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.
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.
The federal eviction moratorium, if it withstands legal challenges from housing industry groups, “buys critical time” for renters to find assistance through the year’s end, said Emily Benfer, founding director of the Wake Forest Law Health Justice Clinic.
“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.”
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Leslie Cutitta said yes, twice, when clinicians from Massachusetts General Hospital in Boston called asking whether she wanted them to take — and then continue — extreme measures to keep her husband, Frank Cutitta, alive.
The first conversation, in late March, was about whether to let Frank go or to try some experimental drugs and treatments for COVID-19. The second call was just a few days later. Hospital visits were banned, so Leslie couldn’t be with her husband or discuss his wishes with the medical team in person. So she used stories to try to describe Frank’s zest for life.
“Frank used to joke that he wanted to be frozen, like Ted Williams, until they could figure out what was wrong with him if he died,” said Leslie Cutitta. It wasn’t a serious end-of-life discussion, but Cutitta knew her husband would want every possible lifesaving measure deployed.
So the Cutittas hung on and a small army of ICU caregivers kept working. On April 21, after 27 days on a ventilator, Frank’s lungs had recovered enough to remove the breathing tube.
After the removal, it typically takes hours, maybe a day, for the patient to return to consciousness. The body needs that time to clear the drugs that keep the patient sedated and comfortable — able to tolerate intubation and mechanical ventilation.
But doctors across the U.S. and in other countries have noted a troubling phenomenon associated with some COVID cases: Even after extubation, some patients remain unconscious for days, weeks or longer. There’s no official term for the problem, but it’s being called a “prolonged” or “persistent” coma or unresponsiveness.
Frank Cutitta, 68, was one of those patients. He just didn’t wake up.
“It was a long, difficult period of not — just not knowing whether he was going to come back to the Frank we knew and loved,” said Leslie Cutitta. “It was very, very tough.”
Doctors studying the phenomenon of prolonged unresponsiveness are concerned that medical teams are not waiting long enough for these COVID-19 patients to wake up, especially when ICU beds are in high demand during the pandemic.
As Frank’s unresponsive condition continued, it prompted a new conversation between the medical team and his wife about whether to continue life support. Although he no longer needed the ventilator, he still required a feeding tube, intravenous fluids, catheters for bodily waste and some oxygen support.
Leslie Cutitta recalled a doctor asking her: “If it looks like Frank’s not going to return mentally, and he’s going to be hooked up to a dialysis machine for the rest of his life in a long-term care facility, is that something that you and he could live with?”
She struggled to imagine the restricted life Frank might face. Every day, sometimes several times a day, she would ask Frank’s doctors for more information: What’s going on inside his brain? Why is this happening? When might something change?
Their candid and consistent answer was: We don’t know.
“Because this disease is so new and because there are so many unanswered questions about COVID-19, we currently do not have reliable tools to predict how long it will take any individual patient to recover consciousness,” said Dr. Brian Edlow, a critical care neurologist at Mass General.
Given all the unknowns, doctors at the hospital have had a hard time advising families of a patient who has remained unresponsive for weeks, post-ventilator. Some families in that situation have decided to remove other life supports so the patient can die. Edlow can’t say how many.
“It is very difficult for us to determine whether any given patient’s future will bring a quality of life that would be acceptable to them,” Edlow said, “based on what they’ve told their families or written in a prior directive.”
Theories abound about why COVID-19 patients may take longer to regain consciousness than other ventilated patients, if they wake up at all. COVID-19 patients appear to need larger doses of sedatives while on a ventilator, and they’re often intubated for longer periods than is typical for other diseases that cause pneumonia. Low oxygen levels, due to the virus’s effect on the lungs, may damage the brain. Some of these patients have inflammation related to COVID-19 that may disrupt signals in the brain, and some experience blood clots that have caused strokes.
“So there are many potential contributing factors,” Edlow said. “The degree to which each of those factors is playing a role in any given patient is still something we’re trying to understand.”
One of the first questions researchers hope to answer is how many COVID-19 patients end up in this prolonged, sleeplike condition after coming off the ventilator.
“In our experience, approximately every fifth patient that was hospitalized was admitted to the ICU and had some degree of disorders of consciousness,” said Dr. Jan Claassen, director of neurocritical care at New York’s Columbia University Medical Center. “But how many of those actually took a long time to wake up, we don’t have numbers on that yet.”
An international research group based at the University of Pittsburgh Medical Center expects to have in September some initial numbers on COVID-19 brain impacts, including the problem of persistent comas. Some COVID patients who do eventually regain consciousness still have cognitive difficulties.
To try to get a handle on this problem at Columbia, Claassen and colleagues created a “coma board,” a group of specialists that meets weekly. Claassen published a study in 2019 that found that 15% of unresponsive patients showed brain activity in response to verbal commands. A case reported by Edlow in July described a patient who moved between a coma and minimal consciousness for several weeks and was eventually able to follow commands.
This spring, as Edlow observed dozens of Mass General COVID-19 patients linger in this unresponsive state, he joined Claassen and other colleagues from Weill Cornell Medical College to form a research consortium. The researchers are sharing their data to determine the cause of prolonged coma in COVID-19 patients, find treatments and better predict which patients might eventually recover, given enough time and treatment.
The global research effort has grown to include more than 222 sites in 45 countries. Prolonged or persistent comas are just one area of research, but one getting a lot of attention.
Dr. Sherry Chou, a neurologist at the University of Pittsburgh Medical Center, is leading the international effort.
Chou said families want to know “whether a patient can wake up and be themselves.” Answering that question “depends on how accurate we are at predicting the future, and we know we’re not very accurate right now.”
A CT scan of Frank Cutitta’s brain showed residue from blood clots but was otherwise “clean.”
“From what they could tell, there was no brain damage,” Leslie Cutitta said.
And then, on May 4, after two weeks with no signs that Frank would wake up, he blinked. Leslie and her two daughters watched on FaceTime, making requests such as “Smile, Daddy” and “Hold your thumb up!”
“At least we knew he was in there somewhere,” she said.
It was another week before Frank could speak and the Cutittas got to hear his voice.
“We’d all be pressing the phone to our ears, trying to catch every word,” Leslie Cutitta recalled. “He didn’t have a lot of them at that point, but it was just amazing, absolutely amazing.”
Frank Cutitta spent a month at Spaulding Rehabilitation Hospital. He’s back home now, in a Boston suburb, doing physical therapy to strengthen his arms and legs. He said he slurs words occasionally but has no other cognitive problems.
While he was in the ICU, Cutitta’s nurses played recorded messages from his family, as well as some of his favorite music from the Beach Boys and Luciano Pavarotti. Frank Cutitta said he believes the flow of these inspiring sounds helped maintain his cognitive function.
The Cutittas said they feel incredibly lucky. Leslie Cutitta said one doctor told the family that during the worst of the pandemic in New York City, most patients in Frank’s condition died because hospitals couldn’t devote such time and resources to one patient.
“If Frank had been anywhere else in the country but here, he would have not made it,” Leslie Cutitta said. “That’s a conversation I will never forget having, because I was stunned.”
Frank Cutitta credits the Mass General doctors and nurses, saying they became his advocates.
It “could have gone the other way,” he said, if clinicians had decided “‘Look, this guy’s just way too sick, and we’ve got other patients who need this equipment.’ Or we have an advocate who says, ‘Throw the kitchen sink at him,’” Frank said. “And we happened to have the latter.”
Many hospitals use 72 hours, or three days, as the period for patients with a traumatic brain injury to regain consciousness before advising an end to life support. As COVID-19 patients fill intensive care units across the country, it’s not clear how long hospital staff will wait beyond that point for those patients who do not wake up after a ventilator tube is removed.
Joseph Giacino, director of rehabilitation neuropsychology at Spaulding, said he’s worried hospitals are using that 72-hour model with COVID-19 patients who may need more time. Even before the coronavirus pandemic, some neurologists questioned that model. In 2018, the American Academy of Neurology updated its guidelines for treating prolonged “disorders of consciousness,” noting that some situations may require more time and assessment.
Some patients, like Frank Cutitta, do not appear to have any brain damage. Whatever caused his extended period of unconsciousness cleared.
Unless a patient has previously specified that she does not want aggressive treatment, “we need to really go slow,” said Giacino, “because we are not at a point where we have prognostic indicators that approach the level of certainty that is necessary before making a decision that we should stop treatment because there is no chance of meaningful recovery.”
Doctors interviewed for this story urged everyone to tell their loved ones what you expect a “meaningful recovery” to include. If confronted with this situation, family members should ask doctors about their levels of certainty for each possible outcome.
Some medical ethicists also urge clinicians not to rush when it comes to decisions about how quickly COVID-19 patients may return to consciousness.
“A significant number of patients are going to have a prolonged recovery from the comatose state that they’re in,” said Dr. Joseph Fins, chief of medical ethics at Weill Cornell Medical College. “This is a time for prudence because what we don’t know can hurt us and can hurt patients.”
Leslie and Frank Cutitta have a final request: Wear a mask.
“This disease is nothing to be trifled with,” Leslie Cutitta said. “It’s a devastating experience.”
Frank Cutitta worries about all of the patients still suffering with COVID-19 and those who have survived but have lasting damage.
“I’m not considering myself one of those,” he said, “but there are many, many people who would rather be dead than left with what they have after this.”
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It’s a familiar moment. The kids want their cereal and the coffee’s brewing, but you’re out of milk. No problem, you think — the corner store is just a couple of minutes away. But if you have COVID-19 or have been exposed to the coronavirus, you’re supposed to stay put.
Even that quick errand could make you the reason someone else gets infected. But making the choice to keep others safe can be hard to do without support.
For many — single parents or low-wage workers, for instance — staying in isolation is difficult as they struggle with how to feed the kids or pay the rent. Recognizing this problem, Massachusetts includes a specific role in its COVID-19 contact-tracing program that’s not common everywhere: a care resource coordinator.
Luisa Schaeffer spends her days coordinating resources for a densely packed, largely immigrant community in Brockton, Massachusetts.
On her first call of the day recently, a woman was poised at her apartment door, debating whether to take that quick walk to get groceries. The woman had COVID-19. Schaeffer’s job is to help clients make the best choice for the public — sometimes, the help she offers is as basic, and important, as the delivery of a jug of milk.
“That’s my priority. I have to put milk in her refrigerator immediately,” Schaeffer said.
“Most of the time it’s the simple things, the simple things can spread the virus.”
The woman who needed milk was one of eight cases referred to Schaeffer through the state government’s Community Tracing Collaborative. Contact tracers make daily calls to people in isolation because they’ve tested positive or those in quarantine because they’ve been exposed to the coronavirus and must wait 14 days to see if they develop an infection. The collaborative estimates that between 10% and 15% of cases request assistance. Those requests are referred to Schaeffer and other care resource coordinators.
“So many people are on this razor-thin edge, and it’s often a single diagnosis like COVID that can tip them over,” said John Welch, director of operations and partnerships for Partners in Health’s Massachusetts Coronavirus Response, which manages the state’s contact-tracing program.
He said a role such as resource coordinator becomes essential in getting people back to “a sense of health, a sense of wellness, a sense of security.”
With milk on its way, Schaeffer dialed a woman who needed to find a primary care doctor, make an appointment and apply for Medicaid. That call was in Spanish.
With her third client, Schaeffer switched to her native language, Cape Verdean Creole. The man on the other end of the line and his mother had both been sick and out of work. He applied for food stamps and was denied. Schaeffer texted the regional head of a state office that manages that program. A few minutes later, the director texted back that he was on the case.
Schaeffer, who has deep roots in the community, is on temporary loan to the state’s contact-tracing collaborative and will later return to her job, helping patients understand and follow their prescribed treatments at the Brockton Neighborhood Health Center.
The collaborative said most client requests are for food, medicine, masks and cleaning supplies. COVID-19 patients who are out of work for weeks or who don’t have salaried jobs may need help applying for unemployment or help with rental assistance — available to qualified Massachusetts residents.
Care resource coordinators even connect people with legal support when they need it. An older woman employed in the laundry room at a nursing home was told she wouldn’t be paid while out sick. Schaeffer got in touch with the Community Tracing Collaborative’s attorney, who reminded the company that paid sick leave is required of most employers during the pandemic.
“So, now, everything’s in place. She started getting paid,” Schaeffer said.
There are glitches as the care resource coordinators try to support people isolating at home. Some workers who are undocumented return to work because they fear losing their jobs. When the local food bank runs out, Schaeffer has had to scramble to find a local grocer to help. The free canned goods or vegetables can be like foreign cuisine for Schaeffer’s clients, some of whom are from Cape Verde and Peru. In those cases, she can reach out to a nutritionist and set up a cooking lesson via conference call.
“I love the three-way calls,” she said, beaming.
Schaeffer and other care resource coordinators have responded to more than 10,500 requests for help so far through Massachusetts’ contact-tracing program. Demand is likely greater in cities such as Brockton, with higher infection rates than most of the state and a 28.7% lower median household income.
Massachusetts has carved out care resource coordination as a separate job in this project. But the role is not new. Local health departments routinely include what might be called support or wrap-around services when tracing contacts. With cases of tuberculosis, for example, a public health worker might make sure patients have a doctor, get to frequent appointments and have their medications.
“You can’t have one without the other,” said Sigalle Reiss, president of the Massachusetts Health Officers Association.
Partners in Health’s Welch, who is advising other states on contact tracing, said the importance of having someone assist with food and rent while residents isolate isn’t getting enough attention.
“I don’t see that as a universal approach with other contact-tracing programs across the U.S.,” he said.
Some contact-tracing programs that schools, employers or states have erected during the pandemic cover only the basics.
“They’re focused on: Get your positive case, find the contacts, read the script, period, the end,” said Adriane Casalotti, chief of government and public affairs at the National Association of City and County Health Officials. “And that’s really not how people’s lives work.”
Casalotti acknowledged that the support role — and services for people isolating or in quarantine — adds to the cost of contact tracing. She urges more federal funding to help with this expense as well as a federal extension of the paid sick time requirement, and more money for food banks so that people exposed to the coronavirus can make sure they don’t give it to anyone else.
“Individuals’ lives can be messy and complicated, so helping them to be able to drop everything and keep us all safe — we can help them through the challenges they might have,” Casalotti said.
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The FDA has 60 days to decide whether or not to accept the application. An analyst wrote that the agency accepting it with a priority or standard review may signal whether the agency is seriously considering approval or has continued reservations about the amyloid beta-targeting drug’s clinical benefit.