—spoiler alert—in general, “food patterns that reduce susceptibility to lead toxicity are consistent with the recommendations for a healthy diet.”
As soon as I learned about the unfolding crisis in Flint, Michigan, I knew I had to take a deep dive into the medical literature to see if there is anything these kids might be able to do diet-wise to reduce their body burden.
Most of the time when I cover a subject on NutritionFacts.org, I’ve addressed it previously, so I just have to research the new studies published in the interim. But I had never really looked deeply into lead poisoning before, so I was faced with more than a century of science to dig through. Yes, I did discover there were foods that could help, but I also learned about cautionary tales like this one about our shameful history with leaded paint. By learning this lesson, hopefully, we can put more critical thought into preventing future disasters that can arise when our society allows profits to be placed over people.
This is part of a series on lead. You can view the rest of the series here:
KNOXVILLE, Tennessee.- Es una época de mucho trabajo para las granjas productoras de tomate en esta parte del estado. Estas plantaciones cuentan con cientos de trabajadores, la mayoría latinos. Algunos viven allí. Otros son migrantes que viajan de granja en granja, para recoger las cosechas de verano. Otros vienen de México o Centroamérica con visas agrícolas temporales.
Pero este año, la temporada se desarrolla con enormes preocupaciones por el coronavirus que afecta directamente a estos trabajadores agrícolas.
“Casi todas las fases del proceso de recolección de tomates deben ser consideradas a la luz de COVID-19”, dijo Ken Silver, profesor asociado de salud ambiental en la Universidad Estatal del Este de Tennessee, que estudia la salud de los trabajadores migrantes en las plantaciones de tomates del estado.
Los trabajadores viven en alojamientos cerrados, durmiendo en literas y compartiendo baños y cocinas. Viajan a los campos en autobuses abarrotados y a menudo trabajan en grupos. Y aunque los empleados de las granjas son considerados trabajadores esenciales, suelen no tener seguro médico o licencia paga por enfermedad.
Las granjas ya han informado de brotes entre cientos de trabajadores en estados como California, Washington, Florida y Michigan. Sin embargo, el gobierno federal no ha establecido ninguna normativa para proteger a los trabajadores agrícolas del coronavirus o para instruir a los empleadores sobre lo que deben hacer cuando sus se enferman.
Mientras que organizaciones de defensa de los trabajadores migrantes dicen que esto permite a las granjas aprovecharse de sus trabajadores y aumentar su riesgo de exposición al coronavirus, las granjas aseguran que están haciendo lo que pueden para proteger a los trabajadores con los recursos limitados que tienen, mientras no se deja de hacer el trabajo.
Lo cierto es que la situación no está clara, expresó Alexis Guild, director de políticas y programas de salud de Farmworker Justice.
La responsabilidad de las granjas
En junio, 10 de los 80 trabajadores temporales de Jones & Church Farms en el condado de Unicoi, Tennessee, dieron positivo para el coronavirus. Otra granja en ese condado tenía 38 trabajadores que también dieron positivo alrededor de la misma época.
“Esto fue lo más aterrador que pudo pasarnos”, dijo Renea Jones Rogers, directora de seguridad alimentaria de la granja.
A nivel nacional, ha habido al menos 3,600 casos de trabajadores agrícolas que han dado positivo para COVID-19, según los informes de los medios de comunicación reunidos por el Centro Nacional para la Salud de los Trabajadores Agrícolas.
A esto hay que añadir que tanto los empleadores como los trabajadores agrícolas reconocen que incluso las intervenciones más básicas para frenar la transmisión —el distanciamiento social y el uso de máscaras— a menudo no son factibles, al trabajar en altas temperaturas.
Saúl, de 52 años, es un trabajador agrícola temporal que ha viajado de México a Virginia todos los años desde 1996 para cosechar tabaco. En una entrevista por WhatsApp, dijo que las máscaras son incómodas en el trabajo porque estás al aire libre: “Es incómodo porque trabajamos a la intemperie”. (Kaiser Health News no publica el apellido de Saúl para que no sea identificado por su empleador).
Saúl dijo que le preocupa el coronavirus, pero como vive en su lugar de trabajo, en la granja, se siente seguro.
Cuando llegó a los Estados Unidos en abril, la granja le proporcionó información sobre la pandemia, máscaras y desinfectante de manos, explicó. Nadie le toma la temperatura, pero trabaja en un grupo de ocho personas, vive con tres trabajadores más y nadie en la granja ha sido diagnosticado con COVID-19.
En Tennessee, Jones & Church Farms puso en marcha su propio protocolo de seguridad para los trabajadores al comienzo de la temporada. Esto incluyó el aumento de la desinfección, la toma de lecturas diarias de temperatura y el mantenimiento de los trabajadores en grupos para que vivan y trabajen con las mismas personas.
Después que los 10 trabajadores dieron positivo para COVID-19, la granja los mantuvo a todos en la misma vivienda y lejos de los demás. Los que eran asintomáticos también siguieron trabajando en los campos, aunque alejados de los otros, señaló Jones Rogers.
Si bien el Departamento de Trabajo no ha ofrecido normas federales de seguridad ejecutables para COVID-19, sí colaboró con los Centros para el Control y Prevención de Enfermedades (CDC) para elaborar un conjunto de pautas voluntarias y específicas para la agricultura. Esto se publicó en junio, pocos días después que Jones & Church notificara del brote en la granja.
Mucho de lo que ya se había hecho en Jones & Church, sin embargo, seguía esas recomendaciones, que también sugerían que los trabajadores fueran examinados todos los días para detectar los síntomas de COVID-19 y que a los que se enfermaran se les diera su propio espacio para recuperarse alejados de los demás.
Otras sugerencias de los CDC y el Departamento de Trabajo, orientadas más hacia las factorías de procesamiento de alimentos, como las plantas de empaque de tomates, incluían la instalación de mamparas plásticas si no es posible que haya una distancia de 6 pies entre los trabajadores, la instalación de estaciones de lavado de manos y la provisión de equipos de protección personal o cubiertas de tela para la cara.
En junio, 10 de los 80 trabajadores temporales de Jones & Church Farms en el condado de Unicoi, en Tennessee, dieron positivo para COVID-19. Otra granja de la zona tuvo 38 trabajadores enfermos para la misma fecha. A nivel nacional, se han registrado al menos 3,400 casos positivos entre trabajadores agrícolas, según datos del National Center for Farmworker Health. (Victoria Knight/KHN)
Los activistas dicen que estas directrices son sólidas, en teoría. Su defecto más evidente es que son voluntarias.
“No creemos que la salud y la seguridad de los trabajadores deban dejarse a la buena voluntad de los empleadores”, señaló María Perales Sánchez, coordinadora de comunicaciones del Centro de Los Derechos del Migrante, una organización con oficinas en México y en los Estados Unidos.
Un vocero del Departamento de Trabajo ofreció una perspectiva diferente. “Los empleadores son y seguirán siendo responsables de proporcionar un lugar de trabajo libre de riesgos conocidos para la salud y la seguridad”, indicó, y añadió que los estándares de seguridad general preexistentes de la Administración de Seguridad y Salud Ocupacional (OSHA) y las directrices de los CDC se utilizan para determinar las violaciones a la seguridad en el lugar de trabajo. La OSHA es una agencia del Departamento de Trabajo.
La industria agrícola ha expresado su temor ante cualquier aumento de la regulación federal.
“No creo que OSHA pueda implementar un tipo de regulación obligatoria que no ponga en desventaja a algunos agricultores”, apuntó Allison Crittenden, directora de relaciones con el Congreso de la American Farm Bureau Federation.
Las granjas ya han tomado muchas medidas contra COVID-19, añadió, “y si estas acciones se están llevando a cabo de forma voluntaria, no vemos la razón de imponer un requisito obligatorio”.
Dificultades para acceder a la atención médica
Los trabajadores agrícolas migrantes, a pesar de ocupar un eslabón esencial en la cadena de suministro de alimentos del país, a menudo no reciben prestaciones en el lugar de trabajo, como seguro médico o licencia de enfermedad remunerada.
Saúl, el trabajador agrícola del tabaco de Virginia, dijo que no creía tener ningún seguro médico. Si se enfermara, tendría que decírselo a su empleador, que luego tendría que llevarlo al médico. La ciudad más cercana a la granja está a 15 millas. ¿Quién es responsable de estos costos? ¿El trabajador o la granja? Depende de las circunstancias individuales.
Muchas granjas emplean principalmente trabajadores latinos, y los datos de los CDC ilustran que es mucho más probable que los latinos se infecten, deban hospitalizarse o mueran por complicaciones de COVID que los blancos no hispanos. Los expertos también advierten que debido a que la pandemia de COVID está afectando desproporcionadamente a las personas de minorías, podría ampliar las disparidades de salud preexistentes.
Además, buscar la atención de un médico puede resultar riesgoso para los trabajadores agrícolas migrantes. Los trabajadores indocumentados pueden temer ser detenidos por autoridades de Immigración mientras que los que tienen la residencia permanente (green card) les puede preocupar la “regla de la carga pública” que la administración Trump endureció.
Esta polémica “regla” tiene en cuenta el uso de los programas públicos, incluyendo la atención sanitaria, a la hora de una solicitud de ciudadanía. Sin embargo, el gobierno federal ha dicho que buscar tratamiento por COVID-19 no aplicaría para esa regla.
Y aunque el rastreo de contactos es importante para detener la propagación de COVID-19 entre los trabajadores agrícolas, muchos departamentos de salud no cuentan con traductores que puedan hablar español o lenguas indígenas centroamericanas, ni ha habido un rastreo sistemático a nivel nacional de los brotes de los trabajadores agrícolas hasta ahora, como se ha hecho con los brotes en las instalaciones de cuidados a largo plazo.
Por lo tanto, “es muy difícil saber cuántos trabajadores agrícolas específicamente están dando positivo,” expresó Guild, de Farmworker Justice.
Eso podría ser un problema para rastrear los brotes, especialmente cuando la temporada de cosecha aumenta para ciertos cultivos y las granjas incrementan su fuerza laboral.
A fines de julio, llegaron a Jones & Church Farms casi 90 trabajadores temporales adicionales para ayudar a cosechar tomates hasta octubre, apuntó Jones Rogers. Aunque los 10 trabajadores que tenían COVID-19 se han recuperado, dijo que teme que si más personas contraen la enfermedad, no habrá suficientes viviendas para mantener a los trabajadores enfermos aislados o suficientes trabajadores sanos para la cosecha.
“Los tomates no esperan a que todos se sientan bien para que se los recoja”, añadió Jones Rogers.
La reportera Carmen Heredia Rodríguez y Katie Saviano asistieron con traducción al español para esta historia.
KNOXVILLE, Tenn. — It’s a busy time for the tomato-producing farms in this part of the state. Farms have staffed up with hundreds of workers, most of whom are Latino. Some live locally. Others are migrant workers who travel from farm to farm, chasing the summer growing seasons. Still others come from Mexico or Central America on temporary agricultural visas to work at certain farms.
But, this year, the season is taking place under a cloud of coronavirus worries that, for these agricultural workers, hit close to home.
“Almost every part of the process for picking tomatoes needs to be considered in light of COVID-19,” said Ken Silver, an associate professor of environmental health at East Tennessee State University, who studies migrant worker health on Tennessee tomato farms.
After all, the workers live in close quarters, sleeping in bunk beds, and sharing bathrooms and kitchens. They ride crowded buses to fields and often work in groups. And even though farm employees are deemed essential workers, they often don’t have health insurance or paid sick leave.
Farms have already reported outbreaks among hundreds of workers in states that include California, Washington, Florida and Michigan. And yet, the federal government has not established any enforceable rules either to protect farmworkers from the coronavirus or to instruct employers what to do when their workers get sick. While migrant worker advocacy groups say this allows farms to take advantage of their workers and increase their risk of exposure to the coronavirus, farms say they’re doing what they can to protect workers with the limited resources they have, while also getting their crops harvested.
The situation certainly isn’t clear-cut, said Alexis Guild, director of health policy and programs at the advocacy group, Farmworker Justice.
Leaving It Up to the Farms
In June, 10 temporary workers out of about 80 at the Jones & Church Farms in Unicoi County, Tennessee, tested positive for the coronavirus. Another farm in that county had 38 workers test positive around the same time.
“This was the scariest thing that could happen,” said Renea Jones Rogers, the farm’s food safety director.
Nationally, there have been at least 3,600 cases of farmworkers testing positive for COVID-19, according to media reports gathered by the National Center for Farmworker Health.
Add to this that farm employers and workers alike acknowledge that even the most basic interventions to stop transmission — social distancing and mask-wearing — often aren’t feasible, especially in the hot temperatures.
Saul, 52, is a temporary farmworker who has traveled from Mexico to Virginia every year since 1996 to harvest tobacco. In a WhatsApp message interview, he said masks are uncomfortable on the job because he is working outdoors, writing in Spanish, “En el trabajo es incómodo porque trabajamos al intemperie.” (Kaiser Health News is not publishing Saul’s last name so that he won’t be identified by his employer.)
Saul said he does worry about the coronavirus, but because he lives at his job on the farm, he feels safe.
When he arrived in the U.S. in April, the farm provided him with information about the pandemic, masks and hand sanitizer, he said. Nobody takes his temperature, but he works in a crew of eight, lives with only three other workers and nobody on the farm has yet been diagnosed with COVID-19.
In Tennessee, the Jones & Church Farms put its own worker safety protocols in place at the beginning of the season. These included increasing sanitation, taking daily temperature readings and keeping workers in groups so they live and work with the same people.
After the 10 workers tested positive for COVID-19, the farm kept them all in the same housing unit and away from the other workers — but those who were asymptomatic also kept working in the fields, though they were able to stay away from others on the job, said Jones Rogers.
While the Department of Labor has not offered enforceable federal safety standards for COVID-19, it did collaborate with the Centers for Disease Control and Prevention to publish a set of voluntary, agriculture-specific guidelines. Those were released in June, just days after Jones & Church became aware of the farm’s outbreak.
Much of what had already been done at Jones & Church, though, tracked closely with those recommendations, which also suggested that workers be screened every day for COVID-19 symptoms and that those who become sick be given their own space to recover apart from others.
Other suggestions in the CDC and Labor Department directive, geared more toward indoor food-processing factories such as tomato-packing plants, included installing plastic shields if 6 feet of distance isn’t possible between workers, putting in hand-washing stations and providing personal protective equipment or cloth face coverings.
In June, 10 of about 80 temporary workers at Jones & Church Farms in Unicoi County, Tennessee, tested positive for COVID-19. Another farm in the county had 38 workers test positive around the same time. Nationally, at least 3,400 positive cases among farmworkers have been counted, according to media reports gathered by the National Center for Farmworker Health. (Victoria Knight/KHN)
Advocates say these guidelines are sound, in theory. Their glaring flaw is that they are voluntary.
“We don’t believe that the health and safety of workers should be left to the goodwill of employers,” said María Perales Sanchez, communications coordinator for Centro de Los Derechos del Migrante, an advocacy group with offices in both Mexico and the U.S.
A Department of Labor spokesperson offered a different take. “Employers are and will continue to be responsible for providing a workplace free of known health and safety hazards,” the spokesperson said, adding that the Occupational Safety and Health Administration’s preexisting general-safety standards and CDC guidelines are used to determine workplace safety violations. OSHA is an agency within the Labor Department.
Farm industry groups are apprehensive of any increased federal regulation.
“I don’t think OSHA would be able to have some sort of mandatory regulation that wouldn’t disadvantage some farmers,” said Allison Crittenden, director of congressional relations for the American Farm Bureau Federation.
Farms have already put many COVID-19 protections in place, she said, “and if these actions are taking place in a voluntary way, we don’t see that we need to have a mandatory requirement.”
Difficulties in Accessing Health Care
Migrant farmworkers, despite occupying an essential link in the country’s food supply chain, often aren’t provided with workplace benefits like health insurance or paid sick leave.
Saul, the Virginia tobacco farmworker, said he didn’t believe he has any health insurance. If he gets sick, he would need to tell his farm employer, who would then have to drive him to the doctor. The closest city to the farm is 15 miles away. Who is responsible for these costs — the worker or the farm — depends on individual circumstances.
Many farms employ mostly Latino workers, and CDC data illustrates that it’s much more likely for Hispanic or Latino people to be infected, hospitalized or die from COVID complications than white people. Experts also warn that because the COVID pandemic is disproportionately affecting people of color, it could widen preexisting health disparities.
Also, seeking a doctor’s care can feel risky for migrant farmworkers. Workers who are undocumented may worry about being detained by Immigration and Customs Enforcement, while workers who have green cards may be concerned about the Trump administration’s “public charge rule.” This controversial rule weighs immigrants’ use of public programs, including health care, against their applications for citizenship. However, the federal government has said seeking treatment for COVID-19 wouldn’t fall under the rule.
And while contact tracing is important to stop the spread of COVID-19 among farmworkers, many health departments don’t have translators on staff who can speak Spanish or Indigenous Central American languages, nor has there been a systematic nationwide tracking of farmworker outbreaks thus far, as has been done with long-term care facilities outbreaks.
So “it’s really hard to get a grasp on how many farmworkers specifically are testing positive,” said Guild, with Farmworker Justice.
That could be an issue for tracing outbreaks, especially as the harvesting season ramps up for certain crops and farms bolster their workforces.
At the end of July, almost 90 additional temporary workers arrived at Jones & Church Farms to help harvest tomatoes through October, said Jones Rogers. Though the 10 workers who had COVID-19 have recovered, she said she’s scared that if more get the disease, there won’t be enough housing to keep sick workers separate from others or enough healthy workers to harvest the crops.
“Tomatoes don’t wait until everyone is feeling good to be harvested,” said Jones Rogers.
Reporter Carmen Heredia Rodriguez and Katie Saviano provided Spanish translation assistance for this story.
Millions of people, including the president of the United States, have seen or shared a video in which a doctor falsely claims there is a cure for the coronavirus, and it’s a medley starring hydroxychloroquine.
The video shows several doctors in white coats giving a press conference outside the Supreme Court in Washington, D.C. It persists on social media despite bans from Facebook, Twitter and YouTube, and it was published by Breitbart, a conservative news site.
The July 27 event was organized by Tea Party Patriots, a conservative group backed by Republican donors, and attended by U.S. Rep. Ralph Norman, R-S.C.
In the video, members of a new group called America’s Frontline Doctors touch on several unproven conspiracy theories about the coronavirus pandemic. One of the most inaccurate claims comes from Dr. Stella Immanuel, a Houston primary care physician and minister with a track record of making bizarre medical claims, such as that DNA from space aliens is being used in medical treatments.
“This virus has a cure. It is called hydroxychloroquine, zinc, and Zithromax,” Immanuel said. “I know you people want to talk about a mask. Hello? You don’t need [a] mask. There is a cure.”
As of July 27, nearly 150,000 Americans had died because of the coronavirus. Could those deaths have been prevented by a drug that’s used to treat lupus and arthritis?
No. Immanuel’s statement is wrong on several points.
‘This Virus Has a Cure’
There is no known cure for COVID-19.
According to the Centers for Disease Control and Prevention, there is no specific antiviral treatment for the virus. Supportive care, such as rest, fluids and fever relievers, can assuage symptoms.
“There is currently no licensed medication to cure COVID-19,” according to the World Health Organization.
The Cure Is ‘Hydroxychloroquine, Zinc and Zithromax’
In spite of Immanuel’s anecdotal evidence, hydroxychloroquine alone or in combination with other drugs is not a proven treatment (or cure) for COVID-19.
The Food and Drug Administration has not approved hydroxychloroquine for the prevention or treatment of COVID-19. In mid-June, the FDA revoked its emergency authorization for the use of hydroxychloroquine and the related drug chloroquine in treating hospitalized COVID-19 patients.
“It is no longer reasonable to believe that oral formulations of HCQ and CQ may be effective in treating COVID-19, nor is it reasonable to believe that the known and potential benefits of these products outweigh their known and potential risks,” FDA Chief Scientist Denise M. Hinton wrote.
The WHO and the National Institutes of Health have also stopped their hydroxychloroquine studies. Among the safety issues associated with treating COVID-19 patients with hydroxychloroquine include heart rhythm problems, kidney injuries and liver problems.
While some studies have found that the drug could help alleviate symptoms associated with COVID-19, the research is not conclusive. Few studies have been accepted into peer-reviewed journals. And large, randomized trials — the gold standard for clinical trials — are still needed to confirm the findings of studies conducted since the pandemic began.
In the video, Immanuel cited a 2005 study that found chloroquine — not hydroxychloroquine — was “effective in inhibiting the infection and spread of SARS CoV,” the official name for severe acute respiratory syndrome. But the drug was not tested on humans, the authors wrote that more research was needed to make any conclusions, and SARS is different from COVID-19.
‘You Don’t Need a Mask’
Health officials advise everyone to wear a mask in public.
The reason has to do with how the coronavirus spreads. When an infected person coughs or sneezes, they expel respiratory droplets containing the virus. Those droplets can then land in the mouths or noses of people nearby.
Since some people infected with the coronavirus may exhibit no symptoms, public health officials say everyone should cover their face in public — even if they don’t feel sick.
“The spread of COVID-19 can be reduced when cloth face coverings are used along with other preventive measures, including social distancing, frequent handwashing, and cleaning and disinfecting frequently touched surfaces,” according to the CDC.
In a viral video, Immanuel said there is a cure for COVID-19, hydroxychloroquine can treat it, and people don’t need to wear masks to prevent the spread of the virus.
All of those claims are inaccurate. There is no known cure for COVID-19, hydroxychloroquine is not a proven treatment, and public health officials advise everyone to wear a face mask in public.
Physical fitness authorities seem to have fallen into the same trap as the nutrition authorities, recommending what they think may be achievable, rather than simply informing us of what the science says and letting us make up our own minds.
Researchers who accept grants from The Coca-Cola Company may call physical inactivity “the biggest public health problem of the 21st century,” but, in actually, physical inactivity ranks down at number five in terms of risk factors for death in the United States and even lower in terms of risk factors for disability, as you can see at 0:17 in my video How Much Should You Exercise? What’s more, inactivity barely makes the top ten globally. As we’ve learned, diet is our greatest killer by far, followed by smoking.
Of course, that doesn’t mean you can just sit on the couch all day. Exercise can help with mental health, cognitive health, sleep quality, cancer prevention, immune function, high blood pressure, and life span extension, topics I cover in some of my other videos. If the U.S. population collectively exercised enough to shave just 1 percent off the national body mass index, 2 million cases of diabetes, one and a half million cases of heart disease and stroke, and 100,000 cases of cancer might be prevented.
Ideally, how much should we exercise? The latest official “Physical Activity Guidelines for Americans” recommends adults get at least 150 minutes a week of moderate aerobic exercise, which comes out to be a little more than 20 minutes a day. That is actually down from previous recommendations from the Surgeon General, as well as from the Centers for Disease Control and Prevention (CDC) and the American College of Sports Medicine, which jointly recommend at least 30 minutes each day. The exercise authorities seem to have fallen into the same trap as the nutrition authorities, recommending what they think may be achievable, rather than simply informing us what the science says and letting us make up our own minds. They already emphasize that “some” physical activity “is better than none,” so why not stop patronizing the public and just tell everyone the truth?
As you can see at 2:16 in my video, walking 150 minutes a week is better than walking 60 minutes a week, and following the current recommendations for 150 minutes appears to reduce your overall mortality rate by 7 percent compared with being sedentary. Walking for just 60 minutes a week only drops your mortality rate about 3 percent, but walking 300 minutes weekly lowers overall mortality by 14 percent. So, walking twice as long—40 minutes a day compared with the recommended 20 daily minutes—yields twice the benefit. And, an hour-long walk each day may reduce mortality by 24 percent. I use walking as an example because it’s an exercise nearly everyone can do, but the same applies to other moderate-intensity activities, such as gardening or cycling.
A meta-analysis of physical activity dose and longevity found that the equivalent of about an hour a day of brisk walking at four miles per hour was good, but 90 minutes was even better. What about more than 90 minutes? Unfortunately, so few people exercise that much every day that there weren’t enough studies to compile a higher category. If we know 90 minutes of exercise a day is better than 60 minutes, which is better than 30 minutes, why is the recommendation only 20 minutes? I understand that only about half of Americans even make the recommended 20 daily minutes, so the authorities are just hoping to nudge people in the right direction. It’s like the Dietary Guidelines for Americans advising us to “eat less…candy.” If only they’d just give it to us straight. That’s what I try to do with NutritionFacts.org.
Most of the content in my book How Not to Die came from my video research, but this particular video actually sprung from the book. I wanted to include exercise in my Daily Dozen list, but needed to do this research to see what was the best “serving size.”
I wish someone would start some kind of FitnessFacts.org website to review the exercise literature. I’ve got my brain full with the nutrition stuff—though there’s so much good information I don’t have time to review that there could be ten more sites just covering nutritional science!
For more on all that exercise can do for our bodies and minds, see
While you, loyal reader, wait for a wonderful new permanent Friday Breeze writer to start breezing, welcome to this week’s rundown brought to you from St. Louis by me, Midwest correspondent Lauren Weber.
I’m sadly here to inform you the news is … still bad. So bad, in fact, that “doomscrolling” — the act of not being able to escape your smartphone feed of misery — was examined by The New York Times.
And that’s because all you need to know about the current state of the coronavirus can be aptly summed up in renowned infectious disease reporter Helen Branswell’s latest piece for Stat, titled “How to Fix the Covid-19 Dumpster Fire in the U.S.”
The Week’s Latest
But to be more precise: New coronavirus cases in the U.S. shattered a single-day record with over 75,000 Thursday. That number of daily cases has more than doubled since June 24. Deaths from COVID-19 are rising yet again while hot spots across the Sun Belt continue to flare. The Center for Public Integrity uncovered an unreleased federal document saying 18 states are in the “red zone” for COVID-19 cases and should consider stricter protective measures.
The big distraction of the week had to be the attacks on the reputation of America’s favorite scientist, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. He withstood a White House attack on his credibility, led by Peter Navarro, Trump’s trade adviser, in an op-ed in USA Today — one that USA Today has since said “did not meet its fact-checking standards.” To his credit, Fauci called to “stop this nonsense” and focus on the coronavirus. For more of a deep dive on the ongoing fireworks, check out this week’s amazing-as-usual episode of KHN’s “What the Health?” podcast. And never forget that Fauci did manage to sneak in this InStyle digital cover with some killer shades and he read a college kid’s thesis on the side during his tenure.
Speaking of op-eds, here’s one worth reading. Larry Hogan, Maryland’s Republican governor, wrote an op-ed about how he felt the Trump administration left his state to fend for itself amid the pandemic. Best part: how he and his wife, who was born and raised in South Korea, were able to secure half a million tests by going outside of the federal response, tapping into her contacts and then protecting them from the feds with the state National Guard.
The disappearance of public data from the CDC website created another firestorm this week. While the data has been restored, it’s another chapter in the saga of tension among the CDC, the administration and public access.
The insurer UnitedHealthcare posted its most profitable quarter — EVER — proving that, yes, you can get rich during the pandemic. Meanwhile, hospitals face the harsh reality of a surge colliding with their plans to resume profitable elective surgery.
And, no, you won’t be getting on a cruise ship anytime soon — the “no sail” order from the CDC has been extended through September 2020.
Plus superhero heartthrob Henry Cavill somehow spent his quarantine staying swole AND learning how to build computers?
But our favorite British superhero might just be Tom Moore, newly knighted by Queen Elizabeth II. The centenarian captured the world’s heart after raising millions for British health care workers by walking laps in his garden with his walker.
Not only does the Trump administration lack a comprehensive plan for addressing the ongoing coronavirus pandemic, it spent much of the past week working to undercut one of the nation’s most trusted scientists, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. Reporters were given “opposition research” noting times when Fauci was allegedly wrong about the course of the pandemic, and Peter Navarro, a trade adviser to President Donald Trump, published an op-ed in USA Today attacking Fauci personally.
Meanwhile, the Supreme Court may not hear the case challenging the constitutionality of the Affordable Care Act before the November elections, although its existence is likely to serve as fodder for Democrats up and down the ballot.
And lower courts have been active on the reproductive health front since the high court declined to fully exercise its anti-abortion majority. Federal judges in Tennessee and Georgia blocked abortion bans, while one in Maryland blocked an administration rule requiring insurance companies that sell plans on the Affordable Care Act exchanges to send customers a separate bill for abortion coverage if it is offered.
This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Paige Winfield Cunningham of The Washington Post and Erin Mershon of Stat News.
Among the takeaways from this week’s podcast:
Despite rosy pronouncements by federal officials that testing efforts in the country are progressing well, many states still report problems getting supplies they need, and delays in getting test results are making contact tracing all but impossible.
The testing problems create major hurdles to opening schools on time, as testing and contact tracing have been prerequisites to open schools safely.
Researchers are complaining that the Trump administration’s decision to have hospitals report their coronavirus data to HHS, instead of the Centers for Disease Control and Prevention, may make it difficult for them to study aspects of the outbreak.
Groups that oppose abortion see efforts by Chief Justice John Roberts to moderate decisions this year as a signal he may not be receptive to their arguments to overturn Roe v. Wade, which legalized abortion nationally. The chance to get one more conservative on the court to replace one of the current liberals could galvanize more support for President Donald Trump’s reelection campaign.
On the issue of abortion, House Democrats surprised some people by keeping the Hyde Amendment — which outlaws federal spending for abortions in nearly all cases — in the HHS appropriations bill. That was likely an effort to protect vulnerable Democrats in conservative districts.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:
Julie Rovner, KHN’s chief Washington correspondent, on Wednesday joined Rob Ferrett, host of “Central Time” on Wisconsin Public Radio, to discuss the Trump administration’s announcement that hospital data on coronavirus cases will no longer be routed to the Centers for Disease and Control and Prevention and instead will go to the Department of Health and Human Services.
Some critics have suggested this could allow officials to politicize the reports and may make it more difficult for independent researchers to get access to the data. You can hear the conversation here.
The focus of the arguing this week was on back-to-school plans. School districts are trying to make that hard decision in order to protect children, staff members and parents. (Well, and the economy, for that matter.) The Atlantic published some suggestions. The Centers for Disease Control and Prevention is under pressure from Trump to water down its reopening safety recommendations so, as Trump put it in a tweet Monday, “SCHOOLS MUST OPEN IN THE FALL!!!” Colleges are coming up with various plans to allow some students back on campus but offer few in-person classes.
The beleaguered World Health Organization, to which Trump says he will cut U.S. funding, got embroiled in a controversy over whether airborne particles transmit the coronavirus. Scientific American attempted to sort out a confusing story, while WHO acknowledges the evidence.
KHN published, with the Los Angeles Times, a very good story about how COVID-19 is starting to kill inmates on California’s death row at San Quentin. A prosecutor of one of the murderers who died wasn’t sympathetic. The Texas Tribune reports how the disease is ravaging Texas prisons and killing people who had very short sentences.
A few other stories from the week that shouldn’t be missed because they give you a good look at how government officials still struggle to get a handle on this crisis: Stat reports that the Food and Drug Administration “again risks being pulled into an ugly political fracas” over hydroxychloroquine. Jim Fallows at the Atlantic did a masterful job of telling the story of the inept coronavirus response, in the style of an aviation accident report. It’s well worth reading. This article in BMJ, the medical journal, is a little harder to read, but worth the effort for the provocative and contrary point it makes: The U.S. purchase of much of the world’s supply of the drug remdesivir, a possible COVID treatment, may be a boon to the rest of the world.
But wait: If you are assembling a toolkit, the great health reporter Charlie Ornstein of ProPublica has already done much of the work for you. Open up this Google Doc to find his very good collection.
Oddly Important News, More Odd Than Important
Well, for all the attention it was getting, some people seemed to think Kanye West running for president was big news. Forbes interviewed him, and here is one thing he said that was health care-related:
“It’s so many of our children that are being vaccinated and paralyzed. … So when they say the way we’re going to fix Covid is with a vaccine, I’m extremely cautious. That’s the mark of the beast. They want to put chips inside of us, they want to do all kinds of things, to make it where we can’t cross the gates of heaven.”
The Italian Mafia has innovated in the health care industry. The Financial Times reports: “By corrupting local officials, organised criminals have been able to make vast profits from contracts given to their own front companies, establishing monopolies on services ranging from delivering patients in faulty ambulances to transporting blood to taking away the dead.”
Here’s a well-told story of a socialite spreading COVID at a party of fellow swells.
To end on an uplifting note, because that’s important in these times, a video of a light display over Seoul with 300 drones telling Koreans to wear masks and wash their hands. (And they do. Korea has one of the lowest infection rates in the world.)
When famed surgeon Michael DeBakey was asked why his studies published back in the 1930s linking smoking and lung cancer were ignored, he had to remind people about what it was like back then. We were a smoking society. Smoking was in the movies, on airplanes. Medical meetings were held in “a heavy haze of smoke.” Smoking was, in a word, normal. Even the congressional debates over cigarettes and lung cancer took place in literal smoke-filled rooms. (This makes me wonder what’s being served at the breakfast buffets of the Dietary Guidelines Committee meetings these days.)
I’ve previously talked about a famous statistician by the name of Ronald Fisher, who railed against what he called “propaganda…to convince the public that cigarette smoking is dangerous.” “Although Fisher made invaluable contributions to the field of statistics, his analysis of the causal association between lung cancer and smoking was flawed by an unwillingness to examine the entire body of data available…” His smokescreen may have been because he was a paid consultant to the tobacco industry, but also because he was himself a smoker. “Part of his resistance to seeing the association may have been rooted in his own fondness for smoking,” which makes me wonder about some of the foods nutrition researchers may be fond of to this day.
As I discuss in my video Don’t Wait Until Your Doctor Kicks the Habit, it always strikes me as ironic when vegetarian researchers are forthright and list their diet as a potential conflict of interest, whereas not once in the 70,000 articles on meat in the medical literature have I ever seen a researcher disclose her or his nonvegetarian habits––because it’s normal. Just like smoking was normal.
How could something that’s so normal be bad for you? And, it’s not as if we fall over dead after smoking one cigarette. Cancer takes decades to develop. “Since at that time most physicians smoked and could not observe any immediate deleterious effects, they were skeptical of the hypothesis and reluctant to accept even the possibility of such a relation”—despite the mountain of evidence.
It may have taken 25 years for the Surgeon General’s report to come out and longer still for mainstream medicine to get on board, but now, at least, there are no longer ads encouraging people to “Inhale to your heart’s content!” Instead, today, there are ads from the Centers for Disease Control and Prevention fighting back.
For food ads, we don’t have to go all the way back to old ads touting “Meat…for Health Defense” or “Nourishing Bacon,” or featuring doctors prescribing meat or soda, or moms relieved that “Trix are habit-forming, thank heavens!” You know things are bad when the sanest dietary advice comes from cigarette ads, as in Lucky Strike’s advertisements proclaiming “More Vegetables––Less Meat” and “Substitute Oatmeal for White Flour.” (You can see these vintage ads from 2:34 in my video).
In modern times, you can see hot dogs and sirloin tips certified by the American Heart Association, right on their packaging. And, of all foods, which was the first to get the Academy of Nutrition and Dietetics’ “Kids Eat Right” logo on its label? Was it an apple? Broccoli, perhaps? Nope, it was a Kraft prepared cheese product.
Now, just as there were those in the 1930s, 40s, and 50s at the vanguard trying to save lives, today, there are those transforming ads about what you can do with pork butt into ads about what the pork can do to your butt: “Hot Dogs Cause Butt Cancer—Processed meats increase colorectal cancer risk” reads an for the Physicians Committee for Responsible Medicine’s “Meat Is the New Tobacco” campaign, which you can see at 3:56 in my video. As Dr. Barnard, PCRM president, tried to convey in an editorial published in the American Medical Association’s Journal of Ethics, “Plant-based diets are the nutritional equivalent of quitting smoking.”
How many more people have to die before the Centers for Disease Control encourages people not to wait for open-heart surgery to start eating healthfully?
Just as we don’t have to wait until our doctor stops smoking to give up cigarettes ourselves, we don’t have to wait until our doctor takes a nutrition class or cleans up his or her diet before choosing to eat healthier. No longer do doctors hold a professional monopoly on health information. There’s been a democratization of knowledge. So, until the system changes, we have to take personal responsibility for our health and for our family’s health. We can’t wait until society catches up with the science again, because it’s a matter of life and death.
Dr. Kim Allan Williams, Sr., became president of the American College of Cardiology a few years back. He was asked why he follows his own advice to eat a plant-based diet. “I don’t mind dying,” Dr. Williams replied. “I just don’t want it to be my fault.”
On December 30, 2019, Dr. Li Wenliang, an ophthalmologist at Wuhan Central Hospital in the Hubei province of China, messaged his fellow physicians, alerting them to the appearance of what he thought as SARS. Thirty-nine days later, after becoming infected with the very virus he tried to warn his colleagues about, he was dead at thirty-three. By that time, the disease we now know as COVID-19 had already spread to dozens of countries.
Before the SARS outbreak in 2002, only two coronaviruses were known to cause disease in humans, but neither caused much more than the common cold. The SARS coronavirus, however, went on to kill about one in ten people it infected. A decade later, in 2012, MERS, another deadly coronavirus, emerged. Like SARS, MERS spread to infect thousands of people across dozens of countries, but that time, one in three died. Today, we’re fighting to protect ourselves from—and to defeat—the COVID-19 coronavirus.
Where are these emerging infectious diseases emerging from?
All human viral infections are believed to originate in animals.
To understand COVID-19 and other deadly viral outbreaks, we have to understand their history and evolution if we’ll ever have a chance at preventing future pandemics. We also have to look back and take lessons from the past. How did we successfully beat back SARS? Why is it more difficult with COVID-19? What do we have to do to slow the pandemic today before we even have a hope at a vaccine?
I covered all of that in my recent four-hour webinar—from origin stories of past killer pandemics to what we should be doing today to stay safe—and then dove into the clinical side of COVID-19 and discussed what the disease looks like and the best way to treat it. If you missed the webinar, the following is an overview of what I covered.
Please note: Recommendations for mitigation and slowing the spread vary by location. Be sure to follow your region’s safety guidelines. Further, as data on COVID-19 is continually changing, we recommend the following sources:
Most human coronaviruses appear to have arisen originally in bats, thought to be the primordial hosts, but jumping the species barrier to infect people appears to require intermediate hosts.
In the case of MERS, the intermediate hosts were found to be camels.
Although we domesticated camels three thousand years ago and MERS had long been circulating in them for decades without crossing the species barrier into humans, more recent intensification of camel production—from foraging outdoors to, today, primarily being confined indoors at high stocking densities—is thought to be what helped drive the spillover of MERS from camels to people.
The first human cases of MERS were reported in 2011, the year after open grazing was banned in Qatar, the Middle Eastern country with the highest camel density.
The Emergence of SARS
The first new global disease outbreak of the 21st century was SARS, even before MERS.
In the case of SARS, the intermediate hosts were found to be civet cats.
SARS-CoV causes the SARS coronavirus, and SARS-CoV-2 causes the COVID-19 coronavirus.
Many of the first cases of SARS were found in the same type of place most of the first cases of our current COVID-19 pandemic have been found: live animal “wet” markets in China.
At wet markets, crowded cages of animals, including exotic animals, are contaminated with the feces, urine, and blood of different species mixed together, and animals may be slaughtered. These conditions lead to a perfect storm for zoonotic (animal-to-human) disease transmission.
The virus uses the spikes on its corona like a key in a lock to access host receptors. Just as a new lock needs a new key, in order to switch from infecting one species to another, the genes coding the spikes must mutate to fit into the new host’s receptors.
Both viruses that cause SARS and COVID-19, SARS-CoV and SARS-CoV-2, respectively, attach to an enzyme coating the cells of our lungs. By the time bat coronaviruses made it into civets, the virus’s docking spikes were just two mutations away from locking in the configuration to bind to human receptors—and then the human-to-human SARS epidemic was born.
The Emergence of COVID-19
Ground zero for the COVID-19 pandemic was the Hua’nan Market in Wuhan, China, named in Dr. Li’s “7 SARS cases confirmed” message. It wasn’t a SARS-coronavirus, though. It was a virus to be named SARS coronavirus 2 (SARS-CoV-2), the cause of coronavirus disease 2019, or COVID-19.
The new COVID-19 coronavirus is about 80 percent identical to the original SARS virus, but it’s more than 95 percent identical to a coronavirus found in a bat in 2013.
The current theory: COVID-19 originated in bats before jumping to humans after passing through an intermediate host, thought to be the pangolin, the most trafficked mammal in the world.
Coronaviruses found in two different groups of diseased pangolins being smuggled into China were found to be about 90 percent identical with the COVID-19 virus. As well, the pangolin coronavirus spike protein’s critical receptor binding region is virtually identical to the human strain.
Coronaviruses Infect Pigs Right Off the Bat
COVID-19 is the fourth coronavirus to jump from bats to cause large deadly outbreaks in the 21st century. First was SARS in 2002, MERS in 2012, and then SADS—Swine Acute Diarrhea Syndrome—in 2016, which devastated commercial pig farms in the same part in China where SARS had broken out. SADS was traced to a coronavirus discovered in a nearby bat cave.
Other emerging and re-emerging coronavirus diseases include Porcine Epidemic Diarrhea and Porcine Deltacoronavirus among pigs, and Infectious Bronchitis Virus in chickens. Increasingly, coronaviruses are emerging and circulating among farm animal populations, and the more novel coronaviruses mix in greater numbers of animals, the greater the likelihood that strains with the potential to spark a pandemic may emerge.
COVID-19 May Not Have Been the First Coronavirus Pandemic
The second most common cause of the common cold are coronaviruses.
To date, four human cold coronaviruses have been discovered, which means seven coronaviruses in all can cause human disease as far as we know. We believe we got SARS from civets, MERS from camels, and COVID-19 perhaps from pangolins.
Though we still don’t know where two of the four mild coronaviruses originated, one—human coronavirus 229E—has been traced back to camels and the other—OC43—traced back to cattle or pigs.
Molecular clock analyses dating human coronavirus OC43’s emergence suggest that the bovine coronavirus now causing “shipping fever” disease in cattle, jumped to humans around 1890. Indeed, that same year, 1890, there was a pandemic, presumed to be influenza.
Because of the timing of the emergence of human coronavirus OC43, some conjecture it actually may have been a COVID-19-like interspecies transmission of a coronavirus. This is supported by the fact that cattle herds the world over were being devastated by a deadly respiratory disease, resulting in massive culling operations between 1870 and 1890.
PUMPING THE BRAKES
Slowing an Outbreak
There were more COVID-19 cases in the first month of reporting than SARS ever caused. Why? The primary reason revolves more around when it is contagious than how contagious it is.
Microbes most likely to cause pandemics have three characteristics: (1) novelty, therefore, without pre-existing immunity; (2) respiratory spread; and (3) transmission before the onset of symptoms.
SARS, despite spreading to twenty-nine countries and regions, was not considered a pandemic. And, we were able to stop it within only a few months, after approximately 8,000 cases and 800 deaths. Why? SARS was spread via respiratory droplets but lacked significant spread before symptoms arise.
SARS’s average incubation period—from first becoming infected to first coming down with symptoms—was around five days, but viral loads took another six to eleven days to ramp up. So, SARS patients weren’t very infectious in the first five or so days of the illness. In that way, transmission from person to person could be stopped if patients were isolated within the first few days after symptoms arose.
One hundred percent of SARS patients developed a fever, as did 98 percent of MERS patients. However, as many as 36 percent—more than one in three—of COVID-19 patients do not present with fever at the onset of symptoms and, more seriously, may be infectious while completely symptom-free during the incubation period.
People can potentially spread COVID-19 before even knowing they have it, even while they’re feeling completely fine, which is why isolation may slow the spread of disease without knowing who is infectious.
Slowing a Pandemic
China enacted “wartime control measures” and initiated the most expansive containment effort in history, affecting about three quarters of a billion people, confining them to their homes.
The seemingly impossible was achieved: the containment of a widely circulating respiratory infection. Ground zero of COVID-19, Hubei Province, reported its first day of no new local cases within two months.
Countries able to rapidly control the disease quickly relied on testing and tracing—mass testing to identify all cases and tracing every patient’s every possible contact—to block as many paths of transmission as possible through isolation and quarantine.
Rapid response varied wildly. By the middle of March, South Korea had tested more than a quarter million people, more than five thousand out of every million citizens, compared to fewer than a hundred per million in the United States.
When the window on containment closes, as it did in the United States, the strategy pivots to suppression and mitigation.
Closing nonessential businesses, cancelling gatherings, and encouraging people to stay at home and shelter in place all attempt to break every possible link in the chain of viral transmission—to “flatten the curve,” that is, to flatten the epidemic curve to slow the spread of disease to more evenly distribute the cases over time.
Until there is wide availability of an effective vaccine, thought unlikely until 2021 at the earliest, population lockdowns can help slow the spread by removing susceptible hosts from the virus’s reach. Once such stay-at-home measures are relaxed, though, the disease could attack again as it did in the 1918 pandemic when some U.S. cities suffered a second peak in mortality after social-distancing measures were lifted.
Triage protocols have been published, establishing a hierarchy of care in anticipation of too few resources, such as hospital beds and ventilators, and too many patients. Wrote a preeminent group of medical ethics experts in the New England Journal of Medicine, “[W]e believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable and that patients should be made aware of this possibility at admission,” adding, “the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patient’s consent.”
TREATING AND AVOIDING COVID-19
The Clinical Course of COVID-19
COVID-19 is thought to have an average incubation period of about five days, which means we are infected and possibly infectious for almost a week before we may even know we have the disease.
Not all infected people show symptoms, but of those who do, about 98 percent start exhibiting them by day twelve, which explains why quarantine after a potential exposure are for two weeks.
After infection, the virus may shed for more than a month (with an average of twenty days), but it is unclear how contagious survivors are during that period.
The most common symptoms are fever (90 percent of patients) and cough (70 percent). About four in ten experience fatigue, three in ten cough up phlegm, two in ten have muscle aches, and one in ten may suffer gastrointestinal symptoms, such as nausea or diarrhea, or common cold-type symptoms, like runny nose, sore throat, or headache.
Difficulty breathing has been the only symptom found predictive of a more severe course of COVID-19 and has resulted in more than six times the odds of eventually being admitted into the ICU.
COVID-19’s severity varies widely based on pre-existing conditions: People with high blood pressure are twice as likely to suffer a severe course and three times as likely with cardiovascular disease, and those with either condition are about four times as likely to end up in the ICU. Those with chronic obstructive pulmonary diseases (COPD) like emphysema appear to be at the highest risk (six times the odds of a severe course) and nearly eighteen times the odds of ICU admission.
As with SARS and MERS, those with diabetes appear to be at higher risk.
Excess body fat also seems to be a risk factor. Those with a body mass index (BMI) of 28 or more appear to have nearly six times the odds of suffering a severe COVID-19 course. (The average BMI in the United States exceeds 29)
Even without taking weight into account, most adult Americans over fifty suffer from a “co-morbidity” that may put them at risk. It’s important to note that the major comorbid conditions for COVID-19 severity and death—obesity, heart disease, hypertension, type 2 diabetes—may all be controlled or even reversed with a healthy enough plant-based diet.
Although newborns through seniors in their nineties have been infected, most COVID-19 patients are between thirty and seventy-nine, but the severity of the disease disproportionately affects older patients. Compared with people aged nineteen to sixty-four, in the United States, those sixty-five and older without underlying conditions or other risk factors appear to be hospitalized or end up in the ICU at approximately three times the rate.
The best data come from South Korea: Of confirmed cases, about 1 in 1,000 died in their thirties and forties, 1 in 150 of those in their fifties, 1 in 50 in their sixties, 1 in 15 in their seventies, and 1 in 5 in their eighties. U.S. data are less reliable due to the relative lack of testing, these age-related death risks are similar based on the first few thousands of American cases that were reported.
On autopsy, the lung’s respiratory surface appears obliterated by scar tissue. Pulmonary fibrosis (lung scarring) is expected to be a long-term complication among survivors of serious COVID-19 infection.
Death from COVID-19 is the result of progressive “consolidation” of the lung—your lungs start filling up with something other than air. In COVID-19 pneumonia, postmortems show you drown in lungs “filled with clear liquid jelly.”
How to Treat COVID-19
Presently, there is no specific proven therapy for COVID-19.
Although there are more than 400 clinical treatment trials underway, we should not expect an effective antiviral drug or vaccine anytime soon.
I support commonsense advice to stay healthy during the crisis, as recommended by trusted authorities such as the American College of Lifestyle Medicine and the World Health Organization, including getting sufficient sleep (seven to nine hours), reducing stress, keeping active, staying connected (remotely) to friends and family, and eating healthfully (a diet centered around whole plant foods).
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Given our near-total ignorance of the immunological aspects of COVID-19, I will not jump on the snake-oily spamwagon to promote foods to boost immunity. We just don’t know if enhancing specific arms of the immune system could make things even worse.
There is an assumption that seniors are more susceptible to serious COVID-19 courses due to their waning, aging immune systems, but that may not be correct. Similarly, though young children, with their relatively immature immune systems, typically suffer disproportionally from infections such as the flu, that doesn’t appear to be with the case with COVID-19 (or SARS or MERS). Likewise, immunosuppressed patients may not be at greater risk of severe complications from COVID-19, although they normally are from respiratory viruses.
Our own immune response may be the primary driver of damage to the lungs during coronavirus infection—somewhat akin to an autoimmune reaction where the body over-reacts and the lungs get caught in the crossfire as the coronavirus is attacked.
How to Avoid COVID-19
Although cancelling gatherings, meetings, and events may slow COVID-19’s spread by as much as 35 percent, according to preliminary evidence from Japan, that has not been enough to contain the outbreak.
Our best course of action is to shelter-in-place—stay home to reduce contact with those outside our households as much as possible—and to do so now.
By the time a community has its first death from the disease, it’s likely that hundreds or even thousands of cases are present.
If you must leave your home to provide essential services such as direct care or food delivery, maintain a safe distance from others and sanitize your hands every time you touch a public surface. It’s critical not to touch your mucous membranes—your eyes and the inside of your nose or mouth—with unsanitized hands.
The virus can’t pass through your skin. It can only replicate in live cells, and our skin’s outer layer is covered by protective dead skin cells. To get into your lungs, the virus has to find its way to your mucous membranes, the moist lining of your eyes, nostrils, or mouth.
To the best of our current understanding, the COVID-19 coronavirus is thought to be transmitted from person to person via respiratory droplets coughed out by the infected into the air and then landing in the eyes, nose, or mouth of another. You can also infect yourself by touching your eyes, nose, or mouth with hands contaminated by a virus-laden object or surface—for instance, by picking your nose or rubbing your eyes after shaking someone’s hand or touching a public surface like a door knob or an elevator button.
The levels of virus in the snot of COVID-19 patients can reach almost a million per drop.
The COVID-19 coronavirus has been detected in stool samples, suggesting another way toilets may potentially transmit infection, beyond just touching the flush handle. Modern flush toilets aerosolize up to 145,000 droplets of toilet water into the air, which can float around for at least thirty minutes, so be sure to close the lid before you flush and then, of course, thoroughly wash your hands.
Coronaviruses are “enveloped” viruses. As they emerge from our infected cells, they cover themselves in the outer layer of our cells. Although that oily coating makes it harder for our immune system to detect them because they look like us, it also makes them susceptible to disinfection and environmental inactivation.
The COVID-19 virus appears to survive for less than three hours on printing paper but may last for one day on cloth. On the outer layer of surgical masks, though, it can survive for a week. COVID-19 virus’s half-life is about six hours on steel or plastic, so, although about 99 percent is gone by forty-eight hours, it may be up to 96 hours for all infectivity to be extinguished.
How to Inactivate COVID-19
Hands can be disinfected by properly washing your hands with soap and water. The CDC recommends washing them for at least twenty seconds. Researchers found the fingertips, thumbs, and backs of hands are the most frequently missed areas when washing, so be sure to wash thoroughly.
There is no need to use hot water when washing your hands.
Researchers found that the COVID-19 virus could be inactivated within thirty seconds by 30% alcohol (ethyl or isopropyl). Most vodka, rum, brandy, gin, and whisky exceed 30% alcohol by volume. Note that 30% alcohol isn’t enough to kill many other pathogens, so I still recommend sanitizers with 60% to 80% alcohol. (One rub to rule them all!) But, if you can’t find them, it’s nice to know you can make your own.
DIY Hand Sanitizer
Basic Recipe: The easiest method would probably be to just use 80-proof liquor straight up as a hand-sanitizing rub. Pour it into a squirt or spray bottle and apply enough to completely cover all surfaces of your hands and then rub them together and leave on for 30 seconds. The addition of a gelling agent such as aloe vera is not recommended as it might compromise antiviral efficacy.
Fancy Recipe: Assuming you have all of the ingredients, you can make a gallon of COVID-19 hand sanitizer by combining 12 cups of an 80-proof liquor (40% alcohol-by-volume) with ¼ cup of glycerine (also spelled glycerin or called glycerol) and a teaspoon of regular strength (3%) hydrogen peroxide and then just fill the rest of the gallon container with water. To make just a quart, simply quarter the recipe: 3 cups liquor, 1 tablespoon glycerine, ¼ teaspoon hydrogen peroxide, and water. Again, don’t add anything else.
Bleach is recommended for disinfection of inanimate surfaces—1 part household bleach diluted in 49 parts water, so about 1 teaspoon bleach per cup of water.
This 1:50 recommendation is for standard bleach (5% sodium hypochlorite). If you have 2.5% hypochlorite bleach, use two teaspoons per cup, and if you have 10% hypochlorite bleach, you only need a half teaspoon per cup.
Prepare the bleach solution fresh and leave it on the surface you’re disinfecting for at least ten minutes. Surfaces visibly contaminated with bodily secretions like snot, blood, or poop may require a stronger bleach solution (1 part standard bleach to 9 parts water, left for ten minutes).
NEVER mix bleach with any other cleanser as it reacts with ammonia (found in many glass cleaners) to create hazardous gases and reacts with acids (like vinegar, or some toilet bowl, drain, and automatic dishwashing detergents) to create chlorine gas, which is also toxic.
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What If You Come Down with COVID-19?
The best option is to try to recover at home, isolated as much as possible from others in your household. Preferably, you should avoid contact with both people and pets, and be cordoned off in a “sick room” with a separate bathroom if possible.
Most people who get infected with the COVID-19 virus recover without medical intervention. If you do come down with it, protect those around you, rest, hydrate, and monitor your symptoms. If you experience difficulty breathing or persistent pain or pressure in the chest, seek medical attention—but, first call your doctor or emergency room before heading in, since they may have special instructions for suspect cases in your area.
Practice good hygiene and social-distancing etiquette: Wash your hands often. Cough or sneeze into a tissue, covering your nose and mouth, then throw the used tissue into a lined bin and immediately sanitize your hands. Don’t share eating utensils, towels, bedding, or other personal household items. Routinely disinfect all high-touch objects (e.g., doorknobs and toilet surfaces) in your sick room and bathroom yourself, but have someone else disinfect the rest of the house. Be sure to wear gloves while cleaning and disinfecting, and open windows if possible and wear a surgical mask.
If you’re sick but must share a room with someone else, wear a face mask. That’s what they were originally designed for: source control, rather than self-protection.
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It’s important to understand that respiratory droplets are not just gobs of mucus. When you’re outside on a cold day and your breath fogs, those are respiratory droplets. That vapor plume you’re exhaling is made up of tiny water droplets straight from your lungs. On a warm day, you breathe out that same cloud—you just can’t see it.
Should everyone cover their face in public since infected individuals are exhaling virus before they even know they have it? The CDC recommends “wearing cloth face coverings in public settings where other social distancing measures are difficult to maintain” such as grocery stores or pharmacies. The U.S. Surgeon General is featured in a video demonstrating how to improvise masks out of a bandana and rubber bands, and the CDC has easy no-sew instructions at bit.ly/CDCDIY.
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Cloth coverings, which should be washed regularly, are no substitute for masks, but may be better than nothing. Scarves, pillowcases, and 100 percent cotton t-shirts are probably the most suitable household materials for making homemade masks, blocking various bacteria and viruses about 60 percent as well as surgical masks.
What about N95 masks? Also known as N95 respirators, these are cup-like masks that fit tighter to the face and, unlike surgical masks, are intended to protect the wearer. The CDC and its European counterpart recommend N95 masks for healthcare workers during routine care of patients, while the World Health Organization suggests surgical masks are sufficient.
Until we know more about how the COVID-19 virus is transmitted, it seems prudent for those in close contact with coughing patients use eye protection (at least a face shield) and N95 respirators.
According to the CDC, once your symptoms start improving, you’ve been fever-free for three full days off of fever-reducing medicines, and it’s been at least one week since your symptoms first appeared, only then can you start relaxing your home isolation. The World Health Organization is more conservative, though, and recommends self-quarantine for a full fourteen days for anyone with symptoms or living with anyone with symptoms.
A note on pets: Dogs have been found infected with the COVID-19 coronavirus in rare cases, but it replicates poorly in dogs and doesn’t seem to make them sick, and they don’t appear to pass the virus along to others. In cats, however, the virus has been shown to reproduce And, cats have been able to experimentally transmit the virus to other cats even though they may not themselves become sick. In the United States, the only confirmed case of animal infection that I know of is a sickened tiger at the Bronx Zoo.
HOW COVID-19 ENDS
We shouldn’t count on COVID-19 going away naturally when the weather gets warmer. Every recent flu pandemic emerged in the spring or summer months, but secondary waves tended to hit the following winter.
Even if the COVID-19 virus’s contagiousness drops in the Northern Hemisphere this summer, thanks to warmer, wetter weather, that’s not expected to make a big impact on the pandemic curve.
Herd immunity would stop the pandemic—when a critical portion of the population is immune to the virus. When there are no longer enough susceptible individuals for a virus to infect, jumping from person to person, the chains of transmission are broken.
Mass vaccination is the ideal way to accomplish this. Without a vaccine, the only way to achieve herd immunity is through mass infection.
Based on estimates for the COVID-19 virus from large outbreaks in affected countries and simplistic mathematical models, the minimum population immunity required varies from approximately 30 percent (based on South Korea’s data) to more like 80 percent (based on an estimate from Spain).
This is why “flattening the curve” is critical. We can’t wait until 80 percent of the population is infected.
One trait the COVID-19 virus shares with HIV is its rapid mutation rate. The possibility that the virus could transform in the near future to become even more transmissible or dangerous cannot be ruled out.
A “best guess” estimate presented to the American Hospital Association was about a half a million U.S. deaths if the virus stayed the course. That may be reduced to under 100,000 with sufficient social distancing.
The CDC developed a Pandemic Severity Index, modelled after the Hurricane Severity Index to define the destructive capacity of a storm. In the 1918 pandemic, about one in three became infected and, of those, about 2 percent died, classifying it as a category 5 pandemic, analogous to a “super typhoon” with sustained winds exceeding 150 miles per hour. COVID-19 infection fatalities are much lower, probably closer to 0.5 percent, meaning 1 in 200 cases dying.
For more than a century, we’ve known about the pandemic potential of the flu virus, but that 2 percent fatality of the 1918 influenza appears to be the deadliest it ever got. In 1997, however, a flu virus was found in chickens that appears to have killed more than 50 percent of the people it infected. What if a virus like that triggered an outbreak?
PREVENTING FUTURE PANDEMICS: Having Our Meat and Eating It Too
We were spared by the last pandemic: In 2009, swine flu only triggered a category 1 pandemic, killing a half million people. It did, however, reveal that industrial pork production was a new origin point for pandemic viruses.
The emergence of H5N1 and other bird flu viruses infecting humans has been blamed on industrial poultry production.
The CDC considers H7N9, a bird flu virus, to be our gravest pandemic flu threat, one that could kill millions of Americans. To date, H7N9 has killed about 40 percent of the people it has infected. Two in five.
At this time, neither H5N1 nor H7N9 has acquired the capacity for easy human-to-human transmission, but neither has been eradicated. They’re still out there, still mutating.
How can we stop the emergence of pandemic viruses in the first place? Whenever possible, treat the cause.
The largest and oldest association of public health professionals in the world, the American Public Health Association, has called for a moratorium on factory farming for nearly two decades. Its journal published an editorial entitled “The Chickens Come Home to Roost” that went beyond calling for a deintensification of the pork and poultry industries:
“It is curious, therefore, given the pandemic threat, that changing the way humans treat animals, most basically ceasing to eat them, or at the very least, radically limiting the quantity of them that are eaten—is largely off the radar as a significant preventive measure. Such a change, if sufficiently adopted or imposed, could still reduce the chances of the much-feared influenza epidemic. It would be even more likely to prevent unknown future diseases that, in the absence of this change, may result from farming animals intensively and killing them for food. Yet humanity doesn’t even consider this option.”
This may be changing, thanks to food innovations like plant-based milks, egg products, and meats.
Our food choices don’t just affect our personal health but our global health. Not just in terms of climate change, but in terms of pandemic risk.
Major meat producers have started blending in vegetable proteins to make hybrid meats like Tyson’s “Whole Blends” sausage links and Perdue’s “next generation” chicken nuggets. The world’s largest pork producer, Smithfield, recently launched a whole line of plant-based products. Egg-free mayo has taken the sandwich spread sector by storm, and Quorn, a brand of meat-free meat made from the mushroom kingdom, opened a facility capable of producing the meat equivalent of twenty million chickens per year.
While these products may not be the healthiest from a personal standpoint, they tend to be healthier than their animal-product counterparts and, from a pandemic standpoint, they present zero risk.
What about cultivated meat? The primary human health benefit of a slaughter-free harvest would be food safety. (If you make meat without intestines, you don’t have to worry about fecal bugs like Salmonella, and if you make meat without lungs, you don’t have to worry about brewing respiratory viruses.) Growing meat directly from muscle cells has been touted for the environmental benefits—reducing water use and greenhouse gas emissions by as much as 96 percent and lower land use by as much as 99 percent—but factoring in pandemic risk, the benefits to human health may rival those to planetary health.
In the webinar, I ended by taking a moment to acknowledge all of the first responders and frontline medical workers. Many of them are not only dealing with physical and mental exhaustion, the torment of difficult triage decisions, and the pain of losing patients and colleagues, but are also—quite literally—putting their own lives at risk. Thousands of healthcare workers have been infected, and more than a hundred have died.
Crises like these can bring out the worst in people, like all the hate crimes and harassment against Asian-Americans, but they can also bring out the best.
You can support those on the front lines from being overwhelmed by staying safe, and, if you can, staying home.
COMING UP NEXT
During the webinar, I was excited to announce that my entire four-hour lecture will be turned into a month-long series of videos on NutritionFacts.org, so stay tuned.