Public health authorities in California are seeking a halt on dosing of one lot of Moderna’s COVID-19 vaccine after reports of allergic reactions at one immunisation clinic.
According to state epidemiologist Dr Erica Pan, there were a higher-than-expected number of suspected allergic reactions at a community clinic being used to administer the shot, with some people needing medical attention in a 24-hour period.
For now there is little information about the Moderna vaccine reactions, other than they are centred around a specific manufacturing lot – number 041L20A – and that “fewer than 10” cases of allergic reactions were reported.
More than 330,000 doses from that lot have already been administered in California since the start of the vaccine roll-out, according to state department of public health. The clinic in question switched to another lot of Moderna vaccine after closing for a few hours.
There were also reports of allergic reactions during the initial roll-out of the Pfizer/BioNTech vaccine, including some cases of anaphylaxis, which also resulted in a temporary pause in dosing at some centres.
Last week, the Centers for Disease Control and Prevention (CDC) published new data which identified 21 cases of anaphylaxis after administration of a reported 1.9 million first doses of the Pfizer/BioNTech shot, mainly within 15 minutes of the injection.
That was equivalent to 11 cases per million doses, according to the agency, which says the reactions can be managed using patient screening for allergies, observation periods after dosing and having epinephrine injections on hand as a precaution.
Both the Pfizer/BioNTech and Moderna vaccines are based on mRNA and use an excipient – called polyethylene glycol (PEG) – that some scientists suggest could be responsible for the allergic reactions, according to a report in the journal Science.
“Our goal is to provide the COVID vaccine safely, swiftly and equitably,” said Dr Pan in a statement.
“Out of an extreme abundance of caution and also recognising the extremely limited supply of vaccine, we are recommending that providers use other available vaccine inventory and pause the administration of vaccines from Moderna lot 041L20A until the investigation by the CDC, FDA, Moderna and the state is complete.
While no vaccine or medical procedure is without risk, the risk of a serious adverse reaction is very small, according to the department. At last count, California had recorded almost 3 million COVID-19 cases, with just over 33,000 deaths, placing it among the worst affected states in the US.
Black Americans are receiving covid vaccinations at dramatically lower rates than white Americans in the first weeks of the chaotic rollout, according to a new KHN analysis.
About 3% of Americans have received at least one dose of a coronavirus vaccine so far. But in 16 states that have released data by race, white residents are being vaccinated at significantly higher rates than Black residents, according to the analysis — in many cases two to three times higher.
In the most dramatic case, 1.2% of white Pennsylvanians had been vaccinated as of Jan. 14, compared with 0.3% of Black Pennsylvanians.
The vast majority of the initial round of vaccines has gone to health care workers and staffers on the front lines of the pandemic — a workforce that’s typically racially diverse made up of physicians, hospital cafeteria workers, nurses and janitorial staffers.
If the rollout were reaching people of all races equally, the shares of people vaccinated whose race is known should loosely align with the demographics of health care workers. But in every state, Black Americans were significantly underrepresented among people vaccinated so far.
Access issues and mistrust rooted in structural racism appear to be the major factors leaving Black health care workers behind in the quest to vaccinate the nation. The unbalanced uptake among what might seem like a relatively easy-to-vaccinate workforce doesn’t bode well for the rest of the country’s dispersed population.
“My concern now is if we don’t vaccinate the population that’s highest-risk, we’re going to see even more disproportional deaths in Black and brown communities,” said Dr. Fola May, a UCLA physician and health equity researcher. “It breaks my heart.”
Dr. Taison Bell, a University of Virginia Health System physician who serves on its vaccination distribution committee, stressed that the hesitancy among some Blacks about getting vaccinated is not monolithic. Nurses he spoke with were concerned it could damage their fertility, while a Black co-worker asked him about the safety of the Moderna vaccine since it was the company’s first such product on the market. Some floated conspiracy theories, while other Black co-workers just wanted to talk to someone they trust like Bell, who is also Black.
But access issues persist, even in hospital systems. Bell was horrified to discover that members of environmental services — the janitorial staff — did not have access to hospital email. The vaccine registration information sent out to the hospital staff was not reaching them.
“That’s what structural racism looks like,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Those groups were seen and not heard — nobody thought about it.”
UVA Health spokesperson Eric Swenson said some of the janitorial crew were among the first to get vaccines and officials took additional steps to reach those not typically on email. He said more than 50% of the environmental services team has been vaccinated so far.
A Failure of Federal Response
As the public health commissioner of Columbus, Ohio, and a Black physician, Dr. Mysheika Roberts has a test for any new doctor she sees for care: She makes a point of not telling them she’s a physician. Then she sees if she’s talked down to or treated with dignity.
That’s the level of mistrust she says public health officials must overcome to vaccinate Black Americans — one that’s rooted in generations of mistreatment and the legacy of the infamous Tuskegee syphilis study and Henrietta Lacks’ experience.
A high-profile Black religious group, the Nation of Islam, for example, is urging its members via its website not to get vaccinated because of what Minister Louis Farrakhan calls the “treacherous history of experimentation.” The group, classified as a hate group by the Southern Poverty Law Center, is well known for spreading conspiracy theories.
Public health messaging has been slow to stop the spread of misinformation about the vaccine on social media. The choice of name for the vaccine development, “Operation Warp Speed,” didn’t help; it left many feeling this was all done too fast.
Benjamin noted that while the nonprofit Ad Council has raised over $37 million for a marketing blitz to encourage Americans to get vaccinated, a government ad campaign from the Health and Human Services Department never materialized after being decried as too political during an election year.
“We were late to start the planning process,” Benjamin said. “We should have started this in April and May.”
And experts are clear: It shouldn’t merely be ads of famous athletes or celebrities getting the shots.
“We have to dig deep, go the old-fashioned way with flyers, with neighbors talking to neighbors, with pastors talking to their church members,” Roberts said.
Speed vs. Equity
Mississippi state Health Officer Dr. Thomas Dobbs said that the shift announced Tuesday by the Trump administration to reward states that distribute vaccines quickly with more shots makes the rollout a “Darwinian process.”
Dobbs worries Black populations who may need more time for outreach will be left behind. Only 18% of those vaccinated in Mississippi so far are Black, in a state that’s 38% Black.
It might be faster to administer 100 vaccinations in a drive-thru location than in a rural clinic, but that doesn’t ensure equitable access, Dobbs said.
“Those with time, computer systems and transportation are going to get vaccines more than other folks — that’s just the reality of it,” Dobbs said.
In Washington, D.C, a digital divide is already evident, said Dr. Jessica Boyd, the chief medical officer of Unity Health Care, which runs several community health centers. After the city opened vaccine appointments to those 65 and older, slots were gone in a day. And Boyd’s staffers couldn’t get eligible patients into the system that fast. Most of those patients don’t have easy access to the internet or need technical assistance.
“If we’re going to solve the issues of inequity, we need to think differently,” Boyd said.
“We are missing the boat on equity,” he said. “If we don’t step back and address that, it’s going to get worse.”
While Plescia is heartened by President-elect Joe Biden’s vow to administer 100 million doses in 100 days, he worries the Biden administration could fall into the same trap.
And the lack of public data makes it difficult to spot such racial inequities in real time. Fifteen states provided race data publicly, Missouri did so upon request, and eight other states declined or did not respond. Several do not report vaccination numbers separately for Native Americans and other groups, and some are missing race data for many of those vaccinated. The CDC plans to add race and ethnicity data to its public dashboard, but CDC spokesperson Kristen Nordlund said it could not give a timeline for when.
One-third of Black adults in the U.S. said they don’t plan to get vaccinated, citing the newness of the vaccine and fears about safety as the top deterrents, according to a December poll from KFF. (KHN is an editorially independent program of KFF.) Half of them said they were concerned about getting covid from the vaccine itself, which is not possible.
Experts say this kind of misinformation is a growing problem. Inaccurate conspiracy theories that the vaccines contain government tracking chips have gained ground on social media.
Just over half of Black Americans who plan to get the vaccine said they’d wait to see how well it’s working in others before getting it themselves, compared with 36% of white Americans. That hesitation can even be found in the health care workforce.
“We shouldn’t make the assumption that just because someone works in health care that they somehow will have better information or better understanding,” Bell said.
In Colorado, Black workers at Centura Health were 44% less likely to get the vaccine than their white counterparts. Latino workers were 22% less likely. The hospital system of more than 21,000 workers is developing messaging campaigns to reduce the gap.
“To reach the people we really want to reach, we have to do things in a different way, we can’t just offer the vaccine,” said Dr. Ozzie Grenardo, a senior vice president and chief diversity and inclusion officer at Centura. “We have to go deeper and provide more depth to the resources and who is delivering the message.”
That takes time and personal connections. It takes people of all ethnicities within those communities, like Willy Nuyens.
Nuyens, who identifies as Hispanic, has worked for Kaiser Permanente Los Angeles Medical Center for 33 years. Working on the environmental services staff, he’s now cleaning covid patients’ rooms. (KHN is not affiliated with Kaiser Permanente.)
In Los Angeles County, 92% of health care workers and first responders who have died of covid were nonwhite. Nuyens has seen too many of his co-workers lose family to the disease. He jumped at the chance to get the vaccine but was surprised to hear only 20% of his 315-person department was doing the same.
So he went to work persuading his co-workers, reassuring them that the vaccine would protect them and their families, not kill them.
“I take two employees, encourage them and ask them to encourage another two each,” he said.
So far, uptake in his department has more than doubled to 45%. He hopes it will be over 70% soon.
Como médica de emergencias, la doctora Eugenia South fue parte del primer grupo de personas en recibir la vacuna contra covid. Tuvo su segunda dosis a principios de enero, incluso antes que el presidente electo Joe Biden.
Así y todo, South dice que no tiene apuro por dejar de usar máscara
“Honestamente, no creo que vuelva a estar sin máscara en el trabajo”, dijo South, quien es directora del Urban Health Lab de la Universidad de Pennsylvania en Philadelphia. “No creo que me sentiría segura”.
Aunque las vacunas contra covid son altamente efectivas, South planea seguir usando máscara dentro y fuera del hospital.
Expertos en salud dicen que hay buenas razones para seguir el ejemplo de esta doctora.
“El uso de máscaras y el distanciamiento social deberán continuar en el futuro, hasta que tengamos cierto nivel de inmunidad colectiva”, dijo el doctor Preeti Malani, oficial de salud jefe de la Universidad de Michigan. “Las máscaras y el distanciamiento están aquí para quedarse”.
Malani y otros expertos en salud explican cinco razones:
Ninguna vacuna es 100% efectiva
Extensos ensayos clínicos hallaron que dos dosis de las vacunas de Moderna y Pfizer-BioNTech prevenían el 95% de las enfermedades causadas por el coronavirus. Si bien esos resultados son impresionantes, 1 de cada 20 personas queda desprotegida, dijo el doctor Tom Frieden, ex director de los Centros para el Control y Prevención de Enfermedades (CDC).
Malani señala que las vacunas se probaron en ensayos clínicos controlados, en los mejores centros médicos, en condiciones óptimas.
Pero en el mundo real, las vacunas suelen ser un poco menos efectivas. Los científicos usan términos específicos para describir el fenómeno. Se refieren a la protección que ofrecen las vacunas en los ensayos clínicos como “eficacia”, mientras que la inmunidad real que se obvserva en la población vacunada es “efectividad”.
La efectividad de las vacunas contra covid podría verse afectada por la forma en que se manipulan, observó Malani. El material genético utilizado en las vacunas elaboradas con ARN mensajero del coronavirus es tán frágil que debe almacenarse y transportarse con cuidado.
Malani explicó que ninguna vacuna ofrece protección apenas la persona se vacuna. El sistema inmunológico tarda aproximadamente dos semanas en producir anticuerpos que bloquean las infecciones virales.
Las vacunas contra covid, sin embargo, tardarán un poco más que otras porque tanto la de Pfizer como la de Moderna, requieren de dos dosis. Las dosis de Pfizer se administran con tres semanas de diferencia, las de Moderna, con cuatro semanas.
Es decir que no habrá protección completa hasta cinco o seis semanas después de la primera dosis. Una persona que se vacunó el día de Año Nuevo no estará completamente protegida hasta el día de San Valentín.
Es posible que las vacunas no impidan propagar el virus
Las vacunas pueden poporcionar dos niveles de protección. Por ejemplo, la vacuna contra el sarampión previene que el virus infecte un organismo, por lo que las personas vacunadas no transmiten la infección ni desarrollan síntomas.
Si bien las vacunas contra covid claramente previenen la enfermedad, los científicos necesitan más tiempo para descubrir si también previenen la transmisión, dijo Saskia Popescu, epidemióloga con sede en Phoenix y profesora asistente en el programa de biodefensa de la Escuela Schar de Gobierno y Políticas de la Universidad George Mason.
“Todavía no sabemos si la vacuna protege contra la infección o solo contra la enfermedad”, dijo Frieden, quien ahora es director ejecutivo de Resolve to Save Lives, una iniciativa mundial de salud pública. “En otras palabras, una persona vacunada podría transmitir el virus, incluso si no se siente enferma”.
Hasta que los investigadores puedan responder esta pregunta, usar cubrebocas es la forma más segura para que las personas vacunadas protejan a quienes las rodean.
Las máscaras protegen a personas con sistemas inmunitarios comprometidos
Las personas con cáncer tienen un riesgo particular de contraer covid. Estudios han mostrado que son más propensos a infectarse y a morir a causa del coronavirus. Y es posible que las vacunas no los protejan dijo el doctor Gary Lyman, profesor del Centro de Investigación del Cáncer Fred Hutchinson.
Los pacientes con cáncer son vulnerables en muchos aspectos. Las personas con cáncer de pulmón son menos capaces de combatir una neumonía, y los que están bajo quimioterapia o radioterapia tienen sistemas inmunes debilitados. La leucemia y el linfoma atacan directamente las células inmunitarias, lo que dificulta que los pacientes combatan el virus.
Lyman dijo que no se sabe cómo reaccionarán a la vacuna los pacientes oncológicos, porque fueron excluidos de los ensayos clínicos. A solo unos pocos participantes se les diagnóstico cáncer después de inscribirse. En este grupo, la protección de las vacunas solo fue del 76%.
“Por ahora, debemos asumir que los pacientes con cáncer pueden no experimentar el 95% de eficacia”, completó Lyman.
Hasta ahora, los estudios sugieren que las vacunas protegerán contra estas cepas. Pero es claro, según explicó Frieden, que los cubrebocas, la distancia física y medidas como evitar multitudes protegen contra todas las formas del virus, y de otros virus respiratorios.
The effort to vaccinate some of the country’s most vulnerable residents against covid-19 has been slowed by a federal program that sends retail pharmacists into nursing homes — accompanied by layers of bureaucracy and logistical snafus.
As of Thursday, more than 4.7 million doses of the Pfizer-BioNTech and Moderna covid vaccines had been allocated to the federal pharmacy partnership, which has deputized pharmacy teams from Walgreens and CVS to vaccinate nursing home residents and workers. Since the program started in some states on Dec. 21, however, they have administered about one-quarter of the doses, according to the Centers for Disease Control and Prevention.
Across the country, some nursing home directors and health care officials say the partnership is actually hampering the vaccination process by imposing paperwork and cumbersome corporate policies on facilities that are thinly staffed and reeling from the devastating effects of the coronavirus. They argue that nursing homes are unique medical facilities that would be better served by medical workers who already understand how they operate.
Mississippi’s state health officer, Dr. Thomas Dobbs, said the partnership “has been a fiasco.”
The state has committed 90,000 vaccine doses to the effort, but the pharmacies had administered only 5% of those shots as of Thursday, Dobbs said. Pharmacy officials told him they’re having trouble finding enough people to staff the program.
Dobbs pointed to neighboring Alabama and Louisiana, which he says are vaccinating long-term care residents at four times the rate of Mississippi.
“We’re getting a lot of angry people because it’s going so slowly, and we’re unhappy too,” he said.
Many of the nursing homes that have successfully vaccinated willing residents and staff members are doing so without federal help.
For instance, Los Angeles Jewish Home, with roughly 1,650 staff members and 1,100 residents on four campuses, started vaccinating Dec. 30. By Jan. 11, the home’s medical staff had administered its 1,640th dose. Even the facility’s chief medical director, Noah Marco, helped vaccinate.
The home is in Los Angeles County, which declined to participate in the CVS/Walgreens program. Instead, it has tasked nursing homes with administering vaccines themselves, and is using only Moderna’s easier-to-handle product, which doesn’t need to be stored at ultracold temperatures, like the Pfizer vaccine. (Both vaccines require two doses to offer full protection, spaced 21 to 28 days apart.)
By contrast, Mariner Health Central, which operates 20 nursing homes in California, is relying on the federal partnership for its homes outside of L.A. County. One of them won’t be getting its first doses until next week.
“It’s been so much worse than anybody expected,” said the chain’s chief medical officer, Dr. Karl Steinberg. “That light at the end of the tunnel is dim.”
Nursing homes have experienced some of the worst outbreaks of the pandemic. Though they house less than 1% of the nation’s population, nursing homes have accounted for 37% of deaths, according to the COVID Tracking Project.
Facilities participating in the federal partnership typically schedule three vaccine clinics over the course of nine to 12 weeks. Ideally, those who are eligible and want a vaccine will get the first dose at the first clinic and the second dose three to four weeks later. The third clinic is considered a makeup day for anyone who missed the others. Before administering the vaccines, the pharmacies require the nursing homes to obtain consent from residents and staffers.
Despite the complaints of a slow rollout, CVS and Walgreens said they’re on track to finish giving the first doses by Jan. 25, as promised.
“Everything has gone as planned, save for a few instances where we’ve been challenged or had difficulties making contact with long-term care facilities to schedule clinics,” said Joe Goode, a spokesperson for CVS Health.
Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, acknowledged some delays through the partnership, but said that’s to be expected because this kind of effort has never before been attempted.
“There’s a feeling they’ll get up to speed with it and it will be helpful, as health departments are pretty overstretched,” Plescia said.
But any delay puts lives at risk, said Dr. Michael Wasserman, the immediate past president of the California Association of Long Term Care Medicine.
“I’m about to go nuclear on this,” he said. “There should never be an excuse about people not getting vaccinated. There’s no excuse for delays.”
Bringing in Vaccinators
Nursing homes are equipped with resources that could have helped the vaccination effort — but often aren’t being used.
Most already work with specialized pharmacists who understand the needs of nursing homes and administer medications and yearly vaccinations. These pharmacists know the patients and their medical histories, and are familiar with the apparatus of nursing homes, said Linda Taetz, chief compliance officer for Mariner Health Central.
“It’s not that they aren’t capable,” Taetz said of the retail pharmacists. “They just aren’t embedded in our buildings.”
If a facility participates in the federal program, it can’t use these or any other pharmacists or staffers to vaccinate, said Nicole Howell, executive director for Ombudsman Services of Contra Costa, Solano and Alameda counties.
But many nursing homes would like the flexibility to do so because they believe it would speed the process, help build trust and get more people to say yes to the vaccine, she said.
Howell pointed to West Virginia, which relied primarily on local, independent pharmacies instead of the federal program to vaccinate its nursing home residents.
The state opted against the partnership largely because CVS/Walgreens would have taken weeks to begin shots and Republican Gov. Jim Justice wanted them to start immediately, said Marty Wright, CEO of the West Virginia Health Care Association, which represents the state’s long-term care facilities.
The bulk of the work is being done by more than 60 pharmacies, giving the state greater control over how the doses were distributed, Wright said. The pharmacies were joined by Walgreens in the second week, he said, though not as part of the federal partnership.
“We had more interest from local pharmacies than facilities we could partner them up with,” Wright said. Preliminary estimates show that more than 80% of residents and 60% of staffers in more than 200 homes got a first dose by the end of December, he said.
Goode from CVS said his company’s participation in the program is being led by its long-term care division, which has deep experience with nursing homes. He noted that tens of thousands of nursing homes — about 85% nationally, according to the CDC — have found that reassuring enough to participate.
“That underscores the trust the long-term care community has in CVS and Walgreens,” he said.
Vaccine recipients don’t pay anything out-of-pocket for the shots. The costs of purchasing and administering them are covered by the federal government and health insurance, which means CVS and Walgreens stand to make a lot of money: Medicare is reimbursing $16.94 for the first shot and $28.39 for the second.
Technically, federal law doesn’t require nursing homes to obtain written consent for vaccinations.
But CVS and Walgreens require them to get verbal or written consent from residents or family members, which must be documented on forms supplied by the pharmacies.
Goode said consent hasn’t been an impediment so far, but many people on the ground disagree. The requirements have slowed the process as nursing homes collect paper forms and Medicare numbers from residents, said Tracy Greene Mintz, a social worker who owns Senior Care Training, which trains and deploys social workers in more than 100 facilities around California.
In some cases, social workers have mailed paper consent forms to families and waited to get them back, she said.
“The facilities are busy trying to keep residents alive,” Greene Mintz said. “If you want to get paid from Medicare, do your own paperwork,” she suggested to CVS and Walgreens.
Scheduling has also been a challenge for some nursing homes, partly because people who are actively sick with covid shouldn’t be vaccinated, the CDC advises.
“If something comes up — say, an entire building becomes covid-positive — you don’t want the pharmacists coming because nobody is going to get the vaccine,” said Taetz of Mariner Health.
Both pharmacy companies say they work with facilities to reschedule when necessary. That happened at Windsor Chico Creek Care and Rehabilitation in Chico, California, where a clinic was pushed back a day because the facility was awaiting covid test results for residents. Melissa Cabrera, who manages the facility’s infection control, described the process as streamlined and professional.
In Illinois, about 12,000 of the state’s roughly 55,000 nursing home residents had received their first dose by Sunday, mostly through the CVS/Walgreens partnership, said Matt Hartman, executive director of the Illinois Health Care Association.
While Hartman hopes the pharmacies will finish administering the first round by the end of the month, he noted that there’s a lot of “headache” around scheduling the clinics, especially when homes have outbreaks.
“Are we happy that we haven’t gotten through round one and West Virginia is done?” he asked. “Absolutely not.”
KHN correspondent Rachana Pradhan contributed to this report.
Dr. Monte Junker, an Oregon dentist, is waiting for his turn to get vaccinated for covid even though he considers himself a front-line health worker.
“If they offered it to me today, I would be there,” he said.
In December, just before the first vaccines were cleared for emergency use, the Centers for Disease Control and Prevention immunization advisory board recommended that health care workers — as well as nursing home residents and staff members — be the first to be inoculated because of their high risks of infection.
But Oregon is one of a handful of states, including Colorado, North Carolina and Texas, that have put dentistslower in priority order than other health professionals who treat patients — even though they have their hands in people’s mouths and are exposed to aerosols that spray germs in their faces during procedures.
As a result, dentists in those states must wait while many of their peers got their shots in December.
Dr. Tam Le, president of the Connecticut State Dental Association, was vaccinated in December along with employees at his practice in Cheshire. He said he lobbied the state to include dentists with other front-line hospital and health workers.
“In Connecticut, we are doing really well,” he said, noting that the state set up an online registration system for eligible health workers and then contacted them about when and where they could get the vaccine. Le said he and his staff went to a nearby community health center for their shots.
Dentists gained goodwill from state officials last spring by donating gloves and masks to hospitals, Le said. They also offered to help administer the shots since they have experience with that.
States are increasingly diverging from CDC guidance in their vaccination plans, according to an analysis by KFF. “Timelines vary significantly across states, regardless of priority group, resulting in a vaccine rollout labyrinth across the country,” the report said. (KHN is an editorially independent program of KFF.)
The American Dental Association said it’s aware that the lack of a national immunization strategy has meant that dentists and their staffs are not being treated equally across the country.
The CDC advisory board included dentists when it recommended that front-line health workers get priority.
“Each state government’s approach to vaccination will be different based on populations and need, but all dental team members should be prioritized in the first-tier distribution as the vaccines roll out by the different state and county public health departments,” said Daniel Klemmedson, the ADA president. An oral surgeon in Arizona, he has been vaccinated.
In Florida, dentists and their staffs are included among front-line workers eligible for vaccines in the first wave, but a lack of supply has hindered some from getting their shots, according to Drew Eason, CEO of the Florida Dental Association. Some county health departments have also incorrectly turned dentists away, he added.
Dr. Cindy Roark, a Boca Raton dentist and chief clinical officer of Sage Dental, which has 15 offices in Florida and Georgia, said she has no idea when she’ll get vaccinated. She said Georgia dentists in her company have been vaccinated, while those in Florida must wait. The only exceptions appear to be the relatively few dentists affiliated with hospitals. “We are equally vulnerable,” she said.
Still, Roark said she is not upset. “I know I can protect myself,” she said, adding that her office staffers wear N95 masks, face shields and gloves to protect themselves and patients. “Most dentists feel completely safe running their practice and preventing transmission.”
Junker, regional dental director at Advantage Dental in The Dalles, Oregon, said he understands that intensive care staff members, emergency department workers and the elderly in nursing homes need the vaccine first.
“But we are definitely up there for the copious quantities of aerosol in our faces each day,” he said. “The atmosphere is highly concentrated” with virus.
He’s upset at the poor planning and coordination between states and the federal government to make dentists a priority.
In cases where hospital staffers are declining the vaccine because they don’t trust it, Junker said, hospitals should offer shots to dentists and others who are eager for them.
“I don’t think it’s fair for them to sit on the vaccine for a month or two. It needs to get used, and if the hospital workers later decide to get vaccinated, they can get back in line,” he said.
Dr. Stan Hardesty, a Raleigh, North Carolina, dentist and president of the state dental society, said it’s disappointing to see dentists in other states get the vaccine while he and his colleagues have been told to wait.
“We have been advocating on behalf of our members to have dentists and our team members included in phase 1a as recommended by the CDC,” he said. “Unfortunately, the decision-makers [in the state government] have decided to utilize a different prioritization in their vaccine implementation.”
North Carolina dentists will be in “phase 1b,” which includes adults 75 and older, essential workers such as police officers and firefighters.
As an emergency physician, Dr. Eugenia South was in the first group of people to receive a covid vaccine. She received her second dose last week — even before President-elect Joe Biden.
Yet South said she’s in no rush to throw away her face mask.
“I honestly don’t think I’ll ever go without a mask at work again,” said South, faculty director of the Urban Health Lab at the University of Pennsylvania in Philadelphia. “I don’t think I’ll ever feel safe doing that.”
And although covid vaccines are highly effective, South plans to continue wearing her mask outside the hospital as well.
Health experts say there are good reasons to follow her example.
“Masks and social distancing will need to continue into the foreseeable future — until we have some level of herd immunity,” said Dr. Preeti Malani, chief health officer at the University of Michigan. “Masks and distancing are here to stay.”
Malani and other health experts explained five reasons Americans should hold on to their masks:
1. No vaccine is 100% effective.
Large clinical trials found that two doses of the Moderna and Pfizer-BioNTech vaccines prevented 95% of illnesses caused by the coronavirus. While those results are impressive, 1 in 20 people are left unprotected, said Dr. Tom Frieden, a former director of the Centers for Disease Control and Prevention.
Malani notes that vaccines were tested in controlled clinical trials at top medical centers, under optimal conditions.
In the real world, vaccines are usually slightly less effective. Scientists use specific terms to describe the phenomenon. They refer to the protection offered by vaccines in clinical trials as “efficacy,” while the actual immunity seen in a vaccinated population is “effectiveness.”
The effectiveness of covid vaccines could be affected by the way they’re handled, Malani said. The genetic material used in mRNA vaccines — made with messenger RNA from the coronavirus — is so fragile that it has to be carefully stored and transported.
Any variation from the CDC’s strict guidance could influence how well vaccines work, Malani said.
2. Vaccines don’t provide immediate protection.
No vaccine is effective right away, Malani said. It takes about two weeks for the immune system to make the antibodies that block viral infections.
Covid vaccines will take a little longer than other inoculations, such as the flu shot, because both the Moderna and Pfizer products require two doses. The Pfizer shots are given three weeks apart; the Moderna shots, four weeks apart.
In other words, full protection won’t arrive until five or six weeks after the first shot. So, a person vaccinated on New Year’s Day won’t be fully protected until Valentine’s Day.
3. Covid vaccines may not prevent you from spreading the virus.
Vaccines can provide two levels of protection. The measles vaccine prevents viruses from causing infection, so vaccinated people don’t spread the infection or develop symptoms.
“We don’t yet know if the vaccine protects against infection, or only against illness,” said Frieden, now CEO of Resolve to Save Lives, a global public health initiative. “In other words, a vaccinated person might still be able to spread the virus, even if they don’t feel sick.”
Until researchers can answer that question, Frieden said, wearing masks is the safest way for vaccinated people to protect those around them.
4. Masks protect people with compromised immune systems.
People with cancer are at particular risk from covid. Studies show they’re more likely than others to become infected and die from the virus, but may not be protected by vaccines, said Dr. Gary Lyman, a professor at Fred Hutchinson Cancer Research Center.
Cancer patients are vulnerable in multiple ways. People with lung cancer are less able to fight off pneumonia, while those undergoing chemotherapy or radiation treatment have weakened immune systems. Leukemia and lymphoma attack immune cells directly, which makes it harder for patients to fight off the virus.
Doctors don’t know much about how people with cancer will respond to vaccines, because they were excluded from randomized trials, Lyman said. Only a handful of study participants were diagnosed with cancer after enrolling. Among those people, covid vaccines protected only 76%.
Although the vaccines appear safe, “prior studies with other vaccines raise concerns that immunosuppressed patients, including cancer patients, may not mount as great an immune response as healthy patients,” Lyman said. “For now, we should assume that patients with cancer may not experience the 95% efficacy.”
Some people aren’t able to be vaccinated.
While most people with allergies can receive covid vaccines safely, the CDC advises those who have had severe allergic reactions to vaccine ingredients, including polyethylene glycol, to avoid vaccination. The agency also warns people who have had dangerous allergic reactions to a first vaccine dose to skip the second.
Lyman encourages people to continue wearing masks to protect those with cancer and others who won’t be fully protected.
5. Masks protect against any strain of the coronavirus, in spite of genetic mutations.
So far, studies suggest vaccines will still work against these new strains.
One thing is clear: Public health measures — such as avoiding crowds, physical distancing and masks — reduce the risk of contracting all strains of the coronavirus, as well as other respiratory diseases, Frieden said. For example, the number of flu cases worldwide has been dramatically lower since countries began asking citizens to stay home and wear masks.
“Masks will remain effective,” Malani said. “But careful and consistent use will be essential.”
The best hope for ending the pandemic isn’t to choose between masks, physical distancing and vaccines, Offit said, but to combine them. “The three approaches work best as a team,” he said.
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.
As a health care journalist in Los Angeles reporting on the pandemic, I knew exactly what I needed to do once I landed in the hospital with covid pneumonia: write my goodbye emails.
I’d seen coverage of some final covid messages during this terrible year. They were usually directed to spouses, but my No. 1 concern was how to explain my own death to my 3-year-old, Marigold, whom we call “Goldie.” How much of me would she remember, and how would she make peace with what happened to me, when I could barely believe it myself?
After the emergency room doctor confirmed pneumonia in both of my lungs on Dec. 17, I was whisked upstairs to the hospital’s covid unit, where I got a blood thinner injection, infusions of steroids and remdesivir, and continued on the supplemental oxygen they had started in the ER.
Immediately after the treatments, my mind was clearer and more focused than it had been in the nine days since my husband, daughter and I had all received positive covid results (and when my raging fevers began). As I lay in my hospital bed, my roommate’s TV blaring, I started thinking about my daughter’s understanding of death. A lapsed evangelical married to a Jewish man, I had adopted his family’s perspective on the afterlife — that discussing it wasn’t very important — but had also inadvertently abdicated the death discussion to Hollywood.
Goldie’s afterlife education began with the movie “Coco,” about the Mexican Day of the Dead, in which families put pictures of their ancestors on a home altar, or ofrenda. Then came “Over the Moon,” in 2020, about a little girl in China who loses her mom to illness and struggles to accept a new stepmother, all while her mom’s spirit visits her in the form of a crane.
That prompted her first question about my death.
“Are you going to die like Fei Fei’s mom did?” Goldie asked me in November, before I got sick. I told her at the time that no one knows when they’re going to die, but that I would love her with all of my heart for as long as I lived.
After that, Goldie would sometimes randomly declare, “I don’t think you’re going to die,” or she would ask if we could all die together, at the same time — to which I’d say, “Sure!”
My covid symptoms started Dec. 7, and we got our positive results back the next morning. Thankfully, my husband and daughter had almost no symptoms except stuffy noses and a day of low fever. But I started off with a fever that would burn me up to 104 degrees, over and over again. Tylenol and Advil could bring it down only to 100 or 101. I would cry as the painful fevers reached their peak and wondered if God had been preparing Goldie all along this year for my eventual death.
My breathing problems began eight days later. The scariest moment during that time was when I was in the middle of a shower (much needed after days of sweaty fevers) and realized I was gasping for air. I punched the shower curtains out of my way and ran to my bed, where I could lie on my stomach and get my oxygen levels up again. As I lay there, hyperventilating, soaking wet, with shampoo still in my hair, the pulse oximeter monitor registered 67, before inching back up to 92. I began thinking of what I wanted to say to Goldie in my final letter to her, but I was too weak to type it out.
Two more uterine procedures led to a successful embryo transfer, but a miscarriage put me in the ER on Oct. 8. By then, Los Angeles County had seen 278,665 cases and 6,726 deaths — horrifying numbers that I monitored and reported on as a health journalist, but data points I couldn’t, or wouldn’t, use to alter the decision-making in my own life.
With four miscarriages now under my belt and no more viable embryos left to use, my husband, Simon, and I decided we’d give in vitro fertilization one final try. I started my injections for an egg retrieval in late November, and by the time the procedure rolled around on Dec. 3, L.A. was well into its scary, almost vertical holiday season ascent, posting 7,854 new cases that day — up fivefold from a month earlier.
A close friend was supposed to start her IVF injections at the same time, but she decided to postpone at the last minute because covid cases were so high in our area. By that point, we were so driven in our pursuing of pregnancy that I was startled to hear her say that, as the thought had never even crossed my mind.
I have no way of knowing for sure if I was exposed to the virus sometime during this last fertility treatment. The surgical center is located on a large medical campus that also hosts a covid-19 testing drive-thru in the garage where we parked. We waited, masks on, for almost an hour outside the building, which we thought was a safer choice than the fertility clinic waiting room, but that actually put us in proximity to a lot of sick people waiting for rides home.
I also had to remove my mask just before the actual egg retrieval, because I was under anesthesia and the doctors needed quick access to my mouth in case I needed a breathing tube.
Five days after the egg retrieval, we found out we were covid-positive. I called the clinic right away to warn them; the fertility doctor told me a few days later that none of her staffers had gotten sick. And also that none of the eggs they retrieved from me had developed properly. We had no embryos to use.
Of course, as anyone who has done fertility treatments knows, all the dangers and risks we undertook would have been “worth it” if it had worked. Because it didn’t work for us, I felt defeated and foolish.
In sum, we wanted to give Goldie a sibling, but attempting to do so may have been what threatened her mother’s life. This thought haunts me and will stay with me forever, even though I’ll never know how exactly the virus entered our home.
Our nanny, who also experienced covid symptoms and tested positive three days before us, could have picked it up at the supermarket. We could have gotten it from her or while walking around our neighborhood or playing in the park. But the act of choosing, over and over again, to engage in fertility treatments as the pandemic raged on, fills me with doubt and remorse.
This was all too much to put in my goodbye letter to Goldie. Instead, this is some of what I wrote:
Around Halloween, you and I were eating breakfast together and I asked you how your life was going, and if there were any improvements I could make for you. You said, with absolute seriousness, “I’m afraid of ghosts.”
Now that I’m a ghost, I hope there’s less reason to be afraid.
Please put my picture on the ofrenda once a year. I’ll always be in your heart and in your memories. I will try to visit you too. But not in a spooky way, just a gentle way.
I will always love you. Thank you so much for being born to us. You made everything better.
After finishing my goodbye letter, I went to sleep. In the morning, I woke up, got a second infusion of steroids and remdesivir, and then was released home with oxygen tanks and an oxygen concentrator. I stayed in bed, on oxygen, for another week before my lungs were strong enough for me to stand and walk on my own. We had a wonderful Christmas morning together opening presents during a Zoom call with my family. Other than fatigue, I am now almost back to normal.
After the holidays, I sat down with Goldie for breakfast as we usually do. Feeling morose about how the year had turned out, I asked, dreading her response, if she would like to have a baby brother or sister one day.
She put her hand on my neck and pressed her forehead into mine, a face-to-face embrace that we call a “pumpkin hug.”
“No, Mom,” she said. “I want it to be just you and me, forever.”
I took a deep breath, and then sighed with relief.
For Heather Suri, a registered nurse in Virginia, the race to vaccinate Americans against covid has thrown up some unprecedented obstacles.
The vaccines themselves are delicate and require a fair bit of focus over time. Consider Moderna’s instructions for preparing its doses: Select the number of shots that will be given. Thaw the vials for 2.5 hours in a refrigerator set between 36 and 46 degrees. Then rest them at room temperature for 15 minutes. Do not refreeze. Swirl gently between each withdrawal. Do not shake. Inspect each vial for particulate matter or discoloration. Store any unused vaccine in refrigeration.
And then there’s this: Once open, a vial is good for only six hours. As vaccines go, that’s not very long. Some flu vaccine keeps almost a month.
“This is very different, administering this vaccine. The process, it takes a whole lot longer than any mass vaccination event that I’ve been involved with,” said Suri, a member of the Loudoun Medical Reserve Corps who joined her first clinic Dec. 28, to vaccinate first responders.
Of the first two covid vaccines on the market, Moderna’s is considered more user-friendly. Pfizer-BioNTech’s shot must be stored in specialized freezers at 94 degrees below zero. Once out of deep freeze, it lasts just five days, compared with 30 days for Moderna’s.
One thing the shots have in common: They last a paltry six hours once the first dose is removed from a vial. That short shelf life raises the stakes for the largest vaccination effort in U.S. history by forcing clinicians to anticipate the exact number of doses they’ll need each day. If they don’t get it right, precious stores of vaccine may go to waste.
During one recent clinic over several hours, Suri estimated she gave “maybe 25” shots, many fewer than the number of flu shots she’s given during similar clinics over the years.
With covid, she said, “the vaccine itself slows things down.”
The slow rollout has frustrated people who at Thanksgiving imagined millions of vaccines in arms by Christmas. Promises that 20 million would be vaccinated by New Year’s fell well short: Just 2.8 million had the first of two required shots by the end of December, according to data from the Centers for Disease Control and Prevention.
Public health officials say many factors are at play, including a shortage of workers trained to administer shots, covid protocols that require physical distancing at clinics and vaccine allocation numbers from the federal government that fluctuate by the week.
And then there are the logistics of the first covid vaccines, which are complex and make hyper-vigilant practitioners wary of opening too many vials over the course of each day, for fear that anything unused will have to be tossed. Vaccine providers also report wasted or spoiled doses to public health authorities.
“If you get to the end of your clinic and every nurse has half a vial left, what are you going to do with that vaccine?” Suri said. “The clock is ticking. You don’t want to waste those doses.”
That impulse has led some health personnel to make dramatic decisions at the end of a day: calling non-front-line health workers or offering shots to whoever is at hand in, say, a grocery store, instead of scrambling to find the health workers and residents of nursing homes in the government’s first tier for injections.
“We jumped and ran and got the vaccine,” said Dr. Mark Hathaway, an OB-GYN in the District of Columbia who received the first dose of a Moderna vaccine on Dec. 26 along with his wife, a registered nurse specializing in nutrition. Both clinicians received vaccines faster than anticipated at a Unity Health Care clinic when there were extra doses because fewer front-line health care workers than expected showed up.
“Health care workers have been priority 1a, so our first attempt has always been our staff,” said Dr. Jessica Boyd, Unity Health Care’s chief medical officer. Since then, the community health center network has broadened its criteria for extra doses to include staff members or high-risk patients visiting a clinic, she said.
Health officials encourage using the doses to get as many Americans vaccinated as quickly as possible. Public health experts say the need to vaccinate people is especially urgent as a new and more contagious variant of the virus first detected in the United Kingdom is showing up in multiple states. Some states, including New York and California, have loosened their guidelines on who can get vaccinated after an outcry over health care providers throwing away doses that didn’t meet officials’ strict criteria.
The tiers “are simply recommendations, and they should never stand in the way of getting shots in arms instead of keeping vaccine in the freezer or wasting vaccine in the vial,” Health and Human Services Secretary Alex Azar said Jan. 6, referring to CDC guidelines saying health care workers and residents and staff of long-term care facilities should be first in line, then people at least 75 years old. The Trump administration this week also said it would make more shots available by releasing second doses and urged states to broaden rules to allow anyone 65 or older and any resident with a serious medical condition to get a shot.
Pfizer-BioNTech’s ultra-cold storage requirements have made it less ideal for local public health departments and rural areas.
Both of the available vaccines arrive in multidose vials — Pfizer-BioNTech’s contains about five doses, Moderna’s 10. Neither contains preservatives and they are viable for only six months frozen. By contrast, during the H1N1 pandemic roughly a decade ago, the swine flu vaccines lasted 18 weeks to 18 months, Sen. Chuck Grassley (R-Iowa) wrote in a May 2010 letter to then-HHS Secretary Kathleen Sebelius.
“We can’t get the vaccine out fast enough; we have people dying. But, at the same time, we have to get it right,” said Claire Hannan, executive director of the Association of Immunization Managers.
The added risk of losing doses due to quick expiration is another thing “causing angst,” Hannan said. “You can’t just draw it up and let it sit. It can’t just sit out like that.”
The Trump administration fell significantly short of its promise that 20 million Americans would be vaccinated by the end of December, partly the result of a disjointed and underfunded public health system that has received limited guidance from federal officials. As of Jan. 11, 25.5 million vaccine doses had been distributed nationwide but only 9 million administered, according to the CDC.
Federal officials have released sparse data about who is getting vaccinated, but state information has shown significant variation in vaccination rates depending on the facility. New York Gov. Andrew Cuomo on Jan. 4 said New York City’s public hospital system had used only 31% of its allocated vaccines, while private health systems NewYork-Presbyterian and Northwell Health had used 99% and 62%, respectively.
“When you target a priority group, it’s inefficient. When you open it up to a larger group, it’s efficient … but you’re not going to have enough supply,” Hannan said. “You still have the challenge of getting those health care workers vaccinated and no matter any way you slice it, you still have limited supply. You can’t please everyone.”
While Pfizer’s vaccine has largely been earmarked for large institutions like hospitals and nursing homes, Moderna’s has been more widely distributed to smaller sites like public health departments and clinics run by volunteers. State and local officials have begun or will soon vaccinate other priority populations, including police officers, teachers and other K-12 school employees, and seniors overall.
Unlike the covid vaccines, many flu vaccines come in prefilled syringes — each syringe’s cap is removed only when a shot is given, which speeds the process and eases some concerns about storage. However, relying on prefilled syringes during a pandemic has its own complications, according to Michael Watson, former president of Valera, a Moderna subsidiary: They take up more fridge space. They’re more expensive. And they can’t be used for frozen products, he said.
“For all these reasons, a vial was the best and only option,” he said.
In Ohio, Eric Zgodzinski, health commissioner for Toledo-Lucas County, said two-thirds of first responders the county surveyed said they would get the vaccine. Still, he said, his department has encountered situations in which a covid vaccine dose is left over in an open vial and officials have turned to a waiting list to find someone who can arrive within minutes to get a jab.
His department also has an internal running list of potential vaccine takers, including health department staffers, people in congregate care settings or those who had scheduled vaccination appointments for later on.
“We’re not going to open up a vial for one individual and figure out nine other people right away,” said Zgodzinski, whose department planned to distribute 2,200 doses of the Moderna vaccine the week of Jan. 4.
“If I have one dose left, who can I give it to?” he added. “A shot in the arm for anybody is better than it being wasted.”
San Francisco editor Arthur Allen and senior correspondent JoNel Aleccia contributed to this report.
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.
Last week, after finishing inoculations of some front-line hospital staff, Jupiter Medical Center was left with 40 doses of precious covid vaccine. So, officials offered shots to the South Florida hospital’s board of directors and their spouses over age 65.
But that decision sparked outrage among workers left unvaccinated, including those at one of the hospital’s urgent care clinics, or who believe the hospital was currying favor with wealthy insiders before getting all its staffers protected, according to a hospital employee who spoke on the condition of not being named.
The move also prompted dozens of calls from donors looking to get vaccinated.
The hospital received 1,000 doses of the Moderna vaccine two days before Christmas, fewer than half of what it requested from the state to cover its workforce. Officials prioritized delivering the vaccine to front-line medical workers who requested it, performing inoculations on Christmas Eve or the holiday weekends.
Patti Patrick, a hospital vice president, said the hospital acted appropriately in its offerings of the vaccine, which has a short shelf life once vials are opened. Neither she nor other administrators who don’t work directly with patients were included in this first round of shots.
“This was a simple way to move 40 doses very quickly” before it spoiled, she said.
She added that all front-line staff from the health system, including the clinics, were given the opportunity to get the shots.
Jupiter is not the only hospital in the nation facing questions about its handling of the vaccines. The initial rollout — aimed at health care workers and nursing home residents — has been uneven at best because of a lack of a federal strategy on how it should work, with states, hospitals, nursing homes and pharmacies often making decisions on their own about who gets vaccinated and when.
In some hospitals, administrators and other personnel who have no contact with patients or face no risk at work from the virus are getting shots, while patients — and even front-line staff — who are at heightened risk for covid complications are being passed by. Some administrators who have been working remotely throughout the pandemic have been vaccinated, especially at hospitals that decided to allocate doses by age group rather than exposure risk.
Although states and federal health groups laid out broad guidelines on how to prioritize who gets the vaccine, in practice what’s mattered most was who controlled the vaccine and where the vaccine distribution was handled.
Stanford Health Care in California was forced to rework its priority list after protests from front-line doctors in training who said they had been unfairly overlooked while the vaccine was given to faculty who don’t regularly see patients. (Age was the important factor in the university’s algorithm.)
Members of Congress have called for an investigation following media reports that MorseLife Health System, a nonprofit that operates a nursing home and assisted living facility in West Palm Beach, Florida, vaccinated donors and members of a country club who donated thousands of dollars to the health company.
Like Jupiter Medical, the hospitals insist that those offered shots were 65 and older, as prioritized by state officials.
Staffing Problems at Hospitals
An advisory board to the Centers for Disease Control and Prevention designated hospitals and nursing homes to get covid vaccines first because their workers and residents were considered at highest risk, and most states have followed that recommendation. But in many cases, the health institutions have found demand from staffers, some of whom are leery of the voluntary shot, is less than anticipated.
In addition, the arrival of promised shipments has been unpredictable. While the federal government approved the first covid vaccine on Dec. 14, some hospitals did not receive allotments until after Christmas.
That was the case at Hendry Regional Medical Center in Clewiston, Florida, which got 300 doses from the state. The hospital vaccinated 30 of its 285 employees between Dec. 28 and Jan. 5, said R.D. Williams, its chief executive officer. Some employees preferred to wait until after New Year’s weekend out of concern about side effects, he said.
The vaccine has been reported to commonly cause pain at the injection site and sometimes produce fever, lethargy or headache. The reactions generally last no more than a few days.
“I’m happy with how it’s going so far,” Williams said. “I know many of our employees want to be vaccinated, but I don’t see it as a panacea that they have to have it today,” he said, noting that staffers already have masks and gloves to protect themselves from the virus.
The hospital is also trying to coordinate vaccination schedules so 10 people at a time get the shot to ensure none of the medication is wasted after the multidose vials are thawed. Once vaccine is thawed, it must be used within hours to retain its effectiveness.
As of Jan. 6, Howard University Hospital in Washington, D.C., had vaccinated slightly more than 900 health workers since its first doses arrived Dec. 14. It has received 3,000 doses.
Success has been limited by reluctance among workers to get a vaccine and a lack of personnel trained to administer it, CEO Anita Jenkins said.
“We still have a hospital to run and have patients in the hospital with heart attacks and other conditions, and we don’t have additional staff to run the vaccine clinics,” she said.
While some hospitals offer the vaccine only to front-line workers who interact with patients, Howard makes it available to everyone, including public relations staff, cafeteria workers and administrators. Jenkins defended the move because, she said, it’s the best way to protect the entire hospital.
She noted such employees as information technology personnel who don’t see patients may be around doctors and nurses who do. “Working in a hospital, almost everyone runs into patients just walking down the hallway,” she said.
At Eisenhower Health, a nonprofit hospital based in Rancho Mirage, California, 2,300 of the 5,000 employees have been vaccinated.
“Our greatest challenge has been managing the current patient surge and staffing demands in our acute and critical care areas while also trying to ensure we have adequate staffing resources to operate the vaccine clinics,” said spokesperson Lee Rice.
A Non-System of Inequitable Distribution
Arthur Caplan, a bioethicist at NYU Langone Medical Center in New York City, said hospitals should not be inoculating board members ahead of hospital workers unless those people have a crucial role in running the hospital.
“That seems, to me, jostling to the head of the line and trying to reward those who may be potential donors,” he said. But he acknowledged that the hospitals’ vaccination systems are not always rational or equitable.
Covid vaccines need to get out as quickly as possible, he added, but hospitals can give them only to people they are connected with.
Caplan noted he was vaccinated at an NYU outpatient site last week, even though his primary care doctor hadn’t yet gotten the vaccine because his clinic had not received any doses.
In December, all states began vaccinating only health care workers and residents and staffers of nursing homes in the “phase 1A” priority group. But, since the new year began, some states have also started giving shots to — or booking appointments for — other categories of seniors and essential workers.
As states widen eligibility requirements for who can get a covid-19 vaccine, health officials are often taking people’s word that they qualify, thereby prioritizing efficiency over strict adherence to distribution plans.
“We are doing everything possible to vaccinate only those ‘in phase,’ but we won’t turn away someone who has scheduled their vaccine appointment and tells us that they are in phase if they do not have proof or ID,” said Bill Christian, spokesperson for the Tennessee Department of Health.
Among the states pivoting to vaccinating all seniors, timelines and strategies vary. Tennessee started offering shots to people 75 and older on Jan. 1. So, Frank Bargatze of Murfreesboro, Tennessee, snagged an appointment online for his father — and then went ahead and put his own name in, though he’s only 63.
“He’s 88,” Bargatze said, pointing to his father in the passenger seat after they both received their initial shots at a drive-thru vaccination site in Murfreesboro, a large city outside Nashville. “I jumped on his bandwagon,” he added with a laugh. “I’m going to blame it on him.”
Bargatze does work a few days a week with people in recovery from addiction, he added, so in a way, he might qualify as a health care worker.
Some departments are trying more than others, but overwhelmed public health departments don’t have time to do much vetting.
Dr. Lorraine MacDonald is the medical examiner in Rutherford County, Tennessee, where she’s been staffing the vaccination site. If people seeking the vaccine make it through the sign-up process online, MacDonald said, and show up for their appointment, health officials are not going to ask any more questions — as long as they’re on the list from the online sign-up.
“That’s a difficult one,” MacDonald acknowledged, when asked about people just under the age cutoff joining with older family members and putting themselves down for a dose, too. “It’s pretty much the honor system.”
People getting vaccinated in several Tennessee counties told a reporter they did not have to show ID or proof of qualifying employment when they arrived at a vaccination site. Tennessee’s health departments are generally erring on the side of simply giving the shot, even if the person is not a local resident or is not in the country legally.
The loose enforcement of the distribution phases extends to other parts of the country, including Los Angeles. In response, New York’s governor is considering making line-skipping a punishable offense.
Still, many people who don’t qualify on paper believe they might need the vaccine as much as those who do qualify in the initial phases.
Gayle Boyd of Murfreesboro is 74, meaning she didn’t quite make the cutoff in Tennessee, which is 75. But she’s also in remission from lung cancer, and so eager to get the vaccine and start getting back to a more normal life, that she joined her slightly older husband at the Murfreesboro vaccination site this week.
“Nobody’s really challenged me on it,” she said, noting she made sure to tell vaccination staffers about her medical issues. “Everybody’s been exceptionally nice.”
Technically, in the state’s current vaccine plan, having a respiratory risk factor like lung cancer doesn’t leapfrog anyone who doesn’t otherwise qualify. But in some neighboring states such as Georgia, where the minimum age limit is 65, Boyd would qualify.
Even for those who sympathize with such situations, anecdotes about line-skipping enrage many trying to wait their turn.
“We try to be responsible,” said 57-year-old Gina Kay Reid of Eagleville, Tennessee.
Reid was also at the Murfreesboro vaccination site, sitting in the back seat as she accompanied her older husband and her mother. She said she didn’t think about trying to join them in getting their first doses of vaccine. “If you take one and don’t necessarily need it, you’re knocking out somebody else that is in that higher-risk group.”
But there is a way for younger, healthier people to get the vaccine sooner than later — and not take a dose away from anyone more deserving.
A growing number of jurisdictions are realizing they have leftover doses at the end of every day. And the shots can’t be stored overnight once they’re thawed. So some pharmacists, such as some in Washington, D.C., are offering them to anyone nearby.
Jackson, Tennesse, has established a “rapid response” list for anyone willing to make it down to the health department within 30 minutes. Dr. Lisa Piercey, the state’s health commissioner, said her own aunt and uncle received a call at 8 p.m. and rushed to the county vaccination site to get their doses.
Piercey called it a “best practice” that she hopes other jurisdictions will adopt, offering a way for people eager for the vaccine to get it, while also helping states avoid wasting precious doses.
This story is part of a partnership that include WPLN, NPR and Kaiser Health News.
Big Tobacco did something unusual in Marlboro Country last fall: It stood aside while Colorado voters approved the state’s first tobacco tax hike in 16 years.
The industry, led by Altria Group, one of the world’s largest tobacco companies, has spent exorbitantly in the past to kill similar state ballot initiatives. In 2018, Altria’s lobbying arm spent more than $17 million to help defeat Montana’s tobacco tax ballot initiative. That same year, it spent around $6 million to help defeat South Dakota’s similar measure.
And four years ago, Altria was the leading funder in a successful $16 million campaign to quash Colorado’s previous proposed tobacco tax increase.
In November, by contrast, Altria didn’t spend a penny in opposition and Colorado voters overwhelmingly approved the tax with two-thirds support. Likewise, in Oregon, Big Tobacco stayed on the sidelines while a tax hike passed there.
The tax measures are major wins for anti-smoking advocates after a string of defeats but, in an example of how politics makes strange bedfellows, Colorado’s tax might not have been possible without Altria’s help. And, advocates said, the way those measures passed could provide a blueprint for states to follow in future elections.
In Colorado, Altria, the parent company of Marlboro cigarette maker Philip Morris, insisted that a minimum price be included in the proposal, according to The Colorado Sun, citing emails between political consultants and Gov. Jared Polis’ office. So while supporters see an increased tobacco tax as more revenue for the state, a disincentive for kids to smoke and a win for public health, the measure could also allow America’s premium tobacco companies to gain market share.
The Colorado measure will increase the total state-levied tax from 84 cents to eventually $2.64 per pack by 2027. The tax rate on vaping products, not currently taxed, will be 30% of the manufacturer’s list price in 2021, gradually increasing to 62% by 2027. The proposition also set the minimum price per pack of cigarettes at $7 as of Jan. 1 and that floor rises to $7.50 in 2024. The change could effectively help premium cigarette companies corner the market, since discount cigarettes would rise to at least $7.
Discount cigarette companies Liggett Group, Vector Tobacco and Xcaliber International — which funded opposition to the tax initiative, Proposition EE — tried to sue the state over the minimum tax provision, alleging “Philip Morris will reap huge benefits from the new legislation” and the changes will “destroy their ability to compete in Colorado.” In December, a federal judge rejected the company’s request for a preliminary injunction. A spokesperson for Liggett said the company plans to appeal.
“When it came to entities like Altria and other stakeholders that we engaged in the legislative process, I think that they saw the writing on the wall,” said Jake Williams, executive director of Healthier Colorado and one of the key organizers behind Proposition EE. “And it helped us get through the legislative process, not just with Democratic votes, but Republican votes to refer the measure to the ballot.”
Altria officials said in a statement that their tobacco companies oppose excise tax increases, but they did not say whether they had worked with Colorado lawmakers.
“Altria did not advocate for or against Proposition EE, and after evaluating the content and intent of this measure, Colorado voters decided to vote in favor of it, some aspects of which were focused on tobacco harm reduction and may help transition adult smokers to a non-combustible future,” the statement said.
Polis’ office did not respond to a request for comment. The Colorado Attorney General’s Office said it would not comment on matters under active litigation. State Democratic Sen. Dominick Moreno and Rep. Julie McCluskie, both state sponsors for the legislation, declined to comment for the same reason. Fellow Democrats Rep. Yadira Caraveo and Sen. Rhonda Fields, also state sponsors for the legislation, did not respond to requests for comment.
Colorado campaign finance records show Altria and Altria’s lobbying arm in 2020 contributed to funds that support both Democratic and Republican candidates in the state — a pattern playing out nationally.
Williams said Altria’s absence of public opposition wasn’t the only factor in the initiative’s success. The tax revenue will initially fund revenue lost during the covid-19 pandemic, then fund tobacco use prevention and eventually preschool education.
The American Lung Association, which supported the Colorado measure, said it believes tobacco taxes are among the most effective ways to reduce tobacco use, especially among youths, who are more sensitive to changes in price. The organization cites studies that found every 10% increase in the price of cigarettes reduces consumption by about 4% for adults and 7% for teens.
“Without tobacco industry opposition, it’s very popular among the public,” Thomas Carr, the association’s director of national policy, said of the tax increase. “We’ve long seen it in polling on the subject.”
There was no major industry opposition to the Oregon increase, either. Its tobacco tax increase — Measure 108 — also got a resounding two-thirds of support. But Oregon didn’t negotiate with Altria lobbyists or set a minimum price provision, according to Elisabeth Shepard, campaign manager for Yes for a Healthy Future.
“I don’t know what the [Colorado] deal was,” Shepard said. “All I know is that before it even made it to the ballot, Altria indicated that they were not going to oppose the measure and stuck with their word.”
While Shepard worried until Election Day whether Big Tobacco would swoop in with opposition in Oregon, it didn’t. She believes her campaign worked because the effort had early resources and money, the tax was targeted to fund the Oregon Health Plan (the state’s Medicaid), and her campaign’s coalition had 300 endorsers, including those in health and business communities.
“We had the left, we had the right, we had the far-right, we had the far-left,” Shepard said.
Her campaign paid its advisory committee members, including representatives from affected communities such as Indigenous Oregonian tribes. At least 30% of American Indian and Alaska Native adults in the state smoke cigarettes. Oregon’s measure increases tobacco taxes $2 per pack, from $1.33 to $3.33, as well as creates a new tax for e-cigarettes. The revenues will help fund an estimated $300 million for the state’s health plan.
Altria did not respond to a request for comment about Oregon tobacco taxes, but the company has previously said it opposed Oregon’s measure.
Shepard believes her campaign model could work in other states. Other anti-smoking advocates took note of the 2020 election.
“We certainly support establishing minimum prices for all tobacco products in conjunction with tobacco tax increases, as we know increasing the price of tobacco products is one of the most effective ways to reduce tobacco use,” said Cathy Callaway, director of state and local campaigns for the American Cancer Society Cancer Action Network.
It could just come down to a state’s voters and its politics, according to Mark Mickelson, a former Republican in South Dakota’s legislature. Mickelson was behind creating his state’s failed 2018 tobacco tax ballot initiative.
“We just got beat,” Mickelson said. The opposition “got ahead of us on the message. They had a lot more money and had just played on doubts that the [tax revenue] money would go to tech ed.”
The average state cigarette tax is $1.88 per pack, but it varies across the country — as high as $4.35 in New York but only 44 cents in North Dakota, where a 2016 ballot initiative to increase that to $2.20 was defeated.
Tax increases can translate into hundreds of millions of dollars in new revenue for states, said Richard Auxier, senior policy associate at the nonpartisan Urban-Brookings Tax Policy Center.
“It’s a little easier to pass a tax on someone else, which is often how this is seen — passing this tax on smokers, rather than passing it on all working people, [compared to] if you were to increase income tax or … a sales tax.”
But not all voters get a say.
In Kentucky, which isn’t a referendum state, Republican state Rep. Jerry Miller said there’s not a lot of sympathy for tobacco companies anymore.
“The agriculture community, which used to be on the same page with cigarette companies, are now always in opposition because the cigarette companies are always trying to tweak their formula to use cheaper tobacco,” he said.
Miller’s recent vaping tax bill failed in the state legislature, but he’s working on a new one.
“We don’t have that tradition or the mechanism that somebody collects 10,000 signatures and they get a referendum on a ballot,” he said. “That’s why things like this have to go through the legislature — and so it really just depends on the state [government].”
SACRAMENTO, Calif. — The coronavirus pandemic doomed Gov. Gavin Newsom’s ambitious plans last year to combat homelessness, expand behavioral health services and create a state agency to control soaring health care costs.
But even as the pandemic continues to rage, California’s Democratic governor said Friday he plans to push forward with those goals in the coming year, due to a rosier budget forecast buoyed by higher tax revenue from wealthy Californians who have fared relatively well during the crisis.
Newsom’s $227.2 billion budget blueprint also prioritizes billions to safely reopen K-12 schools shuttered by the pandemic, $600 payments for nearly 4 million low-income Californians — in addition to federal stimulus payments — and coronavirus relief grants and tax credits for hard-hit small businesses.
However, his 2021-22 fiscal year spending plan does not include additional public health money for local health departments steering California’s pandemic response, which have been chronically underfunded. He vowed to support cities and counties by boosting state testing and contact tracing capacity, speeding vaccination efforts and funding state-run surge hospitals that take overflow patients.
Newsom said Friday his budget reflects a “pandemic-induced reality” with investments aimed at spurring California’s economic recovery by helping businesses and people living in poverty. Wealth and income disparities, he added, “must be addressed.”
But Democrats in control of the state legislature, county leaders and social justice groups say that will be difficult to achieve because Newsom’s spending plan does not sufficiently fund health and social safety-net programs.
And without additional public health money, local leaders worry California will not be able to adequately control the spread of the virus.
“County public health is drowning,” said Graham Knaus, executive director of the California State Association of Counties. “We are triaging right now between testing, contact tracing and vaccination, and it’s impacting the response to the pandemic.”
Newsom’s budget proposal is the first step in a months-long negotiation process with the Democratic-controlled legislature, which has until June 15 to adopt the state budget that takes effect July 1. Lawmakers have become increasingly frustrated with the governor’s response to the pandemic, including his unilateral spending decisions in response to the emergency. Newsom is also facing a burgeoning recall effort, backed by heavyweight Republicans such as former San Diego Mayor Kevin Faulconer, who is considering challenging Newsom in the 2022 California gubernatorial election.
Newsom said he expects to make some tough calls on spending even though the state anticipates a $15 billion budget surplus for the coming fiscal year, largely because a state fiscal analysis projected deficits in subsequent years.
“While we are enjoying the fruits of a lot of one-time energy and surplus, it’s not permanent and we have to be mindful of over-committing,” Newsom said, explaining why he didn’t include funding to expand Medicaid to more unauthorized immigrants.
Some lawmakers say they will nonetheless press Newsom to use higher-than-expected revenues — and perhaps seek new taxes — to expand health coverage to more Californians.
The following health care proposals factor heavily into Newsom’s 2021-22 budget proposal.
Newsom committed $4.4 billion in his budget to vaccine distribution, increased testing, contact tracing and other short-term pandemic expenses. Because that spending is related to the public health emergency, the state expects at least 75% to be reimbursed by the federal government and insurance payments.
He also proposed $52 million to fund costs at state-run surge hospitals, including support staff. And he is asking lawmakers to sign off on a covid relief package that would provide funding before the start of the fiscal year in July. It would include $2 billion to help school districts reopen classrooms to in-person instruction beginning in February by paying for protective equipment, ventilation systems and adequate testing. It would also commit billions to economic recovery, such as stimulus payments for individuals, and grants and tax credits for struggling small businesses.
Newsom also wants to increase the budget for the Department of Industrial Relations by $23 million to fund up to 113 additional workplace inspectors at the California Division of Occupational Safety and Health to police health order violations at businesses and enforce workplace safety laws.
Spending for Medi-Cal, the state’s Medicaid program for low-income residents, is expected to grow in the coming year because of the economic impact of the pandemic — as is its enrollment. The program has roughly 13 million enrollees, or about one-third of the state population.
In the coming year, Newsom will also press forward with a major overhaul of Medi-Cal, through a project called CalAIM, to provide new benefits emphasizing mental health care and substance use treatment, and pay for some nontraditional costs such as housing assistance. The hope is the program would divert homeless and other vulnerable people away from expensive emergency room care and keep them out of jail.
State Medi-Cal officials estimate the program would cost $1.1 billion for the first year. The state is working with the federal Centers for Medicare & Medicaid Services to obtain approval for the program.
Newsom also wants to expand Medi-Cal benefits to cover over-the-counter cold medicine and blood glucose monitors for people with diabetes. His budget includes $95 million for a major expansion of telehealth services that would permanently provide higher payments for virtual doctor visits.
Controlling Health Care Costs
Newsom is proposing a new state agency, the Office of Health Care Affordability, which he said would help control health care costs. He budgeted $63 million over the next three years for the office, which would set health care cost targets for the health care industry — along with financial penalties for failing to meet future targets.
Powerful health industry groups said they are still assessing whether they will support the proposal. But some expressed concern last year when Newsom floated the idea. Doctors and hospitals routinely fight proposals in Sacramento that might limit their revenue.
Newsom acknowledged Friday the task would be “tough.”
Battling Homelessness and Food Insecurity
Newsom is proposing a one-time infusion of $1.75 billion to battle homelessness.
Of that, Newsom said, $750 million would help counties purchase hotels and transform them into permanent housing for chronically homeless people. Another $750 million would allow counties to purchase facilities to treat people with mental illness or substance use disorders. And $250 million would help counties purchase and renovate homes for low-income older people.
Newsom’s budget also includes $30 million to help overwhelmed food banks and emergency food assistance programs.
Lawmakers said they plan to negotiate for even more funding for homelessness and safety-net programs.
“We absolutely need to significantly increase our investment to address homelessness because the need is so intense,” said Assembly member David Chiu (D-San Francisco). “And I don’t think there’s a single legislator who isn’t incredibly concerned about the food insecurity we’re seeing: lines around the block for food banks in what should be the wealthiest state in the country.”
Expanding Health Coverage
Newsom did not include money in his proposed budget to expand Medi-Cal to unauthorized immigrants age 65 and older. He had previously promised to fund the proposal, estimated to cost $350 million per year once fully implemented, but he said Friday the state cannot afford to commit to ongoing costs with a projected budget deficit starting in fiscal year 2022-23. California already offers full Medicaid benefits for income-eligible unauthorized immigrants up to age 26.
Some lawmakers and health care advocates countered that providing health insurance for undocumented immigrants would save lives and reduce costs, especially during the pandemic, and vowed to continue to fight for the expansion.
“To say we are disappointed is describing it very lightly,” said Orville Thomas, a lobbyist with the California Immigrant Policy Center. “These are Californians dying and getting sick at disproportionate rates during covid.”
A new KFF analysis examines the different approaches states are taking to manage the limited initial supply of COVID-19 vaccines and balance the desire to vaccinate those at greatest risk first with the need to ensure a fast and effective statewide vaccination effort. Based on a review of state vaccination plans, the analysis finds that…More
This analysis examines the different approaches states are taking to manage the limited initial supply of COVID-19 vaccines and balance the desire to vaccinate those at greatest risk first with the need to ensure a fast and effective statewide vaccination effort. It includes a state data table.
2020 was the year that changed everything, and as the new year begins many are wondering what awaits the world in 2021. Impetus Digital co-founder and CEO Natalie Yeadon reflects on the last 12 months and shares her views on the healthcare, research and digital changes that could be here to stay.
I think it is fair to say that 2020 will not be particularly missed by anyone. Many started the year with big plans, whether for overseas trips, weddings, or industry events, and then the unthinkable happened. While the world first heard of the novel coronavirus in late 2019, it was not until 11 March 2020 that it was declared a global pandemic and it finally sank in just how serious of a threat it was. But how will the world continue to change in 2021?
Major global events
COVID-19 has amplified many of the issues that society was already facing. Although the pandemic has largely taken the media’s focus away from the climate crisis, it has given us a preview of what is to come if we do not stop exploiting the planet and our wildlife. Indeed, 2020 brought new record forest fires and extreme weather events.
In addition, 2020 was the year where social justice (not least in the form of Black Lives Matter protests) was brought into focus. Racial discrimination and bias were also uncovered in healthcare, with stark differences in COVID-19 rates and mortality between different ethnicities in many countries.
COVID-19 has widened the already large class divides seen between white-collar and service workers, with the former typically having the option of working from home and taking the recommended social distancing precautions. Conversely, the latter group is largely being forced to carry on with their work with little protection and low compensation, if they even have a job to go to after many smaller businesses closed their doors.
Public health has been politicised
Somehow, in 2020, wearing a mask to prevent the spread of a highly contagious disease became a controversial and political issue. People were asked to stay home, watch Netflix, and bake sourdough bread to protect those who are vulnerable, yet photos of packed bars and sports stadiums soon emerged and anti-masking protests were held across the world.
Epidemiologists, researchers, and clinicians are now household names, with people like Dr Anthony Fauci and Sweden’s Anders Tegnell drawing their fair share of both praise and criticism domestically and internationally. Countries’ strategies to contain the spread of the virus have been debated and criticised, and it will likely be years before we will be able to say which approaches were “right” and “wrong”.
“On the upside, the pandemic has brought enhanced focus to mental health issues and innovative approaches on how to best address these. If we can keep the momentum going and retain this focus post-COVID, perhaps the stigma around mental health can be lifted and better treatment strategies can emerge”
Mental health focus
The secondary effects on mental health during the pandemic are vast. We are already seeing increased rates of depression and anxiety because of the pandemic, and there are no signs of this slowing down. Women are especially impacted, disproportionately having to take on childcare or home-schooling compared to their male counterparts.
On the upside, the pandemic has brought enhanced focus to these issues and innovative approaches on how to best address mental health. If we can keep the momentum going and retain this focus post-COVID, perhaps the stigma can be lifted and better treatment strategies can emerge.
United global research
Another positive note is that the pandemic has accelerated laboratory and clinical trial collaboration far beyond what has ever been seen before. From the onset of the pandemic, scientists have been openly sharing their data with investigators from other centres or countries. It has also shown that the time it takes to get a drug to market can be substantially reduced when there is enough funding and political will. How this will affect clinical trials and regulatory approvals in the future remains to be seen, but there is reason to be optimistic.
Healthcare goes virtual
Before 2020, telehealth appointments were few and far between, with many clinics not set up for these services. Since then, the growth of telemedicine has been exponential. Another aspect of healthcare that has had to adapt is the way we monitor chronic conditions. Older patients or those with co-morbidities are at higher risk of severe COVID-19, so frequent clinic visits for routine blood pressure measurements are not always feasible. As a result, we have seen a dramatic increase in the interest and uptake of remote monitoring devices such as wearables and mobile health apps. I predict that this is just the beginning of healthcare’s virtualisation and am excited to see what the new year has in store.
Remote work is the future
Another major change in 2020 was of course the sudden move to remote work. For many, it was a 180-degree shift from business as usual. Interestingly, in a Canadian survey, the majority of respondents (55%) expected at least some of the workforce to remain remote in a substantial way after the pandemic is over, while only 17% expected all staff to be onsite five days a week. Further, major companies like Twitter have announced that employees will be able to work from home permanently, signalling a clear change in the way that we do work. While not without challenges, I see remote work becoming a mainstay due to its greater flexibility and convenience for workers.
Virtual events are rapidly improving
Finally, the ways that pharmaceutical and scientific communities attend meetings and events completely changed in 2020. Virtual meetings such as advisory boards and steering committees were already popular before this year but were often accompanied by in-person meetings. We have now seen without a doubt that it is possible to meet the same objectives virtually, often more effectively and at a lower cost.
The biggest change, however, is the way we now attend larger events such as conferences, congresses, and medical education events. There is no shortage of online conference solutions available, but there is still much to improve on. For example, some aspects of in-person events are not always there or are poor substitutes for the real thing.
Ideally, virtual event platforms should be comprehensive so that everything you need is in the same place. The layout, branding, and inclusions should be completely customisable to your needs, and it should come with all aspects of in-person events such as networking, breakout workshops, exhibitor booths, and poster sessions. The good news is that these types of platforms are getting better by the day, and so are the virtual events that they host.
What have we learned from the last year?
The past 12 months have shown that firstly, we live in a highly polarised world where science and public health are up for debate. Secondly, crisis leads to innovation and finally digital health technologies are the future with remote work and virtual meetings here to stay.
Wishing you all a safe, happy, and healthy 2021.
About the author
Natalie Yeadon is the CEO and co-founder of Impetus Digital, where she helps life science clients virtualise their meetings and events and create authentic relationships with their customers.
As the rollout of covid-19 vaccines picks up across the U.S., moving from hospital distribution to pharmacies, pop-up sites and drive-thru clinics, health experts say it’s vital that these expanded venues be prepared to handle rare but potentially life-threatening allergic reactions.
“You want to be able to treat anaphylaxis,” said Dr. Mitchell Grayson, an allergist-immunologist with Nationwide Children’s Hospital in Columbus, Ohio. “I hope they’re in a place where an ambulance can arrive within five to 10 minutes.”
Of the more than 6 million people in the U.S. who have received shots of the two new covid vaccines, at least 29 have suffered anaphylaxis, a severe and dangerous reaction that can constrict airways and send the body into shock, according to the Centers for Disease Control and Prevention.
Such incidents have been rare — about 5.5 cases for every million doses of vaccine administered in the U.S. between mid-December and early January — and the patients recovered. For most people, the risk of getting the coronavirus is far higher than the risk of a vaccine reaction and is not a reason to avoid the shots, Grayson said.
Still, the rate of anaphylaxis so far is about five times higher for the covid vaccines than for flu shots, and some of those stricken had no history of allergic reactions. In this early phase of the vaccine rollout, all the patients were treated in hospitals and health centers that could offer immediate access to full-service emergency care.
As states look to scale up distribution, the shots will be administered by a varied assortment of professionals at venues including drugstores, dental offices and temporary sites attended by National Guard troops, among others. Health officials say every site involved in the wider community rollout must be able to recognize problems and have the training and equipment to respond swiftly if something goes wrong.
“We are really pushing to make sure that anybody administering vaccines needs not just to have the EpiPen available but, frankly, to know how to use it,” said Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, in a call with reporters. She was referring to a common epinephrine injector that many people with severe allergies carry with them. Those health care workers must also know the warning signs of the need for advanced care, she added.
Anaphylaxis typically occurs within minutes and can cause hives, nausea, vomiting, dizziness or fainting, and life-threatening problems such as low blood pressure and constricted airways. Initial treatment is an injection of epinephrine, or adrenalin, to reduce the body’s allergic response. However, severely affected patients can require intensive treatments including oxygen, IV antihistamines and steroids such as cortisone to save their lives. Community sites are unlikely to have these treatments on hand and would need quick access to emergency responders.
Anybody administering vaccines needs not just to have the EpiPen available, but, frankly, to know how to use it.
Dr. Nancy Messonnier, CDC
Scientists are still investigating what’s triggering the severe reactions to the Pfizer-BioNTech and Moderna mRNA vaccines. They suspect the culprit may be polyethylene glycol, or PEG, a component present in both vaccines that has been associated with allergic reactions.
Even as they call for education and support for providers, experts are urging the more than 50 million Americans with allergies — whether to foods, insect venom, medications or other vaccines — to be proactive about finding a venue that’s properly prepared. Before scheduling a vaccine, contact the site and ask pointed questions about its emergency precautions, said Dr. Kimberly Blumenthal, quality and safety officer for allergy at Massachusetts General Hospital.
“Ask the question: Do they have an anaphylaxis kit? Can they take vital signs?” she said. People who routinely carry EpiPens should remember to bring them when they are vaccinated, she added.
A CDC website details a list of equipment and medications that sites should have on hand and urges that all patients be observed for 15 minutes after vaccination or 30 minutes if they’re at higher risk for reactions. The list recommends — but does not require — that sites stock the more intensive treatments, such as IV fluids. People who experience severe reactions shouldn’t get the recommended second dose of the vaccine, the agency said.
“Appropriate medical treatment for severe allergic reactions must be immediately available in the event that an acute anaphylactic reaction occurs following administration of an mRNA COVID-19 vaccine,” the site says.
Still, that’s a tall order, given the scope of the vaccination effort. The federal government is sending vaccines to more than 40,000 pharmacy locations involving 19 chains, including CVS, Walgreens, Costco and Rite Aid. At the same time, dozens of pop-up inoculation sites are ramping up in New York City, and drive-thru clinics have been set up in Ohio, Florida and other states.
Drive-thru sites, in particular, worry allergists like Blumenthal, who said it’s crucial to recognize symptoms of anaphylaxis quickly. “If you’re in a car, are you going to have your windows open? Where are the medicines? Are you in a parking lot?” she said. “It just sounds logistically more challenging.”
Ask the question: Do they have an anaphylaxis kit? Can they take vital signs?
Dr. Kimberly Blumenthal, Massachusetts General Hospital
In Columbus, more than 2,400 people had been vaccinated by Jan. 6 at a drive-thru clinic set up at the Ohio Expo Center. No allergic reactions have been reported, according to Kelli Newman, a spokesperson for Columbus Public Health. But if they occur, she said, health officials are prepared.
“We have a partnership with our EMS and they are observing those being vaccinated for 15 minutes to make sure there are no adverse reactions,” Newman said in an email. “They have two EMS trucks available with emergency equipment and epinephrine, if needed.”
Similarly, representatives for CVS Health and Walgreens said they have the staff and supplies to handle “rare but severe” reactions.
“We have emergency management protocols in place that are required for all vaccine providers, which, following a clinical assessment, may include administering epinephrine, calling 911 and administering CPR, if needed,” Rebekah Pajak, a spokesperson for Walgreens, said in an email.
If the vaccine sites have appropriately trained staffers, plus adequate supplies and equipment, the vast majority of people should opt for the shot, especially as the pandemic continues to surge, said Dr. David Lang, immediate past president of the American Academy of Allergy, Asthma & Immunology and chairman of the department of immunology at the Cleveland Clinic.
“The overwhelming likelihood is that you won’t have anaphylaxis and the overwhelming benefit far exceeds the risk for harm,” Lang said.
Since the onset of the COVID-19 pandemic, hospitals and health systems have pushed forward with innovative technology solutions with great expediency and proficiency. Healthcare organizations were quick to launch telehealth solutions and advance digital health to maintain critical patient relationships and ensure continuity of care. Behind the scenes, hospitals and health systems have been equally adept at advancing technology solutions to support and enhance clinical care delivery. This includes adopting clinical surveillance systems to better predict and prevent an escalation of the coronavirus.
Clinical surveillance systems use real-time and historical patient data to identify emerging clinical patterns, allowing clinicians to intervene in a timely, effective manner. Over time, these clinical surveillance systems have evolved to help healthcare organizations meet their data analytic, surveillance, and regulatory compliance needs. The adaptability of these systems is evidenced by their expanded use during the pandemic. Healthcare organizations quickly pivoted to incorporate COVID-19 updates into their clinical surveillance activities, providing a centralized, global view of COVID-19 cases.
To gain insight into the COVID-19 crisis, critical data points include patient age, where the disease was likely contracted, whether the patient was tested, and how long the patient was in the ICU, among other things. Surveillance is also able to factor in whether patients have pre-existing conditions or problems with blood clotting, for example. This data trail is helping providers create a constantly evolving coronavirus profile and provides key data points for healthcare providers to share with state and local governments and public health agencies. In the clinical setting, the data are being used to better predict respiratory and organ failure associated with the virus, as well as flag COVID-19 patients at risk for developing sepsis.
What’s driving these advancements? Clinical surveillance systems powered by artificial intelligence (AI). By refining the use of AI for clinical surveillance, we can proactively identify an expanding range of acute and chronic health conditions with greater speed and accuracy. This has tremendous implications in the clinical setting beyond the current pandemic. AI-powered clinical surveillance can save lives and reduce costs for conditions that have previously proven resistant to prevention.
Eliminating healthcare-associated infections
Despite ongoing prevention efforts, healthcare-associated infections (HAIs) continue to plague the US healthcare system, costing up to $45 billion a year.According to the Centers for Disease Control and Prevention (CDC), about one in 31 hospitalized patients will have at least one HAI on any given day. AI can analyze millions of data points to predict patients at-risk for HAIs, enabling clinicians to respond more quickly to treat patients before their infection progresses, as well as prevent spread among hospitalized patients.
Building trust in AI
While the benefits are clear, challenges remain to the widespread adoption and use of AI in the clinical setting. Key among them is a lack of trust among clinicians and patients around the efficacy of AI. Many clinicians remain concerned over the validity of the data, as well as uncertainty over the impact of the use of AI on their workflow. Patients, in turn, express concerns over AI’s ability to address their unique needs, while also maintaining patient privacy. Hospitals and health systems must build trust among clinicians and patients around the use of AI by demonstrating its ability to enhance outcomes, as well as the patient experience.
3 keys to building trust in AI
Building trust among clinicians and patients can be achieved through transparency, expanding data access, and fostering focused collaboration.
1. Support transparency
Transparency is essential to the successful adoption of AI in the clinical setting. In healthcare, just giving clinicians a black box that spits out answers isn’t helpful. Clinicians need “explainability,” a visual picture of how and why the AI-enabled tool reached its prediction, as well as evidence that the AI solution is effective. AI surveillance solutions are intended to support clinical decision making, not serve as a replacement.
2. Expand data access
Volume and variety of data are central to AI’s predictive power. The ability to optimize emerging tools depends on comprehensive data access throughout the healthcare ecosystem, no small task as large amounts of essential data remain siloed, unstructured, and proprietary.
3. Foster focused collaboration
Clinicians and data scientists must collaborate in developing AI tools. In isolation, data scientists don’t have the context for interpreting variables they should be considering or excluding in a solution. Conversely, doctors working alone may bias AI by telling it what patterns to look for. The whole point of AI is how great it is at finding patterns we may not even consider. While subject matter expertise should not bias algorithms,
it is critical in structuring the inputs, evaluating the outputs, and effectively incorporating those outputs in clinical workflows. More open collaboration will enable clinicians to make better diagnostic and treatment decisions by leveraging AI’s ability to comb through millions of data points, find patterns, and surface critically relevant information.
AI-enabled clinical surveillance has the potential to deliver next-generation decision-support tools that combine the powerful technology, the prevention focus of public health, and the diagnosis and treatment expertise of clinicians. Surveillance is poised to assume a major role in attaining the quality and cost outcomes our industry has long sought.
John Langton is director of applied data science at Wolters Kluwer, Health, where artificial intelligence is being used to fundamentally change approaches to healthcare. @wkhealth
Los suministros de vacunas contra covid-19 son escasos, por eso un panel asesor federal recomienda primero administrarlas a los trabajadores de salud, que mantienen en funcionamiento el sistema médico del país, y a los adultos mayores en hogares, que tienen más probabilidades de morir a causa del coronavirus.
En ninguna parte de la lista de personas prioritarias están los cónyuges de los funcionarios públicos.
Sin embargo, las primeras damas de Kentucky y West Virginia; Karen Pence, la esposa del vicepresidente Mike Pence; Jill Biden, la esposa del presidente electo Joe Biden; y Doug Emhoff, el esposo de la vicepresidenta electa Kamala Harris, estuvieron entre los primeros estadounidenses en recibir las vacunas que podrían salvar vidas.
Kentucky también vacunó a seis ex gobernadores y cuatro ex primeras damas, incluidos los padres de Andy Beshear, el actual gobernador demócrata.
Las primeras vacunas a los cónyuges provocaron indignación en las redes sociales, y varios usuarios de Twitter dijeron que no deberían poder “saltar la fila” antes que los médicos, enfermeras y personas mayores.
En la mayoría de los 29 estados que respondieron a las consultas de KHN (que llamó a las 50 oficinas de gobierno estatales), los principales funcionarios electos dijeron que ellos, y sus cónyuges, serán vacunados, pero han optado por esperar su turno detrás de electores más vulnerables.
Algunos miembros del Congreso de ambos partidos dijeron lo mismo cuando rechazaron las primeras dosis ofrecidas, en nombre de mantener al gobierno en funcionamiento.
Los gobernadores que recibieron las vacunas junto con sus cónyuges, y la oficina del vicepresidente, dijeron que querían dar el ejemplo a los residentes, generar confianza, salvar las divisiones ideológicas y demostrar que la vacuna es segura y eficaz.
Pero algunos cuestionan esta razón.
“Se parece más a hacer trampa. Los políticos pueden conseguir que los hospitales los vacunen bajo esta ilusión de generar confianza. Pero es una fachada”, dijo Arthur Caplan, profesor de bioética y director fundador de la división de ética médica de la Escuela de Medicina Grossman de la Universidad de Nueva York. “La gente podría decir: ‘Típica gente rica. No se puede confiar en ellos’. Esto socava la meta original”.
Caplan agregó que, de todos modos, el público no confía demasiado en los políticos, por lo que la vacunación de celebridades, líderes religiosos o figuras deportivas probablemente ayudaría más a aumentar la confianza en la vacuna.
El doctor José Romero, presidente del Comité Asesor de Prácticas de Inmunización de los Centros para el Control y Prevención de Enfermedades (CDC), dijo en un correo electrónico a KHN que si bien su grupo proporciona un esquema para distribuir dosis limitadas de vacunas, “las jurisdicciones tienen la flexibilidad de hacer lo que sea apropiado para su población”.
Los funcionarios de Kentucky y Texas señalaron que el doctor Robert Redfield, director de los CDC, alentó a los gobernadores a vacunarse públicamente.
Nadie mencionó razones médicas para que sus cónyuges se vacunaran; los hospitales generalmente no están vacunando a los cónyuges de los profesionales médicos que han recibido la vacuna.
La oficina del gobernador de West Virginia, el republicano Jim Justice, publicó fotografías de él, su esposa, Cathy Justice, y otros funcionarios recibiendo las dosis. También posteó su propia vacunación en YouTube.
La oficina de Beshear en Kentucky también publicó fotos del gobernador recibiendo la vacuna en diciembre, el mismo día que su esposa, Britainy Beshear, y otros funcionarios estatales.
“Es cierto que hay dudas sobre las vacunas”, dijo Beshear en una reunión informativa sobre el coronavirus, el día en el que los ex gobernadores de Kentucky y sus cónyuges fueron vacunados. Aludió a un programa futuro que involucra a líderes religiosos y a otras personas influyentes.
Su padre, el ex gobernador demócrata Steve Beshear, publicó fotos de su vacunación en su página de Facebook, diciendo que él y su esposa, Jane Beshear, junto con otros ex gobernadores de Kentucky de ambos partidos y sus cónyuges, intervinieron en parte para alentar a los residentes a vacunarse.
Kentucky se encuentra actualmente en la primera etapa de distribución de vacunas, dirigida a trabajadores de salud y a residentes de centros de vida asistida. Se habían distribuido menos de 15,000 de las 58,500 dosis para estas residencias cuando los ex gobernadores y sus cónyuges fueron vacunados.
Tres Watson, ex director de comunicaciones del Partido Republicano de Kentucky, que fundó una firma de consultoría política, se mostró escéptico sobre las intenciones detrás del evento. Dijo que parecía ser un esfuerzo de relaciones públicas creado para que el gobernador pudiera vacunar a sus padres.
“Entiendo la continuidad del gobierno, pero las primeras damas no tienen parte en la continuidad del gobierno”, dijo. “Tienes que ajustarte a las prioridades. Una vez que empiezas a hacer excepciones, es cuando tienes problemas”.
Los funcionarios que representan al equipo de transición de Biden-Harris y otros tres estados donde se vacunaron los gobernadores (West Virginia y Texas liderados por republicanos, y Kansas liderado por un demócrata) no respondieron a KHN. El gobernador republicano de Alabama, Kay Ivey, recibió la vacuna y está divorciado.
Políticos de otros estados han hecho lo opuesto.
En Arkansas, el gobernador republicano Asa Hutchinson se centra en garantizar que los grupos de alta prioridad, como los trabajadores de salud, y el personal y residentes de centros de vida asistida, se vacunen, dijo la vocera LaConda Watson. “Él y su esposa recibirán la vacuna cuando sea su turno”, informó.
En Missouri, Kelli Jones, directora de comunicaciones del gobernador republicano Mike Parson, dijo en un correo electrónico que él y la primera dama tienen la intención de vacunarse. Al igual que los gobernadores de Colorado, Nevada y otros lugares, ambos se han recuperado de covid-19, dijo Jones, y “esperarán hasta que su grupo de edad sea elegible” según el plan estatal. Los médicos recomiendan las vacunas incluso para personas que ya han tenido covid.
Cissy Sanders, de 52 años, directora de eventos que vive en Austin, Texas, dijo que entiende por qué los legisladores deberían vacunarse. Su propio gobernador, el republicano Greg Abbott, se vacunó por televisión en vivo para infundir confianza, dijo su secretaria de prensa, Renae Eze, quien no quiso comentar si la esposa de Abbott se había vacunado.
Pero Sanders dijo que los cónyuges de los políticos no deben vacunarse antes que los residentes de un asilo, como su propia madre de 71 años. La madre de Sanders recibió la vacuna a fines de diciembre pero dijo que todavía hay demasiados residentes de hogares esperando en todo el país.
“¿Por qué un grupo que no es de alto riesgo, es decir, estos cónyuges, va a vacunarse antes que el grupo de mayor riesgo? ¿Quién toma estas decisiones?, se preguntó. “Los cónyuges de los políticos no han estado en la zona cero del virus. Los residentes de hogares sí”.
La corresponsal de Montana, Katheryn Houghton, la corresponsal de California Healthline, Angela Hart y los corresponsales Markian Hawlyruk y JoNel Aleccia colaboraron con esta historia.
The contact tracers of Washtenaw County in Michigan have been deluged with work and, to cope, the overburdened health department has a new tactic: It is asking residents who test positive for covid-19 to do their own contact tracing.
Washtenaw is a county of nearly 350,000 residents who live in and around the city of Ann Arbor, about 45 minutes from Detroit. Until mid-October, a county team of 15 contact tracers was managing the workload. But by Thanksgiving, more than 1,000 residents were testing positive for the coronavirus every week, and the tracers could not keep pace.
In Washtenaw County, the process starts with people called case investigators, who receive lab reports of positive coronavirus tests. Their job is to call anyone who has tested positive, tell them they need to isolate and ask them for the names of people with whom they have had close contact. After creating a list of potentially exposed “contacts,” investigators pass it to a new team to start the actual contact tracing. As the number of positive cases builds, the number of calls tracers must make swells.
But in recent weeks, it’s not just the number of positive cases that has increased, overwhelming the capacity of case investigators — so has the number of contacts that each infected person has, said contact tracer Madeline Bacolor.
“There’s just so many more people that are gathering and that are exposed,” she said. “It used to be, we had a case, and maybe that person had seen two people, and now it’s a whole classroom full of day care students or a whole workplace.”
The work to keep people who have been exposed to the virus away from people who have not is crucial, said public health professor Angela Beck, because it breaks viral transmission chains and prevents the virus from spreading unchecked through a community.
Beck teaches at the University of Michigan and runs the campus program for tracing coronavirus exposures among students.
When you’re trying to contain an infectious disease, she said, running out of contact tracers is “not a situation that you want to be in.”
But it’s happening now in health departments in Michigan and around the U.S. where contact tracing workforces have grown, but not fast enough to keep pace with the pandemic’s spread.
As a result, health departments are asking some residents with covid to reach out to their contacts on their own.
Trying ‘a Compromised Strategy’
Once billed as one of the fundamental tools for stemming the spread of the virus, contact tracing has fallen apart in many regions of the country. It’s a systematic breakdown that Lawrence Gostin, a professor of global health law at Georgetown University, said hasn’t happened since the spread and stigma of HIV and AIDS in the 1980s and ’90s.
In Michigan’s rural Upper Peninsula, a public health district spanning five counties warned residents that its tracers were overwhelmed and that they might not receive a call at all, despite testing positive. Health workers would need to focus their efforts on residents 65 and older, teens and children attending school in person, and people living in group settings.
In Michigan’s southwestern corner, contact tracers in Van Buren and Cass counties can no longer keep up with their calls. It’s the same situation in Berrien County: “If you test positive, take action immediately by isolating and notifying close contacts,” the county health officer urged residents in a press release.
Within many health departments, the shortage of contact tracers has been exacerbated by the communications challenge of relaying a recent change in quarantine guidance from the Centers for Disease Control and Prevention — it reduced the quarantine period from 14 days to 10 for some individuals exposed to the virus.
The idea behind the change was that the risk of transmission after 10 days of quarantine was low, and shorter quarantine periods might increase people’s willingness to comply with the orders. But the shift also meant that contact tracers had to spend time learning and explaining the new procedures just when caseloads were exploding.
“It makes things more confusing,” said Bacolor, the contact tracer in Washtenaw County. “People might be hearing something different from their job or school than they are from the health department.”
Asking infected people, some of whom might be sick, to call their own friends and families — in effect, conduct their own contact-tracing operation — is far from ideal, public health experts said.
“It is a last-resort tool,” said Beck, the University of Michigan professor. “It is the best that we can do in the situation that we’re in, but it’s a compromised strategy.”
Contact tracing is more than just alerting people to a potential exposure so they can quarantine. Part of the process is to conduct carefully structured interviews with those exposed, to determine if they’ve developed symptoms of covid-19. If so, contacts of those people also need to be traced and told to quarantine, to prevent the virus from proliferating through successive chains of people in the community.
Trained contact tracers also often ask valuable questions to learn more about how the virus was transmitted from person to person so that local health officials can piece together an understanding about which settings and activities seem particularly likely to promote spread — in-person choir rehearsals and crowded bars, for example — and which are unlikely to generate outbreaks.
Contact tracing is a key part of a tried-and-true strategy known as “test, trace and isolate.” Public health professor Beck said the strategy has been used allovertheworld and it works — when there are enough people and enough time to do it properly.
And she said effective contact tracing can help mitigate the economic pain of a pandemic because it means that only people with known exposures to the virus must stay away from workplaces and school and refrain from other activities.
But success requires significant investment in public health infrastructure, something that Beck and other researchers said has been lacking for decades in the U.S.
This story is part of a partnership that includes NPR and KHN.
With supplies of covid-19 vaccines scarce, a federal advisory panel recommends first putting shots into the arms of health care workers, who keep the nation’s medical system running, and long-term care residents most likely to die from the coronavirus.
Nowhere on the list of prioritized recipients are public officials’ spouses.
Yet the first ladies of Kentucky and West Virginia; Republican Vice President Mike Pence’s wife, Karen Pence; Democratic President-elect Joe Biden’s wife, Jill Biden; and Vice President-elect Kamala Harris’ husband, Doug Emhoff, were among the first Americans to get the potentially lifesaving shots.
Kentucky also vaccinated six former governors and four former first ladies, including current Democratic Gov. Andy Beshear’s parents.
The early vaccinations of political spouses spurred outrage on social media, with several Twitter users saying they should not be able to “jump the line” ahead of doctors, nurses and older people.
In most of the 29 states that responded to KHN inquiries of all 50 governors’ offices, top elected officials said they — and their spouses — will be vaccinated but have chosen to wait their turn behind more vulnerable constituents. Some Congress members from both parties said much the same when they refused early doses offered in the name of keeping the government running. Those weren’t offered to their spouses.
Governors who got the shots along with their spouses, and the vice president’s office, said they wanted to set an example for residents, build trust, bridge ideological divides and show that the vaccine is safe and effective.
But that’s a rationale some critics don’t buy.
“It looks more like cutting in line than it does securing trust. The politicians can get the hospitals to give it to them under this illusion of building trust. But it’s a façade,” said Arthur Caplan, a bioethics professor and founding head of the medical ethics division at New York University Grossman School of Medicine. “People might say: ‘Yup, typical rich people. They can’t be trusted.’ This undermines what they set out to do.”
Besides, Caplan said, the public doesn’t trust politicians all that much anyway, so inoculating celebrities, religious leaders or sports figures would likely do more to boost confidence in the vaccine. Rock ’n’ roll king Elvis Presley famously got the polio vaccine in 1956 to help win over those who were skeptical; the actions of governors’ wives from that period are less remembered.
Dr. José Romero, chairperson of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, said in an email to KHN that while his group provides an outline for distributing limited vaccine doses, “jurisdictions have the flexibility to do what’s appropriate for their population.” Kentucky and Texas officials pointed out that CDC Director Dr. Robert Redfield encouraged governors to publicly get the vaccine.
No one mentioned medical reasons for their spouses to get vaccines; hospitals are generally not vaccinating the spouses of medical professionals who have gotten the shot. (It’s unclear whether vaccinated people can still spread the virus, so it’s possible that a vaccinated person could pass the virus to their spouse or have to quarantine if an unvaccinated spouse were to get covid.)
The office of West Virginia’s governor, Republican Jim Justice, released pictures of him, his wife, Cathy Justice, and other officials receiving shots. He also showed his own vaccination on YouTube.
Beshear’s office in Kentucky also released photos of him getting the vaccine in December on the same day as his wife, Britainy Beshear, and other state officials.
“There is no question that there is vaccine hesitancy out there,” Beshear said at a coronavirus briefing on Monday, the day former Kentucky governors and their spouses were vaccinated. He alluded to a future program involving faith leaders and others. “Validators are incredibly important to building that confidence.”
His father, Democratic former Gov. Steve Beshear, posted photos of his vaccination on his Facebook page, saying that he and his wife, Jane Beshear, along with other former Kentucky governors of both parties and their spouses, stepped up partly to show residents the vaccine is safe and encourage them to get it when it’s available to them.
Kentucky is currently in the first stage of vaccine distribution, which targets health care workers and residents of long-term care and assisted living facilities. Fewer than 15,000 of the 58,500 doses received for long-term care had been given out when the former governors and their spouses were vaccinated.
Tres Watson, a former communications director for the Republican Party of Kentucky who founded a political consulting firm, was skeptical about the intentions behind the event. He said it seemed to be a public relations effort created so the governor could vaccinate his parents.
“I understand the continuity of government, but first ladies have no part in the continuity of government,” he said. “You need to stick with the priorities. Once you start making exceptions, that’s when you run into problems.”
Officials representing the Biden-Harris transition team and three other states where governors got vaccinated — Republican-led West Virginia and Texas, and Democratic-led Kansas — either didn’t respond to KHN or didn’t answer questions about spouses. Alabama’s Republican governor, Kay Ivey, got the vaccine and is divorced.
Politicians in other states have taken the opposite tack.
In Arkansas, Republican Gov. Asa Hutchinson is focused on ensuring high-priority groups such as health care workers, long-term care staffers and residents are vaccinated, said spokesperson LaConda Watson. “He and his wife will receive the vaccination when it’s their turn,” she said.
In Missouri, Kelli Jones, communications director for Republican Gov. Mike Parson, said in an email that he and the first lady fully intend to get the vaccine. Like governors from Colorado, Nevada and elsewhere, they’ve both recovered from covid-19, Jones said, and will “wait until their age group is eligible” under the state plan. Doctors recommend vaccinations even for people who have already had covid.
Cissy Sanders, 52, an events manager who lives in Austin, Texas, said she understands why lawmakers would need to get the vaccine. Her own governor, Republican Greg Abbott, received it on live television to instill confidence, said his press secretary, Renae Eze, who wouldn’t address whether Abbott’s wife was vaccinated.
But Sanders said politicians’ spouses should not be vaccinated before nursing home residents like her 71-year-old mom. Sanders’ mother received the vaccine in late December — after some public officials’ spouses — but she said far too many nursing home residents across America are still waiting.
“Why is a non-high-risk group — i.e., these spouses — going before the most high-risk group? Who makes these decisions? Who thinks this is a good, responsible, safe decision to make?” she said. “Political spouses have not been at ground zero for the virus. Nursing home residents have been.”
KHN Montana correspondent Katheryn Houghton, California Healthline correspondent Angela Hart and KHN senior correspondents Markian Hawryluk and JoNel Aleccia contributed to this report.
Surprise Democratic victories in Georgia’s two runoff elections this week will give Democrats control of the Senate, which means they will be in charge of both houses of Congress and the White House for the first time since 2010. Although the narrow majorities in the House and Senate will likely not allow Democrats to pass major expansions to health programs, it will make it easier to do things such as pass fixes for the Affordable Care Act.
Meanwhile, the speedy development and approval of vaccines to protect against covid-19 is being squandered by the lack of a national strategy to get those vaccines into people’s arms. Straightening out and speeding up vaccinations will be a major priority for the incoming administration of President-elect Joe Biden.
This week’s panelists are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico and Mary Ellen McIntire of CQ Roll Call.
Among the takeaways from this week’s podcast:
The Georgia election results will make it easier for some of Biden’s Cabinet picks to be confirmed, including Xavier Becerra, his choice to head the Department of Health and Human Services.
Among the ACA fixes that congressional Democrats may seek is a restoration of a small penalty for people who do not have health coverage. That could negate the case before the Supreme Court now that was brought by Republican state officials.
One strategic error in the covid vaccine distribution efforts was that the release of the vaccine was not coupled with a major messaging campaign to explain what the vaccine does and dispel fears about it.
Late last month, a federal court blocked the Trump administration from implementing a plan to tie what Medicare pays for some drugs to the prices in other countries. It’s not clear if the Biden administration will continue the legal fight to keep the program, but the president-elect has suggested he is more interested in bringing down drug prices by negotiating with manufacturers.
The Trump administration has sued retail giant Walmart, alleging it unlawfully dispensed opioids from its pharmacies.
Also, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:
SAN FRANCISCO — In early 2019, Tom Wolf posted a thank-you on Twitter to the cop who had arrested him the previous spring, when he was homeless and strung out in a doorway with 103 tiny bindles of heroin and cocaine in a plastic baggie at his feet.
“You saved my life,” wrote Wolf, who had finally gotten clean after that bust and 90 days in jail, ending six months of sleeping on scraps of cardboard on the sidewalk.
Today, he joins a growing chorus of people, including the mayor, calling for the city to crack down on an increasingly deadly drug trade. But there is little agreement on how that should be done. Those who demand more arrests and stiffer penalties for dealers face powerful opposition in a city with little appetite for locking people up for drugs, especially as the Black Lives Matter and Defund the Police movements push to drastically limit the power of law enforcement to deal with social problems.
Drug overdoses killed 621 people in the first 11 months of 2020, up from 441 in all of 2019 and 259 in 2018. San Francisco is on track to lose an average of nearly two people a day to drugs in 2020, compared with the 178 who had died by Dec. 20 of the coronavirus.
As in other parts of the country, most of the overdoses have been linked to fentanyl, the powerful synthetic opioid that laid waste to the eastern United States starting in 2013 but didn’t arrive in the Bay Area until about five years later. Just as the city’s drug scene was awash with the lethal new product — which is 50 times stronger than heroin and sells on the street for around $20 for a baggie weighing less than half a gram — the coronavirus pandemic hit, absorbing the attention and resources of health officials and isolating drug users, making them more likely to overdose.
The pandemic is contributing to rising overdose deaths nationwide, according to the Centers for Disease Control and Prevention, which reported last month that a record 81,000 Americans died of an overdose in the 12 months ending in May.
“This is moving very quickly in a horrific direction, and the solutions aren’t matching it,” said Supervisor Matt Haney, who represents the Tenderloin and South of Market neighborhoods, where nearly 40% of the deaths have occurred. Haney, who has hammered City Hall for what he sees as its indifference to a life-or-death crisis, is calling for a more coordinated response.
“It should be a harm reduction response, it should be a treatment response — and yes, there needs to be a law enforcement aspect of it too,” he said.
Tensions within the city’s leadership came to a head in September, when Mayor London Breed supported an effort by City Attorney Dennis Herrera to clean up the Tenderloin by legally blocking 28 known drug dealers from entering the neighborhood.
But District Attorney Chesa Boudin, a progressive elected in 2019 on a platform of police accountability and racial justice, sided with activists opposing the move. He called it a “recycled, punishment-focused” approach that would accomplish nothing.
People have died on the Tenderloin’s needle-strewn sidewalks and alone in hotel rooms where they were housed by the city to protect them from covid-19. Older Black men living alone in residential hotels are dying at particularly high rates; Blacks make up around 5% of the city’s population but account for a quarter of the 2020 overdoses. Last February, a man was found hunched over, ice-cold, in the front pew at St. Boniface Roman Catholic Church.
The only reason drug deaths aren’t in the thousands, say health officials, is the outreach that has become the mainstay of the city’s drug policy. From January to October, 2,975 deaths were prevented by naloxone, an overdose reversal drug that’s usually sprayed up the nose, according to the DOPE Project, a city-funded program that trains outreach workers, drug users, the users’ family members and others.
“If we didn’t have Narcan,” said program manager Kristen Marshall, referring to the common naloxone brand name, “there would be no room at our morgue.”
The city is also hoping that this year state lawmakers will approve safe consumption sites, where people can do drugs in a supervised setting. Other initiatives, like a 24-hour meth sobering center and an overhaul of the city’s behavioral health system, have been put on hold because of pandemic-strained resources.
Efforts like the DOPE Project, the country’s largest distributor of naloxone, reflect a seismic shift over the past few years in the way cities confront drug abuse. As more people have come to see addiction as a disease rather than a crime, there is little appetite for locking up low-level dealers, let alone drug users — policies left over from the “war on drugs” that began in 1971 under President Richard Nixon and disproportionately punished Black Americans.
In practice, San Francisco police don’t arrest people for taking drugs, certainly not in the Tenderloin. On a sunny afternoon in early December, a red-haired young woman in a beret crouched on a Hyde Street sidewalk with her eyes closed, clutching a piece of foil and a straw. A few blocks away, a man sat on the curb injecting a needle into a thigh covered with scabs and scars, while two uniformed police officers sat in a squad car across the street.
Last spring, after the pandemic prompted a citywide shutdown, police stopped arresting dealers to avoid contacts that might spread the coronavirus. Within weeks, the sidewalks of the Tenderloin were lined with transients in tents. The streets became such a narcotics free-for-all that many of the working-class and immigrant families living there felt afraid to leave their homes, according to a federal lawsuit filed by business owners and residents. It accuses City Hall of treating less wealthy ZIP codes as “containment zones” for the city’s ills.
The suit was settled a few weeks later after officials moved most of the tents to designated “safe sleeping sites.” But for many, the deterioration of the Tenderloin, juxtaposed with the gleaming headquarters of companies like Twitter and Uber just blocks away, symbolizes San Francisco’s starkest contradictions.
The Federal Initiative for the Tenderloin was one such effort, announced in 2019. It aims to “reclaim a neighborhood that is being smothered by lawlessness,” U.S. Attorney David Anderson said at a recent virtual news conference held to announce a major operation in which the feds arrested seven people and seized 10 pounds of fentanyl.
Law enforcement agencies have blamed the continued availability of cheap, potent drugs on lax prosecutions. Boudin, however, said his office files charges in 80% of felony drug cases, but most involve low-level dealers whom cartels can easily replace in a matter of hours.
He pointed to a 2019 federal sting that culminated in the arrest of 32 dealers — mostly Hondurans who were later deported — after a two-year undercover operation involving 15 agencies.
“You go walk through the Tenderloin today and tell me if it made a difference,” said Boudin.
His position reflects a growing “progressive prosecutor” movement that questions whether decades-old policies that focus on putting people behind bars are effective or just. In May, the killing of George Floyd by the Minneapolis police energized a nationwide police reform campaign. Cities around the country, including San Francisco, have promised to redirect millions of dollars from law enforcement to social programs.
“If our city leadership says in one breath that they want to defund the police and are for racial and economic justice and in the next talk about arresting drug dealers, they’re hypocrites and they’re wrong,” said Marshall, the leader of the DOPE Project.
But Wolf, 50, believes a concerted crackdown on dealers would send a message to the drug networks that San Francisco is no longer an open-air illegal drug market.
Like hundreds of thousands of other Americans who’ve succumbed to opiate misuse, he began with a prescription for the painkiller oxycodone, in his case following foot surgery in 2015. When the pills ran out, he made his way from his tidy home in Daly City, just south of San Francisco, to the Tenderloin, where dealers in hoodies and backpacks loiter three or four deep on some blocks.
When he could no longer afford pills, Wolf switched to heroin, which he learned how to inject on YouTube. He soon lost his job as a caseworker for the city and his wife threw him out, so he became homeless, holding large quantities of drugs for Central American dealers, who sometimes showed him photos of the lavish houses they were having built for their families back home.
Looking back, he wishes it hadn’t taken six arrests and three months behind bars before someone finally pushed him toward treatment.
“In San Francisco, it seems like we’ve moved away from trying to urge people into treatment and instead are just trying to keep people alive,” he said. “And that’s not really working out that great.”
KHN Editor-in-Chief Elisabeth Rosenthal appeared on Diane Rehm’s “On My Mind” podcast on NPR to discuss the bottlenecks that have prevented doses of precious covid-19 vaccine from making it from drugmakers’ factories into patients’ arms. It didn’t have to be this way, she explains.
As Los Angeles hospitals give record numbers of covid patients oxygen, the systems and equipment needed to deliver the life-sustaining gas are faltering.
It’s gotten so bad that Los Angeles County officials are warning paramedics to conserve it. Some hospitals are having to delay releasing patients as they don’t have enough oxygen equipment to send home with them.
“Everybody is worried about what’s going to happen in the next week or so,” said Cathy Chidester, director of the L.A. County Emergency Medical Services Agency.
Oxygen, which makes up 21% of the Earth’s air, isn’t running short. But covid damages the lungs, and the crush of patients in hot spots such as Los Angeles, the Navajo Nation, El Paso, Texas, and in New York last spring have needed high concentrations of it. That has stressed the infrastructure for delivering the gas to hospitals and their patients.
The strain in those areas is caused by multiple weak links in the pandemic supply chain. In some hospitals that pipe oxygen to patients’ rooms, the massive volume of cold liquid oxygen is freezing the equipment needed to deliver it, which can block the system.
“You can completely — literally, completely — shut down the entire hospital supply if that happens,” said Rich Branson, a respiratory therapist with the University of Cincinnati and editor-in-chief of the journal Respiratory Care.
There is also pressure on the availability of both the portable cylinders that hold oxygen and the concentrators that pull oxygen from the air. And in some cases, vendors that supply the oxygen have struggled to get enough of the gas to hospitals. Even nasal cannulas, the tubing used to deliver oxygen, are now running low.
“It’s been nuts, absolutely nuts,” said Esteban Trejo, general manager of Syoxsa, an industrial and medical gas distributor based in El Paso. He provides oxygen to several temporary hospitals set up specifically to treat people with covid.
In November, he said, he was answering calls in the middle of the night from contractors worried about oxygen supplies. At one point, when the company’s usual supplier fell through, they were hauling oxygen from Houston, which is a more than 10-hour drive each way.
Branson has been sounding the alarm about logistical limitations on critical care since the SARS pandemic nearly 20 years ago, when he and others surveyed experts about the specific equipment and infrastructure needed during a future pandemic. Oxygen was near the top of the list.
Oxygen as Cold as Neptune
Last spring, New York, New Jersey and Connecticut faced a challenge similar to what is now unfolding in Los Angeles, said Robert Karcher, a vice president of contract services for Acurity, a group purchasing organization that worked with many hospitals during that surge.
To take up less space, oxygen is often stored as a liquid around minus 300 degrees Fahrenheit, about as cold as the surface of Neptune. But as covid patients filling ICUs were given oxygen through ventilators or nasal tubes, some hospitals began to see ice form over the equipment that converts liquid oxygen into a gas.
When a hospital draws more and more liquid oxygen from those tanks, the super-cold liquid can seep further into the vaporizing coils where liquid oxygen turns to gas.
Branson said some ice is normal, but a lot of ice can cause valves on the device to freeze in place. And the ice can restrict airflow in the pipes sending the oxygen into patients’ rooms, Karcher said. To combat this, hospitals could switch to a backup vaporizer if they had one, hose down iced vaporizers or move patients to cylinder-delivered oxygen. But that puts additional strain on the hospitals’ cylinder oxygen supply, as well as the medical gas supplier, Karcher said.
Hospitals in New York began to panic in the spring because the icing of the vaporizer was much greater than they had seen before, he added. It got so bad, he said, that some hospitals worried they’d have to close their ICUs.
“They thought they were in imminent danger of their tank piping shutting down,” he said. “We came pretty close in a couple of our hospitals. It was a rough few weeks.”
The strain on Los Angeles health care infrastructure could be worse given the now-common treatment of putting patients on oxygen using high-flow nasal cannulas. That requires more of the gas pumped at a higher rate than with ventilators.
“I don’t know of any system that is really set to triple patient volumes — or 10 times the oxygen delivery,” Chidester said of the L.A. County hospitals. “They’re having a hard time keeping up.”
The Oxygen Shortage Doom Loop
In and around Los Angeles, the Army Corps of Engineers has so far surveyed 11 hospitals for freezing oxygen pipe issues. The hospitals are a mix of older facilities and smaller suburban hospitals seeing such high demand amid skyrocketing cases in the area, said Mike Petersen, a Corps spokesperson.
One of the worst examples he saw included pipes that looked like a home freezer that had not been defrosted in some time.
The problem gets worse for hospitals that have had to convert regular hospital rooms to intensive care units. ICU pipes are bigger than those leading to other parts of a hospital. When rooms get repurposed as pop-up ICUs, the pipes can simply be too narrow to deliver the oxygen that covid patients need. And so, Chidester said, the hospitals switch to large cylinders of oxygen. But vendors are having a hard time refilling those quickly enough.
Even smaller cylinders and oxygen concentrators are in short supply amid the surge, she said. Those patients who could be sent home with an oxygen cylinder are left stuck in a hospital waiting for one, taking up a much-needed bed.
In early December, doctors serving the Navajo Nation said they needed more of everything: the oxygen itself and the equipment to get oxygen to patients both in the hospital and recovering at home.
“We’ve never reached capacity before — until now,” said Dr. Loretta Christensen, chief medical officer for the Navajo Area Indian Health Service, in mid-December. Its hospitals serve a patient population in the southwestern U.S. that’s spread across an area bigger than West Virginia.
The buildings are aging, and they aren’t built to house a large number of critical patients, said Christensen. As the number of patients on high-flow oxygen climbed, several facilities started to notice their oxygen flow weaken. They thought something was broken, but when engineers took a look, Christensen said, it became clear the system was just not able to provide the amount of high-flow oxygen patients needed.
She said a hospital in Gallup, New Mexico, put in new filters to maximize oxygen flow. After delays from snowy weather, a hospital serving the northern part of the Navajo Nation managed to hook up a second oxygen tank to boost capacity.
But medical facilities in the area are always a little on edge.
“Honestly, we worry about supply a lot out here because — and I call it extreme rurality — you just can’t get something tomorrow,” said Christensen. “It’s not like being in an urban area where you can say, ‘Oh, I need this right now.’”
Because of the small size of certain hospitals and the difficulty of getting to some of them, Christensen said, Navajo facilities aren’t attractive to big vendors, so they rely on local vendors, which may prove more vulnerable to supply chain hiccups.
Tséhootsooí Medical Center in Fort Defiance, Arizona, has at times had to keep patients in the hospital and transfer incoming patients to other facilities because it couldn’t get the oxygen cylinders needed to send recovering patients home.
Tina James-Tafoya, covid incident commander at Fort Defiance Indian Hospital Board, which runs the center, said at-home oxygen is out of the question for some patients. Oxygen concentrators require electricity, which some patients don’t have. And for patients who live in hogans, homes often heated with a wood stove, the use of oxygen cylinders is a hazard.
“It’s really interesting and eye-opening for me to see that something that seems so simple like oxygen has so many different things tied to it that will hinder it getting to the patient,” she said.
It would be the last hike of the season, Jessica Newton had excitedly posted on her social media platforms. With mild weather forecast and Colorado’s breathtaking fall foliage as a backdrop, she was convinced an excursion at Beaver Ranch Park would be the quintessential way to close out months of warm-weather hikes with her “sister friends.”
Still, when that Sunday morning in 2018 arrived, she was shocked when her usual crew of about 15 had mushroomed into about 70 Black women. There’s a first time for everything, she thought as they broke into smaller groups and headed toward the nature trail. What a sight they were, she recalled, as the women — in sneakers and hiking boots, a virtual sea of colorful headwraps, flowy braids and dreadlocks, poufy twists and long, flowy locks — trekked peacefully across the craggy terrain in the crisp mountain air.
It. Was. Perfect. Exactly what Newton had envisioned when in 2017 she founded Black Girls Hike to connect with other Black women who share her affinity for outdoor activities. She also wanted to recruit others who had yet to experience the serenity of nature, a pastime she fell for as a child attending an affluent, predominately white private school.
But their peaceful exploration of nature and casual chatter — about everything from food and family to hair care and child care — was abruptly interrupted, she said, by the ugly face of racism.
“We had the sheriff called on us, park rangers called on us,” recalled Newton, now 37, who owns a construction industry project development firm in Denver.
“This lady who was horseback riding was upset that we were hiking on her trail. She said that we’d spooked her horse,” she said of a woman in a group of white horseback riders they encountered. “It just didn’t make any sense. I felt like, it’s a horse and you have an entire mountain that you can trot through, run through, gallop through or whatever. She was just upset that we were in her space.”
Eventually, two Jefferson County sheriff’s deputies, with guns on their hips, approached, asking, “What’s going on here?” They had been contacted by rangers who’d received complaints about a large group of Black women being followed by camera drones in the park; the drones belonged to a national television news crew shooting a feature on the group. (The segment aired weeks later, but footage of the confrontation wasn’t included.)
“‘Move that mob!’” attendee Portia Prescott recalled one of the horseback riders barking.
“Why is it that a group of Black women hiking on a trail on a Sunday afternoon in Colorado is considered a ‘mob?’” Prescott asked.
A man soon arrived who identified himself as the husband of one of the white women on horseback and the manager of the park, according to the Jefferson County Sheriff’s Office incident report, and began arguing with the television producers in what one deputy described in the report as a “hostile” manner.
The leader of the horseback tour told the deputies that noise from the large group and the drones startled the horses and that when she complained to the news crew, they told her to deal with it herself, the report said. The news crew told deputies that the group members felt insulted by the horseback riders use of the term “mob.” The woman leading the horseback riders, identified in the incident report as Marie Elliott, said that she did not remember calling the group a mob, but she told the officers she “would have said the same thing if the group had been a large group of Girl Scouts.”
In the end, Newton and her fellow hikers were warned for failing to secure a permit for the group. Newton said she regrets putting members in a distressing — and potentially life-threatening — situation by unknowingly breaking a park rule. However, she suspects that a similarly sized hiking group of white women would not have been confronted so aggressively.
“You should be excited that we are bringing more people to use your parks,” added Newton. “Instead, we got slammed with [threats of] violations and ‘Who are you?’ and ‘Please, get your people and get out of here.’ It’s just crazy.”
Mike Taplin, spokesperson for the Jefferson County Sheriff’s Office, confirmed that no citations were issued. The deputies “positively engaged with everyone, with the goal of preserving the peace,” he said.
Newton said the “frustrating” incident has reminded her why her group, which she has revamped and renamed Vibe Tribe Adventures, is so needed in the white-dominated outdoor enthusiasts’ arena.
With the tagline “Find your tribe,” the group aims to create a sisterhood for Black women “on the trails, on waterways and in our local communities across the globe.” Last summer, she secured nonprofit status and expanded Vibe Tribe’s focus, adding snowshoeing, fly-fishing, zip lining and kayaking to its roster. Today, the Denver-based group has 11 chapters across the U.S. (even Guam) and Canada, with about 2,100 members.
Research suggests her work is needed. The most recent National Park Service survey found that 6% of visitors are Black, compared with 77% white. Newton said that must change — especially given the opportunities parks provide and the health challenges that disproportionately plague Black women. Research shows they experience higher rates of chronic preventable health conditions, including diabetes, hypertension and cardiovascular disease. A 2020 study found that racial discrimination also may increase stress, lead to health problems and reduce cognitive functioning in Black women. Newton said it underscores the need for stress-relieving activities.
Newton said participation in the group generally tapers off in winter. She is hopeful, though, that cabin fever from the pandemic will inspire more Black women to try winter activities.
Atlanta member Stormy Bradley, 49, said the group has added value to her life. “I am a happier and healthier person because I get to do what I love,” said the sixth grade teacher. “The most surprising thing is the sisterhood we experience on and off the trails.”
Patricia Cameron, a Black woman living in Colorado Springs, drew headlines this summer when she hiked 486 miles — from Denver to Durango — and blogged about her experience to draw attention to diversity in the outdoors. She founded the Colorado nonprofit Blackpackers in 2019.
“One thing I caught people saying a lot of is ‘Well, nature is free’ and ‘Nature isn’t racist’ — and there’s two things wrong with that,” said Cameron, a 37-year-old single mother of a preteen.
“Nature and outside can be free, yes, but what about transportation? How do you get to certain outdoor environments? Do you have the gear to enjoy the outdoors, especially in Colorado, where we’re very gear-conscious and very label-conscious?” she asked. “Nature isn’t going to call me the N-word, but the people outside might.”
Efforts to draw more Black people, especially women, outdoors, Cameron said, must include addressing barriers, like cost. For example, Blackpackers provides a “gear locker” to help members use pricey outdoor gear free or at discounted rates. She has also partnered with businesses and organizations that subsidize and sponsor outdoor excursions. During the pandemic, Vibe Tribe has waived all membership fees through this month.
Cameron said she dreams of a day when Black people are free from the pressures of carrying the nation’s racial baggage when participating in outdoor activities.
Vibe Tribe member and longtime outdoor enthusiast Jan Garduno, 52, of Aurora, Colorado, agreed that fear and safety are pressing concerns. For example, leading up to the presidential election she changed out of her “Let My People Vote” T-shirt before heading out on a solo walk for fear of how other hikers might react.
Groups like Vibe Tribe, she said, provide camaraderie and an increased sense of safety. And another plus? The health benefits can also be transformative.
“I’ve been able to lose about 40 pounds and I’ve kept it off,” explained Garduno.
La primavera pasada, Maritza Beniquez, enfermera de una sala de emergencias de Nueva Jersey, fue testigo de “una oleada tras otra” de pacientes enfermos, cada uno con una mirada aterrada que se volvió familiar a medida que pasaban las semanas.
Pronto, fueron sus colegas del Hospital Universitario de Newark, enfermeras, técnicos y médicos con los que había estado trabajando codo con codo, quienes se presentaban en la emergencia luchando por respirar. “Muchos de nuestros propios compañeros de trabajo se enfermaron, especialmente al principio; literalmente diezmó a nuestro personal”, contó.
A fines de junio, 11 de los colegas de Beniquez habían muerto. Como los pacientes que habían estado tratando, la mayoría eran de raza negra y latinos (que pueden ser de cualquier raza).
“Nos vimos afectados de manera desproporcionada por la forma en que nuestras comunidades se han visto afectadas de manera desproporcionada en cada [parte de] nuestras vidas, desde las escuelas hasta los trabajos y los hogares”, dijo.
El 14 de diciembre, Beniquez se convirtió en la primera persona en Nueva Jersey en recibir la vacuna contra el coronavirus, y fue una de los muchos trabajadores médicos de color destacados en los titulares.
Fue una ocasión alegre, que reavivó la posibilidad de volver a ver a sus padres y a su abuela de 96 años, quienes viven en Puerto Rico. Pero esas imágenes transmitidas a nivel nacional también fueron un recordatorio de aquéllos para quienes la vacuna llegó demasiado tarde.
Covid-19 se ha cobrado un precio enorme entre los afroamericanos y los hispanounidenses. Y esas disparidades se extienden a los trabajadores médicos que los intubaron, limpiaron sus sábanas y tomaron sus manos en sus últimos días, halló una investigación de KHN/The Guardian.
Las personas de color representan aproximadamente el 65% de las muertes en los casos en los que hay datos de raza y etnia.
Un estudio reciente encontró que los trabajadores de salud de color tienen más del doble de probabilidades que sus contrapartes caucásicas de dar positivo para el virus. Son más propensos a tratar a pacientes diagnosticados con covid, y a trabajar en hogares de adultos mayores, los principales focos de coronavirus; y también a reportar un suministro inadecuado de equipo de protección personal, según el informe.
En una muestra nacional de 100 casos recopilados por KHN/The Guardian en los que un trabajador de salud expresó su preocupación por la insuficiencia de EPP antes de morir por covid, tres cuartas partes de las víctimas fueron identificadas como negras, hispanas, nativas americanas o asiáticas.
“Es más probable que los trabajadores de salud de raza negra quieran ir a atenderse al sector público donde saben que tratarán de manera desproporcionada a las comunidades de color”, dijo Adia Wingfield, socióloga de la Universidad de Washington en St. Louis, quien ha estudiado la desigualdad racial en el industria del cuidado de salud. “Pero también es más probable que estén en sintonía con las necesidades y desafíos particulares que puedan tener las comunidades de color”, dijo.
Wingfield agregó que muchos miembros del personal de atención médica afroamericanos no solo trabajan en centros de salud de bajos recursos, sino que también son más propensos a sufrir muchas de las mismas comorbilidades que se encuentran en la población negra en general, un legado de décadas de inequidades sistémicas.
Y pueden ser víctimas de estándares de atención más bajos, agregó la doctora Susan Moore, pediatra de raza negra de 52 años de Indiana, quien fue hospitalizada con covid en noviembre y, según un video publicado en su cuenta de Facebook, tuvo que pedir repetidamente pruebas, remdesivir y analgésicos. Dijo que su médico (caucásico) desestimó sus quejas de dolor y fue dada de alta, solo para ser internada en otro hospital 12 horas después.
Numerosos estudios han encontrado que los afroamericanos a menudo reciben peor atención médica que sus contrapartes blancas: en marzo, una empresa de biotecnología de Boston publicó un análisis que mostraba que era menos probable que los médicos remitieran a pacientes negros sintomáticos para pruebas de coronavirus que a los blancos sintomáticos.
“Si fuera blanca, no tendría que pasar por eso”, dijo Moore en el video publicado desde su cama de hospital. “Así es como matan a los negros, cuando los envías a casa, y no saben cómo luchar por sí mismos”. Moore murió el 20 de diciembre por complicaciones de covid, dijo su hijo Henry Muhammad a los medios de comunicación.
Junto con las personas de color, los trabajadores de salud inmigrantes han sufrido pérdidas desproporcionadas a causa de covid-19. Más de un tercio de los trabajadores de salud que mueren por covid en el país nacieron en el extranjero, desde Filipinas y Haití, hasta Nigeria y México, según un análisis de KHN/The Guardian de casos registrados. Representan el 20% del total de trabajadores de salud de los Estados Unidos.
El doctor Ramon Tallaj, médico y presidente de Somos, una red sin fines de lucro de proveedores de atención médica en Nueva York, dijo que los médicos y enfermeras inmigrantes a menudo ven a pacientes de sus propias comunidades, y muchas comunidades inmigrantes de clase trabajadora han sido devastadas por covid.
“Nuestra comunidad son trabajadores esenciales. Tuvieron que ir a trabajar al comienzo de la pandemia, y cuando se enfermaban, iban a ver al médico de la comunidad”, dijo. Doce médicos y enfermeras de la red Somos han muerto por covid, dijo.
El doctor Eriberto Lozada era médico de familia de 83 años en Long Island, Nueva York. Todavía estaba viendo pacientes fuera de su consulta cuando los casos comenzaron a aumentar la primavera pasada. Originario de Filipinas, un país con un historial de envío de trabajadores médicos calificados a los Estados Unidos, estaba orgulloso de ser médico y “de haber sido un inmigrante próspero”, dijo su hijo James Lozada.
Los miembros de la familia de Lozada lo recuerdan como estricto y de voluntad fuerte; lo llamaban cariñosamente “el rey”. Inculcó a sus hijos la importancia de una buena educación. Murió en abril.
Dos de sus cuatro hijos, John y James Lozada, son médicos. Ambos fueron vacunados el mes pasado. Considerando todo lo que habían pasado, dijo John, fue una ocasión “agridulce”. Pero pensó que era importante por otra razón: ser un ejemplo para sus pacientes.
Las desigualdades en las infecciones, y las muertes, por covid podrían alimentar la desconfianza en la vacuna. En un estudio reciente del Pew Research Center, alrededor del 42% de los encuestados de raza negra dijeron que “definitivamente o probablemente” recibirían la vacuna en comparación con el 60% de la población general.
Esto tiene sentido para Patricia Gardner, enfermera nacida en Jamaica y gerenta en el Centro Médico de la Universidad de Hackensack, en Nueva Jersey, quien contrajo el coronavirus junto con familiares y colegas. “Mucho de lo que escucho es, ‘¿Cómo es que no fuimos los primeros en recibir atención, pero ahora somos los primeros en vacunarnos?’”, dijo.
Al igual que Beniquez, se vacunó el 14 de diciembre. “Para mí, dar un paso al frente y decir: ‘Quiero estar en el primer grupo’, espero que eso envíe un mensaje”, dijo.
Beniquez dijo que sintió el peso de esa responsabilidad cuando se inscribió para ser la primera persona en su estado en recibir la vacuna. Muchos de sus pacientes han expresado escepticismo, impulsado, opinó, por un sistema de salud que les ha fallado durante años.
“Recordamos los juicios de Tuskegee. Recordamos las ‘apendicectomías’ ”: informes de mujeres que fueron esterilizadas a la fuerza en un centro de detención del Servicio de Inmigración y Control de Aduanas de Georgia. “Estas son cosas que le han sucedido a esta comunidad, a las comunidades negras y latinas durante el último siglo. Como trabajadora de salud, tengo que reconocer que sus temores son legítimos y explicarles ‘Esto no es lo mismo’”, dijo.
Beniquez dijo que su alegría y alivio por recibir la vacuna se ven atenuados por la realidad del aumento de casos en la sala de emergencias. La adrenalina que ella y sus colegas sintieron la primavera pasada se ha ido, reemplazada por la fatiga y la cautela de los meses venideros.
Su hospital colocó 11 árboles en el vestíbulo, uno por cada empleado que murió de covid; han sido adornados con recuerdos y obsequios de sus colegas.
Hay uno para Kim King-Smith, de 53 años, el amable técnico de EKG, que visitaba a amigos de amigos, o a familiares cada vez que terminaba en el hospital.
Uno para Danilo Bolima, 54, el enfermero de Filipinas que se convirtió en profesor y era el jefe de servicios de atención al paciente.
Otro para Obinna Chibueze Eke, de 42 años, asistente de enfermería nigeriano, que pidió a sus amigos y familiares que oraran cuando estuvo hospitalizado con covid.
“Cada día, recordamos a nuestros colegas y amigos caídos como los héroes que nos ayudaron a seguir adelante durante esta pandemia y más allá”, dijo el doctor Shereef Elnahal presidente y director ejecutivo del hospital, en un comunicado. “Nunca olvidaremos sus contribuciones y su pasión colectiva por esta comunidad y por los demás”.
Justo afuera del edificio, está el árbol número 12. “Será para otro u otra que perdamos en esta batalla”, dijo Beniquez.
Esta historia es parte de “Lost on the Frontline”, un proyecto en curso de The Guardian y Kaiser Health News que tiene como objetivo documentar las vidas de los trabajadores de salud de los Estados Unidos que mueren a causa de COVID-19, e investigar por qué tantos son víctimas de la enfermedad. Si tienes un colega o un ser querido que deberíamos incluir, por favor comparte su historia.
As I prepared to get my shot in mid-December as part of a covid vaccine trial run by Janssen Pharmaceuticals, I considered the escape routes. Bailing out of the trial was a very real consideration since two other vaccines, made by Moderna and Pfizer-BioNTech, had been deemed safe and effective for emergency approval.
Leaving the trial would be a perfectly sane decision for me or anyone who had volunteered for an ongoing covid experiment. Why risk getting covid-19 if I was given a placebo, a shot with no vaccine in it? The way tests are designed, I might not be told whether I received the vaccine until the clinical trial is over, months from now.
Dropping the placebo arm could also be ethically sound from the company’s point of view. Researchers frequently halt trials when they have a product that works — or manifestly doesn’t. And the two approved vaccines are 95% effective.
That very real choice for thousands of people offering to join or remain in the ongoing vaccine tests creates a conundrum for science and for society. If trials can’t go forward, that could very well have an impact on the world’s supply of covid vaccines and eventually on vaccine prices, especially if booster shots are needed in years to come. In markets where there are only two competing drugs, prices can shoot sky-high. If there are four or five on the market, competition usually kicks in to control costs.
In short, the welcome arrival of two covid vaccines deemed safe has uncovered a series of ethical and logistical challenges. And it has governments, companies and scientists scrambling for solutions.
“The world’s vaccine experts are saying the longer we can carry out a placebo-controlled trial the better,” Matthew Hepburn, who runs the vaccine development arm of Operation Warp Speed, the multibillion-dollar federal program to fight covid-19, told me. “But as a volunteer in the Janssen trial, you can always drop out.”
As for the best way to resolve broader problems, “it’s a debate in real time,” he said.
Generally, there are two aspects to the debate. First, what should be done with placebo recipients of the Moderna and Pfizer trials now that it’s clear both shots prevent the disease and appear safe? Second, how can the scores of companies in the United States and overseas that are still testing covid vaccines adapt when there are apparently reliable products already on the market?
The FDA’s advisory committee debated the first question during two meetings in December. They heard Stanford University statistician Steven Goodman argue in favor of a “double-blind crossover” modification of the Pfizer and Moderna trials. Everyone who got placebo shots in the trials would now get two doses of the real vaccine, and vice versa. That way everyone would be protected but still “blind” as to when they were properly vaccinated.
Such a rejigger of the current trial would provide more data on the vaccine’s safety and durability of protection, although the longer-term comparison of vaccine versus placebo would be lost. It’s a marvelous idea in principle, the panelists agreed, but pretty hard to carry out. Neither Moderna nor Pfizer has agreed to it.
Pfizer wants to “unblind” placebo recipients of its vaccine — to reveal they got the saline solution and give them the real thing — once their risk group gets its turn in line for the vaccine. It has already started vaccinating health care workers who got the placebo.
Moderna, which has thousands of soon-to-expire leftover doses from its trial, said it intends to unblind its trial and vaccinate all the placebo recipients. In doing so, it would be recognizing the altruistic service the test subjects made to science and society by joining the trial.
Another proposal would split the placebo recipients in the trial into two groups. In one group, everyone would get a single dose of the vaccine. In the other, each would get two doses. This would be a way of testing evidence that emerged during the Pfizer and Moderna trials that a single dose might provide sufficient protection. If that were true, vaccination of the country could happen nearly twice as fast, because there would be twice as many doses of vaccine to go around.
No one knows to what extent the Food and Drug Administration could force the hands of the two companies, which still expect to get full licensure for their vaccines this year. Moderna is considered more amenable to the suggestion since, unlike Pfizer, it got nearly $1 billion in federal funding to develop its vaccine.
Other vaccine developers — including Operation Warp Speed participants Janssen (owned by Johnson & Johnson), AstraZeneca, Novavax, Sanofi and Merck & Co. — are closely watching to see which path is taken.
They are in a race against time — a race that may not end well for those running late in getting their vaccine out. And halting those efforts could hurt billions of people elsewhere in the world whose lives and livelihoods will depend on the arrival of plentiful, cheap vaccines.
One problem is finding willing test subjects. As increasing numbers of Americans are vaccinated, and the virus recedes from our shores, “the fewer the number of people eligible to participate in trials,” said Susan Ellenberg, professor of biostatistics at the University of Pennsylvania.
For now, AstraZeneca and Janssen appear well situated. Both have closed enrollment in their U.S. trials and are likely to file within a few months for emergency use authorizations, like those that have allowed Moderna and Pfizer to start vaccinating the public.
Novavax officials last week started their late-stage trial in the U.S. and predict they can get full enrollment before the majority of the U.S. population is vaccinated.
Sanofi and Merck, whose timetables are more drawn out, are more likely to conduct most of their trials overseas.
In theory, drug companies could overcome these hurdles by testing multiple vaccines against one another and against approved vaccines. Dr. Steven Joffe, a University of Pennsylvania bioethicist, proposed in a recent JAMA article that Operation Warp Speed pay for such a trial.
Scientists and policymakers batted around the idea of a single U.S. trial, with multiple vaccine candidates competing against one another and a single placebo arm, during initial discussions last spring about the creation of Operation Warp Speed.
The idea went nowhere in the United States. It was taken up by World Health Organization officials and major biomedical research groups, which have tried to create such a vaccine trial in the rest of the world — with little success thus far.
So, for now, future vaccine trials are somewhat up in the air.
“There’s this tension created by getting the first vaccines out there so quickly,” said David Wendler, a senior researcher in bioethics at the National Institutes of Health’s Clinical Center. “For public health it’s good, but it has the potential to undermine our ability to keep going on the research side and really knock out the virus.”
Companies, governments and outside funders need to quickly develop consensus on appropriate trial designs and regulatory processes for additional covid vaccines, added Mark Feinberg, president and CEO of the International AIDS Vaccine Initiative.
As for me, I decided I would stay in the Janssen trial. However, the day before I was scheduled to get my injection — real or fake — the research organization running the inoculations called to say I failed to make the cut: J&J had stopped its trial enrollment.
So, I’ll buy some new masks and get in line for my vaccine with everyone else.
Last spring, New Jersey emergency room nurse Maritza Beniquez saw “wave after wave” of sick patients, each wearing a look of fear that grew increasingly familiar as the weeks wore on.
Soon, it was her colleagues at Newark’s University Hospital — the nurses, techs and doctors with whom she had been working side by side — who turned up in the ER, themselves struggling to breathe. “So many of our own co-workers got sick, especially toward the beginning; it literally decimated our staff,” she said.
By the end of June, 11 of Beniquez’s colleagues were dead. Like the patients they had been treating, most were Black and Latino.
“We were disproportionately affected because of the way that Blacks and Latinos in this country have been disproportionately affected across every [part of] our lives — from schools to jobs to homes,” she said.
Now Beniquez feels like a vanguard of another kind. On Dec. 14, she became the first person in New Jersey to receive the coronavirus vaccine — and was one of many medical workers of color featured prominently next to headlines heralding the vaccine’s arrival at U.S. hospitals.
It was a joyous occasion, one that kindled the possibility of again seeing her parents and her 96-year-old grandmother, who live in Puerto Rico. But those nationally broadcast images were also a reminder of those for whom the vaccine came too late.
Covid-19 has taken an outsize toll on Black and Hispanic Americans. And those disparities extend to the medical workers who have intubated them, cleaned their bedsheets and held their hands in their final days, a KHN/Guardian investigation has found. People of color account for about 65% of fatalities in cases in which there is race and ethnicity data.
One recent study found health care workers of color were more than twice as likely as their white counterparts to test positive for the virus. They were more likely to treat patients diagnosed with covid, more likely to work in nursing homes — major coronavirus hotbeds — and more likely to cite an inadequate supply of personal protective equipment, according to the report.
In a national sample of 100 cases gathered by KHN/The Guardian in which a health care worker expressed concerns over insufficient PPE before they died of covid, three-quarters of the victims were identified as Black, Hispanic, Native American or Asian.
“Black health care workers are more likely to want to go into public-sector care where they know that they will disproportionately treat communities of color,” said Adia Wingfield, a sociologist at Washington University in St. Louis who has studied racial inequality in the health care industry. “But they also are more likely to be attuned to the particular needs and challenges that communities of color may have,” she said.
Not only do many Black health care staffers work in lower-resourced health centers, she said, they are also more likely to suffer from many of the same co-morbidities found in the general Black population, a legacy of systemic inequities.
And they may fall victim to lower standards of care. Dr. Susan Moore, a 52-year-old Black pediatrician in Indiana, was hospitalized with covid in November and, according to a video posted to her Facebook account, had to ask repeatedly for tests, remdesivir and pain medication. She said her white doctor dismissed her complaints of pain and she was discharged, only to be admitted to another hospital 12 hours later.
Numerous studies have found Black Americans often receive worse medical care than their white counterparts: In March, a Boston biotech firm published an analysis showing physicians were less likely to refer symptomatic Black patients for coronavirus tests than symptomatic whites. Doctors are also less likely to prescribe painkillers to Black patients.
“If I was white, I wouldn’t have to go through that,” Moore said in the video posted from her hospital bed. “This is how Black people get killed, when you send them home, and they don’t know how to fight for themselves.” She died on Dec. 20 of covid complications, her son Henry Muhammad told news outlets.
Along with people of color, immigrant health workers have suffered disproportionate losses to covid-19. More than one-third of health care workers to die of covid in the U.S. were born abroad, from the Philippines to Haiti, Nigeria and Mexico, according to a KHN/Guardian analysis of cases for which there is data. They account for 20% of health care workers in the U.S. overall.
Dr. Ramon Tallaj, a physician and chairman of Somos, a nonprofit network of health care providers in New York, said immigrant doctors and nurses often see patients from their own communities — and many working-class, immigrant communities have been devastated by covid.
“Our community is essential workers. They had to go to work at the beginning of the pandemic, and when they got sick, they would come and see the doctor in the community,” he said. Twelve doctors and nurses in the Somos network have died of covid, he said.
Dr. Eriberto Lozada was an 83-year-old family physician in Long Island, New York. He was still seeing patients out of his practice when cases began to climb last spring. Originally from the Philippines, a country with a history of sending skilled medical workers to the United States, he was proud to be a doctor and “proud to have been an immigrant who made good,” his son James Lozada said.
Lozada’s family members remember him as strict and strong-willed — they affectionately called him “the king.” He instilled in his children the importance of a good education. He died in April.
Two of his four sons, John and James Lozada, are doctors. Both were vaccinated last month. Considering all they had been through, John said, it was a “bittersweet” occasion. But he thought it was important for another reason — to set an example for his patients.
The inequities in covid infections and deaths risk fueling distrust in the vaccine. In a recent Pew study, around 42% of Black respondents said they would “definitely or probably” get the vaccine compared with 60% of the general population.
This makes sense to Patricia Gardner, a Black, Jamaican-born nursing manager at Hackensack University Medical Center in New Jersey who has been infected with the coronavirus along with family members and colleagues. “A lot of what I hear is, ‘How is it that we weren’t the first to get the care, but now we’re the first to get vaccinated?’” she said.
Like Beniquez, the nurse in Newark, she was vaccinated on Dec. 14. “For me to step up to say, ‘I want to be in the first group’ — I’m hoping that sends a message,” she said.
Beniquez said she felt the weight of that responsibility when she signed on to be the first person in her state to receive the vaccine. Many of her patients have expressed skepticism over the vaccine, fueled, she said, by a health system that has failed them for years.
“We remember the Tuskegee trials. We remember the ‘appendectomies’” — reports that women were forcibly sterilized in a U.S. Immigration and Customs Enforcement detention center in Georgia. “These are things that have happened to this community to the Black and Latino communities over the last century. As a health care worker, I have to recognize that their fears are legitimate and explain ‘This is not that,’” she said.
Beniquez said her joy and relief over receiving the vaccine are tempered by the reality of rising cases in the ER. The adrenaline she and her colleagues felt last spring is gone, replaced by fatigue and wariness of the months ahead.
Her hospital placed 11 trees in the lobby, one for each employee who has died of covid; they have been adorned with remembrances and gifts from their colleagues.
There is one for Kim King-Smith, 53, the friendly EKG technician, who visited friends of friends or family whenever they ended up in the hospital.
One for Danilo Bolima, 54, the nurse from the Philippines who became a professor and was the head of patient care services.
One for Obinna Chibueze Eke, 42, the Nigerian nursing assistant, who asked friends and family to pray for him when he was hospitalized with covid.
“Each day, we remember our fallen colleagues and friends as the heroes who helped keep us going throughout this pandemic and beyond,” hospital president and CEO Dr. Shereef Elnahal said in a statement. “We can never forget their contributions and their collective passion for this community, and each other.”
Just outside the building, stands a 12th tree. “It’s going to be for whoever else we lose in this battle,” Beniquez said.
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.
As the covid-19 pandemic heads for a showdown with vaccines it’s expected to lose, many experts in the field of emerging infectious diseases are already focused on preventing the next one.
They fear another virus will leap from wildlife into humans, one that is far more lethal but spreads as easily as SARS-CoV-2, the strain of coronavirus that causes covid-19. A virus like that could change the trajectory of life on the planet, experts say.
“What keeps me up at night is that another coronavirus like MERS, which has a much, much higher mortality rate, becomes as transmissible as covid,” said Christian Walzer, executive director of health at the Wildlife Conservation Society. “The logistics and the psychological trauma of that would be unbearable.”
SARS-CoV-2 has an average mortality rate of less than 1%, while the mortality rate for Middle East respiratory syndrome, or MERS — which spread from camels into humans — is 35%. Other viruses that have leapt the species barrier to humans, such as bat-borne Nipah, have a mortality rate as high as 75%.
“There is a huge diversity of viruses in nature, and there is the possibility that one has the Goldilocks characteristics of pre-symptomatic transmission with a high fatality rate,” said Raina Plowright, a virus researcher at the Bozeman Disease Ecology Lab in Montana. (Covid-19 is highly transmissible before the onset of symptoms but fortunately is far less lethal than several other known viruses.) “It would change civilization.”
That’s why in November the German Federal Foreign Office and the Wildlife Conservation Society held a virtual conference called One Planet, One Health, One Future, aimed at heading off the next pandemic by helping world leaders understand that killer viruses like SARS-CoV-2 — and many other less deadly pathogens — are unleashed on the world by the destruction of nature.
With the world’s attention gripped by the spread of the coronavirus, infectious disease experts are redoubling their efforts to show the robust connection between the health of nature, wildlife and humans. It is a concept known as One Health.
While the idea is widely accepted by health officials, many governments have not factored it into policies. So the conference was timed to coincide with the meeting of the world’s economic superpowers, the G20, to urge them to recognize the threat that wildlife-borne pandemics pose, not only to people but also to the global economy.
The Wildlife Conservation Society — America’s oldest conservation organization, founded in 1895 — has joined with 20 other leading conservation groups to ask government leaders “to prioritize protection of highly intact forests and other ecosystems, and work in particular to end commercial wildlife trade and markets for human consumption as well as all illegal and unsustainable wildlife trade,” they said in a recent press release.
Experts predict it would cost about $700 billion to institute these and other measures, according to the Wildlife Conservation Society. On the other hand, it’s estimated that covid-19 has cost $26 trillion in economic damage. Moreover, the solution offered by those campaigning for One Health goals would also mitigate the effects of climate change and the loss of biodiversity.
The growing invasion of natural environments as the global population soars makes another deadly pandemic a matter of when, not if, experts say — and it could be far worse than covid. The spillover of animal, or zoonotic, viruses into humans causes some 75% of emerging infectious diseases.
But multitudes of unknown viruses, some possibly highly pathogenic, dwell in wildlife around the world. Infectious disease experts estimate there are 1.67 million viruses in nature; only about 4,000 have been identified.
SARS-CoV-2 likely originated in horseshoe bats in China and then passed to humans, perhaps through an intermediary host, such as the pangolin — a scaly animal that is widely hunted and eaten.
While the source of SARS-CoV-2 is uncertain, the animal-to-human pathway for other viral epidemics, including Ebola, Nipah and MERS, is known. Viruses that have been circulating among and mutating in wildlife, especially bats, which are numerous around the world and highly mobile, jump into humans, where they find a receptive immune system and spark a deadly infectious disease outbreak.
“We’ve penetrated deeper into eco-zones we’ve not occupied before,” said Dennis Carroll, a veteran emerging infectious disease expert with the U.S. Agency for International Development. He is setting up the Global Virome Project to catalog viruses in wildlife in order to predict which ones might ignite the next pandemic. “The poster child for that is the extractive industry — oil and gas and minerals, and the expansion of agriculture, especially cattle. That’s the biggest predictor of where you’ll see spillover.”
When these things happened a century ago, he said, the person who contracted the disease likely died there. “Now an infected person can be on a plane to Paris or New York before they know they have it,” he said.
Meat consumption is also growing, and that has meant either more domestic livestock raised in cleared forest or “bush meat” — wild animals. Both can lead to spillover. The AIDS virus, it’s believed, came from wild chimpanzees in central Africa that were hunted for food.
One case study for how viruses emerge from nature to become an epidemic is the Nipah virus.
Nipah is named after the village in Malaysia where it was first identified in the late 1990s. The symptoms are brain swelling, headaches, a stiff neck, vomiting, dizziness and coma. It is extremely deadly, with as much as a 75% mortality rate in humans, compared with less than 1% for SARS-CoV-2. Because the virus never became highly transmissible among humans, it has killed just 300 people in some 60 outbreaks.
One critical characteristic kept Nipah from becoming widespread. “The viral load of Nipah, the amount of virus someone has in their body, increases over time” and is most infectious at the time of death, said the Bozeman lab’s Plowright, who has studied Nipah and Hendra. (They are not coronaviruses, but henipaviruses.) “With SARS-CoV-2, your viral load peaks before you develop symptoms, so you are going to work and interacting with your family before you know you are sick.”
If an unknown virus as deadly as Nipah but as transmissible as SARS-CoV-2 before an infection was known were to leap from an animal into humans, the results would be devastating.
Plowright has also studied the physiology and immunology of viruses in bats and the causes of spillover. “We see spillover events because of stresses placed on the bats from loss of habitat and climatic change,” she said. “That’s when they get drawn into human areas.” In the case of Nipah, fruit bats drawn to orchards near pig farms passed the virus on to the pigs and then humans.
“It’s associated with a lack of food,” she said. “If bats were feeding in native forests and able to nomadically move across the landscape to source the foods they need, away from humans, we wouldn’t see spillover.”
A growing understanding of ecological changes as the source of many illnesses is behind the campaign to raise awareness of One Health.
One Health policies are expanding in places where there are likely human pathogens in wildlife or domestic animals. Doctors, veterinarians, anthropologists, wildlife biologists and others are being trained and training others to provide sentinel capabilities to recognize these diseases if they emerge.
The scale of preventive efforts is far smaller than the threat posed by these pathogens, though, experts say. They need buy-in from governments to recognize the problem and to factor the cost of possible epidemics or pandemics into development.
“A road will facilitate a transport of goods and people and create economic incentive,” said Walzer, of the Wildlife Conservation Society. “But it will also provide an interface where people interact and there’s a higher chance of spillover. These kinds of costs have never been considered in the past. And that needs to change.”
The One Health approach also advocates for the large-scale protection of nature in areas of high biodiversity where spillover is a risk.
Joshua Rosenthal, an expert in global health with the Fogarty International Center at the National Institutes of Health, said that while these ideas are conceptually sound, it is an extremely difficult task. “These things are all managed by different agencies and ministries in different countries with different interests, and getting them on the same page is challenging,” he said.
Researchers say the clock is ticking. “We have high human population densities, high livestock densities, high rates of deforestation — and these things are bringing bats and people into closer contact,” Plowright said. “We are rolling the dice faster and faster and more and more often. It’s really quite simple.”
Funeral director Kevin Spitzer has been overwhelmed with covid-related deaths in the small city of Aberdeen, South Dakota.
He and his two colleagues at the Spitzer-Miller Funeral Home have been working 12-15 hours a day, seven days a week, to keep up with the demand in the community of 26,000. The funerals are sparsely attended, which would have been unthinkable before the pandemic.
“We had a funeral for a younger man one recent Saturday, and not 20 people came, because most everyone was just afraid,” he said.
As covid-19 has spread from big cities to rural communities, it has stressed not only hospitals, but also what some euphemistically call “last responders.” The crush has overwhelmed morgues, funeral homes and religious leaders, required ingenuity and even changed the rituals of honoring the dead.
Officials in many smaller cities and towns learned from seeing the overflow of bodies during last spring’s first wave of covid deaths in places such as Detroit, where nurses at Detroit Medical Center Sinai-Grace Hospital alerted the media to bodies accumulating in hospital storage rooms. They watched as New York hospitals and funeral homes marshaled refrigerated trucks to store bodies. More than 600 bodies of people who died in the spring covid surge remain in freezer trucks on the Brooklyn waterfront because officials can’t find next of kin, or relatives are also sick or unable to pay for burial.
People like Dr. Robert Kurtzman, Montana’s chief medical examiner, took heed. Last spring, he worked with funeral directors and others to study the state’s morgue capacity. After looking at covid projections, the state arranged with the Montana National Guard to have 13 refrigerated semitrucks ready to dispatch anywhere in the state.
“We are already in a precarious position, and the projections present a scary proposition,” he said. “We need to be ready for worst-case scenarios.”
Chad Towner, CEO of St. Joseph Health System, which has two hospitals in northern Indiana, ordered two refrigerated semitrailers in April. For a time, things were relatively quiet. But the pandemic has hit.
“I told a friend who was a covid doubter that if my wife needed a bed today, I could not arrange one. That’s the dire situation we face here,” Towner said. “All our competitors in the area are in the same boat, and we’re working together instead of competing.”
Although the freezer trucks have not yet been needed, he worries that the sharp increase in cases, and those anticipated from holiday gatherings, will make last-resort measures necessary.
“We recently had four deaths in one afternoon,” said Towner. “A priest approached me to say he’d been asked to provide last rites to three patients in one hour.”
Moving bodies from the hospital morgue is a slower process than usual, he said. “Morticians and funeral homes are overflowing as well. Families that are sick or quarantined at the time of the loved one’s death often can’t work with us on a transfer, meaning bodies are here longer. The entire system is stressed to the tipping point,” said Towner.
Private enterprise has created a solution for smaller communities. In Bozeman, Montana, a specialty truck company has retrofitted trailers that can be pulled by an SUV or a pickup.
Acela Truck Co. has already sold hundreds of the pull-behind refrigerated units created in response to the covid pandemic. They range from 9 to 53 feet and have racks that each hold four body trays. “We’re very busy and have orders in all of the lower 48 states,” said CEO David Ronsen. Acela has partnered with Mopec, a Michigan autopsy supply company, to help sell and deliver the new product.
Billings Clinic in Montana also anticipated a flood of deaths last spring by reserving a semitrailer for delivery, if needed. The clinic, which has just two morgue spaces, has dealt with 80 covid deaths, including seven on the weekend after Thanksgiving.
Chief Nursing Officer Laurie Smith said the hospital is at capacity, despite adding beds by converting office space and building an addition. The hospital, which currently has 335 beds, so far has handled the additional deaths through what she calls a “sad partnership” with funeral homes, which have been quickly picking up bodies the hospital cannot store.
The hospital does its best to allow relatives to say goodbye, but that often involves family members standing at an interior window outside the patient’s room, using a computer tablet to communicate their last words.
That is just one way in which the rituals of grieving have changed during the covid pandemic.
Typical congregational hymns are pretty much gone, as are choirs.
“We are using mostly recordings, sometimes a soloist,” said Spitzer.
Funeral home directors who pride themselves on spending time comforting grieving families say they are so busy that some days they have to rush out from one funeral to begin the next one.
“Families are being robbed of the whole funeral rite experience and losing the support of having friends and family around them,” said Shauna Kjos-Miotke of Fiksdal Funeral Home in Webster, South Dakota.
Native communities have not only been among the hardest hit with covid illnesses and deaths, but their grieving rituals have been among the most seriously disrupted.
“Normally a funeral is a two- or three-day process with hundreds of people,” said Josiah Hugs, a Crow tribal member who is the outreach coordinator for Billings Urban Indian Health and Wellness Center. “Now there is no time to tell stories about the person, not a lot of singing and praying. I’ve been to three recent covid funerals, and everything was at the burial site, with maybe 30 people sitting in their cars and not getting out.”
Covid has even affected body disposal. A survey by the National Funeral Directors Association found that more than half of their members reported increased cremation rates due to covid. The NFDA also found that half its members have clients who have postponed services to hold a memorial later.
In the largely impoverished Hidalgo County, a Texas border area, county officials began using covid funds to help cover the burial costs for struggling families. Then they begin hearing of the emotional costs, including the anguish of videoconferenced funerals, such as for a family that had lost a husband, a mother and an aunt in one month. They wondered if there would be interest in an alternative way to honor the dead.
“We sent out a social media post asking if anyone wanted to post a photograph of a relative who died of covid if we created a county memorial page,” said county spokesperson Carlos Sanchez, who himself barely survived a bout with covid in July. “Within minutes, we got more than 20 emails. Several sent photos of multiple relatives. They want them to be remembered.”
That is the question by a recent paper in by Baugh et al. (2020) in JAMA Open. The authors surveyed nearly 300 current college football players from 4 teams in the 5 most competitive NCAA football conferences. They found that:
Of the 265 participants for whom all relevant data were available, 111 (42%) underestimated their risk of concussion (χ2 = 98.6; P = .003). A similar proportion of athletes (113 [43%]) underestimated their risk of injury, although this was not statistically significant (χ2 = 34.0; P = .09). An alternative analytic strategy suggested that 241 athletes (91%) underestimated their risk of injury (Wilcoxon statistic, 7865; P < .001) and 167 (63%) underestimated their risk of concussion (Wilcoxon statistic, 26 768; P < .001).
Overall, the answer seems like that answer is ‘yes’, athletes are underestimating their risk of concussion, but not at widely low rates. This study does not, however, get at whether individuals perceive the severity of a concussion accurately. In expected value terms, football’s risk involves likely probability of injury times the expected injury levels conditional on the event occurring. The Baugh et al. study only deals with the first issue. A follow-on study should examine whether football players are accurately understanding concussion severity.
An important topic to insure that football players and their families internalize risks and benefits of playing this game.
– Healthcare technology company Forcura names the five
most significant trends for the post-acute care industry in 2021.
The post-acute care (PAC) sector saw some of its most
profound challenges this year, from deadly COVID-19
outbreaks in skilled nursing facilities (SNFs) to a suddenly accelerated need
for the services provided by home health and hospice. The biggest question now
is that what does the post-acute care future hold for all of us?
Forcura, a healthcare technology company that enables safer patient care transitions along the care continuum recently released their report, What Happened and What’s Next in Post-Acute Care,” which synthesizes the top takeaways for the post-acute care industry in 2020, and explores the five themes it projects will be the leading business influencers on the sector in 2021 and for years to come.
The report names these as the five most significant drivers
for the post-acute care industry in 2021:
1. Interoperability: The Industry Inches Closer to a
In its guide to “Interoperability in Healthcare,” HIMSS
as “the ability of different information systems, devices and applications
(systems) to access, exchange, integrate and cooperatively use data in a
coordinated manner, within and across organizational, regional and national
boundaries, to provide timely and seamless portability of information and
optimize the health of individuals and populations globally.”
Individuals and organizations have worked tirelessly for
years to create a technological foundation that will make care transitions
safer and more holistic. They’ve made incredible progress…with patients and PAC
providers beginning to reap the benefits of increased data sharing.
2. Healthcare will be Increasingly Built Around the
Service providers talk about the “user experience” and now
users are finally seeking better care experiences. People are becoming savvier
and more demanding about their healthcare in the same ways they have done so in
consuming other services. While technology is certainly a component of the move
towards patient centricity, it is a tool that enables or enhances care
delivery. Post-acute care is poised for the shift to patient centricity.
3. Payment Models and Reimbursement Plans Remain in Play
The post-acute care industry will continue to be shaped by
regulatory and financial forces. By being proactive, fully understanding the
impacts of payment models (like unified payments), learning from the lessons of
acute care payment reform, and choosing the right partners, PAC providers
should be able to more confidently control their bottom lines in the coming
4. New Business Models are Not Your Parents’ PAC
PAC companies themselves also are beginning to explore new
options for their business operations. Post-acute care is being asked to
deliver better patient outcomes and greater value – and it’s time to respond.
Driven in part by the explosion of home-based health care services from legacy
players and new entrants, PAC organizations will be scrambling to retain as
much patient share as possible. By diversifying, providers can reduce the
vulnerability experienced by single service line agencies.
5. Healthcare for All Remains Elusive
COVID-19 has revealed some harsh realities about the ongoing
effects of structural inequity…to no one’s surprise. Some steps towards equity
are occurring. Research led by Oregon Health & Science University shows
that a new national care program for hip and knee joint replacements seems to
reduce health outcome disparities for Black patients. The CMS Comprehensive
Care for Joint Replacement model is a bundled payment model designed to reduce
spending and improve outcomes for all joint replacement patients. “Although
Black patients were discharged to institutional post-acute care more than white
patients, the gap narrowed under the new bundled payment model. Readmission
risk decreased about 3 percentage points for Black patients under the new
model, and stayed roughly the same for Hispanic and white patients.”
“Everyone realizes that 2020 is historic for the unprecedented disruption and lives lost to the COVID-19 public health crisis” says Forcura founder and CEO, Craig Mandeville, “and operating in-the-moment has been a necessity. It has also possibly reduced the time the industry has to plan for what else is around the corner.” Craig continues, “Our original research and conversations from our CONNECT Summit clearly point to five market drivers that everyone should factor into their strategic initiatives. We’re proud to offer this report and believe it will guide health industry companies to focus more on patients and better secure their bottom lines.”
ERIE, Colo. — Whenever Larry Kelderman looks up from the car he’s fixing and peers across the street, he’s looking across a border. His town of 28,000 straddles two counties, separated by County Line Road.
Kelderman’s auto repair business is in Boulder County, whose officials are sticklers for public health and have topped the county website with instructions on how to report COVID violations. Kelderman lives in Weld County, where officials refuse to enforce public health rules.
Weld County’s test positivity rate is twice that of its neighbor, but Kelderman is pretty clear which side he backs.
“Which is worse, the person gets the virus and survives and they still have a business, or they don’t get the virus and they lose their livelihood?” he said.
Boulder boasts one of the most highly educated populations in the nation; Weld boasts about its sugar beets, cattle and thousands of oil and gas wells. Summer in Boulder County means concerts featuring former members of the Grateful Dead; in Weld County, it’s rodeo time. Boulder voted for Biden, Weld for Trump. Per capita income in Boulder is nearly 50% higher than in Weld.
Even their COVID outbreaks are different: In Boulder County, the virus swirls around the University of Colorado. In Weld County, some of the worst outbreaks have swept through meatpacking plants.
It’s not the first time County Line Road has been a fault line.
“I’ve been in politics seven years and there’s always been a conflict between the two counties,” said Jennifer Carroll, mayor of Erie, once a coal mining town and now billed as a good place to raise a family, about 30 minutes north of Denver.
Shortly before the coronavirus hit Colorado, Erie’s board of trustees extended a moratorium on new oil and gas operations in the town. Weld County was not pleased.
“They got really angry at us for doing that, because oil and gas is their thing,” Carroll said.
Most of the town’s businesses are on the Weld side. To avoid public health whiplash, Carroll and other town leaders have asked residents to comply with the more restrictive stance of the Boulder side.
The feud got ugly in a dispute over hospital beds. At one point, the state said Weld County had only three intensive care beds, while Weld County claimed it had 43.
“It made my job harder, because people were doubting what I was saying,” said Carroll. “Nobody trusted anyone because they were hearing conflicting information.”
Weld’s number, it turned out, included not just the beds in its two hospitals, but also those in 10 other hospitals across the county line, including in the city of Longmont.
Longmont sits primarily in Boulder County but spills into Weld, where its suburbs taper into fields pockmarked with prairie dog holes. Its residents say they can tell snow is coming when the winds deliver a pungent smell of livestock from next door. Longmont Mayor Brian Bagley worried that Weld’s behavior would deliver more than a stench: It might also deliver patients requiring precious resources.
“They were basically encouraging their citizens to violate the emergency health orders … with this cowboy-esque, you know, ‘Yippee-ki-yay, freedom, Constitution forever, damn the consequences,’” said Bagley. “Their statement is, ‘Our hospitals are full, but don’t worry, we’re just going to use yours.’”
So, “for 48 hours, I trolled Weld County,” he said. Bagley asked the city council to consider an ordinance that could have restricted Weld County residents’ ability to receive care at Longmont hospitals. Bagley, who retracted his proposal the next day, said he knew it was never going to come to fruition — after all, it was probably illegal — but he wanted to prove a point.
“They’re going to be irresponsible? Fine. Let me propose a question,” he said. “If there is only one ICU bed left and there are two grandparents there — one from Weld, one from Boulder — and they both need that bed, who should get it?”
Weld County commissioners volleyed back, calling Bagley a “simple mayor.” They wrote that the answer to the pandemic was “not to continually punish working-class families or the individuals who bag your groceries, wait on you in restaurants, deliver food to your home while you watch Netflix and chill.”
“I know we’re all trying to get along, but people are starting to do stupid and mean things and so I’ll be stupid and mean back,” Bagley said during a Dec. 8 council meeting.
In another Longmont City Council meeting, Bagley (who suspects the commissioners don’t know what “Netflix and chill” typically means) often referred to Weld simply as “our neighbors to the East,” declining to name his foe. The council shrugged off his statement about withholding medical treatment but demanded that Weld County step up to fight the pandemic.
“We would not deny medical care to anybody. It’s illegal and it’s immoral,” said council member Polly Christensen. “But it is wrong for people to expect us to bear the burden of what they’ve been irresponsible enough to let loose.”
“They’re the reason why I can’t be in the classroom in front of my kids,” said council member and teacher Susie Hidalgo-Fahring, whose school district straddles the counties. “I’m done with that. Everybody needs to be a good neighbor.”
The council decided Dec. 15 to send a letter to Weld County’s commissioners encouraging them to enforce state restrictions and to make a public statement about the benefits of wearing masks and practicing physical distancing. They’ve also backed a law allowing Democratic Gov. Jared Polisto withhold relief money from counties that don’t comply with restrictions.
Weld County Commissioner Scott James said his county doesn’t have the authority to enforce public health orders any more than a citizen has the authority to give a speeding ticket.
“If you want me as an elected official to assume authority that I don’t have and arbitrarily exert it over you, I dare you to look that up in the dictionary,” said James, who is a rancher turned country radio host. “It’s called tyranny.”
James doesn’t deny that COVID-19 is ravaging his community. “We’re on fire, and we need to put that fire out,” he said. But he believes that individuals will make the right decisions to protect others, and demands the right of his constituents to use the hospital nearest them.
“To look at Weld County like it has walls around it is shortsighted and not the way our health care system is designed to work,” James said. “To use a crudity, because I am, after all, just a ranch kid turned radio guy, there’s no ‘non-peeing’ section in the pool. Everybody’s gonna get a little on ’em. And that’s what’s going on right now with COVID.”
The dispute is not just liberal and conservative politics clashing. Bagley, the Longmont mayor, grew up in Weld County and “was a Republican up until Trump,” he said. But it is an example of how the virus is tapping into long-standing Western strife.
“There’s decades of reasons for resentment at people from a distance — usually from a metropolis and from a state or federal governmental office — telling rural people what to do,” said Patty Limerick, faculty director at the Center of the American West at the University of Colorado-Boulder, and previously state historian.
In the ’90s, she toured several states performing a mock divorce trial between the rural and urban West. She played Urbana Asphalt West, married to Sandy Greenhills West. Their child, Suburbia, was indulged and clueless and had a habit of drinking everyone else’s water. A rural health care shortage was one of many fuels of their marital strife.
Limerick and her colleagues are reviving the play now and adding COVID references. This time around, she said, it’ll be a last-ditch marriage counseling session for high school classes and communities to adopt and perform. It likely won’t have a scripted ending; she’s leaving that up to each community.
Nine months into the pandemic that has killed more than 320,000 people in the U.S., Kim Larson is still trying to convince others in her northern Montana county that COVID-19 is dangerous.
As Hill County Health Department director and county health officer, Larson continues to hear people say the coronavirus is just like a bad case of the flu. Around the time Montana’s governor mandated face coverings in July, her staffers saw notices taped in several businesses’ windows spurning the state’s right to issue such emergency orders.
For a while, the county with a population of 16,000 along the Canadian border didn’t see much evidence of the pandemic. It had only one known COVID case until July. But that changed as the nation moved into its third surge of the virus this fall. By mid-December, Hill County had recorded more than 1,500 cases — the vast majority since Oct. 1 — and 33 people there had died.
When Larson hears people say pandemic safety rules should end, she talks about how contagious the COVID virus is, how some people experience lasting effects and how hospitals are so full that care for any ailment could face delays.
“In public health, we’ve seen the battle before, but you typically have the time to build your evidence, research showing that this really does save lives,” Larson said. “In the middle of a pandemic, you have no time.”
Public health laws typically come long after social norms shift, affirming a widespread acceptance that a change in habits is worth the public good and that it’s time for stragglers to fall in line. But even when decades of evidence show a rule can save lives — such as wearing seat belts or not smoking indoors — the debate continues in some places with the familiar argument that public restraints violate personal freedoms. This fast-moving pandemic, however, doesn’t afford society the luxury of time. State mandates have put local officials in charge of changing behavior while general understanding catches up.
Earlier this month, U.S. Surgeon General Jerome Adams stood next to Montana’s governor in Helena and said he hopes people wear masks because it’s the right thing to do — especially as COVID hospitalizations rise.
“You don’t want to be the reason that a woman in labor can’t get a hospital bed,” Adams said, adding a vaccine is on the way. “It’s just for a little bit longer.”
He spoke days after state lawmakers clashed over masks as a majority of Republican lawmakers arrived for a committee meeting barefaced and at least one touted false information on the dangers of masks. As of Dec. 15, the Republican majority hadn’t required masks for the upcoming legislative session, set to begin Jan. 4.
And now a group opposed to masks from Gallatin and Flathead counties has filed a lawsuit asking a Montana judge to block the state’s pandemic-related safety rules.
Public health laws typically spark political battles. Changing people’s habits is hard, said Lindsay Wiley, director of the health law and policy program at American University in Washington, D.C. Despite the misconception that there was universal buy-in for masks during the 1918 pandemic, Wiley said, some protesters intentionally built rap sheets of arrests for going maskless in the name of liberty.
She said health officials realize any health restrictions amid a pandemic require the public’s trust and cooperation for success.
“We don’t have enough police to walk around and force everyone to wear a mask,” she said. “And I’m not sure we want them to do it.”
Local officials have the best chance to win over that support, Wiley said. And seeing elected leaders such as President Donald Trump rebuff his own federal health guidelines makes that harder. Meanwhile, public shaming like calling unmasked people selfish or stupid can backfire, Wiley said, because if they were to give in to mask-wearing, they would essentially be accepting those labels.
In the history of public health laws, even rules that have had time to build widely accepted evidence weren’t guaranteed support.
It’s illegal in Montana to go without a seat belt in a moving car. But, as in 13 other states, authorities aren’t allowed to pull people over for being unbuckled. Every few years, a Montana lawmaker, backed by a collection of public health and law enforcement organizations, proposes a law to allow seat belt traffic stops, arguing it would save lives. In 2019, that request didn’t even make it out of committee, squelched by the arguments of personal choice and not giving too much power to the government.
Main opposition points against public health laws — whether it’s masks, seat belts, motorcycle helmets or smoking — can sound alike.
When Missoula County became the first place in Montana to ban indoor smoking in public spaces in 1999, opponents said the change would destroy businesses, be impossible to enforce and violate people’s freedom of choice.
“They are the same arguments in a lot of ways,” said Ellen Leahy, director of the Missoula City-County Health Department. “Public health was right at that intersection between what’s good for the whole community and the rights and responsibilities of the individual.”
Montana adopted an indoor smoking ban in 2005, but many bars and taverns were given until 2009 to fall in line. And, in some places, debate and court battles continued for a decade more on how the ban could be enforced.
Amid the COVID pandemic, Missoula County was again ahead of much of the state when it passed its own mask ordinance. The county has two hospitals and a university that swells its population with students and commuters.
“If you have to see it to believe it, you’re going to see the impact of a pandemic first in a city, most likely,” Leahy said.
Compliance hasn’t been perfect and she said the need for strict enforcement has been limited. As of early December, out of the more than 1,500 complaints the Missoula health department followed up on since July, it sent closure notices to four businesses that flouted the rules.
In Hill County, when the health department gets complaints that a business is violating pandemic mandates, two part-time health sanitarians, who perform health inspections of businesses, talk with the owners about why the rules exist and how to live by them. Often it works. Other times the complaints keep coming.
County attorney Karen Alley said the local health officials have reached out to her office with complaints of noncompliance on COVID safety measures, but she has not seen enough evidence to bring a civil case against a business. Unlike other health laws, she said, mask rules have no case studies yet to offer a framework for enforcing them through the Montana courts. (A handful of cases against businesses skirting COVID rules were still playing out as of mid-December.)
“Somebody has to be the test case, but you never want to be the test case,” said Alley, who is part of a team of three. “It’s a lot of resources, a lot of time.”
Larson, with the Hill County Health Department, said her focus is still on winning over the community. And she’s excited about some progress. The town’s annual live Nativity scene, which typically draws crowds with hot cocoa, turned into a drive-by event this year.
She doesn’t expect everyone to follow the rules — that’s never the case in public health. But Larson hopes enough people will to slow down the virus. That could be happening. By mid-December, the county’s tally of daily active cases was declining for the first time since its spike began in October.
“You just try to figure out the best way for your community and to get their input,” Larson said. “Because we need the community’s help to stop it.”
WASHINGTON — Even before there was a vaccine, some seasoned doctors and public health experts warned, Cassandra-like, that its distribution would be “a logistical nightmare.”
After Week 1 of the rollout, “nightmare” sounds like an apt description.
Dozens of states say they didn’t receive nearly the number of promised doses. Pfizer says millions of doses sat in its storerooms, because no one from President Donald Trump’s Operation Warp Speed task force told them where to ship them. A number of states have few sites that can handle the ultra-cold storage required for the Pfizer product, so, for example, front-line workers in Georgia have had to travel 40 minutes to get a shot. At some hospitals, residents treating COVID patients protested that they had not received the vaccine while administrators did, even though they work from home and don’t treat patients.
The potential for more chaos is high. Dr. Vivek Murthy, named as the next surgeon general under President-elect Joe Biden, said this week that the Trump administration’s prediction — that the general population would get the vaccine in April — was realistic only if everything went smoothly. He instead predicted wide distribution by summer or fall.
The Trump administration had expressed confidence that the rollout would be smooth, because it was being overseen by a four-star general, Gustave Perna, an expert in logistics. But it turns out that getting fuel, tanks and tents into war-torn mountainous Afghanistan is in many ways simpler than passing out a vaccine in our privatized, profit-focused and highly fragmented medical system. Gen. Perna apologized this week, saying he wanted to “take personal responsibility.” It’s really mostly not his fault.
Throughout the COVID pandemic, the U.S. health care system has shown that it is not built for a coordinated pandemic response (among many other things). States took wildly different COVID prevention measures; individual hospitals varied in their ability to face this kind of national disaster; and there were huge regional disparities in test availability — with a slow ramp-up in availability due, at least in some part, because no payment or billing mechanism was established.
Why should vaccine distribution be any different?
In World War II, toymakers were conscripted to make needed military hardware airplane parts, and commercial shipyards to make military transport vessels. The Trump administration has been averse to invoking the Defense Production Act, which could help speed and coordinate the process of vaccine manufacture and distribution. On Tuesday, it indicated it might do so, but only to help Pfizer obtain raw materials that are in short supply, so that the drugmaker could produce — and sell — more vaccines in the United States.
Instead of a central health-directed strategy, we have multiple companies competing to capture their financial piece of the pandemic health care pie, each with its patent-protected product as well as its own supply chain and shipping methods.
Add to this bedlam the current decision-tree governing distribution: The Centers for Disease Control and Prevention has made official recommendations about who should get the vaccine first — but throughout the pandemic, many states have felt free to ignore the agency’s suggestions.
Instead, Operation Warp Speed allocated initial doses to the states, depending on population. From there, an inscrutable mix of state officials, public health agencies and lobbyists seem to be determining where the vaccine should go. In some states, counties requested an allotment from the state, and then they tried to accommodate requests from hospitals, which made their individual algorithms for how to dole out the precious cargo. Once it became clear there wasn’t enough vaccine to go around, each entity made its own adjustments.
Some doses are being shipped by FedEx or UPS. But Pfizer — which did not fully participate in Operation Warp Speed — is shipping much of the vaccine itself. In nursing homes, some vaccines will be delivered and administered by employees of CVS and Walgreens, though issues of staffing and consent remain there.
The Moderna vaccine, rolling out this week, will be packaged by the “pharmaceutical services provider” Catalent in Bloomington, Indiana, and then sent to McKesson, a large pharmaceutical logistics and distribution outfit. It has offices in places like Memphis, Tennessee, and Louisville, which are near air hubs for FedEx and UPS, which will ship them out.
Is your head spinning yet?
Looking forward, basic questions remain for 2021: How will essential workers at some risk (transit workers, teachers, grocery store employees) know when it’s their turn? (And it will matter which city you work in.) What about people with chronic illness — and then everyone else? And who administers the vaccine — doctors or the local drugstore?
In Belgium, where many hospitals and doctors are private but work within a significant central organization, residents will get an invitation letter “when it’s their turn.” In Britain, the National Joint Committee on Vaccination has settled on a priority list for vaccinations — those over 80, those who live or work in nursing homes, and health care workers at high risk. The National Health Service will let everyone else “know when it’s your turn to get the vaccine ” from the government-run health system.
In the United States, I dread a mad scramble — as in, “Did you hear the CVS on P Street got a shipment?” But this time, it’s not toilet paper.
Combine this vision of disorder with the nation’s high death toll, and it’s not surprising that there is intense jockeying and lobbying — by schools, unions, even people with different types of preexisting diseases — over who should get the vaccine first, second and third. It’s hard to “wait your turn” in a country where there are 200,000 new cases and as many as 2,000 new daily COVID deaths — a tragic per capita order of magnitude higher than in many other developed countries.
So kudos and thanks to the science and the scientists who made the vaccine in record time. I’ll eagerly hold out my arm — so I can see the family and friends and colleagues I’ve missed all these months. If only I can figure out when I’m eligible, and where to go to get it.
– The governor of Virginia announced that the state
will allocate $10 million from the federal CARES Act to
implement a statewide integrated technology platform, Unite Virginia designed
to connect vulnerable Virginians to crucial health and social services.
– Unite Virginia will utilize the Unite Us platform to create
a statewide coordinated care network to help government
agencies, health care providers, and community-based partners ensure
medical care and social services are appropriately delivered to
Virginians, identify gaps in the system to better target resources, supporting
ongoing COVID-19 response/recovery, reduce barriers to care, and advance
Governor Ralph Northam announced that Virginia will allocate
$10M in federal Coronavirus Aid, Relief, and Economic Security (CARES) Act
funding to create Unite Virginia, a statewide technology platform designed to
connect vulnerable Virginians to health and social services. Powered by Unite Us, a technology company that builds coordinated care
networks of health and social service providers, the Commonwealth will
implement an integrated e-referral system that unites government agencies,
health care providers, and community-based partners and supports Virginia’s
response and recovery efforts.
Unite Us Network
Unite Us provides unifying infrastructure between health
care providers and community-based organizations as the foundation for social
care transformation at scale. With networks in more than 40 states, Unite Us is
the statewide technology platform in North Carolina and the company is
developing programs similar to what is planned in Virginia in communities in
Kansas, Minnesota, Missouri, Nebraska, North Dakota, Ohio, Oregon, and South
Dakota. In Virginia, Unite Us already powers networks in the Hampton Roads and
Shenandoah Valley regions. When fully established, this network will be an
integral part of the Commonwealth’s broader public health framework.
This initial funding allocation will cover startup and
implementation costs to operate the e-referral system, which can integrate with
widely used electronic medical record systems in place at hospitals, health
systems, and medical practice groups across Virginia. Establishing those links
will enable health care providers to refer patients to social service
organizations that can provide other supports such as food, transportation assistance,
housing, employment services, and more. In turn, participating organizations
will be able to refer patients and clients to each other.
This interconnected approach also increases the likelihood
that vulnerable Virginians will access support services to manage their health
conditions and the environmental factors that contribute to them. Data insights
gleaned from the integrated technology platform will help state government,
providers, and other partners identify critical needs and better focus efforts
to serve these Virginians.
“The ongoing and widespread impacts of the COVID-19 pandemic underscore the need to unite traditional health care settings and community organizations that address social determinants of health,” said Governor Northam. “This is about connecting people with the supports they need to live healthy lives. Having this critical infrastructure in place will also position our Commonwealth to better respond to and recover from the twin public health and economic crises we face, and advance health equity by ensuring medical care and social services are appropriately delivered to Virginians, reducing barriers to care, and identifying gaps to better our target resources.”
– Amazon, CVS Health, Thermo Fisher Scientific join forces to
promote employer-based testing As part of a comprehensive COVID-19 testing strategy.
– The coalition, named Workplace Employers Alliance for
COVID-19 Testing (WE ACT), believes
that employer-based testing programs are essential to keeping employees safe
during the current public health emergency.
– WE ACT aims to
advance a comprehensive national testing strategy that includes clear guidance
for the implementation of testing programs and results reporting; to ensure
access to high-quality, FDA authorized COVID-19 tests for employers; and to
serve as a resource for any employer who wishes to launch or expand an
employer–based testing program.
– As a nonpartisan coalition, WE ACT and its partners
believe that combating the COVID-19
pandemic requires an all-hands-on-deck approach.
– Philips and BioIntelliSense has been selected by the
U.S. Army Medical Research and Development Command (USAMRDC) to receive nearly $2.8M
from the U.S. Department of Defense (DoD) to validate BioIntelliSense’s
FDA-cleared BioSticker device for the early detection of COVID-19 symptoms.
– Working with the University of Colorado Anschutz
Medical Campus, the clinical study will consist of 2,500 eligible participants
with a recent, known COVID-19 exposure and/or a person experiencing early
Philips and BioIntelliSense,
Inc., a continuous health monitoring and clinical intelligence company, today
announced they have been selected by the U.S. Army Medical Research and
Development Command (USAMRDC) to receive nearly $2.8M from the U.S. Department
of Defense (DoD) through a Medical Technology Enterprise Consortium (MTEC)
award to validate BioIntelliSense’s FDA-cleared BioSticker device for the early
detection of COVID-19
symptoms. The goal of the award is to accelerate the use of wearable
diagnostics for the benefit of military and public health through the early
identification and containment of pre-symptomatic COVID-19 cases.
Medical-Grade Wearable for Early COVID-19 Detection
As millions of individuals have been screened and tested, the emerging research on traditional screening methods is revealing how challenging it is to detect the risk of COVID-19 infections early. Temperature checks have proven to be unreliable and even amplified testing (PCR) has proven to be ineffective in identifying the virus in the early days of infection.
The FDA-cleared BioSticker is an advanced on-body sensor
that allows for effortless continuous monitoring of temperature and vital signs
combined with advanced analytics, enables the BioSticker to identify
statistically meaningful trends and screen for early potential COVID-19
“The medical-grade BioSticker wearable, combined with advanced diagnostic algorithms, may serve as the basis for identifying pre- and very early symptomatic COVID-19 cases, allow for earlier treatment for infected individuals, as well as reduce the spread of the virus to others,” said James Mault, MD, Founder and CEO of BioIntelliSense.
Clinical Trial Details
Working with the University of Colorado Anschutz Medical Campus, the
clinical study will consist of 2,500 eligible participants with a recent, known
COVID-19 exposure and/or a person experiencing early COVID-19 symptoms.
Individuals may learn more about the study eligibility and enroll online
The research will focus on the validation of BioIntelliSense’s BioSticker for
early detection of COVID-like symptoms, as well as assessment of scalability,
reliability, software interface, and user environment testing.
Turning Data into Actionable Insights
While previous studies have shown potential using consumer wearables in relation to COVID-19, this study will leverage BioIntelliSense’s medical-grade wearable, the BioSticker, which enables continuous multi-parameter vital signs monitoring for 30 days and captures data across a broad set of vital signs, physiological biometrics and symptomatic events, including those directly associated with COVID-19. With its integration into Philips’ remote patient monitoring offerings, this is another example of how cloud-based data collection takes place seamlessly, across multiple settings, from the hospital to the home. Allowing data to be turned into actionable insights and care interventions, while providing connected, patient-centered care across the health continuum.
Dr. Vik Bebarta, the Founder and Director of the CU Center for COMBAT Research and Professor of Emergency Medicine on the CU Anschutz Medical Campus added: “The University of Colorado School of Medicine and the CU Center for COMBAT Research in the Department of Emergency Medicine are excited to be a lead in this effort that will change how we care for our service members in garrison and our civilians in our communities. The COMBAT Center aims to solve the DoD’s toughest clinical challenges, and the pandemic is certainly one example. With this progressive solution, we aim to detect COVID in the pre-symptomatic or early symptomatic phase to reduce the spread and initiate early treatment. This trusted military-academic-industry partnership is our strength, as we optimize military readiness and reduce this COVID burden in our community and with frontline healthcare workers.”
More than 2,900 U.S. health care workers have died in the COVID-19 pandemic since March, a far higher number than that reported by the government, according to a new analysis by KHN and The Guardian.
Fatalities from the coronavirus 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 — about 680 — occurred in New York and New Jersey, which were hit hard early in the pandemic. Significant numbers also died in Southern and Western states in the ensuing months.
The findings are part of “Lost on the Frontline,” a nine-month data and investigative project by KHN and The Guardian to track every health care worker who dies of COVID-19.
One of those lost, Vincent DeJesus, 39, told his brother Neil that he’d be in deep trouble if he spent much time with a COVID-positive patient while wearing the surgical mask provided to him by the Las Vegas hospital where he worked. DeJesus died on Aug. 15.
Another fatality was Sue Williams-Ward, a 68-year-old home health aide who earned $13 an hour in Indianapolis, and bathed, dressed and fed clients without wearing any PPE, her husband said. She was intubated for six weeks before she died May 2.
“Lost on the Frontline” is prompting new government action to explore the root cause of health care worker deaths and take steps to track them better. Officials at the Department of Health and Human Services recently asked the National Academy of Sciences for a “rapid expert consultation” on why so many health care workers are dying in the U.S., citing the count of fallen workers by The Guardian and KHN.
“The question is, where are they becoming infected?” asked Michael Osterholm, a member of President-elect Joe Biden’s COVID-19 advisory team and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “That is clearly a critical issue we need to answer and we don’t have that.”
The Dec. 10 report by the national academies suggests a new federal tracking system and specially trained contact tracers who would take PPE policies and availability into consideration.
Doing so would add critical knowledge that could inform generations to come and give meaning to the lives lost.
“Those [health care workers] are people who walked into places of work every day because they cared about patients, putting food on the table for families, and every single one of those lives matter,” said Sue Anne Bell, a University of Michigan assistant professor of nursing and co-author of the national academies report.
The recommendations come at a fraught moment for health care workers, as some are getting the COVID-19 vaccine while others are fighting for their lives amid the highest levels of infection the nation has seen.
The toll continues to mount. In Indianapolis, for example, 41-year-old nurse practitioner Kindra Irons died Dec. 1. She saw seven or eight home health patients per week while wearing full PPE, including an N95 mask and a face shield, according to her husband, Marcus Irons.
The virus destroyed her lungs so badly that six weeks on the most aggressive life support equipment, ECMO, couldn’t save her, he said.
Marcus Irons said he is now struggling financially to support their two youngest children, ages 12 and 15. “Nobody should have to go through what we’re going through,” he said.
In Massachusetts, 43-year-old Mike “Flynnie” Flynn oversaw transportation and laundry services at North Shore Medical Center, a hospital in Salem, Massachusetts. He and his wife were also raising young children, ages 8, 10 and 11.
Flynn, who shone at father-daughter dances, fell ill in late November and died Dec. 8. He had a heart attack at home on the couch, according to his father, Paul Flynn. A hospital spokesperson said he had full access to PPE and free testing on-site.
Since the first months of the pandemic, more than 70 reporters at The Guardian and KHN have scrutinized numerous governmental and public data sources, interviewed the bereaved and spoken with health care experts to build a count.
The total number includes fatalities identified by labor unions, obituaries and news outlets and in online postings by the bereaved, as well as by relatives of the deceased. The previous total announced by The Guardian and KHN was approximately 1,450 health care worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments. These deaths include the facility names but not worker names. Reporters cross-checked each record to ensure fatalities did not appear in the database twice.
The tally has been widely cited by other media as well as by members of Congress.
Rep. Norma Torres (D-Calif.) referenced the data citing the need for a pending bill that would provide compensation to the families of health care workers who died or sustained long-term disabilities from COVID-19.
Sen. Ron Wyden (D-Ore.) mentioned the tally in a Senate Finance Committee hearing about the medical supply chain. “The fact is,” he said, “the shortages of PPE have put our doctors and nurses and caregivers in grave danger.”
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.
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.”
Lorraine Rogge and her husband, Michael Rogge, travel the country in a recreational vehicle, a well-earned adventure in retirement. This spring found them parked in Artesia, New Mexico, for several months.
In May, Rogge, 60, began to feel pelvic pain and cramping. But she had had a total hysterectomy in 2006, so the pain seemed unusual, especially because it lasted for days. She looked for a local gynecologist and found one who took her insurance at the Carlsbad Medical Center in Carlsbad, New Mexico, about a 20-mile drive from the RV lot.
The doctor asked if Rogge was sexually active, and she responded yes and that she had been married to Michael for 26 years. Rogge felt she made it clear that she is in a monogamous relationship. The doctor then did a gynecological examination and took a vaginal swab sample for laboratory testing.
The only lab test Rogge remembered discussing with the doctor was to see whether she had a yeast infection. She wasn’t given any medication to treat the pelvic pain and eventually it disappeared after a few days.
Then the bill came.
The Patient: Lorraine Rogge, 60. Her insurance coverage was an Anthem Blue Cross retiree plan through her husband’s former employer, with a deductible of $2,000 and out-of-pocket maximum of $6,750 for in-network providers.
Total Bill: Carlsbad Medical Center billed $12,386.93 to Anthem Blue Cross for a vaginosis, vaginitis and sexually transmitted infections (STI) testing panel. The insurer paid $4,161.58 on a negotiated rate of $7,172.05. That left Rogge responsible for $1,970 of her deductible and $1,040.36 coinsurance. Her total owed for the lab bill was $3,010.47. Rogge also paid $93.85 for the visit to the doctor.
Service Provider:Carlsbad Medical Center in Carlsbad, New Mexico. It is owned by Community Health Systems, a large for-profit chain of hospital systems based in Franklin, Tennessee, outside Nashville. The doctor Rogge saw works for Carlsbad Medical Center and its lab processed her test.
Medical Service: A bundled testing panel that looked for bacterial and yeast infections as well as common STIs, including chlamydia, gonorrhea and trichomoniasis.
What Gives: There were two things Rogge didn’t know as she sought care. First, Carlsbad Medical Center is notorious for its high prices and aggressive billing practices and, second, she wasn’t aware she would be tested for a wide range of sexually transmitted infections.
The latter bothered her a lot since she has been sexually active only with her husband. She doesn’t remember being advised about the STI testing at all. Nor was she questioned about whether she or her husband might have been sexually active with other people, which could have justified broader testing. They have been on the road together for five years.
“I was incensed that they ran these tests, when they just said they were going to run a yeast infection test,” said Rogge. “They ran all these tests that one would run on a very young person who had a lot of boyfriends, not a 60-year-old grandmother that’s been married for 26 years.”
Although a doctor doesn’t need a patient’s authorization to run tests, it’s not good practice to do so without informing the patient, said Dr. Ina Park, an associate professor of family community medicine at the University of California-San Francisco School of Medicine. That is particularly true with tests of a sensitive nature, like STIs. It is doubly true when the tests are going to costs thousands of dollars.
“Quite frankly, the retail prices on [the bill] are ridiculous, they make no sense at all,” said Root. “Those are tests that cost about $10 to run.”
In fall 2019, The New York Times and CNN investigated Carlsbad Medical Center and found the facility had taken thousands of patients to court for unpaid hospital bills. Carlsbad Medical Center also has higher prices than many other facilities — a 2019 Rand Corp. study found that private insurance companies paid Carlsbad Medical Center 505% of what Medicare would pay for the same procedures.
The bundled testing panel run on Rogge’s sample was a Quest Diagnostics SureSwab Vaginosis Panel Plus. It included six types of tests. Quest Diagnostics didn’t provide the cost for the bundled tests, but Kim Gorode, a company spokesperson, said if the tests had been ordered directly through Quest rather than through the hospital, it was likely “the patient responsibility would have been substantially less.”
According to Medicare’s Clinical Laboratory Fee Schedule, Medicare would have reimbursed labs only about $40 for each test run on Rogge’s sample. And Medicaid would reimburse hospitals in New Mexico similarly, according to figures provided by Russell Toal, superintendent of New Mexico’s insurance department.
But hospitals and clinics can — and do — add substantial markups to clinical tests sent out to commercial labs.
Although private health insurance doesn’t typically reimburse hospitals at Medicare or Medicaid rates, Root said, private insurance reimbursement rates are rarely much more than 200% to 300% of Medicare’s rates. Assuming a 300% reimbursement rate, the total private insurance would have reimbursed for the six tests would have been $720.
That $720 is less than what Carlsbad Medical Center charged Rogge for her chlamydia test alone: $1,045. And for several of the tests, the medical center charged multiple quantities — presumably corresponding to how many species were tested for — elevating the cost of the yeast infection test to over $4,000.
Toal, who reviewed Rogge’s bill, called the prices “outrageous.”
Resolution: Rogge contacted Anthem Blue Cross and talked to a customer service representative, who submitted a fraud-and-waste claim and an appeal contending the charges were excessive.
The appeal was denied. Anthem Blue Cross told Rogge that under her plan the insurance company had paid the amount it was responsible for, and that based on her deductible and coinsurance amounts, she was responsible for the remainder.
Anthem Blue Cross said in a statement to KHN all the tests run on Rogge were approved and “paid for in accordance with Anthem’s pre-determined contracted rate with Carlsbad Medical Center.”
By the time Rogge’s appeal was denied, she had researched Carlsbad Medical Center and read the stories of patients being brought to court for medical bills they couldn’t pay. She had also gotten a notice from the hospital that her account would be sent to a collection agency if she didn’t pay the $3,000 balance.
Fearing the possibility of getting sued or ruining her credit, Rogge agreed to a plan to pay the bill over three years. She made three payments of $83.63 each in September, October and November, totaling $250.89.
After a Nov. 18 call and email from KHN, Carlsbad Medical Center called Rogge on Nov. 20 and said the remainder of her account balance would be waived.
Rogge was thrilled. We “aren’t the kind of people who have payment plans hanging over our heads,” she said, adding: “This is a relief.”
“I’m going to go on a bike ride now” to celebrate, she said.
The Takeaway: Particularly when visiting a doctor with whom you don’t have a long-standing trusted relationship, don’t be afraid to ask: How much is this test going to cost? Also ask for what, exactly, are you being tested? Do not be comforted by the facility’s in-network status. With coinsurance and deductibles, you can still be out a lot.
If it’s a blood test that will be sent out to a commercial lab like Quest Diagnostics anyway, ask the physician to just give you a requisition to have the blood drawn at the commercial lab. That way you avoid the markup. This advice is obviously not possible for a vaginal swab gathered in a doctor’s office.
Patients should always fight bills they believe are excessively high and escalate the matter if necessary.
Rogge started with her insurer and the provider, as should most patients with a billing question. But, as she learned: In American medicine, what’s legal and in accordance with an insurance contract can seem logically absurd. Still, if you get no satisfaction from your initial inquiries, be aware of options for taking your complaints further.
Toal, the insurance superintendent in New Mexico, said his office doesn’t (and no office in the state does that he’s aware of) have the authority to tell a hospital its prices are too high. But he can look into a bill like Rogge’s if a complaint is filed with his office.
“If the patient wants, they can request an independent review, so the bill would go to an independent organization that could see if it was medically necessary,” Toal said.
That wasn’t needed in this case because Rogge’s bill was waived. And after being contacted by KHN, Melissa Suggs, a spokesperson with Carlsbad Medical Center, said the facility is revising their lab charges.
“Pricing for these services will be lower in the future,” Suggs said in a statement.
Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
In late summer, as researchers accelerated the first clinical trials of COVID-19 vaccines for humans, a group of scientists in Colorado worked to inoculate a far more fragile species.
About 120 black-footed ferrets, among the most endangered mammals in North America, were injected with an experimental COVID vaccine aimed at protecting the small, weasel-like creatures rescued from the brink of extinction four decades ago.
The effort came months before U.S. Department of Agriculture officials began accepting applications from veterinary drugmakers for a commercial vaccine for minks, a close cousin of the ferrets. Farmed minks, raised for their valuable fur, have died by the tens of thousands in the U.S. and been culled by the millions in Europe after catching the COVID virus from infected humans.
Vaccinating such vulnerable species against the disease is important not only for the animals’ sake, experts say, but potentially for the protection of people. Some of the most pernicious human diseases have originated in animals, including the new coronavirus, which is believed to have spread from bats to an intermediary species before jumping to humans and sparking the pandemic.
The worry when it comes to animals like farmed minks, which are kept in crowded pens, is that the virus, contracted from humans, can mutate as it spreads rapidly in the susceptible animals, posing a new threat if it spills back to people. Danish health officials in November reported detecting more than 200 COVID cases in humans that had variants associated with farmed minks, including a dozen with a mutation scientists feared could undermine the effectiveness of vaccines. However, officials now say that variant appears to be extinct.
In the U.S., scientists have not found similar COVID mutations in the domestic farmed mink populations, though they recently noted with concern the discovery of the first case of the virus in a wild mink in Utah.
“For highly contagious respiratory viruses, it’s really important to be mindful of the animal reservoir,” said Dr. Corey Casper, a vaccinologist and chief executive of the Infectious Disease Research Institute in Seattle. “If the virus returns to the animal host and mutates, or changes, in such a way that it could be reintroduced to humans, then the humans would no longer have that immunity. That makes me very concerned.”
For the newly vaccinated ferrets, the main risk is to the animals themselves. They’re part of a captive population at the National Black-footed Ferret Conservation Center outside Fort Collins, Colorado, where there have been no cases of COVID-19 to date. But the slender, furry creatures — known for their distinctive black eye mask, legs and feet — are feared to be highly vulnerable to the ravages of the disease, said Tonie Rocke, a research scientist at the National Wildlife Health Center who is testing the ferret vaccine. They’re all genetically similar, having come from a narrow breeding pool, which weakens their immune systems. And they likely share many of the features that have made the disease so deadly to minks.
“We don’t have direct evidence that black-footed ferrets are susceptible to COVID-19, but given their close relationship to minks, we wouldn’t want to find out,” Rocke said.
Rocke began working on the experimental vaccine in the spring, as she and Pete Gober, black-footed ferret recovery coordinator for the U.S. Fish and Wildlife Service, watched reports about the new coronavirus with growing alarm. An exotic disease is “the biggest nemesis for ferret recovery,” said Gober, who has worked with black-footed ferrets for 30 years. “It can knock you right back down to zero.”
The ferrets are a native species that once roamed vast areas of the American West. Their ranks declined precipitously over many decades as populations of prairie dogs, the ferrets’ primary source of food and shelter, were decimated by farming, grazing and other human activity.
In 1979, black-footed ferrets were declared extinct — until a small population was discovered on a ranch in Wyoming. Most of those rare animals were then lost to disease, including sylvatic plague, the animal version of the Black Death that has plagued humans. The species survived only because biologists rescued 18 ferrets to form the basis of a captive breeding program, Gober said.
With the threat of new disease looming, Gober doubled-down on the strict infection prevention precautions at the center, which houses more than half of the 300 black-footed ferrets in captivity. An additional 400 have been reintroduced to the wild. Then he called Rocke, who previously created a vaccine shown to protect ferrets from sylvatic plague. It uses a purified protein from Yersinia pestis, the bacterium that causes the disease.
Would the same technique work against the virus that causes COVID-19? Under the research authority granted by the Fish and Wildlife Service, the scientists were free to try.
“We can do these sorts of things experimentally in animals that we can’t do in humans,” Rocke noted.
Rocke acquired purified protein of a key component of the SARS-CoV-2 virus, the spike protein, from a commercial producer. She mixed the liquid protein with an adjuvant, a substance that enhances immune response, and injected it under the animals’ skin.
The first doses were given in late spring to 18 black-footed ferrets, all male, all about a year old, followed by a booster dose a few weeks later. Within weeks of getting the second shots, tests of the animals’ blood showed antibodies to the virus, a good — and expected — sign.
By early fall, 120 of the 180 ferrets housed at the center were inoculated, with the rest remaining unvaccinated in case something went wrong with the animals, which generally live four to six years in captivity. So far, the vaccine appears safe, but there’s no data yet to show whether it protects the animals from disease. “I can tell you, we have no idea if it will work,” said Rocke, who plans to conduct efficacy tests this winter.
But Rocke’s effort makes sense, said Casper, who has created several vaccines for humans. Rocke’s approach — introducing an inactivated virus in an animal to stimulate an immune response — is the basis for many common vaccines, such as those that prevent polio and influenza.
Vaccines containing inactivated virus to prevent COVID-19 have been tested in certain animals — and in human vaccines, including CoronaVac, created by the Chinese firm Sinovac Life Sciences. But the effort in Colorado may be among the first aimed at preventing COVID-19 in a specific animal population, Rocke said.
Gober said he is optimistic that the ferrets are protected, but it will take a well-designed study to settle the question. Until then, he’ll work to keep the fragile ferrets free of COVID-19. “The price of peace is eternal vigilance, they say. We can’t let our guard down.”
The tougher task is doing the same for people, Gober observed.
“We’re just holding our breath, hoping we can get all the humans vaccinated in the country. That will give us all a sigh of relief.”
WOLF POINT, Mont. — Fallen pine cones covered 16-year-old Leslie Keiser’s fresh grave at the edge of Wolf Point, a small community on the Fort Peck Indian Reservation on the eastern Montana plains.
Leslie, whose father is a member of the Fort Peck Assiniboine and Sioux Tribes, is one of at least two teenagers on the reservation who died by suicide this summer. A third teen’s death is under investigation, authorities said.
Leslie’s mother, Natalie Keiser, was standing beside the grave recently when she received a text with a photo of the headstone she had ordered.
She looked at her phone and then back at the grave of the girl who took her own life in September.
“I wish she would have reached out and let us know what was wrong,” she said.
In a typical year, Native American youth die by suicide at nearly twice the rate of their white peers in the U.S. Mental health experts worry that the isolation and shutdowns caused by the COVID-19 pandemic could make things worse.
“It has put a really heavy spirit on them, being isolated and depressed and at home with nothing to do,” said Carrie Manning, a project coordinator at the Fort Peck Tribes’ Spotted Bull Recovery Resource Center.
It’s not clear what connection the pandemic has to the youth suicides on the Fort Peck reservation. Leslie had attempted suicide once before several years ago, but she had been in counseling and seemed to be feeling better, her mother said.
Keiser noted that Leslie’s therapist canceled her counseling sessions before the pandemic hit.
“Probably with the virus it would have been discontinued anyway,” Keiser said. “It seems like things that were important were kind of set to the wayside.”
Tribal members typically lean on one another in times of crisis, but this time is different. The reservation is a COVID hot spot. In remote Roosevelt County, which encompasses most of the reservation, more than 10% of the population has been infected with the coronavirus. The resulting social distancing has led tribal officials to worry the community will fail to see warning signs among at-risk youth.
So tribal officials are focusing their suicide prevention efforts on finding ways to help those kids remotely.
“Our people have been through hardships and they’re still here, and they’ll still be here after this one as well,” said Don Wetzel, tribal liaison for the Montana Office of Public Instruction and a member of the Blackfeet Nation. “I think if you want to look at resiliency in this country, you look at our Native Americans.”
Poverty, high rates of substance abuse, limited health care and crowded households elevate both physical and mental health risks for residents of reservations.
“It’s those conditions where things like suicide and pandemics like COVID are able to just decimate tribal people,” said Teresa Brockie, a public health researcher at Johns Hopkins University and a member of the White Clay Nation from Fort Belknap, Montana.
Montana has seen 231 suicides this year, with the highest rates occurring in rural counties. Those numbers aren’t much different from a typical year, said Karl Rosston, suicide prevention coordinator for the state’s Department of Public Health and Human Services. The state has had one of the highest suicide rates in the country each year for decades.
As physical distancing drags on, fatality numbers climb and the economic impacts of the pandemic start to take hold of families, Rosston said, and he expected to see more suicide attempts in December and January.
“We’re hoping we’re wrong in this, of course,” he said.
For rural teenagers, in particular, the isolation caused by school closures and curtailed or canceled sports seasons can tax their mental health.
“Peers are a huge factor for kids. If they’re cut off, they’re more at risk,” Rosston said.
Furthermore, teen suicides tend to cluster, especially in rural areas. Every suicide triples the risk that a surviving loved one will follow suit, Rosston said.
On average, every person who dies by suicide has six survivors. “When talking about small tribal communities, that jumps to 25 to 30,” he said.
Maria Vega, a 22-year-old member of the Fort Peck Tribes, knows this kind of contagious grief. In 2015, after finding the body of a close friend who had died by suicide, Vega attempted suicide as well. She is now a youth representative for a state-run suicide prevention committee that organizes conferences and other events for young people.
Vega is a nursing student who lives six hours away from her family, making it difficult to travel home. She contracted COVID-19 in October and was forced to isolate, increasing her sense of removal from family. While isolated, Vega was able to attend therapy sessions through a telehealth system set up by her university.
“I really do think therapy is something that would help people while they’re alone,” she said.
But Vega points out that this is not an option for many people on rural reservations who don’t have computers or reliable internet access. The therapists who offer telehealth services have long waitlists.
Other prevention programs are having difficulties operating during the pandemic. Brockie, who studies health delivery in disadvantaged populations, has twice had to delay the launch of an experimental training program for Native parents of young children. She hopes the program will lower the risk of substance abuse and suicide by teaching resiliency and parenting skills.
At Fort Peck, the reservation’s mental health center has had to scale down its youth events that teach leadership skills and traditional practices like horseback riding and archery, as well as workshops on topics like coping with grief. The events, which Manning said usually draw 200 people or more, are intended to take teenagers’ minds away from depression and allow them to have conversations about suicide, a taboo topic in many Native cultures. The few events that can go forward are limited now to a handful of people at a time.
Tribes, rural states and other organizations running youth suicide intervention and prevention initiatives are struggling to sustain the same level of services. Using money from the federal CARES Act and other sources, Montana’s Office of Public Instruction ramped up online prevention training for teachers, while Rosston’s office has beefed up counseling resources people can access by phone.
On the national level, the Center for Native American Youth in Washington, D.C., hosts biweekly webinars for young people to talk about their hopes and concerns. Executive Director Nikki Pitre said that on average around 10,000 young people log in each week. In the CARES Act, the federal government allocated $425 million for mental health programs, $15 million of which was set aside for Native health organizations.
Pitre hopes the pandemic will bring attention to the historical inequities that led to lack of health care and resources on reservations, and how they enable the twin epidemics of COVID-19 and suicide.
“This pandemic has really opened up those wounds,” she said. “We’re clinging even more to the resiliency of culture.”
In Wolf Point, Natalie Keiser experienced that resiliency and support firsthand. The Fort Peck community has come together to pay for Leslie’s funeral.
SACRAMENTO, Calif. — Nearly six months since Gov. Gavin Newsom promised to target businesses that are flagrantly violating public health orders to control the spread of COVID-19, California regulators have issued just 424 citations and suspended two business licenses as of Monday, according to data from 10 state regulatory and law enforcement agencies.
Instead of strictly penalizing businesses for violations, the Democratic governor and businessman with a portfolio of wineries, bars and restaurants under the brand name PlumpJack, has relied on educating owners about infectious disease mandates. State agencies have contacted establishments primarily by email, sending them 1.3 million messages since July 1 to urge them to comply with state and local public health rules.
Enforcement at bars and restaurants where alcohol is served, identified by the Centers for Disease Control and Prevention as among the highest-risk environments for COVID transmission, has been limited, data shows. The state Department of Alcoholic Beverage Control, which can issue criminal misdemeanor citations, fine businesses and revoke liquor licenses, has issued just 45 citations against bars and 119 against restaurants since July. No fines have been issued or licenses revoked for the 94,000 businesses it regulates.
By comparison, the state of New York — with half the population of California and far fewer eating and drinking establishments — has issued 1,867 fines against bars and restaurants and temporarily suspended 279 business liquor licenses from June 18 to Dec. 8.
“The reality is it’s not enough to send an email and say ‘Wear a mask,’” said Dr. Kirsten Bibbins-Domingo, a professor of epidemiology and biostatistics at the University of California-San Francisco. “We see workplace violations that we know are major sources of transmission. We have to be willing to enforce or there’s no point in doing these things.”
Like much of the country, both California and New York, the nation’s two most populous Democratic-led states, have put primary responsibility for enforcing public health mandates on cities and counties. Newsom and New York Gov. Andrew Cuomo have bolstered local enforcement efforts by forming statewide task forces to go after businesses that repeatedly violate or ignore public health rules, such as mask mandates and business closures.
But California has been less aggressive than New York in targeting and penalizing bad actors. Newsom and state agencies have instead relied on tough talk and persuasion, emphasizing “personal responsibility,” informing businesses about their responsibilities — and giving them plenty of time to comply.
“I’m not coming out with a fist. We want to come out with an open heart,” Newsom said July 1. “We have, I think, a responsibility at the same time to go after people that are thumbing their nose, that are particularly being aggressive and reticent to do anything.”
The state’s lenient enforcement policy has put enormous responsibility and pressure on cities and counties struggling to gain compliance with COVID measures. Local government leaders are preparing for deep budget cuts and can’t find resources to undertake a coherent enforcement strategy of their own. Many are also fighting intense political battles over mask mandates, curfews and other COVID safety measures.
As a result, some counties enforce the rules and some don’t. And because the state hasn’t stepped in to assist with adequate enforcement, some local officials say, businesses are often free to ignore the rules, allowing the virus to run rampant.
“It would be nice to have some air support from the governor,” said Nevada City Councilman Doug Fleming, who backs the city’s new ordinance imposing fines for violating the state mask mandate. “He’s kind of forcing local jurisdictions to enforce his rules without any air support.”
California is experiencing a COVID surge as never before, setting records almost daily for infections and deaths. Hospitals across the state are running dangerously low on intensive care beds, with the state reporting 2.5% ICU capacity as of Monday.
Most of California is under a mandatory stay-at-home order, which prohibits indoor and outdoor dining and requires closure of a wide swath of businesses, from barbershops to wineries. Retail operations are limited to 20% capacity and churches must hold services outside.
Yet across the state, many people continue to flout the rules, keeping businesses open and refusing to wear masks in public. Pastors Jim and Cyndi Franklin, for instance, continue to hold indoor Sunday sermons at the Cornerstone Church in Fresno. Bars in Los Angeles County were packed with maskless football fans on a recent Sunday. And the owners of Calla Lily Crepes in Nevada City have repeatedly refused to close or require masks despite more than 20 warnings and attempts by Nevada County to gain compliance.
As ICUs run out of capacity, this Huntington Beach, CA scene was posted by a resident noting that today’s Green Bay/ Detroit game can be seen on overhead TVs. pic.twitter.com/Dcr3IlOOaS
“We are free thinkers. I hope I’m not stepping out too far by saying we strongly question the masks, but we do,” said Rebecca Sweet Engstrom, who owns the restaurant with her husband, Darren Engstrom. “We feel that it should be people’s choice.”
Newsom in July threatened to withhold money from cities and counties that refuse to enforce public health orders. To date, the state has withheld federal funding from two cities in the Central Valley, Atwater and Coalinga, for allowing businesses to remain open in defiance of state and local health orders.
The governor has also directed 10 state agencies to police egregious violators of state and local health orders, primarily businesses, to protect workers and the public. State enforcement officials have issued few harsh penalties, they argue, because most businesses are complying — and the state doesn’t want to be punitive.
In interviews, regulators described long hours of back-breaking work to inform business owners about the rapidly changing COVID restrictions and enforcement rules.
“We’re not trying to get into an adversarial situation here,” said Erika Monterroza, chief spokesperson for the state Department of Industrial Relations, which oversees Cal/OSHA, the agency responsible for regulating workplace safety and employer public health mandates.
Cal/OSHA issued 219 COVID-related citations to 90 employers from Aug. 25 to Dec. 14, accompanied by about $2.2 million in proposed fines, according to department data. The penalties ranged from $475 on Sept. 30 against a Taco Bell in Anaheim for failing to require employees to maintain 6 feet of physical distance, to $108,000 on Oct. 29 against Apple Bistro in Placerville for not requiring masks indoors and for not providing adequate physical distance between employees and guests. The department is investigating about 1,700 other cases.
The state Board of Barbering and Cosmetology, which regulates about 54,000 salons and barbershops, has levied just two citations and suspended two licenses, both held by Primo’s Barbershop in Vacaville, which has “very adamantly” opposed state health orders, said Matt Woodcheke, a spokesperson for the state Department of Consumer Affairs, which oversees the board.
No citations have been issued for COVID-related public health violations by California’s 280 state parks, nor by the California Highway Patrol.
Regulators said they have felt tremendous angst trying to get businesses to follow rapidly changing rules, but they aim for voluntary compliance and don’t want to cause businesses to go under.
“This is extremely difficult and we don’t want to do it,” said Luke Blehm, an acting supervising agent in charge for the state Department of Alcoholic Beverage Control. “We are all compassionate and empathetic and it’s a very hard thing to tell somebody that they’ve got to close and they may lose everything because of these rules they have to comply with.”
The state Department of Public Health, which is not one of the 10 task force agencies but assists them, has not issued fines or citations for health order violations, even though it is the primary agency responsible for issuing statewide mandates, according to spokesperson Corey Egel.
In New York, by contrast, Cuomo has leaned on political leaders and law enforcement agencies to aggressively police violations of COVID public health rules and has publicly admonished sheriffs who refuse to enforce violations. He ordered a statewide crackdown on bars and restaurants as cases surged this summer after contact-tracing data indicated drinking and dining were a major source of community spread, said Cuomo spokesperson Jack Sterne.
In hard-hit counties and towns where political leadership rebuffed enforcement, the Cuomo administration deployed COVID strike teams composed of state inspectors — in some cases, retrained Department of Motor Vehicles employees — to police business violations of public health rules. Cuomo argues it has made a difference.
“Compliance on bars has increased dramatically from when we started,” he said in September, “because if you know someone is going to check, if you know there’s monitoring, people tend to increase compliance.”
“We’re supportive of enforcement here,” said San Diego County Sheriff’s Lt. Ricardo Lopez. “COVID-19 is exploding and our view is, let’s get this over with as fast as possible.”
But elsewhere, county health officers pushing for stricter enforcement face intense political opposition from their bosses and law enforcement agencies. Sacramento County, for example, dropped its plan to impose fines this month after confronting resistance from businesses. Sacramento County Sheriff Scott Jones also has refused to enforce mask and other public health mandates.
Dr. Georges Benjamin, executive director of the American Public Health Association, said the state, ideally, should develop a consistent statewide enforcement system that starts with warnings and a strong public messaging campaign, then moves to graduated fines if noncompliance continues.
Until that happens, local leaders say, the patchwork of rules and enforcement strategies is causing confusion and chaos.
“People are continuing to disobey,” said Dr. Olivia Kasirye, Sacramento County’s health officer. “Some people are outright angry with us, asking why aren’t we doing something, but all we can do is refer problems to the state enforcement agencies.”
One tray of COVID-19 vaccine from pharmaceutical giant Pfizer contains 975 doses — way too many for a rural hospital in Arkansas.
But with the logistical gymnastics required to safely get the Pfizer vaccine to rural health care workers, splitting the trays into smaller shipments has its own dangers. Once out of the freezer that keeps it at 94 degrees below zero, the vaccine lasts only five days and must be refrigerated in transit.
In Arkansas — where over 40% of its counties are rural and COVID infections are climbing — solving this distribution puzzle is urgently critical, said Dr. Jennifer Dillaha, the state’s epidemiologist.
“If their providers come down with COVID-19,” Dillaha said, “there’s no one there to take care of the patients.”
Such quandaries resonate with officials in Georgia, Kentucky, Utah, Indiana, Wisconsin and Colorado. The first push of the nation’s mass COVID vaccination effort has been chaotic, marked by a lack of guidance and miscommunication from the federal level.
With Washington punting most vaccination decisions, each state and county is left to weigh where to send vaccines first and which of two vaccines authorized by the Food and Drug Administration for emergency use makes the most sense for each nursing home, hospital, local health department and even school. And after warning for months that they lacked the resources to distribute vaccines, state officials are only now set to receive a major bump in funding — $8.75 billion in Congress’ latest relief bill, which lawmakers are likely to pass this week.
The feat facing public health officials has “absolutely no comparison” in recent history, said Claire Hannan, executive director of the Association of Immunization Managers.
Officials who thought the H1N1 swine flu shot in 2009 was a logistical nightmare say it now looks simple in comparison. “It was a flu vaccine. It was one dose. It came at refrigerator-stable temperatures,” Hannan said. “It was nothing like this.”
Within just a few days, the logistical barriers of the vaccine made by Pfizer and BioNTech were laid bare. Many officials now hang their hopes on Moderna, whose vaccine comes in containers of 100 doses, doesn’t require deep freezing and is good for 30 days from the time it’s shipped.
The federal government had divvied up nearly 8 million doses of Pfizer and Moderna’s vaccines to distribute this week, on top of roughly 3 million Pfizer shots that were sent last week, said Army Gen. Gustave Perna, chief operating officer of the Trump administration’s Operation Warp Speed effort.
Perna said he took “personal responsibility” for overstating how many Pfizer doses states would receive.
Federal delays have led to confusion, Dillaha said: “Sometimes we don’t have information from CDC or Operation Warp Speed until right before a decision needs to be made.”
Officials in other states painted a mixed picture of the rollout.
Georgia’s Coastal Health District, which oversees public health for eight counties and has offices in Savannah and Brunswick, spent more than $27,000 on two ultra-cold freezers for the Pfizer vaccine, which it’s treating “like gold,” said Dr. Lawton Davis, its health director. Health care workers are being asked to travel, some up to 40 minutes, to get their vaccinations, because shipping them would risk wasting doses, he said. Vaccination uptake has been lower than Davis would like to see. “It’s sort of a jigsaw puzzle and balancing act,” he said. “We’re kind of learning as we go.”
In Utah, sites to vaccinate teachers and first responders starting in January had no capability to store the Pfizer vaccine, although officials are trying to secure some ultra-cold storage, a state department of health spokesperson said. Very few of Kentucky’s local health offices could store the Pfizer shots, because of refrigeration requirements and the size of shipments, said Sara Jo Best, public health director of the Lincoln Trail District. Indiana’s state health department had to identify alternative cold storage options for 17 hospitals following changes in guidance for the vaccine thermal shippers.
And in New Hampshire, where the National Guard will help administer vaccines, officials last week were still finalizing details for 13 community-based sites where first responders and health care workers are due to get vaccinated later this month. Jake Leon, a state Health and Human Services spokesperson, said that while the sites will be able to administer both companies’ vaccines, most likely they’ll get Moderna’s because of its easier transport. Even as the earliest vaccines are injected, much remains up in the air.
“It’s day to day and even then hour by hour or minute by minute — what we know and how we plan for it,” Leon said Friday. “We’re building the plane while flying it.”
In all, the Trump administration has bought 900 million COVID vaccine doses from six companies, but most of the vaccines are still in clinical studies. Even the front-runners whose shots have received FDA emergency authorization— Pfizer and BioNTech on Dec. 11, Moderna on Dec. 18 — will require months to manufacture at that scale. The Trump administration plans to distribute 20 million vaccine doses to states by early January, Perna said Saturday.
By spring, officials hope to stage broader vaccine deployment beyond top-priority populations of health care workers, nursing home residents and staff, as well as first responders.
During the effort to vaccinate Americans against H1N1, Dillaha said, health departments set up mass vaccination clinics in their counties and delivered doses to schools. But hospitals are taking charge of parts of the initial COVID immunization campaign, both because health care workers are at highest risk of illness or death from COVID-19, and to pick up the slack from health departments overwhelmed by case investigations and contact tracing from an unending stream of new infections.
Best said her workforce is struggling to keep up with COVID infections alone, much less flu season and upcoming COVID vaccinations. Public health department personnel in Kentucky shrank by 49% from 2009 to 2019, according to state data she supplied. Across the country, 38,000 state and local health positions have disappeared since the 2008 recession. Per capita spending for local health departments has dropped by 18% since 2010.
Nationally, Pfizer and Moderna have signed contracts with the federal government to each provide 100 million vaccine doses by the end of March; Moderna is set to deliver a second tranche of 100 million doses by June. States were playing it safe last week, directing Pfizer vials mainly to facilities with ultra-cold freezers, Hannan said.
“A lot of that vaccine is destined for institutional facilities,” Sean Dickson, director of health policy for West Health Policy Center, said of the Pfizer shots. The center, with the University of Pittsburgh School of Pharmacy, found that 35% of counties have two or fewer facilities to administer COVID vaccines.
The analysis found tremendous variation in how far people would need to drive for the vaccine. Residents of North Dakota, South Dakota, Montana, Wyoming, Nebraska and Kansas face the longest drives, with more than 10% living more than 10 miles from the closest facility that could administer a shot.
Counties with long driving distances between sites and a low number of sites overall “are going to be the hardest ones to reach,” said Inmaculada Hernandez, an assistant professor at the University of Pittsburgh School of Pharmacy and lead author of the analysis.
Certain vaccines could be better suited for such places, including Johnson & Johnson’s potential offering, which is a single shot, and health departments could distribute in rural areas through mobile units, she said. The company is expected to apply for FDA emergency authorization in February, Operation Warp Speed chief scientific adviser Moncef Slaoui said this month.
Until then, Pfizer and Moderna are the companies supplying doses for the country, and they’re not considered equal even though each is more than 90% effective at reducing disease.
In Wisconsin, the Moderna vaccine “gives us many more options” and “allows for us to get doses to those smaller clinics, more-rural clinics, in a way that reduces the number of logistics” needed for ultra-cold storage, Dr. Stephanie Schauer, the state’s immunization program manager, told reporters Wednesday.
Alan Morgan, head of the National Rural Health Association, echoed that the Moderna vaccine is being looked to as a “rural solution.” But he said states including Kansas have shown that a Pfizer rural rollout can be done.
“It’s where these states put a priority — either they prioritize rural or they don’t,” he said. “It’s a cautionary tale of what we may see this spring, of rural populations perhaps being second-tier when it comes to vaccination.”
Virginia, too, has a plan for getting the Pfizer vaccine to far-flung places. It’s shipping the vaccines to 18 health facilities with ultra-cold freezers across the state. The hubs are distributed widely enough so vaccinators can bring shots from there to health workers even in thinly populated areas before they spoil, said Brookie Crawford, spokesperson for the Virginia Department of Health’s central region.
Washington, on the other hand, allows hospitals without ultra-cold freezers to temporarily store Pfizer vaccines in the thermal boxes they arrive in, said Franji Mayes, spokesperson for the state’s health department. That means a box needs to be used quickly, before doses expire. “We are also working on a policy that will allow hospitals who don’t expect to vaccinate 975 people to transfer extra vaccine to other enrolled facilities,” she said. “This will reduce wasted vaccine.”
A recent Advisory Board briefing examined the annual Centers for Medicare & Medicaid Services (CMS) Readmission penalties. Of the 3,080 hospitals CMS evaluated, 83% received a penalty for payments to be made in 2021, based on expected outcomes for a wide variety of treated conditions. While CMS indicated that some of these penalties might be waived or delayed due to the impacts of the Covid pandemic on hospital procedure volumes and revenue, they are indicative of a much larger issue.
For too long, patients discharged from the hospital have been handed a stack of papers to fill prescriptions, seek follow-up care, or take other steps in their journey from treatment to recovery. More recently, the patient is given access to an Electronic Health Record (EHR) portal to view their records, and a care coordinator may call in a few days to check-in. These are positive steps, but is it enough? Although some readmissions cannot be avoided due to unforeseen complications, many are due to missed follow-up visits, poor medication adherence, or inadequate post-discharge care.
Probably because communication with outside providers has never worked reliably, almost all hospitals have interpreted ‘care coordination’ to mean staffing a local team to help patients with a call center-style approach. Wouldn’t it be much better if the hospital could directly engage and enable the Primary Care Physician (PCP) to know the current issues and follow-up directly with their patient?
We believe there is still a real opportunity to hold the patient’s hand and do far more to guide them through to recovery while reducing the friction for the entire patient care team.
Strengthening Care Coordination for a Better Tomorrow
Coordinating and collaborating with primary care, outpatient clinics, mental health professionals, public health, or social services plays a crucial role in mitigating readmissions and other bumps along the road to recovery. Real care coordination requires three related communication capabilities:
1. Notification of the PCP or other physicians and caregivers when events such as ED visits or Hospitalization occur.
2. Easy, searchable, medical record sharing allows the PCP to learn important issues without wading through hundreds of administrative paperwork.
3. Secure Messaging allows both clinicians and office staff to ask the other providers questions, clarify issues, and simplify working together.
There are some significant hurdles to improve the flow of patient data, and industry efforts have long been underway to plug the gaps. EHR vendors, Health Information Exchanges (HIEs), and a myriad of vendors and collaboratives have attempted to tackle these issues. In the past few decades, government compliance efforts have helped drive medical record sharing through the Direct Messaging protocol and CCDAs through Meaningful Use/Promoting Interoperability requirements for “electronic referral loops.” Kudos to the CMS for recognizing that notifications need to improve from hospitals to primary care—this is the key driver behind the latest CMS Final Rule (CMS-9115-F) mandating Admission, Discharge, and Transfer (ADT) Event Notifications. (By March 2021, CMS Conditions of Participation (CoPs) will require most hospitals to make a “reasonable effort” to send electronic event notifications to “all” Primary Care Providers (PCPs) or their practice.)
However, to date, the real world falls far short of these ideals: for a host of technical and implementation reasons, the majority of PCPs still don’t receive digital medical records sent by hospitals, and the required notifications are either far too simple, provide no context or relevant encounter data, rarely include patient demographic and contact information, and almost never include a method for bi-directional communications or messaging.
Delivering What the Recipient Needs
PCPs want what doctors call the “bullet” about their patient’s recent hospitalization. They don’t want pages of minutia, much of it repetitively cut and pasted. They don’t want to scan through dozens or hundreds of pages looking for the important things. They don’t want “CYA” legalistic nonsense. Not to mention, they learn very little from information focused on patient education.
An outside practitioner typically doesn’t have access to the hospital EHR, and when they do, it can be too cumbersome or time-consuming to chase down the important details of a recent visit. But for many patients—especially those with serious health issues—the doctor needs the bullet: key items such as the current medication list, what changed, and why.
Let’s look at an example of a patient with Congestive Heart Failure (CHF), which is a condition assessed in the above-mentioned CMS Readmission penalties. For CHF, the “bullet” might include timely and relevant details such as:
– What triggered the decompensation? Was it a simple thing, such as a salty meal? Or missed medication?
– What was the cardiac Ejection Fraction?
– What were the last few BUN and Creatinine levels and the most recent weight?
– Was this left- or right-sided heart failure?
– What medications and doses were prescribed for the patient?
– Is she tending toward too dry or too wet?
– Has she been postural, dizzy, hypotensive?
Ideally, the PCP would receive a quick, readable page that includes the name of the treating physician at the hospital, as well as 3-4 sentences about key concerns and findings. Having the whole hospital record is not important for 90 percent of patients, but receiving the “bullet” and being able to quickly search or request the records for more details, would be ideal.
Similar issues hold true for administrative staff and care coordinators. No one should play “telephone tag” to get chart information, clarify which patients should be seen quickly, or find demographic information about a discharged patient so they can proactively contact them to schedule follow-up.
Building a Sustainable, Long-Term Solution
Having struggled mightily to build effective communications in the past is no excuse for the often simplistic and manual processes we consider care coordination today.
Let’s use innovative capabilities to get high-quality notifications and transitions of care to all PCPs, not continue with multi-step processes that yield empty, cryptic data. The clinician needs clinically dense, salient summaries of hospital care, with the ability to quickly get answers—as easy as a Google search—for the two or three most important questions, without waiting for a scheduled phone call with the hospitalist. X-Rays, Lab results, EKGs, and other tests should also be available for easy review, not just the report. After all, if the PCP needs to order a new chest x-ray or EKG how can they compare it with the last one if they don’t have access to it?
Clerical staff needs demographic information at their fingertips to “take the baton” and ensure quick and appropriate appointment scheduling. They need to be able to retrieve more information from the sender, ask questions, and never use a telephone. Additionally, both the doctor and the office staff should be able to fire off a short note and get an answer to anyone in the extended care team.
That is proper care coordination. And that is where we hope the industry is collectively headed in 2021.
About Peter Tippett MD, PhD: Founder and CEO, careMESH
Dr. Peter S. Tippett is a physician, scientist, business leader and technology entrepreneur with extensive risk management and health information technology expertise. One of his early startups created the first commercial antivirus product, Certus (which sold to Symantec and became Norton Antivirus). As a leader in the global information security industry (ICSA Labs, TruSecure, CyberTrust, Information Security Magazine), Tippett developed a range of foundational and widely accepted risk equations and models.
About Catherine Thomas: Co-Founder and VP, Customer Engagement, careMESH
Catherine Thomas is Co-Founder & VP of Customer Engagement for careMESH, and a seasoned marketing executive with extensive experience in healthcare, telecommunications and the Federal Government sectors. As co-founder of careMESH, she brings 20+ years in Strategic Marketing and Planning; Communications & Change Management; Analyst & Media Relations; Channel Strategy & Development; and Staff & Project Leadership.
It was a down-in-the-mud presidential campaign, but the dirtiest part comes on Inauguration Day.
As Joe Biden lifts his right hand to take the oath of office at noon on Jan. 20 at the Capitol, a team of specially trained cleaners will be lifting their hands to disinfect the White House.
The executive mansion will get a deep clean after two COVID-19 outbreaks this fall led to President Donald Trump and members of his staff and family becoming infected.
The departure of one president and the arrival of another is always a fast but highly synchronized behind-the-scenes ballet by White House staff members and moving crews.
But this year is different. The shift means more than rearranging the Oval Office and putting new clothes in bedroom closets: It means a top-to-bottom disinfection amid a pandemic. Biden, who at 78 is taking office as the oldest president in U.S. history, is at high risk of complications from the virus.
So, the General Services Administration will oversee a thorough cleaning and disinfection of every doorknob, toilet handle, light switch, stair railing, telephone, elevator button, computer keyboard and other objects inside the 55,000-square-foot mansion at 1600 Pennsylvania Ave.
But can such a large building get fully clean in just five or six hours?
Experts say that should not be a problem with a large enough team and preparation time.
K. Mark Wiencek, lead microbiologist for South Carolina-based Contec Inc., which sells cleaning supplies to hospitals, said GSA cleaners should focus on the rooms last occupied by the Trump staff, since the virus can’t survive long on surfaces. Cleaning crews, he added, should wear masks and gloves to protect themselves and not introduce any germs.
He recommended replacing the air filters and using fogging and spraying disinfectant to kill viruses.
The GSA said it is already cleaning the White House East Wing and West Wing offices daily with disinfectant.
GSA officials said they expect no difficulties in making the transition and pledged that all furniture and surfaces would be cleaned. “GSA will thoroughly clean and disinfect the building spaces between the administrations and ensure that everything is up to standard,” a spokesperson said in a statement.
It’s vital that cleaners leave the cleaning chemicals on surfaces a full 10 minutes before wiping them down, said O.P. Almaraz, a disaster relief expert in West Covina, California, and president of Allied Restoration, which has cleaned dozens of businesses after suspected COVID cases.
“With a large enough crew, a professional disinfection company could apply disinfectants to the entire White House in six hours,” he said. It’s important, he explained, that the crew pay “special attention to points that may be touched often, like tabletops, door handles and light switches.”
As long as cleaners have an organized plan for each room, Almaraz doesn’t see them having trouble getting done before the Bidens move in at the end of the day.
Sheldon Yellen, CEO of Michigan-based Belfor Property Restoration, said cleaning crews need to be rehearsed and in fully ventilated suits to clean the White House in one afternoon.
“It’s a level 3 clean,” he said, noting the building needs the most intensive service because of confirmed COVID cases. That means disposing of anything that doesn’t have to stay for the Bidens, including pillows and bedsheets. He said books need to be wiped down, not just on the binding but all sides. He recommended cleaning the ductwork and ventilation systems as well.
Jack Shevel, co-founder of San Diego disinfection company Zappogen, said that because COVID-19 spreads by airborne transmission, it is best to disinfect using an electrostatic sprayer or fogger filled with a disinfectant designed to kill airborne pathogens. That covers a large area more easily than just wiping surfaces.
“To truly disinfect all those rooms quickly and thoroughly, they should be sprayed with a fine micron mist that can reach all crevices and surfaces evenly,” he said.
Still, the White House cleaners must be careful to remove paintings, antiques and other valuable items before spraying with disinfectant, said Ernesto Abel-Santos, professor of biochemistry at the University of Nevada-Las Vegas. Those items should be cleaned by hand.
Abel-Santos said a simple alcohol-based disinfectant should be enough to kill the COVID virus. Although the virus can be detected on some surfaces for days, it typically degrades within hours. People are much more likely to be infected by droplets expelled when someone coughs, sneezes or talks.
During the turnover, cleaners should focus on the most commonly used areas of the building, he said, such as the Oval Office and bedrooms. “The rest can get deep-cleaned as needed,” he added.
Even more important than cleaning, however, is asking the new president and his family and staff to physically distance, wear their masks and wash their hands, according to Abel-Santos.
“You don’t realize how many times in a day you touch your face with your hands,” he said. “If you touch a surface and then touch your face, it increases the probability of contagion.”
In March, during the first week of the San Francisco Bay Area’s first-in-the-nation stay-at-home order, KHN spoke with emergency department physicians working on the front lines of the burgeoning COVID-19 pandemic. At the time, these doctors reported dire shortages of personal protective equipment and testing supplies. Health officials had no idea how widespread the virus was, and some experts warned hospitals would be overwhelmed by critically ill patients.
In the end, due to both the early sweeping shutdown order and a state-sponsored effort to bolster the supply chain, Bay Area hospitals were able to avert that catastrophe. The region so far has fared much better than most other U.S. metro regions when it comes to rates of COVID infection and death. Even so, with intensive care unit capacity dwindling to critical levels statewide, San Francisco on Thursdayissued another drastic order, announcing a mandatory 10-day quarantine for anyone returning to the city who has spent time outside the region.
Amid this fierce second surge, we circled back last week to check in with Dr. Jeanne Noble, director of the COVID response at the University of California-San Francisco medical center emergency department, to get her reflections on the Bay Area’s experience. She explained how even as her hospital has made so many improvements, including recently launching universal testing so that everyone who comes to the emergency room is tested for COVID-19, the lockdown and burnout are wearing on her and her colleagues. The conversation has been edited for length.
Q: How are you doing at UCSF right now?
We’re OK in terms of our numbers. We have our ICU capacity; today’s numbers are 74% occupied. Acute care is a little bit tighter; the emergency department is seeing an increase in patients. [Editor’s note: As of Sunday, ICU capacity had dropped to 13%.]
We did have a period of time before this last surge where we often had a few days with no COVID patients. That was great. That ended in late September. This morning we have 11 patients on ventilators in the ICU.
I think we’re the first hospital in the state for universal testing. Everyone who comes to the ER gets tested. I’ve been working on this for months, but it’s new this week. Now we have testing, so we don’t have to do so much guesswork.
Q: When we spoke during the week of the first stay-at-home order, back in March, you were very worried. How do things compare now?
The supply [of masks] is just much better than it was back in March. In March, we had furloughed engineers from our local museum, the Exploratorium, making us face shields, and we started a makers lab in the library across the street to make supplies. It doesn’t feel like that this time around. We have a longer horizon.
I think in terms of our COVID care and our hospital capacity, we are fine. But my own sort of perspective on all of this is: When are we going to be done with this? Because even though things are smoother — we have PPE, we have testing — it’s a tremendous amount of work and stress. Frankly, the fact that my children have not been in school since March is one of my major sources of stress.
We’re all working way more than we ever have before. And nine months into it, the adrenaline is gone and it’s just purely exhausting.
Q: Can you tell me more about that, the physical and emotional toll on the hospital staff?
We don’t allow eating in the ED anymore, so we don’t have break rooms. Especially if you’re the supervising doctor, you need to do this elaborate handoff to another doctor if you need to eat. You know, it’s 10 hours into your shift and you want a cup of coffee.
The hassles and the discomforts. Wearing an N95 day after day is really uncomfortable. A lot of us have ulcers on our noses. They become painful.
And the lack of being able to socialize with colleagues is hard. The ED has always been a pretty intense environment. That’s offset by this closeness and being a team. All of this emotional intensity, treating people day after day at these incredible junctures in their lives — a lot of the camaraderie and morale comes from being able to debrief together. When you’re not supposed to be closer than a few feet from one another and you don’t take off your masks, it’s a lot of strain.
People are much less worried about coming home to their families. It hasn’t been the fomite disease we were all worried about initially, worried we’d give our kids COVID from our shoes. But there’s still the concern. Every time you get a runny nose or a sore throat you need to get tested, and you worry about what if you infected your family.
Q: So will you and your colleagues be able to take a break over the holidays?
We’ll see what happens. We’re just now starting to feel like we’re seeing the post-Thanksgiving numbers. But I think that even without having to do extra shifts in the ED, certainly for someone like me doing COVID response, there’s always a huge number of issues to work through. We just got the monoclonal antibodies, which is great, but that’s a whole new workflow.
I think what is going to bother people the most is that we are in lockdown. Kind of longing for that relaxation and time with family that we’re all kind of craving.
Q: It sounds like things are hard, but the hospital is in a relatively good place.
I was deployed to the Navajo Nation and helped with their surge in May in Gallup, New Mexico, and that is much, much harder than what we’ve faced in the Bay Area. In Gallup, at Indian Health Service, they were incredible in just the can-do attitude with way fewer resources than we have here. As of this summer, they had had the worst per capita surge in the country. They redesigned their ED essentially by cutting every room in half, hanging plastic on hooks you would use to hang your bicycle wheel. They hung thick plastic and right there doubled their capacity of patients they could see.
Our tents at UCSF are these blue medical tents with HVAC systems, heaters, negative pressure. They are really nice. There they had what looked like beach cabanas — open walls with just a tent overhead. In March and April they were taking care of patients in the snow. In the summer, it was hot and windy. When I was there, almost every single one of my patients had COVID.
That level of intensity was not something we had to go through in the Bay Area. Not to say that it’s easy [here]; I just told you all the ways it’s hard. But everything is relative. In terms of the COVID landscape, we have been very lucky.
Q: The Bay Area was early to close and has had stricter regulations than many parts of the country. As someone directly affected, what do you think of the response?
I think that we have benefited from early closures, unquestionably, when we did our shelter-in-place in March and probably saved 80,000 lives. It was really a tremendous and a bold move.
We’ve done some things well and other things not so well. We were very late to implement closures in a targeted fashion. Restaurants and dining reopened this summer, and a lot of us couldn’t figure out why indoor dining was open. Why is indoor dining something we need to even be considering when we’ve just barely flattened our curve? It was very predictable that cases would go up when dining happened. And they did.
We need to evaluate what is more important for our society and well-being, and to say what is the risk associated with that activity. Schools are of high social value. And [the closures are] really hard for kids. We’re seeing a lot of adolescents with suicidal ideation brought to the emergency department, which is related to school closure. I would put dining and restaurants as being of minimal social importance and very high risk.
We could have done this better. Closing [down society] when numbers go up is reasonable and that saves lives. But I think we know enough that it should not be an across-the-board closing. I mean, with this latest order, they temporarily closed parks. And we’ve been telling people to go outside. It’s like, what? Are you kidding?
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.”
Administrators at Howard University Hospital in Washington, D.C., were thrilled to be among the city’s first hospitals to get a COVID-19 vaccine, but they knew it could be a tough sell to get staffers to take the shot.
They were right.
The hospital, located on the campus of one the nation’s oldest historically Black colleges, received 725 doses of the vaccine made by Pfizer and BioNTech on Dec. 14 and expects 1,000 more vaccine doses this week to immunize its workers.
Yet, as of Friday afternoon, about 600 employees had signed up for the shots, touted as about 95% effective in preventing the deadly disease. Howard has about 1,900 employees, not counting hundreds of independent contractors it also hoped to vaccinate.
“There is a high level of mistrust and I get it,” said Anita Jenkins, the hospital’s chief executive officer who received the shot Tuesday in hopes of inspiring her staff to follow her lead. “People are genuinely afraid of the vaccine.”
Studies showed few serious side effects in more than 40,000 people before the vaccine was authorized for emergency use in the U.S. A few people worldwide have had allergic reactions in the past week.
In late November, a hospital survey of 350 workers found 70% either did not want to take a COVID vaccine or did not want it as soon as it became available.
So, officials are not dismayed at the turnout so far, saying it shows their educational campaign is beginning to work.
“This is a significant win,” said Jenkins, who added she was happy to “take one for the team” when she and other health care personnel got the first shots. About 380 Howard employees or affiliated staff had been vaccinated by Friday afternoon.
Although hesitancy toward the vaccine is a challenge nationally, it’s a significant problem among Black adults because of their generations-long distrust of the medical community and racial inequities in health care.
When Jenkins posted a picture of herself getting vaccinated on her Facebook page, she received many thumbs up but also pointed criticism. “One called me a sellout and asked why I would do that to my people,” she said.
Before being vaccinated, Jenkins said, she read about the clinical trials and was glad to learn the first vaccines in development were unlike some that use weakened or inactivated viruses to stimulate the body’s immune defense. The COVID vaccine by Pfizer and BioNTech does not contain the actual virus.
And one factor driving her to take the shot was that some employees said they would be more willing to do it if she did.
The hesitancy among her staff members has its roots in the Tuskegee syphilis experiment, said Jenkins, who started at Howard in February.
The 40-year study, which was run by the U.S. Public Health Service until 1972, followed 600 Black men infected with syphilis in rural Alabama over the course of their lives. The researchers refused to tell patients their diagnosis or treat them for the debilitating disease. Many men died of the disease and several wives contracted it.
Jenkins said she was not surprised that many Howard employees — including doctors — are questioning whether to take a vaccine, even though Black patients are twice as likely to die of COVID-19.
While African Americans make up 45% of the population in the District of Columbia, they account for 74% of the 734 COVID deaths. Nationally, Blacks are nearly four times more likely to be hospitalized due to COVID compared with whites and nearly three times more likely to die.
Howard, which has treated hundreds of COVID patients, was one of six hospitals in the city to get the first batch of nearly 7,000 doses of the Pfizer vaccine Monday. About one-third of those doses were administered by Friday morning, said Justin Palmer, a vice president of the District of Columbia Hospital Association.
Federal officials Friday authorized a second vaccine, made by Moderna, for emergency use. That vaccine is expected to be distributed starting this week.
The political bickering over the COVID response has also hurt efforts to instill confidence in the vaccine, Jenkins said.
Other than a sore arm, Jenkins said, she’s had no side effects from the vaccine, which can also commonly cause fatigue and headache. “Today I am walking the halls,” she explained, “and I got the shot two days ago.”
Part of the challenge for Jenkins and other hospital officials will be persuading employees not just to take a vaccine now but to return for the booster shot three weeks later. One dose offers only partial protection.
Jenkins said the hospital plans to make reminder calls to get people to follow up. She said efforts to increase participation at the hospital will also continue.
“It was important for me to be a standard-bearer to show the team I am in there with them,” she said.
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launches a COVID-19 vaccine management platform with partners Accenture and
Avanade, EY, and Mazik Global to help government and healthcare customers
provide fair and equitable vaccine distribution, administration, and monitoring
of vaccine delivery.
Microsoft Consulting Services (MCS) has deployed over 230 emergency COVID-19 response missions globally since the pandemic began in March, including recent engagements to ensure the equitable, secure, and efficient distribution of the COVID-19 vaccine.
Accenture recently rolled out a comprehensive vaccine management solution to help government and healthcare organizations rapidly and effectively plan and develop COVID-19 vaccination programs and related distribution and communication initiatives. Expanding on Accenture’s contact tracing capability that leverages Salesforce’s manual contact tracing solution, the platform is rapidly deployable and designed to securely track a resident’s vaccination journey, from registration and appointment scheduling to final vaccine administration and symptom follow-ups.
VigiLanz, a clinical surveillance company launched their new mass vaccination support software, VigiLanz Vaccinate provides end-to-end management of the entire vaccination process, enabling hospitals to maximize the success of mass vaccination events for healthcare workers. VigiLanz Vaccinate streamlines vaccine administration and management by making it easy for staff to register and provide consent while automating workflows for program administrators. Its real-time insights into volume needs to reduce vaccine waste, while analytics give visibility into vaccination and immunity rates at the individual, department, hospital, and system-level.
UCHealth recently deployed BioIntelliSense BioButton™ Vaccine
Monitoring Solution, an FDA-cleared medical-grade wearable for continuous
vital sign monitoring for up to 90-days (based on configuration) to healthcare
workers receiving COVID-19 vaccine UCHealth’s staff and providers will wear the
BioButton device for two days prior and seven days following a COVID-19 vaccine dose
to detect potential adverse vital sign trends. Together with a daily
vaccination health survey and data insights, the wearer may be alerted of signs
and symptoms to guide appropriate follow-up actions and further medical management.
VaxAtlas launches a
digital platform to support the COVID-19 vaccination process making it easy for
anyone to schedule and manage their vaccinations. Through a comprehensive suite
of on-demand tools, VaxAtlas manages the process of getting COVID vaccinations
from beginning to end. The platform provides access to a national certified
pharmacy network for local appointment scheduling, recall alerts, second dose
reminders, as well as QR clearance passes for vaccine validation. VaxAtlas
alleviates the complexity associated with vaccine logistics and helps to get
people back to work and back to living their lives.
DocASAP launches COVID-19
Vaccination Coordination Solution to help healthcare providers and payers meet
the urgent demand for vaccinating the nation. DocASAP’s COVID-19 Vaccination
Coordination Solution will help providers and payers guide people through the
vaccination process with pre-appointment engagement, online appointment scheduling
and reminders, and post-appointment wellness tracking. This will help reduce
the burden on staff and call centers to manage the sheer volume and complexity
of these appointments, and better coordinate the influx so providers can
effectively deliver the needed care. DocASAP will support the phased approach
to rolling out vaccinations, beginning with front-line healthcare staff.
7. Allied Identity
Allied Identity announced the launch of Vaxtrac, comprehensive vaccination management and credentialing platform designed to aid in the local, national and international response to COVID-19 and other communicable diseases. Vaxtrac uses SICPA’s proprietary CERTUS™ service in order to ensure the security of vaccination records and credentials.
8. Net Health
Net Health has developed a proprietary web-based Mobile Immunization Tracking platform to more efficiently manage on-site
immunizations. To ensure compliance, Net Health’s Mobile Immunization
Tracking platform tracks verification and enables employee consent forms to be
electronically recorded. Immunization data and the Vaccine Information Sheet
(VIS) are pulled directly from the Centers for Disease Control (CDC) database
and fields are auto-populated so clinicians do not have to manually enter data.
This ensures information in the employee record is accurate and saves time as
the clinician moves from one employee to the next.
9. Traction on Demand
Vancouver tech company, Traction on Demand,
has developed a COVID-19 Vaccine Clinic Accelerator. The accelerator helps
health authorities track all the critical details of their clinics including
type, location, staff members, and cold storage units available on-site and
applies CDC’s COVID-19 Temporary Clinic Best Practices to a
Salesforce-based mobile app, providing organizations with a digitized CDC
checklist, auditable clinic administration including a permanent auditable
record of all vaccination clinics an organization holds, critical risk
identification, and shift tracking.
10. MTX Group
MTX Group launches a
comprehensive end-to-end COVID-19 vaccine administration, management, and
distribution Solution for state and local public health agencies built on
Salesforce. The MTX vaccine management solution brings together the various
components of a COVID-19 vaccination program, including vaccine administration
and inventory management. MTX also works with public health departments to
identify necessary steps to promote vaccination adoption within a community.
The vaccine management solution is secure, portable, interoperable, and
provides data-driven vaccination program management capabilities.
Vaccination Management (IVM) Salesforce Solution is an end-to-end offering
for automating tasks, integrating data sources, and delivering a seamless
vaccination program that offers supply chain visibility and future demand
forecasting. Disparate systems won’t work for this unprecedented health crisis.
Phresia provides an end-to-end COVID-19 vaccine management solution for outreach, intake, reminder, and recall tools to increase vaccine uptake. Key features include communicating with patients about vaccine availability, send appointment reminders and boost recall, manage your waitlist, automate patient intake for vaccine visits, including consents, questionnaires, and patient education, and screen patients for vaccine hesitancy and maximize uptake by delivering personalized messaging based on those survey results.
She lay behind a glass barrier, heavily sedated, kept alive by a machine that blew oxygen into her lungs through a tube taped to her mouth and lodged at the back of her throat. She had deteriorated rapidly since arriving a short time earlier.
“Her respiratory system is failing, and her cardiovascular system is failing,” said Dr. Luis Huerta, a critical care expert in the intensive care unit. The odds of survival for the patient, who could not be identified for privacy reasons, were poor, Huerta said.
The woman, in her 60s, was among 50 patients so ill with COVID-19 that they required constant medical attention this week in ICUs at Los Angeles County+USC Medical Center, a 600-bed public hospital on L.A.’s Eastside. A large majority of them had diabetes, obesity or hypertension.
An additional 100 COVID patients, less ill at least for the moment, were in other parts of the hospital, and the numbers were growing. In the five days that ended Wednesday, eight COVID patients at the hospital died — double the number from the preceding five days.
As COVID patients have flooded into LAC+USC in recent weeks, they’ve put an immense strain on its ICU capacity and staff — especially since non-COVID patients, with gunshot wounds, drug overdoses, heart attacks and strokes, also need intensive care.
No more ICU beds were available, said Dr. Brad Spellberg, the hospital’s chief medical officer.
Similar scenes — packed wards, overworked medical staffers, harried administrators and grieving families — are playing out in hospitals across the state and the nation.
In California, only 4.1% of ICU beds were available as of Wednesday. In the 11-county Southern California region, just 0.5 % of ICU beds were open, and in the San Joaquin Valley, none were.
County health officials reported Wednesday that the number of daily new COVID cases, deaths and hospitalizations had all soared beyond their previous highs for the entire pandemic.
LAC+USC has had a heavy COVID burden since the beginning of the pandemic, largely because the low-income, predominantly Latino community it serves has been hit so hard. Latinos represent about 39% of California’s population but have accounted for nearly 57% of the state’s COVID cases and 48% of its COVID deaths, according to data updated this week.
Many people who live near the hospital have essential jobs and “are not able to work from home. They are going out there and exposing themselves because they have to make a living,” Spellberg said. And, he said, “they don’t live in giant houses where they can isolate themselves in a room.”
The worst cases end up lying amid a tangle of tubes and bags, in ICU rooms designed to prevent air and viral particles from flowing out into the hall. The sickest among them, like the woman described above, need machines to breathe for them. They are fed through nose tubes, their bladders draining into catheter bags, while intravenous lines deliver fluids and medications to relieve pain, keep them sedated and raise their blood pressure to a level necessary for life.
To take some pressure off the ICUs, the hospital this week opened a new “step-down” unit, for patients who are still very sick but can be managed with a slightly lower level of care. Spellberg said he hopes the unit will accommodate up to 10 patients.
Hospital staff members have also been scouring the insurance plans of patients to see if they can be transferred to other hospitals. “But at this point, it’s become almost impossible, because they’re all filling up,” Spellberg said.
Two weeks ago, a smaller percentage of COVID patients in the ER were showing signs of severe disease, which meant fewer needed to be admitted to the hospital or the ICU than during the July surge. That was helping, as Spellberg put it, to keep the water below the top of the levee.
But not anymore.
“Over the last 10 days, it is my distinct impression that the severity has worsened again, and that’s why our ICU has filled up quickly,” Spellberg said Monday.
The total number of COVID patients in the hospital, and the number in its ICUs, are now well above the peak of July — and both are nearly six times as high as in late October. “This is the worst it’s been,” Spellberg said. And it will only get worse over the coming weeks, he added, if people travel and gather with their extended families over Christmas and New Year’s as they did for Thanksgiving.
“Think New York in April. Think Italy in March,” Spellberg said. “That’s how bad things could get.”
They are already bad enough. Nurses and other medical staffers are exhausted from long months of extremely laborious patient care that is only getting more intense, said Lea Salinas, a nurse manager in one of the hospital’s ICU units. To avoid being short-staffed, she’s been asking her nurses to work overtime.
Normally, ICU nurses are assigned to two patients each shift. But one really sick COVID patient can take up virtually the entire shift — even with help from other nurses. Jonathan Magdaleno, a registered nurse in the ICU, said he might have to spend 10 hours during a 12-hour shift at the bedside of an extremely ill patient.
Even in the best case, he said, he typically has to enter a patient’s room every 30 minutes, because the bags delivering medications and fluids empty at different rates. Every time nurses or other care providers enter a patient’s room, they must put on cumbersome protective gear — then take it off when they leave.
One of the most delicate and difficult tasks is a maneuver known as “proning,” in which a patient in acute respiratory distress is flipped onto his or her stomach to improve lung function. Salinas said it can take a half-hour and require up to six nurses and a respiratory therapist, because tubes and wires have to be disconnected, then reconnected — not to mention the risks involved in moving an extremely fragile person. And they must do it twice, because every proned patient needs to be flipped back later in the day.
For some nurses, working on the COVID ward at LAC+USC feels very personal. That’s the case for Magdaleno, a native Spanish speaker who was born in Mexico City. “I grew up in this community,” he said. “Even if you don’t want to, you see your parents, you see your grandparents, you see your mom in these patients, because they speak the language.”
He planned to spend Christmas only with members of his own household and urged everyone else to do the same. “If you lose any member of your family, then what’s the purpose of Christmas?” he asked. “Is it worth it going to the mall right now? Is it worth even getting a gift for somebody who’s probably going to die?”
That the darkest hour of the pandemic should come precisely at the moment when COVID vaccines are beginning to arrive is especially poignant, said Dr. Paul Holtom, chief epidemiologist at LAC+USC.
“The tragic irony of this is that the light is at the end of the tunnel,” he said. “The vaccine is rolling out as we speak, and people just need to keep themselves alive until they can get the vaccine.”
TELLURIDE, Colo. — The day after Thanksgiving, Dr. Jana Eller and Dr. Shiraz Naqvi were seated beside an outdoor fire pit at the base of Telluride Ski Resort, taking a short break from skiing.
The two physicians from Houston had driven more than 18 hours to get here for the holiday weekend, and they were staying (and preparing meals) in a rented home. They traveled with another couple and their kids, colleagues they’ve been “bubbling” with in Houston.
“We got a COVID test prior to leaving and will get another when we return,” Naqvi said.
The skiing itself doesn’t feel much different during the pandemic, Eller said, but “the après ski scene is just gone.”
In March, at the beginning of the pandemic, Colorado Gov. Jared Polis issued an executive order requiring the state’s ski resorts to close in response to COVID-19, which had hit the state’s ski towns early and hard. Now, as the resorts enter their busy season, the state has taken pains to avoid blanket closures even though cases of COVID-19 are reaching their highest levels yet.
How to stay open amid the pandemic is an issue resorts across the U.S. are facing. Mandatory face coverings have become the norm, but other COVID mitigation efforts vary by site. Vermont resorts ask skiers to certify their compliance with rules governing interstate travel during the pandemic when buying a lift ticket, and in Colorado’s Pitkin County (home to Aspen), visitors will be required to confirm they’ve had a negative COVID test result within 72 hours of travel or pledge to quarantine for 14 days after arrival or until they obtain a negative test result.
Telluride is an internationally renowned destination trying to operate safely while protecting the 8,000 or so permanent residents in the area. Located in a remote southwestern part of Colorado, its economy depends on tourism, and the resort posts as many as 6,500 visitors on its busiest days.
On Nov. 25, with its COVID case numbers skyrocketing and its positivity rate hitting 4.6%, San Miguel County, which includes Telluride, closed its bars and restricted its restaurants to takeout and outdoor dining only. Signs posted throughout the resort remind visitors of the “five commitments of containment” — wear a mask, maintain 6 feet of physical distance, minimize group size, wash hands frequently and, when you feel sick, stay home and get tested.
How bad would things have to get to close the resort? That’s hard to gauge, said Grace Franklin, public health director for the county. People are going to do what they will regardless, she said.
“If we shut down the ski resort, how many people will take to the backcountry and get injured or trigger avalanches where the impact is greater? It’s a ‘damned if you do, damned if you don’t’ situation,” Franklin said.
Instead, Franklin said, the question becomes “How do we create safer, engineered events so people have an outlet, but we minimize as much risk as possible?”
Skiing itself poses relatively little risk, said Kate Langwig, an epidemiologist at Virginia Tech. “You’re outside with a lot of airflow, you’ve got something strapped to your feet so you’re not in super close contact with other people, and most of the time you’re riding the lift with people in your group.”
Gathering in the lodge or bar is by far the biggest COVID risk associated with skiing, said Langwig, who grew up skiing in northern New York. “In my family, one of the things you do after a day of skiing is connect with friends and have a beer in the lodge,” and it’s this social aspect of skiing that’s too risky right now, she said.
In an effort to discourage tourists and residents from congregating, local governments, medical facilities and the ski resort released a co-signed letter in November urging people to cancel any plans to gather with those outside their immediate household and celebrate the holidays solely with people from their own household. Keeping the resort open will require everybody to do their part, said Lindsey Mills, COVID public information consultant for San Miguel County.
“We are not telling anybody not to come, at least not yet,” said Todd Brown, Telluride’s mayor pro tem. But local officials are broadcasting a strong message to everyone in the area — “Chill out. Don’t have the big party with five families.”
Officials aren’t worried only about coronavirus transmission; they’re also concerned about overtaxing their medical facilities. San Miguel County has an urgent care center but no hospital, and its medical center experienced a 22% staffing shortage at the end of November, mostly because so many employees are in quarantine. Hospitals in nearby Mesa County reached their ICU capacity last month, and other hospitals in the region are also pinched.
“We can’t have a situation where people break their legs on the slopes and we can’t get them care,” said Franklin.
The resort has taken steps to facilitate physical distancing among visitors. Reservations aren’t required at Telluride, but lift tickets must be purchased in advance, and the resort can restrict ticket sales if necessary, said Jeff Proteau, vice president of operations and planning at the Telluride Ski Resort. Gondolas are operating with the windows open and each load is restricted to members of the same household.
To reduce contact in and around the lifts, workers have created “ghost lines” of empty space to ensure a 6-foot distance between groups while they wait in lift lines. People from the same household can stand in line together and ride the two- to four-person lifts next to one another, Proteau said, but when riding a lift with someone from another household, guests are asked to leave a vacant seat between them.
Langwig was a children’s ski instructor for many years and worries about ski school. “You interact pretty closely with the kids,” she said, noting that runny noses are common. “You spend a lot of time getting kids bundled up and to and from the bathroom.” This could be especially challenging if indoor spaces are closed, she said. “Hot chocolate breaks are one of the ways you get kids through the day, and that’s not safe anymore.”
In anticipation of visitors needing to take breaks to warm up, the resort has installed six temporary structures around the mountain with insulated ceilings and heated panels. When the sides are rolled up, they’re considered outdoor spaces, Proteau said, but they can be closed into confined spaces with limited occupancy as needed, especially on a blustery day.
The risk for most employees on the mountain should be relatively minimal, Langwig said, at least at work. “Lift attendants are outside wearing thick gloves and a mask most of the time. Compared to someone who works in a restaurant, their risk is pretty low.”
Employees are generally assigned to work in small groups that can be quarantined, if necessary, without wiping out a whole department, Proteau said. There’s also contact tracing in place for resort employees.
Arizona native Joey Rague moved to Telluride last year and works as a ski valet on the mountain. He said there’s a huge incentive among employees to keep the resort open. With affordable housing sparse in Telluride, “all of us are struggling seasonally to be able to pay rent.”
So far, he said, most visitors have been respectful and conscientious of the rules.
“It seems as though people understand that if we want to stay open, we have to come together,” he said.
KHN Editor-in-Chief Elisabeth Rosenthal discussed COVID prevention PSAs and why they should be scarier on WNYC’s “The Takeaway” on Tuesday. She also discussed COVID and President-elect Joe Biden’s health care team on WBUR’s “On Point” on Dec. 11.
Like tens of millions of other parents nationwide, Jonathan and Sara Sadowski struggle to assist their four children, ages 5 to 11, with their online schooling at home. In addition, their eldest child, who has cerebral palsy and is in a wheelchair, needs special care.
So to help the kids and keep them safe — especially their oldest child — Jonathan opted to take 12 weeks of paid leave from his teaching job under a program authorized by an emergency federal law enacted in March.
“Qualifying for paid leave was a huge relief and has worked out really well,” said Jonathan, who lives in Concord, New Hampshire.
But the family has learned about a new wrinkle: The 11-year old needs surgery in January. The operation is expected to require a month or two of recovery. Unfortunately, Jonathan’s leave will be used up by then; what’s more, the emergency federal paid leave program it is based on lapses Dec. 31.
Unions and workers’ rights and consumer advocacy groups are this week waging a last-ditch effort to get Congress to extend the program into 2021. They argue that the program is a critical component helping to prevent the spread of the virus and providing financial assistance to struggling families.
They also assert that a number of unwise exemptions — plus a lack of enforcement and public awareness — have limited the program’s effectiveness.
“The emergency paid-leave provisions have been one important step in helping American families deal with this crisis,” said Sen. Kirsten Gillibrand (D-N.Y.). “Congress must extend the provision until this crisis is over. Paid leave is critical as the economy recovers.”
The program is among two dozen pandemic-related relief measures set to expire at the end of the year. Those include unemployment benefits, protections against evictions, student loan relief and payments for COVID testing.
The Democratic-controlled House twice approved bills extending most of those, including paid leave. But Republican leaders in the Senate have until this month refused to consider new relief and stimulus legislation. This week, negotiations have intensified on a compromise bill that extends some of the expiring measures. But an extension of paid sick days and paid leave is not included in that bill.
Capitol Hill staffers and workers’ rights advocates say a paid-leave extension could still be added to the relief bill or a government spending bill that Congress must pass this month.
“It’s outrageous that paid leave is not in this legislation,” said Vicki Shabo, a senior fellow for paid-leave policy and strategy at New America, a Washington think tank. “The evidence is very clear paid sick days and leave help prevent spread of the virus, and it’s a benefit families overwhelmingly want and need.”
Neither the Trump administration nor President-elect Joe Biden responded to requests for comment, and neither has announced a position on the issue.
Paid Sick Leave ‘Is in the Public Interest’
The current law requires businesses with fewer than 500 workers to allow their employees to take up to 10 days of sick leave at full pay and up to 50 more at two-thirds pay to care for a child when schools or day care centers are closed because of COVID-19.
The federal government covers the cost via tax credits to employers. The benefit covers mandatory 14-day quarantine periods for those exposed to the virus, whether they get sick or not.
Larger firms were exempted on the theory that most already provide paid sick days and some forms of extended paid leave — and don’t need federal subsidies.
But an analysis after the law was enacted found that the exemption leaves about 70 million workers in large businesses — roughly half the nation’s workforce — without the full protections offered under the COVID law.
The law and subsequent Department of Labor rules also permit firms with 50 or fewer employees to opt out of providing paid sick days or leave if they think their business will be adversely affected.
About 34 million people work for those small businesses — and the majority offer fewer than 10 paid sick days, if any. Few have extended paid leave.
In addition, the law has no guarantee of paid sick days or leave for the nation’s 13 million health care and emergency response workers.
The justification for that when the measure was enacted: Hospitals, clinics, nursing homes and emergency response companies needed to ensure that these essential workers would show up in a time of crisis.
“This was extremely shortsighted and bad policy,” said Pronita Gupta, director of job quality at the Center for Law and Social Policy in Washington, D.C. “We have seen the harmful outcome — the high number of coronavirus cases in health care facilities, especially among low-wage nursing home workers.”
Nor does the law offer extended paid leave for people who have COVID-19 or need to care for a family member with the disease beyond 10 days. Republicans opposed a broad-based benefit beyond at-home child care, advocates for the benefit noted.
“The problem is we now know that thousands of people who have COVID are sick for more than two weeks, some for months,” said Shabo. “These people need to be able to stay home and recover; that’s in the public interest as well.”
In a letter this month, a coalition of nine national public health groups urged Congress to extend the paid-leave benefits. “Paid sick leave can reduce the spread of COVID-19 in workplaces and communities by removing the barrier to employees staying home if they might have the virus,” the groups wrote. “Even one infection can set off an outbreak.”
Business groups are sympathetic, but some still oppose extending paid leave. Chief among them is the National Federation of Independent Business, a lobbying powerhouse that represents small businesses. Beth Milito, the group’s senior executive counsel, said that while small-business owners have been “highly sensitive” to their workers’ needs during the pandemic, mandating paid sick days and extended leave puts an undue burden on them.
“Figuring out who qualifies, monitoring who takes leave and then applying for the tax credit is all too much red tape,” Milito said. “It’s the hassle factor at a time when many businesses are barely making ends meet.”
Estimates of the Program’s Costs Vary Widely
Surveys show a majority of the estimated 70 million private- and public-sector workers covered under the law — after all the exemptions and carve-outs — don’t know about their right to paid sick days or leave.
“The lack of awareness has limited the potential of this benefit,” said Dawn Huckelbridge, director of the Paid Leave for All campaign, which is supported by a coalition of unions and employees and other groups. The Department of Labor, which administers the benefit, “simply fell down on the job,” she said.
Estimates last spring of the use and cost of the benefit varied widely — from around $20 billion to $105 billion.
But more recent estimates suggest it may be less. According to a Government Accountability Office report citing IRS data, as of the end of October about 150,000 employers had filed for paid family and sick leave tax credits, totaling $1.3 billion. The report noted, however, that many employers will likely wait until filing their taxes in the spring to claim the credit and recoup their costs.
The congressional Joint Committee on Taxation last month released fresh projections on the cost of an extension of paid leave — $1.4 billion if extended for two months and $1.8 billion for three months.
Although it’s too early for any full assessment of the paid-leave program’s impact, advocates point to a key study, published online in October in the journal Health Affairs. Researchers at Cornell University and the KOF Swiss Economic Institute found that in states where workers gained the right to paid sick leave under the emergency law, 400 fewer confirmed COVID cases were reported per day.
The researchers conclude: “Our findings suggest that the U.S. emergency sick leave provision was a highly effective policy tool to flatten the curve in the short run.”
As apprehension about the pandemic intensifies, more Americans — nearly three-quarters — say they wear masks every time they leave the house, according to a poll released Friday.
The poll from KFF also found that 68% of American adults were worried someone in their family will get sick from the coronavirus, the highest level since the nonprofit began tracking the question in February. The public was least worried in April, when 53% were concerned the infection might strike their family. Since April, fewer than half of Republicans have consistently expressed fear that a family member will be sickened by COVID-19. (KHN is an editorially independent program of KFF.)
The latest survey, conducted among 1,676 adults from Nov. 30 to Dec. 8, found that 51% of Americans believed the worst is yet to come from the pandemic, which has claimed more than 300,000 lives in the U.S. The height of optimism occurred in September, when 38% of adults expected things to get worse.
Public support has risen for consistent use of masks, which has been a highly politicized marker of partisan affiliation. The poll found 73% of people said they wear a mask every time they leave home, an increase of 21 percentage points since May due to greater compliance among all partisan and age groups. The same percentage of 73% of respondents said they believe wearing a mask is part of the communal responsibility to prevent the spread of COVID, though nearly half of Republicans view it primarily as a personal choice.
While 87% of Democrats said they always wear a mask out of the house, 71% of independents and 55% of Republicans said the same.
Seven in 10 adults said they are prepared to adhere to physical distancing guidelines for another half-year or more until vaccines are widely available. Nearly 9 in 10 Democrats said they had the wherewithal but only half of Republicans did.
Political leanings polarized people in their views about whether their states have enacted enough restrictions to limit the spread of COVID-19. Half of Republicans thought their state had too many restrictions on businesses, while only 7% of Democrats and 24% of independents did. Four of 10 Republicans thought the state had too many restrictions on individuals, while only 3% of Democrats and 19% of independents did.
About half of Americans said stress related to the coronavirus has affected their mental health. The concerns are most widespread among women, young adults, minorities and people who have lost income, either personally or via their spouse, since the start of the outbreak.
Congress appears to be inching ever closer to agreement on a long-delayed COVID-19 relief bill, which would extend unemployment insurance and other emergency programs set to expire in the next several days. That bill, however, apparently will not include the top-priority items for both political parties: business liability protections supported by Republicans and aid to states and localities sought by Democrats.
The bill is likely to be part of a giant spending bill to keep the federal government funded for the rest of the fiscal year. And it might include a last-minute surprise: legislation to put an end to “surprise” medical bills sent to patients who inadvertently obtain care outside their insurance network.
This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Rebecca Adams of CQ Roll Call and Mary Agnes Carey of KHN.
Among the takeaways from this week’s podcast:
Congress has essentially agreed on a federal spending bill for the rest of the fiscal year — which began in October. But it will likely wait as lawmakers continue squabbling over the COVID relief package, with negotiations now centering on small details.
Republicans for months have been hesitant to move forward on a bill that would provide more relief for consumers affected by the pandemic because party leaders did not like Democrats’ insistence that it include more state and local aid. But that provision has been jettisoned, so Republicans are less opposed to the measure. Plus, they see a political downside to holding up the bill: Their two Georgia candidates for Senate — facing Democratic opponents in a special runoff election — are being hammered on the issue.
The compromise on surprise medical bills came after supporters secured agreement among Democrats who had favored varying remedies and all the committees in the House and Senate on the bill, a consensus that was forged with major concessions by progressives.
But doctors’ groups and other industry critics are still attacking the surprise billing proposal — even though many observers see the bill as tilted in their favor over insurers — so its passage is not guaranteed. Supporters are banking on the looming end of the congressional session to move the measure over the finish line.
Vice President Mike Pence announced he will get vaccinated against COVID-19 in public this week in hopes of convincing anyone skeptical about the shots that they are safe. President-elect Joe Biden is planning to do the same soon. But this is a difficult stance for politicians. They don’t want to look as if they are pushing themselves ahead in line, but they also want to normalize the use of the vaccine.
About 200 state and local public health leaders have quit or been fired because of public opposition to measures to curb the coronavirus. Although President Donald Trump has reined in his criticism of some of these officials and their efforts, the opposition is still strong. Those critics may be buttressed by fears that new restrictions imposed to control the surging virus will hurt the economy.
Also this week, Rovner interviews Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health, about the future of employer-provided health insurance.
Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:
MINNEAPOLIS.- Gloria Torres-Herbeck se aplica la vacuna contra la gripe cada temporada. Pero la maestra de 53 años de Rochester, Minnesota, aún no está convencida de querer estar primera en la fila para una contra COVID-19.
“No soy muy mayor, pero no soy tan fuerte como otras personas”, dijo. “Por eso, necesito ser realista sobre mi situación. ¿Quiero participar en algo que podría ponerme en riesgo? ”
La Administración de Drogas y Alimentos (FDA) ya otorgó la autorización de uso de emergencia para una vacuna y está considerando la aprobación de una segunda.
Mientras tanto, funcionarios de salud pública de todo el país se preparan para lo que podría ser tan desafiante como la distribución de la vacuna: persuadir a comunidades que han sido duramente afectadas por el virus, familias de bajos ingresos, personas de raza negra y latinos (de cualquier raza) de que se vacunen.
Sin embargo, funcionarios creen que algunas zonas tienen ventaja. Rochester, en Minnesota, sede de la Clínica Mayo, es uno de ellas. La Rochester Healthy Community Partnership ha estado trabajando para reducir las disparidades de salud en las comunidades de inmigrantes del área, residentes somalíes, hispanos, camboyanos, sursudaneses y etíopes, durante 15 años.
La asociación está compuesta por investigadores y proveedores de salud de Mayo, funcionarios de salud pública del condado y voluntarios comunitarios como Torres-Herbeck, quien emigró desde México hace 27 años.
“Cuando la pandemia impactó en marzo, nos dimos cuenta que con estas alianzas de larga data estábamos en una posición única por la confianza construida a lo largo de los años entre los expertos de Mayo y sus socios comunitarios”, dijo el doctor Mark Wieland, quien apoya al grupo y estudia el impacto de estas asociaciones.
Aunque hasta ahora solo se ha recopilado evidencia preliminar, hay indicios de que desde que comenzaron estos esfuerzos, Rochester ha aumentado las pruebas para COVID-19, ha mejorado el rastreo de contactos y ha impulsado comportamientos preventivos como el uso de máscaras y el distanciamiento físico en estas comunidades vulnerables, agregó Wieland.
El grupo espera que esos primeros éxitos sean un buen augurio para la aceptación de la vacuna.
Aprendiendo del sarampión
La asociación de Rochester apuesta por un enfoque de sentido común que se centra en valores compartidos, transparencia y comunicación clara.
Es una estrategia que ha tenido éxito en el pasado.
Cuando una epidemia de sarampión golpeó a la población somalí en Minneapolis-St. Paul, en 2017, la Clínica Mayo se acercó a los líderes comunitarios de los 25,000 inmigrantes somalíes que viven en el área de Rochester.
Muchos tenían miedo de vacunarse por la falsa presunción de que la vacuna podría causar autismo, y las tasas de vacunación eran bajas en la comunidad. Médicos realizaron reuniones públicas en mezquitas y centros comunitarios, respondiendo preguntas sobre la seguridad de las vacunas y asegurando a los residentes que no había evidencia científica de un vínculo con el autismo.
Actores somalíes crearon videos de YouTube para ayudar a abordar preocupaciones comunes. Al final, no se registraron casos de sarampión en el condado de Olmsted, hogar de Rochester.
Hace aproximadamente un año, y a pedido de un rabino, el doctor Robert Jacobson, director médico del Programa de Ciencias de la Salud de la Población en la Clínica Mayo, visitó una comunidad judía ortodoxa en Nueva York en la que el rechazo a la vacuna estaba generando otro brote de sarampión. Ayudó a líderes de la atención médica a disipar preocupaciones.
“Los judíos ortodoxos de esa comunidad rechazaban esa vacuna por la misma razón por la que la recomendamos”, dijo Jacobson. “Estaban tratando de proteger a sus hijos”.
Los esfuerzos de líderes judíos, expertos en salud pública como Jacobson y legisladores que endurecieron las leyes sobre exenciones de vacunas, ayudaron a sofocar el brote.
Desde marzo, la asociación de Rochester ha transmitido mensajes similares sobre COVID-19. El miedo o los malentendidos fueron un problema al comienzo de la pandemia. Los miembros de las comunidades de inmigrantes colgaban cuando los llamaban del departamento de salud.
Entonces, la asociación desarrolló mensajes en varios idiomas para explicar la importancia de esas llamadas telefónicas. Resolvieron problemas de comunicación. Por ejemplo, en somalí se usa la misma palabra para “resfriado” y “gripe”.
Ahora, menos gente cuelga.
Los miembros de esta alianza “son expertos en las sutilezas de sus comunidades”, observó Wieland.
Cuando el grupo se enteró de que muchos inmigrantes se sentían intimidados por las pruebas de COVID-19 y no estaban seguros de la logística, recomendó simplificar el proceso: ahora, videos con líderes comunitarios en las redes sociales dirigen a las personas a los sitios de prueba. Una vez allí, cualquiera que no hable inglés puede realizar la prueba sin necesidad de identificación ni tarjeta de seguro médico.
Faltaba el “por qué”
Solo el 40% de los adultos mayores de raza negra y el 51% de los hispanos mayores dijeron que probablemente se vacunarían contra COVID-19, en comparación con el 63% de los blancos no hispanos mayores, reveló una encuesta de la Universidad de Michigan.
Sus preocupaciones reflejan las de Torres-Herbeck: qué tan bien funciona la vacuna o qué tan segura es.
Una encuesta aún más reciente de personas de todas las edades para COVID Collaborative, un grupo de defensa de salud, mostró que la confianza en la seguridad de las vacunas es tan baja como el 14% para los afroamericanos y el 34% para los latinos.
Los adultos mayores dijeron que les gustaría recibir recomendaciones de personas en las que confían, según la encuesta de Michigan. Y los afroamericanos tienen el doble de probabilidades de confiar en voceros de su propia raza, reveló la otra encuesta.
La ventaja de grupos como la asociación de Rochester es que sus miembros son mensajeros de confianza.
Torres-Herbeck contó que había estado hablando con un jardinero que no usaba máscara. Ella le explicó que COVID-19 es un virus y cómo se propaga. El jardinero se sorprendió y se puso un cubrebocas.
A menudo, los funcionarios de salud pública ofrecen instrucciones sobre cómo actuar y qué hacer, como usar una máscara y lavarse las manos, pero no explican por qué, dijo Torres-Herbeck.
Sin embargo, no se trata solo de difundir hechos. Centrarse en los valores compartidos es clave para generar confianza. Cuando Adeline Abbenyi, gerente del programa de Mayo Clinic para el Centro de Investigación sobre Equidad Saludable y Participación Comunitaria, dijo que su madre, que nunca había temido a las vacunas, dudaba en recibir una vacuna COVID-19, Jacobson entendió.
“Muchos de nosotros sentimos lo mismo”, dijo Jacobson en una reunión por Zoom. “Participo del optimismo de que tendremos una vacuna que sea segura y efectiva, pero no la usaré hasta que vea esa evidencia”.
Es normal que la gente dude, no son anti-vacunas. Los médicos y enfermeras que están recibiendo las primeras dosis probablemente ayudarán a muchas personas a superar esa vacilación, agregó.
De hecho, Torres-Herbeck dijo que lo que la persuadiría a ella de vacunarse es ver a Jacobson recibir la vacuna.
MINNEAPOLIS — Gloria Torres-Herbeck gets the flu vaccine every year, but the 53-year-old teacher in Rochester, Minnesota, isn’t yet convinced she wants to be first in line for a potential COVID-19 vaccine.
“I’m not super old, but I’m not as strong as other people,” she said. “So, I need to be realistic on my own situation. Do I want to participate in something that might be a big risk for me?”
This month, the Food and Drug Administration gave emergency use authorization for one vaccine and is weighing approval of another. So, public health officials around the country are gearing up for what might be as challenging as figuring out how to store a vaccine at 70 degrees below zero Celsius. They need to persuade people who are part of communities that have been hit hard by the virus — those in low-income families and some minority populations, especially Black and Latino residents — to take a vaccine developed in less than a year and approved under emergency use authorization.
Yet there are a few places where officials think they have a head start. Rochester, Minnesota, home of the Mayo Clinic, is one of them. The Rochester Healthy Community Partnership has been working to reduce health disparities in the area’s immigrant communities, including Somali, Hispanic, Cambodian, South Sudanese and Ethiopian residents, for 15 years.
The partnership is composed of Mayo health providers and researchers, county public health officials and community volunteers like Torres-Herbeck, who immigrated to the U.S. 27 years ago from Mexico. One of the first of its kind, other similar efforts have sprung up around the country, but no one officially tracks such partnerships.
“What we realized when the pandemic hit in spades in March was that with long-established partnerships we were uniquely positioned to leverage” trust built up over the years between Mayo experts and their community partners, said Dr. Mark Wieland, who helps direct the group and studies the impact of such partnerships. “We realized we were obligated to jump in with two feet.”
Although only preliminary evidence has been gathered so far, there are indications that since the efforts began, Rochester has increased COVID-19 testing, improved contact tracing and boosted preventive behaviors such as mask-wearing, hand-washing and physical distancing in these vulnerable communities, he said. The group is hoping those early successes portend well for vaccine acceptance.
Learning From a Measles Outbreak
The Rochester partnership is banking on a commonsense approach that focuses on shared values, transparency and clear communication.
It’s a strategy that has succeeded in the past.
When a measles epidemic hit the large Somali population in Minneapolis-St. Paul in 2017, the Mayo Clinic reached out to community leaders among the 25,000 Somali immigrants in the Rochester area. Many had been frightened of the measles vaccine by baseless claims that it could cause autism, and vaccination rates were low in the community. Medical experts held town hall meetings in mosques and community centers, answering questions about vaccine safety and reassuring people that there was no scientific evidence of a link to autism. Somali actors created YouTube videos to help address common concerns. In the end, there were no recorded cases of measles in Olmsted County, home to Rochester.
About a year ago, Dr. Robert Jacobson, medical director for the Population Health Science Program at Mayo Clinic, at the request of a rabbi visited an Orthodox Jewish community in New York in which vaccine refusal was fueling another measles outbreak. He helped health care leaders there allay concerns.
“The Orthodox Jews in that community were refusing that vaccine for the same reason we were recommending it,” Jacobson said. “They were trying to protect their children.”
Efforts by Jewish leaders, public health experts such as Jacobson and lawmakers who tightened up laws on vaccine exemptions helped quell the outbreak.
Since March, the Rochester partnership has broadcast similar messages about COVID-19 to diverse audiences. Fear or misunderstanding was an issue at the beginning of the pandemic. Health leaders found that members of the immigrant communities were hanging up when the public health department called. So, the partnership developed messaging in several languages to explain the importance of the phone calls. They worked around problems, including that other languages don’t always have terms that mesh with English words for illnesses. For example, the word for “cold” and “flu” is the same in Somali.
Now fewer people hang up.
At the same time, these public health teams report back to the medical experts on what the community needs. “They’re the experts on the subtleties of their communities,” Wieland said.
So when the group learned that many immigrants were intimidated by COVID-19 testing and unsure of the logistics, the group recommended simplifying the process: Now, videos featuring community leaders on social media direct people to testing sites. Once there, anyone who doesn’t speak English automatically gets tested — no identification or insurance card necessary.
“We think that’s part of the reason that, as a county, we have overtested minority populations in relation to white populations,” Wieland said.
The ‘Why’ Was Missing
Only 40% of older Black adults and 51% of older Hispanics said they are somewhat or very likely to get the COVID-19 vaccination — compared with 63% of older white people, a University of Michigan poll shows. Their concerns mirror Torres-Herbeck’s: how well will the vaccine work or how safe it will be.
Older adults said they would like recommendations from doctors, health officials, or family and friends — people they trust, according to the Michigan poll. And Black Americans are twice as likely to trust Black messengers versus white messengers, the other survey showed.
“Even if people don’t trust doctors in general, they trust their own doctor,” said Dr. Preeti Malani, one of the authors of the Michigan survey and chief health officer of the university.
The advantage of groups like the Rochester partnership is that its members are also trusted messengers.
Several weeks ago, Torres-Herbeck said, she talked to a landscaper who didn’t wear a mask while working with his business partner. She told him that COVID-19 is a virus and explained how it spreads. He was surprised, and Torres-Herbeck understood. “When I came here 27 years ago, we were not as educated on that,” she said. “When I grew up, it was believed that if you walk barefoot you will catch a cold.”
Often, she said, public health officials provide directions on how to act and what to do, such as use a mask and clean your hands, but don’t explain why.
“That ‘why’ was missing for him,” she said.
Now when she talks to him, he puts a mask on.
In mid-November, Jacobson visited with members of the Rochester partnership via Zoom, part of the group’s initial effort to disseminate vaccine information.
Approving a vaccine under emergency use authorization is no less stringent than the normal procedure, he explained. The process has been dramatically sped up and condensed, he said, by the amount of money poured in and newer technology — and by increased FDA resources.
It’s not all about disseminating facts, however. Focusing on shared values is key to building trust. So when Adeline Abbenyi, the Mayo Clinic program manager for the Center for Healthy Equity and Community Engagement Research, said her mother, who had never feared vaccines, was hesitant to get a COVID-19 vaccine, Jacobson understood.
“A lot of us are feeling the same way,” Jacobson said in that Zoom meeting. “I go into this optimistic that we will have a vaccine that’s safe and effective, but I won’t use it until I see that evidence” of safety and efficacy the FDA is reviewing.
It’s normal for people to hesitate, he said, but that is far different from — and more widespread than — the anti-vaccine movement. Doctors and nurses getting the first doses will likely help many people overcome that hesitancy, he said.
Indeed, one thing that would persuade Torres-Herbeck to be inoculated? Seeing Jacobson get the vaccine, she said.
I read your article “Need a COVID-19 Nurse? That’ll Be $8,000 a Week” (Nov. 24) in the Springfield Journal-Register. It was an interesting article as I have a daughter who is a nurse. Nurses have been underpaid and unappreciated for years. It made me angry that the article characterized the wages some hospitals are willing to pay for nurses as exorbitant. Hogwash if you think someone should risk their life every hour of the day to care for COVID patients without proper compensation. How many doctors make over a million a year? You don’t cite that as unusual. I feel that nurses should go for the gold as they have been taken advantage of for years and, too bad, but good for them. Choose your words more carefully in the future. Nurses ROCK!!!!
— Mike Booher, Lincoln, Illinois
Hospitals go out of their way to avoid competing for nursing labor by raising wages. Now hospital executives and public health advocates act like it’s a travesty that COVID nurses are finally getting paid market rates to take on risky jobs. https://t.co/6z0idToVn6
I must note two important omissions in the article “Time to Discuss Potentially Unpleasant Side Effects of COVID Shots? Scientists Say Yes” (Nov. 12). First, although these were interim trial results, the placebo arm should also have been reported out. What was the placebo infection rate? Reporting 90% effectiveness is irrelevant without reporting the placebo rate simultaneously. And one needs to align the infection rate in trial subjects with the incidence of disease in the U.S. population. They should be similar, but if not, any discrepancy must be explained (such as, no elderly people or children participating in the trial). Secondly, and perhaps more important: What other mitigating measures were volunteers in this trial required/advised to take? For example, physical distancing, masks, etc. I could find no mention of this, positively or negatively, when reading the protocol on clinicaltrials.gov. Any vaccine alone could not provide 94.5% efficacy. To determine the relative contributions of other measures, you’d need, say, a four-arm study — placebo with mask, placebo without mask, vaccine with mask, vaccine without mask. Statistically and clinically, one must account for other variables that may confound an apparent result.
This is a crucial point as the lay public is thinking that, by getting the vaccine, masks might no longer be necessary and they’ll have a 95% chance of not being infected. This is rubbish. The media and the public “experts” need to address this as they are setting themselves up for an immense PR failure and still greater skepticism. People may need to wear masks for many more months, maybe years, even with an effective vaccine.
Your story “Clots, Strokes and Rashes: Is COVID a Disease of the Blood Vessels?” (Nov. 13) was reprinted in my local newspaper. My brother, James L. Kinsella Ph.D., led the original work at the National Institutes of Health researching how the chemotherapy drug Taxol could reduce inflammation in coronary articles following the placement of coronary stents. This led to the very effective use of drug-eluting coronary stents. My unprofessional musing causes me to wonder if this anti-inflammatory response to Taxol might have some application as an early therapeutic intervention to reduce the inflammatory response of COVID-19 being studied by Dr. William Li. I can’t ask my brother; he passed away.
— Rick Kinsella, Oneida, New York
He wouldn’t be dead without covid. We’ve learned that things that aren’t life threatening are made life threatening by this disease. It attacks your blood vessels so it can exacerbate anything anywhere in your body that uses blood vessels. Stay safe indeed https://t.co/BFsqrKSFmH
Birth control medication is so much more than a pawn in politics (“Coming Abortion Fight Could Threaten Birth Control, Too,” Nov. 5). It changes the lives of so many women for the better. Birth control access has been proven to lead to higher rates of education for women, lower levels of child poverty, lower Medicaid costs for women’s health and higher productivity of society as a whole. It also treats a large number of medical conditions associated with women’s health. It effectively treats severe menstrual migraines, hormonal acne, endometriosis, severe menstrual pain, uterine abnormalities, anemia and heavy menstrual bleeding, among other health conditions. This medication is involved in treating so many women’s health concerns, improves infant and child health outcomes, and reduces child poverty, and yet almost 20 million women in the U.S. currently have no access to birth control medication. American politicians need to consider, if nothing else, the spillover costs to society when birth control access is reduced.
Women’s reproductive health should not be up for debate and yet it is at the center of so many political agendas. As a 24-year-old woman pursuing dual master’s degrees in public health and physician assistant studies, my focus should be on learning to become an exceptional health care provider, not whether my health will be up for debate in court. If politicians truly have the best interests of Americans at heart, they should be looking to expand birth control access, not restrict it. Evidence needs to be incorporated into political agendas, and the evidence shows that when women succeed, society succeeds. Women’s education, health and reproductive rights should be at the forefront of every discussion on what constitutes a thriving population — the evidence has proven that women’s autonomy holds the answer and access to birth control is a vital piece of that.
— Gabby Henshue, Madison, Wisconsin
Scary times for women’s bodies.
“States could effectively ban contraception by arguing that some contraceptives act as abortifacients.” Threat is real. I’ve worked in states where this argument has been made.https://t.co/LmdWFRUNOZ
KHN Morning Briefing: A Wealth of Information in One Spot!
I just wanted to say it is awesome to have portions of articles from many major news outlets because never does one tell the whole story. Case in point: I was trying to research what exactly President Donald Trump had done that “allowed doctors to discriminate against LGBT people,” and it was very helpful having a wide array of media sources on a single page to help get the bigger picture and try and weed through the bias of all of them (“Trump Administration’s Expanded Conscience Rule Will Allow Medical Professionals To Refuse To Provide Health Care Services,” May 3). Just sending my compliments. Keep up the great work.
Communities of color deserve better. Members of the Congressional PAD Caucus — led by Rep. Donald Payne Jr. (D-N.J.) — recently introduced the Amputation Reduction and Compassion (ARC) Act to establish an education program about the disease — particularly for high-risk populations — and update reimbursement policy to disallow payment for non-emergent amputations unless arterial testing has been done in the three months before amputation. These simple solutions have the power to prevent thousands of avoidable amputations, and begin to correct health disparities in minority communities.
While we still have a long way to go as our country continues to grapple with systemic racism in health care, the ARC Act represents an important step toward ending disparities in PAD care.
— Dr. Foluso Fakorede, CEO of Cardiovascular Solutions of Central Mississippi, Cleveland, Mississippi
Racism in Health Care? Another example of injecting Politics. Inarguably, racism exists everywhere, but to make this a big issue is a disservice. Diff DX requires inclusion of Race/Ethnicity, to wit: Sickle Cell in Blacks,Alpha & Beta Thalassemia in Asians https://t.co/xyP54dPjH8
I found this article interesting (“Biden Plan to Lower Medicare Eligibility Age to 60 Faces Hostility From Hospitals,” Nov. 11) but was surprised that the Affordable Care Act was referred to as “Obamacare.” Please don’t politicize the ACA — we really need it to continue allowing people to access health care. Many people do not have health care through their workplace and are unable to afford private insurance premiums. I was once one of those people before I was hired at our local library. It was really tough. Thank you for your reporting.
— Pamela Elicker, Port Townsend, Washington
Putting People First on the Podcast
When you were talking about drug policy and the ballot in a recent podcast (“KHN’s ‘What the Health?’: Change Is in the Air,” Nov. 6), you used terms that are considered incorrect or stigmatizing. For example, saying “opioid epidemic” when it’s really a crisis and referring to substance use as “abuse.” The Associated Press and NPR, among others, have pledged to use people-first language, as also supported by the American Psychological Association.
— Deirdre Dingman, Philadelphia
The Backbone of the Insurance Industry
It’s disingenuous to assert that people “can’t always rely on insurance brokers to give them accurate information or steer them to comprehensive coverage” based on the unfortunate experience of one consumer with a short-term health plan, as Michelle Andrews did in the article “Think Your Health Care Is Covered? Beware of the ‘Junk’ Insurance Plan” (Dec. 4).
Agents and brokers are crucial to our nation’s efforts to get people covered. This year, they assisted almost half of all healthcare.gov enrollees — and brought 1.12 million new enrollees into the marketplace. It’s no wonder that a new report from the Centers for Medicare & Medicaid Services has called agents and brokers “instrumental in driving greater participation in the individual health insurance market.”
Further, agents and brokers have long maintained that short-term plans are not appropriate substitutes for comprehensive exchange coverage. We at the National Association of Health Underwriters stated as much in official comments filed with the Trump administration before it finalized a rule extending the duration of short-term plans to 12 months.
— Janet Trautwein, CEO of the National Association of Health Underwriters, Washington, D.C.
Not Tickling My Funny Bone
You ought to find some cartoonists who are not so flagrantly left-leaning — continuing to provide left-sided commentary is not right. It’s like all of the news stations pushing for socialism.
— Harry Gousha, Upland, California
Editor’s note: It is the tradition and mission among editorial cartoonists to satirize those in power. As with the nation’s leadership, the targets of political cartoons toggle from right to left. Balance is not these artists’ goal, but over time their commentary balances out. Stick with us, and we hope to amuse you in the future.
Troy Muenzer has seen the damage that COVID can do. A flight attendant who was diagnosed with a “suspected” case of the deadly virus, Muenzer, 32, endured months of lingering breathing problems; hefty, unexpected medical bills; lost wages, then furlough; and, earlier this month, the loss of his health insurance.
Last week, his bank account was hacked, causing him to lie awake one night worrying he wouldn’t be able to get back all that 2020 has taken. “From everything that’s happened this year, it just seems like it’s never-ending,” he said.
At the beginning of the pandemic, Congress passed several relief bills to help the country’s companies and its workforce: business grants and loans, paycheck protection for furloughed workers, one-time stimulus checks for taxpayers, expanded unemployment benefits. Much of the aid is set to expire by year’s end, if it hasn’t already.
This week, Muenzer’s furlough checks will stop coming. His monthly unemployment check is not enough to cover food and rent. He gave up his health insurance earlier this month because he could no longer afford the premium.
A little over two months ago, just before cutting his hours from few to none, his employer — a major airline — told him Congress could save his job. But lawmakers have shown they can’t, or won’t, put partisan politics aside to help the millions of Americans like Muenzer suffering the devastating impacts of the pandemic.
The chances for another round of pandemic relief before the end of the year look grim. Senate Majority Leader Mitch McConnell has signaled that Republicans could not accept a $908 billion bipartisan compromise written by moderates. Last spring, House Democrats introduced a proposal more than three times larger that they said was necessary to tackle the pandemic. Congress approved its last substantial relief bill nearly eight months ago.
Muenzer first got blindsided by COVID-19 in March. He was on a business trip, and as he got ready for bed in his hotel room, he began having trouble breathing. A former college football player who normally ran near his home by Lake Michigan, he lay awake, short of breath and terrified he would die in his sleep.
When the pandemic first gripped the nation, he had taken what precautions he could but was not permitted to wear a mask while working crowded flights. The Centers for Disease Control and Prevention did not recommend that Americans wear masks in public until April 3, but Muenzer was already sick.
Muenzer notified his employer that he had COVID symptoms and isolated himself at home. A telehealth doctor told him he needed in-person medical attention, but he was afraid he couldn’t afford it. He was already burning through his sick days.
Meanwhile, on April 14, with COVID cases exploding in cities like New York and San Francisco and among close-quartered groups like nursing homes and prisons, McConnell announced the Senate would extend its already weeks-long recess on the advice of public health officials. The day before, Democratic leaders said the House would do the same.
Congress had just passed a record $2 trillion stimulus package, its third relief measure. With House Democrats calling for more, including worker protections and medical leave, Rep. Kevin McCarthy of California, the House Republican minority leader, said it was too soon to talk about more aid. “I wouldn’t be so quick to say you have to write something else,” he said, according to NPR. “Let’s let this bill work.”
Muenzer did benefit from those early interventions. He received the one-time $1,200 stimulus check. But it barely made a dent in the wages he had lost being out sick, let alone once passenger demand cratered and the airline reduced his hours.
His employer was one of many companies that accepted help from the government on the condition they would temporarily hold off on furloughing employees. Muenzer was furloughed Oct. 1.
Muenzer has been receiving unemployment since then. But the extra $600 Congress gave the unemployed early in the pandemic expired long before that, and his monthly $1,200 unemployment check is not enough to cover his rent in Chicago, let alone food or medical care.
The relief legislation also required Muenzer’s private insurance plan to cover testing to detect or diagnose COVID-19 without Muenzer being required to pay anything. But that didn’t work.
The day the Senate extended its recess, Muenzer was so short of breath that he went to Northwestern Memorial Hospital’s emergency room. There, health care workers in full protective suits examined him and administered a chest X-ray. Diagnosed as “suspected COVID” and sent home to quarantine for 14 days, he did not get a COVID test.
With those critical diagnostic tests in short supply across the country at that time, they were reserved for seniors or patients with serious health conditions.
Muenzer received a bill for $108.59 for that emergency room visit, which he paid. Then another arrived, this one for $806.85 for the chest X-ray and other emergency room charges. Such billing problems were not unusual in the early days of the pandemic. Because COVID tests were not administered widely, patients like Muenzer lacked the official COVID diagnosis that required the medical system to zero out patient charges.
“I went to the COVID testing sign,” Muenzer said. “Then I didn’t even get tested and still got billed all that money.”
Muenzer was fortunate: A local television reporter heard about his problems and called the billing department herself. Though he had been fighting the bills for weeks, that day, the hospital returned Muenzer’s calls, blaming the problem on a coding error and assuring him his bills would be covered. But the hospital never returned his first payment.
When the payroll protection program’s conditions expired on Oct. 1, thousands of pilots, flight attendants like Muenzer and other airline employees — whose hours had already been trimmed — were furloughed. Muenzer said they were told the airline may be able to hold onto them a little longer, if Congress could pass another relief bill.
Indeed, Congress had considered legislation that would specifically bail out the airline industry. Muenzer watched as lawmakers debated bills that could have saved his job. But he did not overtly root for the legislation to pass. “It felt almost selfish,” he said. “Everybody’s hurting.”
Muenzer’s employer will stop sending him furlough pay on Dec. 15. Because it was calculated by averaging his pay for the past year, and his pay is based on flight hours, it wasn’t much. And given he has barely worked since he began feeling sick in March, his average work hours dropped significantly. He has tried to find a new job, but no luck yet.
But he feels lucky because he received furlough pay at all. He feels lucky because the hospital reduced his COVID testing bill to just $109. He feels lucky because he has family who can help him.
His company has assured its furloughed employees that they hope to bring them back in waves next year, if a vaccine is successful, if customer demand goes up again and if Congress can pass a relief bill.
That’s a lot of ifs at the moment — especially that last one, with Congress at a partisan logjam over a new COVID stimulus bill as it also tries to close out business for the year. Republicans are pushing for broader protections for businesses that could be sued if workers or customers become infected with the coronavirus. Democrats are pushing for funding for state and local governments battling the pandemic. Some lawmakers are also pushing for another round of one-time, $1,200 stimulus checks.
Even the bipartisan compromise would boost unemployment by only $300 a week through April. But it also includes support for the transportation sector, including airlines.
When he isn’t drowning out his anxieties watching Netflix, he keeps a close eye on Congress, “praying for something to happen.” It has been “very stressful, to say the least,” he said, “to feel like your life depends on the decisions of people in political power.”
The plain truth is that rural America has always had a market failure problem.
In the 1930s, the problem manifests as woefully inadequate telephone and electrical service. The spaces were just too wide open, the potential customers too few, for companies to invest in America’s in-between places.
In response to this market inefficiency, a federal government led by Franklin Roosevelt stepped in and created the Rural Electrification Administration (REA). Within 20 years, phone service was available to 65 percent of rural residents, and electricity extended to 96 percent. With the help of Washington, DC, modernity was extended to the heartland.
And now, when market orthodoxy is almost an unassailable truth and the federal government is less trusted than ever, another market failure stares us in the face. This time the technology is fast internet service (broadband), which was a concern before Covid-19 and is now a need arguably on par with electricity in 1936.
“The strength of High-Performance Broadband is that it will—if fully accessible to all in America—help solve some of our most critical challenges and help people overcome key barriers regardless of where they live and who they are,” reads an editorial published by the Benton Institute for Broadband and Society this past October.
It’s not that the federal government has simply entrusted rural internet service to companies that don’t provide it, though there is some of that. Since 1995, the Rural Utilities Service (successor to the REA) and Federal Communications Commission have doled out billions in subsidies. What the feds have not done is replace stop-gap funding mechanisms with a comprehensive plan that solves particular problems associated with inadequate rural broadband almost all urban dwellers never have to face.
At the time of the Benton Institute editorial, the most obvious critical challenge was Covid-19 and it remains so, even with the prospect of a vaccine on the horizon. It’s worth looking specifically at the ways Covid-19 has elevated the importance of broadband, particularly with regard to healthcare.
Most obviously and importantly, the pandemic has boosted the importance of telehealth as a means of bringing clinicians and patients safely together. What was an industry experiencing modest growth is now a healthcare sector boosted by rocket fuel.
“Between April 2019 and April 2020, national privately insured telehealth claims’ increased by 8,336 percent (as a proportion of total medical claims),” says the Health Affairs Blog. “While those ratios eventually tapered in the proceeding months as in-person visits rebounded, there’s no doubt that more patients and providers are relying on telehealth than ever before.”
Of course, safety is only the most pressing concern when it comes to telehealth. Before the pandemic, remote patient visits were driven by the pursuit of lower costs and greater convenience—factors that will once again rise to the top when Covid-19 is managed. The difference, when we arrive at that longed-for future date, will be that telehealth will have proliferated and wormed its way more deeply into common clinical practice.
All of that seems like progress, except that true progress doesn’t exclude millions of Americans. With limited broadband in rural areas, the blessings of telehealth will currently not fall on a large segment of the population.
According to Health Affairs, “The lack of broadband in rural areas is one of the most striking inequalities in US society. Due to the lack of broadband availability, tens of millions of rural Americans aren’t able to ‘see’ their doctor over the internet in the same way urban Americans can. Making matters worse, financially strapped rural hospitals are being shuttered by the dozens.”
It would be a mistake to see the failure of rural hospitals as uniquely a healthcare issue on either the cause or effect side of the technology equation. On the one hand, slow internet makes telehealth visits more difficult and sometimes impossible. On the other, slow internet also makes living in rural areas and earning a decent living very challenging, which dramatically limits the rural hospital’s potential patient base.
According to Alex Marre, a regional economist for the Federal Reserve, access to broadband improves wages, lowers unemployment, grows the population, and boosts home values, all of which creates a more stable base of support for local hospitals.
So, is there a market solution for what to date is a market failure? In a word, no. Well, not yet, at least. While the government may not be the broadband provider in the short or long term, some government involvement is probably a necessary component of the overall solution, especially with regard to money.
Another solution might be cooperatives, which helped extend the reach of electricity in the 1930s and have seen some broadband success in the modern era.
As CEO of Oklahoma Electric Cooperative, Patrick Grace leads an effort started in 2018 to extend fiber broadband to cooperative members. Working toward providing broadband to all 43,000 members, OK Fiber currently offers 100 Mbps speeds for $55 a month and 1 Gbps speeds for $85.
But what was true of electricity access also holds for broadband. Absent sufficient dollars, fiber networks take a long time to implement, regardless of how well managed the cooperative. For rural areas, time is of the essence, and concerted action may create a rural renaissance where there is currently a steady decline.
Returning to the Health Affairs Blog:
“Federal investment in rural electrification helped ignite investment across the country. Manufacturers didn’t have to locate near big cities, instead, they could build factories in rural areas where land was cheaper. Electric machinery and refrigeration made farms and ranches more productive. Today, in an era where remote work is increasingly common, rural and urban Americans alike need broadband to stay connected and productive.”
Again and again, we see that public health is an interrelated web of contributing factors. It’s education, and it’s housing, and it’s family support, and it’s job security. In the 1930s public health could undoubtedly be tied to electricity. In modern times, the equivalent is access to high-speed internet. The market has had sufficient time to provide a solution. Time for the public sector to come up with a comprehensive plan that includes private industry.
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.
BEVERLY HILLS, Calif. — As the pandemic took hold and well-grooved music festivals canceled their mainstream events, Krista Selico saw an opening. She had been organizing the Helix Festival as an opportunity to give artists in the urban music community a chance to redefine the genre for themselves, as well as choose more racially diverse headliners.
The industry’s destination festivals had excluded many diverse performers and types of music, she said, adding: “Urban music is so much more than what we hear on the radio.”
Although the COVID crisis dealt a blow to entertainment events worldwide, it also gave birth to new channels of entertainment. Netflix, Fever and Secret Cinema joined forces to create the Stranger Things “drive-into experience,” an immersive drive-thru concept that leads patrons through the world of the Netflix series “Stranger Things” from the safety — and distance — of their cars. A R I Z O N A, a band signed by Atlantic Records, performed an immersive livestream concert from Nashville on Oct. 29 through mySongbird, a new live-performance streaming app. Comedian Dave Chappelle has been hosting physically distanced comedy shows and music events at Wirrig Pavilion in Yellow Springs, Ohio, since May.
And Selico’s Helix Festival seemed primed for the COVID era.
Her goal was to feature less-mainstream offerings in a protected Caribbean environment — reportedly more affordable this year because COVID-19 has greatly eaten into conventional tourism. The lineup included Noise Cans, a Bermuda-born DJ based in the U.S. known as Collas who fuses Caribbean carnival music with electronic dance, Nigerian-American Afrobeats star Davido, and contemporary R&B/hip-hop artist Ty Dolla $ign.
“It’s called Helix Festival because we’re talking about our DNA,” said Selico, a University of Southern California graduate and health care administrator in Los Angeles. The festival was scheduled for October and sales were hot, with tickets in the $1,800-$3,000 price range.
Of course, with the pandemic spreading, Selico realized that festival patrons would see more health and safety precautions implemented. That could mean limited-capacity tickets with potentially higher price tags, suggesting that, in turn, artists and promoters would have to offer more of an experience in exchange for those sales.
At USC, Selico majored in cultural arts, with an emphasis in classical voice. She loved singing opera but felt shut out of the operatic world due to race. As a Black woman, she said, she felt pressured to fit into the limited mainstream molds Black artists are often pressed into: mainly hip-hop and R&B. She created Helix Festival to elevate and broaden the urban music menu.
Selico had been planning the luxury, urban music festival for two years before the pandemic hit. Because the festival was designed to be high-end, boasting private accommodations for attendees, she and her crew pushed forward with planning and promoting through the summer months, even as established festivals were canceling (many not offering refunds). “We’ll be on lockdown for two weeks, then two weeks turns into two months … but the ticket sales continued and no one’s asking for refunds,” she said.
Some large festivals such as Tomorrowland — a two-week-long Belgian electronic dance music festival — went fully virtual using streaming services, but Selico’s was planned for overseas, on an island — Jamaica — with a low COVID case count. And at an expansive resort — the Bahia Principe Grand in Runaway Bay — where safe outdoor enjoyment and social distancing seemed plausible.
The festival’s COVID-19 precautions were developed using the same protocols established by Jamaica’s Ministry of Tourism, Ministry of Health & Wellness (MoHW), the Jamaica Tourist Board and the Tourism Product Development Co. From intake to departure, Selico said, coronavirus precautions would be in place.
She knew she would have to orchestrate her first festival with more precautions than any prior such event and less of a fun-filled, devil-may-care attitude: “If someone gets dehydrated and passes out, we’ve got to test them for everything now,” she said.
Because of the setting, Selico reasoned that COVID-era safety adjustments wouldn’t seem onerous. Even before the pandemic, a luxury component of Helix was private beach “pods” for patrons spaced at least 6 feet apart for lounging on the beach. And “everything is digital,” she said. There would be no exchange of physical money or tickets at Helix Festival, similar to procedures restaurants across America are adopting, along with doing away with physical menus.
She put extra safeguards in place:
Attendees would be required to submit negative COVID test results 48 hours before arrival and, in lieu of rum punch, would be greeted with temperature checks at the airport, at other transit points and before entering the festival grounds. Face masks would be required on all trips to and from the airport and resort.
If an attendee exhibited COVID-19 symptoms, the Helix Festival site stated, they would be moved into a designated isolation room at the venue for screening by a COVID-19 Safety Point Person — an employee designated to conduct spot checks, which the Jamaican government now requires of both the hotel and festival organizers. The MoHW would be contacted and, if necessary, the attendee would be put into mandatory quarantine.
During concerts, guests would be seated in every other seat in all open seating areas, while groups who arrive together could sit next to one another. A minimum distance of 6 feet would be maintained between patrons and performers on designated stage areas, an easy feat considering the Helix Festival’s main stage was to be set on the ocean in the middle of a small bay on the resort.
For an even more enhanced luxury experience, and elevated social distancing, guests could purchase such upgrades as a VIP cabana for up to six people, or for $6,000 guests could rent a private catamaran — the festival’s version of box seats — for up to 10 people, docked around the floating stage.
When patrons weren’t getting their urban music palates expanded by acts on the main stage, themed events would feature visual artists, fire dancers and even a hologram light show presented by Chad Knight, a 3D designer with Nike. These activities — including any water sports — would be limited to follow social distancing requirements, the festival’s site stated.
According to the festival site, no food or beverages would be sold on festival grounds — another break from pre-COVID music festivals. Prepaid top-shelf liquor and snack boxes would be prepackaged and individually sealed before distribution at check-in. Hand-sanitizer stations would be strategically placed throughout the festival grounds, as well as touchless waste bins.
With the average ticket pricing starting at around $2,000 and no sure way to guarantee attendees would be permitted across the Jamaican border or quarantined, in late August Selico decided to postpone the festival until fall 2021. Tickets to the nearly sold-out event were refunded at 100%. “We’re going to add more artists. We’re going to be able to expand on this health care aspect,” Selico said.
And, since COVID-19 is likely to be around for a while, vaccine or not, she is confident she has developed the expertise to be a pandemic-friendly festival promoter. “I think this is the model for festivals going forward,” Selico said.
During a Dec. 8 press conference about Operation Warp Speed, President Donald Trump likened the spread of the coronavirus throughout the population — which experts agree bestows some immunity on the people who became ill — to having a COVID-19 vaccine.
“You develop immunity over a period of time, and I hear we’re close to 15%. I’m hearing that, and that is terrific. That’s a very powerful vaccine in itself,” said Trump, who was responding to a reporter’s question about what his message to the American people was as the holidays approach and levels of COVID cases in the U.S. continue to rise.
It wasn’t the first time Trump had given credence to the idea that if enough people in a population gain immunity to a disease by being exposed to it, the illness won’t be able to spread through the remainder of the population — a concept known as “herd immunity.”
However, experts have warned that attempting to achieve herd immunity naturally, by allowing people to get sick with COVID-19, could result in more than a million deaths and potentially long-term health problems for many. A better way to achieve protection across the population, experts say, is through widespread vaccination.
So, we thought it was important to check whether 15% is anywhere close to the herd immunity threshold, and whether this level of natural immunity could be considered “as powerful as a vaccine.”
15% Is Nowhere Close
The White House did not respond to our request for more information about the comment or about Trump’s 15% figure.
It may be derived from a Nov. 25 Centers for Disease Control and Prevention report using mathematical models to estimate that 53 million Americans — about 16% of the population — have likely been infected with COVID-19. Those models took into consideration the nation’s number of confirmed cases, and then used existing data to calculate estimates of the number of people who had COVID-19 but didn’t seek medical attention, weren’t able to access a COVID-19 test, received a false-negative test result or were asymptomatic and unaware they had COVID-19.
It’s important to note this estimate is based on data from February through September — and it’s now mid-December, so the share of Americans who have been infected with the coronavirus would likely be much higher. For instance, an independent data scientist, Youyang Gu, estimated that 17.5% of Americans have had COVID-19 as of Nov. 30. His estimate is published on his website, COVID Projections.
Experts have said that a 15% infection rate among Americans is nowhere close to the threshold needed to reach herd immunity against COVID.
“To get to herd immunity, an estimated 60-80% of people need to have immunity (either through natural infection or through the vaccine),” Dr. Leana Wen, an emergency physician and visiting professor at George Washington University, wrote in an email. “We are a very long way off from that.”
Also, Wen said, scientists still don’t know enough about how effective natural immunity is in defending against COVID-19. It appears that once someone has had COVID-19 and recovered, the antibodies their body produced can protect them for at least several months. But, there have also been reports of COVID-19 re-infection.
Dr. Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases, recently set the saturation level for herd immunity even higher — between 75% and 80% — in an interview with Axios.
At that point, he said, “you create an umbrella of herd immunity — that even though there is virus around, it is really almost inconsequential because it has no place to go, because almost all of the people are protected.”
Both the Pfizer and Moderna COVID-19 vaccines have shown 95% effectiveness at protecting people from developing COVID-19 in clinical trials. The Food and Drug Administration on Friday authorized Pfizer’s vaccine for emergency use. This Thursday, an independent panel will consider whether to recommend that the FDA authorize the emergency use of Moderna’s COVID-19 vaccine.
So, that leads to the next question: Is 15% natural immunity among the American population anywhere close to a “powerful vaccine,” as Trump alleges?
No, said the experts. And there’s nothing “terrific” about that level of infection within the community.
“Fifteen percent ‘natural immunity’ is nowhere close to as powerful as a vaccine,” Dr. Rachel Vreeman, director of the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai, wrote in an email.
Assuming that natural immunity is effective, reaching a level of 15% of the population would prevent only those individuals who have had COVID from getting sick again, said Stephen Morse, an epidemiology professor at Columbia University.
“But [it] won’t do much to prevent virus spread in the community, because there are still so many susceptible people,” Morse wrote in an email. Plus, 15% of the American population having had COVID-19 “has come at a high cost,” Morse wrote. To achieve 15% natural immunity, more than 300,000 people in the U.S. have been sacrificed.
Though Trump was in the ballpark when he referenced the share of Americans who have been infected with the coronavirus, his overall point — that the natural immunity these people acquired is a powerful vaccine — does not hold up. Experts repeatedly have warned that not enough is known about the immunity people appear to gain after recovering from a COVID-19 infection to know how effective or lasting it is. And there have been reported cases of COVID re-infections.
Also, experts agree more than 70% of the U.S. population needs to be vaccinated in order to reach herd immunity. Fifteen percent is nowhere close to that threshold and should not be considered as effective as a COVID-19 vaccine. Moreover, that 15% statistic brought with it hundreds of thousands of deaths.
Tisha Coleman ha vivido en el muy unido condado de Linn, Kansas, por 42 años. Y nunca se ha sentido tan sola.
Como administradora de salud pública, ha luchado cada día de la pandemia para mantener a salvo a su condado rural, ubicado a lo largo de la frontera con Missouri. A cambio, ha sido acosada, demandada, vilipendiada y le han gritado “cumple-órdenes”.
Los meses de peleas por máscaras y cuarentenas ya la estaban desgastando. Luego contrajo COVID-19, probablemente de su esposo, quien se ha negado a exigir el uso de máscaras en la ferretería familiar. Su madre también lo contrajo y murió el domingo 13 de diciembre.
En todo Estados Unidos, funcionarios de salud pública estatales y locales se han encontrado en el centro de una tormenta política.
Algunos han sido el blanco de activistas de extrema derecha, grupos conservadores y extremistas antivacunas, que se han unido en torno a objetivos comunes: luchar contra los mandatos de uso de máscaras, las cuarentenas y el rastreo de contactos, con protestas, amenazas y ataques personales.
El poder de la salud pública también se está socavando en los tribunales. Legisladores, en al menos 24 estados, han diseñado leyes para debilitar poderes que la salud pública ha mantenido por mucho tiempo.
En medio de este retroceso, desde el 1 de abril, al menos 181 líderes de salud pública estatales y locales, en 38 estados, han renunciado, se han jubilado o han sido despedidos, según una investigación en curso de The Associated Press y KHN. Expertos dicen que se trata del éxodo más grande de líderes de salud pública en la historia de los Estados Unidos.
Uno de cada 8 estadounidenses, 40 millones de personas, vive en una comunidad que perdió a su líder de salud pública local durante la pandemia. En 20 estados, los principales funcionarios de salud pública han dejado sus puestos, y también se ha ido un número incalculable de empleados de niveles inferiores.
Muchos de los líderes se retiraron debido al retroceso político o la presión de la pandemia. Algunos se fueron para ocupar puestos de más alto perfil o por problemas de salud. Otros fueron despedidos por mal desempeño. Docenas se jubilaron.
“No tenemos gente haciendo fila afuera para cubrir estos puestos”, dijo el doctor Gianfranco Pezzino, oficial de salud en el condado de Shawnee, Kansas, quien se está retirando anticipadamente de su trabajo. “Es una gran pérdida que es probable que impacte en las generaciones futuras”.
Estas partidas son una erosión adicional a la ya frágil infraestructura de salud pública del país, antes de la campaña de vacunación más grande en la historia de los Estados Unidos.
AP y KHN informaron anteriormente que, desde 2010, el gasto per cápita de los departamentos de salud pública estatales se había reducido en un 16%, y en los departamentos de salud locales, un 18%. Al menos 38,000 empleos de salud pública estatales y locales han desaparecido desde la recesión de 2008.
Desde que comenzó la pandemia, la fuerza laboral de salud pública en Kansas se ha visto muy afectada: 17 de los 100 departamentos de salud del estado han estado perdiendo a sus líderes desde finales de marzo.
La gobernadora demócrata Laura Kelly emitió un mandato de uso de máscaras en julio, pero la legislatura estatal permitió que los condados optaran por no participar. Un informe reciente de los Centros para el Control y Prevención de Enfermedades (CDC) mostró que los 24 condados de Kansas que habían cumplido con este mandato registraron una disminución del 6% en los casos de COVID-19, mientras que los 81 condados que optaron por no participar por completo vieron un aumento del 100%.
Coleman presionó para que el condado de Linn mantuviera la regla, pero los comisionados escribieron que las máscaras “no son necesarias para proteger la salud pública y la seguridad del condado”.
Coleman se sintió decepcionada, pero no sorprendida. “Al menos sé que he hecho todo lo posible para intentar proteger a la gente”, dijo.
En Boise, Idaho, el 8 de diciembre, cientos de manifestantes, algunos armados, invadieron las oficinas de salud del distrito y las casas de los miembros de la junta de salud, gritando y haciendo sonar las bocinas. Entre ellos había miembros del grupo anti-vacunas Health Freedom Idaho.
Según expertos, el movimiento contra las vacunas se ha vinculado con extremistas políticos de derecha, y ha asumido un papel más amplio en contra de la ciencia, rechazando otras medidas de salud pública.
Ahora, los opositores están recurriendo a las legislaturas estatales, e incluso a la Corte Suprema, para despojar a los funcionarios públicos del poder legal que han tenido durante décadas para detener las enfermedades transmitidas por alimentos y las enfermedades infecciosas mediante el cierre de negocios y las cuarentenas, entre otras medidas.
Legisladores de Missouri, Louisiana, Ohio, Virginia y al menos otros 20 estados han elaborado proyectos de ley para limitar los poderes de la salud pública. En algunos estados, estos esfuerzos han fracasado; en otros, los han acogido con entusiasmo.
Mientras tanto, los gobernadores de varios estados, incluidos Wisconsin, Kansas y Michigan, han sido demandados por sus propios legisladores, u otros, por utilizar sus poderes ejecutivos para restringir las operaciones comerciales y exigir máscaras.
Un fallo de 5-4 el mes pasado indicó que la Corte Suprema también está dispuesta a imponer nuevas restricciones a los poderes de la salud pública. Lawrence Gostin, experto en derecho de salud pública de la Universidad Georgetown, en Washington, DC, dijo que la decisión podría animar a legisladores estatales y a gobernadores a buscar limitaciones adicionales.
Junto con la reacción política, muchos funcionarios de salud se han enfrentado a amenazas violentas. En California, un hombre con vínculos con el movimiento de derecha Boogaloo, que está asociado con múltiples asesinatos, fue acusado de acechar y amenazar al funcionario de salud de Santa Clara. Fue arrestado y se declaró inocente.
Linda Vail, funcionaria de salud del condado de Ingham, en Michigan, recibió correos electrónicos y cartas en su casa diciendo que sería “derrocada como la gobernadora”, lo que interpretó como una referencia al intento frustrado de secuestrar a la gobernadora demócrata Gretchen Whitmer.
“Puedo entender completamente por qué algunas personas simplemente se fueron”, dijo. “Hay otros lugares para ir a trabajar”.
A medida que los funcionarios de salud pública a lo largo del país parten, la cuestión de quién ocupa sus lugares preocupa a la doctora Oxiris Barbot, quien dejó su trabajo como comisionada del departamento de salud de la ciudad de Nueva York en agosto en medio de un enfrentamiento con el alcalde demócrata Bill de Blasio.
“Me preocupa si tendrán la fortaleza necesaria para decirles a los funcionarios electos lo que necesitan escuchar en lugar de lo que quieren escuchar”, dijo Barbot.
En el condado de Linn, los casos están aumentando. Hasta el 14 de diciembre, 1 de cada 24 residentes había dado positivo para COVID.
“Por supuesto, podría rendirme y colgar la toalla, pero todavía no he llegado a ese punto”, dijo Coleman.
Ha notado que más personas usan máscaras en estos días.
Pero en la ferretería familiar, todavía no son mandatorias.
Michelle R. Smith es reportera de AP, y Anna Maria Barry-Jester, Hannah Recht y Lauren Weber son reporteras de KHN.
Esta historia es una colaboración entre The Associated Press y KHN (Kaiser Health News), un servicio de noticias sin fines de lucro que cubre temas de salud. Es un programa editorialmente independiente de KFF (Kaiser Family Foundation) que no tiene relación con Kaiser Permanente.
More than 300,000 people have died from COVID-19 in the United States.
It is the latest sign of a generational tragedy — one still unfolding in every corner of the country — that leaves in its wake an expanse of grief that cannot be captured in a string of statistics.
“The numbers do not reflect that these were people,” said Brian Walter, of New York City, whose 80-year-old father, John, died from COVID-19. “Everyone lost was a father or a mother, they had kids, they had family, they left people behind.”
There is no analogue in recent U.S history to the scale of death brought on by the coronavirus, which now runs unchecked in countless towns, cities and states.
“We’re seeing some of the most deadly days in American history,” said Dr. Craig Spencer, director of Global Health in Emergency Medicine at NewYork-Presbyterian/Columbia University Medical Center.
During the past two weeks, COVID-19 was the leading cause of death in the U.S., outpacing even heart disease and cancer.
“That should be absolutely stunning,” Spencer said. And yet the most deadly days of the pandemic may be to come, epidemiologists predict.
Even with a rapid rollout of vaccines, the U.S. may reach a total of more than half a million deaths by spring, said Ali Mokdad of the Institute for Health Metrics and Evaluation at the University of Washington.
Some of those deaths could still be averted. If everyone simply began wearing face masks, more than 50,000 lives could be saved, IHME’s model shows. And physical distancing could make a difference too.
No other country has come close to the calamitous death toll in the U.S. And the disease has amplified entrenched inequalities. Blacks and Hispanics/Latinos are nearly three times more likely to die from COVID-19 than whites.
“I’m really amazed at how we have this sense of apathy,” said Dr. Gbenga Ogedegbe, a professor of medicine and population health at New York University Grossman School of Medicine. He said there’s evidence that socioeconomic factors, not underlying health problems, explain the disproportionate share of deaths.
The disease, he said, reveals “the chronic neglect of Black and brown communities” in this country.
Though the numbers are numbing, for bereaved families and for front-line workers who care for people in their dying moments, every life is precious.
Here are reflections from people who’ve witnessed this loss — how they are processing the grief and what they wish the rest of America understood.
‘There Are Things We Can Do to Still Make a Difference’
Darrell Owens, a doctor of nursing practice in Seattle, was startled to learn recently that he had signed more death certificates for COVID-19 than anyone else in Washington.
“I’m feeling much more anger and frustration than I did before because much of what we’re dealing with now was preventable,” Owens said.
“We’re all in this great big storm, but some people are in a yacht and some people are on a cruise ship and some people are on a raft,” he added. “We’re not all in this together.”
Owens still finds moments of grace and meaning as he cares for the dying.
“The other day, there was a lady I was taking care of who’d come from a local nursing home and it was very clear that she was nearing the end,” Owens said. “I just picked up her hand. I sat there. I held her hand for about 25 minutes until she took her last breath.”
He stepped out of the room and called the patient’s daughter.
“It made such a difference for her that her mom was not alone,” he said. “What an incredible gift that she gave me and that I was able to give her daughter. So there are things that we can do to still make a difference.”
‘It’s Not a Joke. It’s Not a Hoax.’
Since his father died of COVID-19 in the spring, Brian Walter of Queens, New York, has helped run a support group on Facebook for people who’ve lost family and friends to COVID-19.
It’s helped him grieve his father John, whom he describes as a very loving man dedicated to his autistic grandson and to running a youth program for teenagers.
“It’s been lifesaving in a lot of ways,” Walter said. “Together, we face a lot of issues since we are grieving in isolation. But at the same time, we’re also dealing with people that openly tell us that this is not a real condition, that this is not a real issue.”
Some in their group admit they denied the severity of the virus and shunned precautions until it was too late.
“It’s not a joke. It’s not a hoax, and you will not understand how horrible this is until it enters your family and takes away someone,” he said.
All of this complicates the grief, but it has also led Walter and others in his group to speak out and share their stories, so that numbers don’t obscure the actual people who were leading full lives before dying from COVID-19.
“I know what it’s like to have to say goodbye to somebody over a Zoom call and to not have a funeral,” Walter said.
‘300,000 Stories That Got Shut Down Too Quickly’
Martha Phillips, an ER nurse who took assignments in New York and Texas in the spring and summer, said there is one patient who has become almost a stand-in for the grief of the many whose deaths she witnessed.
It was the very last COVID patient she cared for in Houston.
“I reached down to just adjust her oxygen tubing just a little bit,” Phillips recalled. “And she looks up at me and she sees me through my goggles and my mask and my shield and meets my eyes and she goes, ‘Do you think I’m going to get better?’”
“What do you say to someone who’s not ready to die? Who has so much to live for, but got this and now they’re trapped?”
Two months later, Phillips discovered the woman’s obituary online.
“That one was the hardest,” she said. “But there’s 300,000 people who had time left that was stolen from them; 300,000 stories that got shut down too quickly.”
‘This Is Worse Than Being in War’
ER physician Dr. Cleavon Gilman, a veteran of the Iraq War, said it’s still hard to communicate the brutality of a disease that kills people in the privacy of a hospital wing.
When Gilman was in New York City during the spring surge, he never imagined the U.S. would be losing thousands of people each day to COVID-19 so many months later.
“That 300,000 Americans would be dead and life would go on and people would not have empathy for their fellow Americans,” he said. “I can tell you this is worse than being in war.”
The enemy is invisible, he said, the war zone is everywhere, and many refuse to take the most simple actions to combat the virus, even as morgues fill up in their own community.
Throughout the pandemic, Gilman, who is now working in Yuma, Arizona, has shared photos and stories of people who’ve died from COVID-19 each day on social media. “It’s really important to honor them,” he said.
This story is from a reporting partnership with NPR and KHN.
If clinical trials for COVID-19 vaccines aren’t expanded soon to include children, it’s unlikely that even kids in their teens will be vaccinated in time for the next school year.
The hurdle is that COVID vaccine makers are only in the early stages of testing their products on children. The Pfizer vaccine authorized for use by the Food and Drug Administration on Friday was greenlighted only for people ages 16 and up. Moderna just started trials for 12- to 17-year-olds for its vaccine, likely to be authorized later this month.
It will take months to approve use of the vaccines for middle- and high school-aged kids, and months more to test them in younger children. But some pediatricians say that concerns about the safety of the front-runner vaccines make the wait worthwhile.
Although most pediatricians believe the eventual vaccination of children will be crucial to subduing the COVID virus, they’re split on how fast to move toward that, says Dr. James Campbell, professor of pediatrics at the University of Maryland School of Medicine’s Center for Vaccine Development and Global Health. Campbell and colleagues say it’s a matter of urgency to get the vaccines tested in kids, while others want to hold off on those trials until millions of adults have been safely vaccinated.
Much of the debate centers on two issues: the degree of harm COVID-19 causes children, and the extent to which children are spreading the virus to their friends, teachers, parents and grandparents.
COVID-19’s impact on children represents a tiny fraction of the suffering and death experienced by vulnerable adults. Yet it would qualify as a pretty serious childhood disease, having caused 154 deaths and more than 7,500 hospitalizations as of Dec. 3 among people 19 and younger in the United States. Those numbers rank it as worse than a typical year of influenza, and worse than diseases like mumps or hepatitis B in children before the vaccination era.
Studies thus far show that 1%-2% of children infected with the virus end up requiring intensive care, Dr. Stanley Plotkin, professor emeritus of pediatrics at the University of Pennsylvania, told a federal panel. That’s in line with the percentage who become gravely ill as result of infections like Haemophilus influenza type B, or Hib, for which doctors have vaccinated children since the 1980s, he pointed out.
Campbell, who with colleagues has developed a plan for how to run pediatric COVID vaccine trials, points out that “in a universe where COVID mainly affected children the way it’s affecting them now, and we had potential vaccines, people would be clamoring for them.”
The evidence that teens can transmit the disease is pretty clear, and transmission has been documented in children as young as 8. Fear of spread by children has been enough to close schools, and led the American Academy of Pediatrics to demand that children be quickly included in vaccine testing.
“The longer we take to start kids in trials, the longer it will take them to get vaccinated and to break the chains of transmission,” said Dr. Yvonne Maldonado, a professor of pediatrics at Stanford University who chairs the AAP’s infectious disease committee. “If you want kids to go back to school and not have the teachers union terrified, you have to make sure they aren’t a risk.”
Other pediatricians worry that early pediatric trials could backfire. Dr. Cody Meissner, chief of pediatric infectious diseases at Tufts Medical Center and a member of the FDA’s advisory committee on vaccines, is worried that whatever causes Multisystem Inflammatory Syndrome in Children, a rare but frightening COVID-related disorder, might also be triggered, however rarely, by vaccination.
Meissner abstained from the committee’s vote Thursday that supported, by a 17-4 vote, an emergency authorization of the Pfizer vaccine for people 16 and older.
“I have trouble justifying it for children so unlikely to get the disease,” he said during debate on the measure.
But panel member Dr. Ofer Levy, director of the Precision Vaccines Program at Boston Children’s Hospital, said the 16-and-up authorization would speed the vaccine’s testing in and approval for younger children. That is vital for the world’s protection from COVID-19, he said, since in the United States and most places “most vaccines are delivered early in life.”
While vaccines given to tens of thousands of people so far appear to be safe, the lack of understanding of the inflammatory syndrome means that children in any trials should be followed closely, said Dr. Emily Erbelding, director of the Division of Microbiology and Infectious Diseases at the National Institute of Allergy and Infectious Diseases.
Under a 2003 law, vaccine companies are required eventually to test all their products on children. By late last month, Pfizer had vaccinated approximately 100 children 12-15 years of age, said spokesperson Jerica Pitts.
Moderna has started enrolling 3,000 children 12 and over in another clinical trial, and other companies have similar plans. Assuming the trials show the vaccines are safe and provide a good immune response, future tests could include progressively younger children, moving to, say, 6- to 12-year-olds next, then 2- to 6-year-olds. Eventually, trials could include younger toddlers and infants.
Similar stepdown approaches were taken to test vaccines against human papillomavirus (HPV), influenza and other diseases in the past, Erbelding noted. Such trials are easiest to conduct when researchers know that a measurable immune response, like antibody levels in the blood, translates to effective protection against disease. Armed with such knowledge, they can see whether children were protected without them having to be exposed to the virus. Federal scientists hope to get that data from the Moderna and Pfizer adult vaccine trials, she said.
Vaccine trials geared to tweens or younger children may involve testing half-doses, which, if protective, would require less vaccine and might cause fewer incidents of sore arms and fevers that afflicted many who’ve received the Pfizer and Moderna vaccines, Campbell said.
But unless additional studies begin quickly, the window for having an FDA-authorized vaccine available before the next school year “will be closed even for our oldest children,” said Dr. Evan Anderson, a pediatrics professor at Emory University. “Our younger children are almost certainly going into next school year without a vaccine option available for them.”
In the meantime, teachers are likely to be high on the priority list for vaccination. Protecting school staff could allow more schools to reopen even if most children can’t be vaccinated, Erbelding said.
Eventually, if the SARS-CoV-2 virus remains in circulation, governments may want to mandate childhood vaccination against the virus to protect them as they grow up and protect society as a whole, Plotkin said.
In the 1960s, Plotkin invented the rubella vaccine that has been given to hundreds of millions of children since. Like COVID-19, rubella, or German measles, is not usually a serious illness for children. But congenital rubella syndrome afflicted babies in the womb with blindness, deafness, developmental delays and autism. Immunizing toddlers, which, in turn, protects their pregnant mothers, has indirectly prevented hundreds of thousands of such cases.
“We don’t want to use children to protect everyone in the community,” said Campbell. “But when you can protect both children and their community, that’s important.”
And while a coronavirus infection may not be bad for most children, missed school, absent friends and distanced families have caused them immense suffering, he said.
“It’s a huge burden on a child to have their entire world flipped around,” Campbell said. “If vaccinating could help to flip it back, we should begin testing to see if that’s possible.”
Over the course of the pandemic, COVID-19 infections have battered high-poverty neighborhoods in California on a staggeringly different scale than more affluent areas, a trend that underscores the heightened risks for low-wage workers as the state endures a deadly late-autumn surge.
A California Healthline review of local data from the state’s 12 most populous counties found that communities with relatively high poverty rates are experiencing confirmed COVID-19 infection rates two to three times as high as rates in wealthier areas. By late November, the analysis found, about 49 of every 1,000 residents in the state’s poorest urban areas — defined as communities with poverty rates higher than 30% — had tested positive for COVID-19. By comparison, about 16 of every 1,000 residents in comparatively affluent urban areas —communities with poverty rates lower than 10% — had tested positive.
Epidemiologists say the findings offer evidence of the outsize risk being shouldered by the millions of low-wage workers who live in those communities and do the jobs state and federal officials have deemed essential in the pandemic. These are the grocery store clerks, gas station cashiers, home health aides, warehouse packers, meat processors, hospital janitors and myriad other retail and service employees whose jobs keep the rest of us comfortable, clothed and fed. Those jobs cannot be done remotely.
“People are being forced to go to work, possibly not able to protect themselves adequately,” said Dr. Christian Ramers, an infectious disease specialist at Family Health Centers of San Diego. “If you are living paycheck to paycheck, it’s a very hard decision for some people, if they feel OK, to not go to work or to even quarantine if they know that they were exposed, because they need to pay rent and they need to pay the bills.”
To examine income and COVID infection rates, California Healthline obtained data showing the number of cases for each ZIP code in nine of the state’s 12 most populous counties: Alameda, Fresno, Kern, Orange, Riverside, Sacramento, San Diego, San Francisco and Santa Clara. For three other counties that organize the data differently — Los Angeles, Contra Costa and San Bernardino — we obtained infection rates at the neighborhood and city level. We then cross-referenced those infection figures with U.S. census data showing poverty levels by community. Federal regulations set the poverty line for the 48 contiguous states at $26,200 in annual income for a family of four.
The analysis revealed a common pattern of COVID spread, in which neighborhoods within the same city, often just miles apart, had vastly different infection rates, with higher-poverty areas hit hardest.
For example, in the 94621 ZIP code in southern Oakland, where nearly 30% of residents live below the poverty line, there were about 54 confirmed infections per 1,000 people as of late November. Several miles north, in the 94618 ZIP code — the Rockridge and Upper Rockridge neighborhoods, where about 5% of residents live below the poverty line — there were about four confirmed infections per 1,000 people as of late November.
At Family Health Centers of San Diego, which operates dozens of primary care, dental and behavioral health clinics in San Diego County, more than 90% of patients qualify as low-income and nearly 30% don’t have insurance. Ramers said the recent surge in coronavirus cases has ripped through his patients’ communities at a quicker pace than in San Diego’s many affluent neighborhoods.
“It’s southeast San Diego, it’s El Cajon and it’s all of the South Bay communities right by the [Mexican] border,” Ramers said. “They have the lowest socioeconomic status amongst other indicators, and that is exactly where we’re seeing the hardest-hit communities with COVID.”
Ramers said he recently treated a patient who works at a sandwich shop. She developed a fever and told her boss she had possible COVID symptoms. “He said, ‘No, you have to get to work,’” Ramers said. “I started asking about what kind of PPE [personal protective equipment] does she get? She is in a crowded kitchen making sandwiches for hundreds of people, probably, and I think she got one mask every couple of days.”
Her employer ultimately gave her permission to miss work, but only after Ramers confirmed the COVID diagnosis and issued a formal doctor’s note saying she needed to stay home.
Research indicates residents of low-income neighborhoods are curtailing outings and social gatherings as much as anyone else during the pandemic — with the key exception that, unlike many white-collar workers, they have to leave home to work. Jonathan Jay, assistant professor of community health sciences at Boston University, recently co-authored a study that used smartphone data to see whether people in low-income areas were maintaining physical distance as much as people in more affluent areas.
“We didn’t find anything that would confirm the idea that lower-income people were unaware or unmotivated,” Jay said. “What we found was suggestive of their having the same level of awareness, the same level of motivation, and simply the only evidence we found to explain the difference in physical distancing was the work-related behaviors.”
Dr. Kirsten Bibbins-Domingo, professor and chair of the Department of Epidemiology and Biostatistics at the University of California-San Francisco, noted that low-wage workers also tend to live in densely crowded households. In other words, she said, it is often hard to isolate yourself if you are poor.
“If somebody has a positive test, I advise them that they should not be living with other people in their household; or, if they have to stay in the same household, that they separate to a separate room, a separate bathroom, ideally, and that people wear masks in the house,” she said.
“You can see that if their normal living environment is doubled up, tripled up, quadrupled up, that those strategies won’t work.”
Bibbins-Domingo called on community and business leaders to embrace policies that ensure essential workers get paid time off if they contract COVID-19. Legislators at the federal and state level have passed laws intended to expand the ranks of employees guaranteed paid sick leave for COVID-19, but many small businesses are exempt. She said public agencies also should consider paying for hotel rooms so people who live in crowded households can quarantine.
She praised California’s decision to tie COVID-related restrictions on activities in each county to a “health equity metric,” which ensures infection rates are low in all neighborhoods, not just wealthy ones.
“What the failure has been is to recognize that poor communities always have higher transmission during a pandemic; that we sort of expect to happen,” she said. “Knowing that is going to happen, it’s the responsibility of policymakers to actually put protections in place, to help the communities with the least resources to address the needs in the pandemic.”
Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.
Data for this article came from 12 county health departments and the U.S. Census Bureau’s five-year 2014-18 American Community Survey. The Census Bureau creates geographies called ZIP Code Tabulation Areas that are based on ZIP codes but may not exactly match ZIP code boundaries. For most counties, a ZIP code is the smallest geography available for infection data released online. Infection data was obtained from county websites on Nov. 23. All counties appear to update their ZIP code data frequently but some may lag more than others. When available, the analysis used confirmed infection rates and population data provided by counties; otherwise, census data was used to calculate infection rates. The analysis excluded ZIP codes, cities and neighborhoods with fewer than 5,000 residents.
As 170 research teams race to develop a vaccine for COVID-19, some that are in late-stage approvals have seen recent progress, but it is still not yet clear when a vaccine will become widely available. Until then, healthcare organizations continue to rely heavily on data analytics to try to improve COVID-19 outcomes and public health.
Since the novel coronavirus became widespread in the U.S., healthcare data scientists have leveraged clinical and claims data to pinpoint which underlying conditions put patients at higher risk of complications from COVID-19. Health systems are mining clinical data to predict surges in COVID-19 cases and looking at key factors—including increases in hospital website traffic, such as searches for emergency department (ED) wait times and physician page clicks—to understand how COVID-19 is ramping up locally in real-time. Meanwhile, risk-based modeling has helped health plans address social determinants of health that could impede recovery.
Now, providers and health plans are refining their approach. The more they learn, the greater the benefit to public health and long-term outcomes. Three evolving use cases for using claims and clinical data to combat COVID-19 stand out.
Reduce disparities in care. Early in the pandemic, lack of complete information around patient demographics prevented the identification of members in communities that were most vulnerable to COVID-19 infection. The impact: severe differences in mortality rates. In Chicago, the rate of mortality among Black residents was alarmingly high—70% of COVID-19 deaths—even though these residents comprise just 29% of the city’s population. Meanwhile, Spanish-speaking residents account for 18.3% of the nation’s population, yet comprise 34.3% of coronavirus cases.
One of the reasons demographic data was often missing from COVID-19 lab tests is that laboratory and hospital staff were too overwhelmed with cases to have time to input all of a patient’s non-clinical information. Today, data scientists are working to fill in the gaps using clinical history and medical claims. With these analyses, healthcare organizations are closing gaps in care, such as by expanding access to COVID-19 testing for the nation’s most vulnerable populations and increasing access to professional interpreters to more effectively gather key patient details. They are also addressing social determinants of health that heighten risks, such as food insecurity and lack of access to prescription medications.
Alleviate reliance on spotty testing. Not everyone who contracts COVID-19 has a healthcare encounter. For instance, if one member of the household tests positive for the coronavirus, other members may decide not to undergo testing if their symptoms are mild. These are instances where analyses of clinical and claims information already in the system—both emerging and historical data—can help spot unconfirmed cases of COVID-19. Such analyses give public health officials the information they need to contact, test,s and quarantine individuals that have contracted the virus, helping to limit the spread of the disease.
On a wider scale, data analysis can also provide early warning surveillance of potential COVID-19 cases, strengthening the pandemic response. For example, by observing increases in medical claims for telemedicine, rapid flu tests, and chest X-rays, data scientists can detect patterns in claims that suggest a COVID-19 outbreak is likely to occur. From there, they can forecast demand for hospital care up to 10 days in advance, ensuring that facilities have sufficient staff, supplies, and beds available to meet their community’s needs. Similarly, disruptions to seasonal flu trends, which remain fairly consistent within a region year over year, could alert public health officials to a potential COVID-19 outbreak.
Avoid preventable deaths. Information regarding patients’ underlying medical conditions can be hard to come by during a public health crisis as overwhelming and widespread as the current pandemic. In fact, just 5.8% of medical records for patients hospitalized with COVID-19 in Q1 2020 had data available related to their underlying health conditions and other risk factors. Today, it is known that certain chronic conditions raise the patient’s risk for severe complications from COVID-19—and that list of conditions is growing. The insight gained from these analyses not only informs how healthcare providers treat an individual’s illness, but also gives those with chronic disease the ability to make informed decisions based on their risk level for infection.
Moreover, the availability of actionable, real-time intelligence to improve health can set the stage for increased care collaboration. During COVID-19, healthcare providers across geographies are sharing their knowledge, especially regarding treatment protocols. Such learnings include the value of using high-flow nasal oxygen in treating severe cases of COVID-19. Early results show that this technique has a positive impact on patients with mild to moderate respiratory failure. It also reduces intubation rates and improves clinical prognosis for patients with acute respiratory failure. By sharing data-driven insights, organizations can work together to improve COVID-19 outcomes and reduce avoidable deaths.
Improving Outcomes and Reducing Risk
Clinical and claims data analysis helps healthcare organizations respond proactively to COVID-19. With the race toward a COVID-19 vaccine well underway, these analyses will help identify which populations should receive the vaccine first, assess reactions to the vaccine by demographic group and spot trends that could affect vaccination protocols. They also give healthcare organizations up-to-date contact information to engage patients, which will be critical to clinical efficacy if a second dose of the vaccine must be administered. In 2020 and beyond, continued focus on clinical and claims data analysis will be key to facilitating a robust response that enhances outcomes and saves lives.
About Emad Rizk, M.D.
Emad Rizk, M.D., is President and CEO of Cotiviti and brings a 30-year, well-documented track record of delivering improved quality and financial performance to healthcare organizations through forward-thinking leadership, business acumen, and clinical expertise.
Tisha Coleman has lived in close-knit Linn County, Kansas, for 42 years and never felt so alone.
As the public health administrator, she’s struggled every day of the coronavirus pandemic to keep her rural county along the Missouri border safe. In this community with no hospital, she’s failed to persuade her neighbors to wear masks and take precautions against COVID-19, even as cases rise. In return, she’s been harassed, sued, vilified — and called a Democrat, an insult in her circles.
Even her husband hasn’t listened to her, refusing to require customers to wear masks at the family’s hardware store in Mound City.
“People have shown their true colors,” Coleman said. “I’m sure that I’ve lost some friends over this situation.”
By November, the months of fighting over masks and quarantines were already wearing her down. Then she got COVID-19, likely from her husband, who she thinks picked it up at the hardware store. Her mother got it, too, and died on Sunday, 11 days after she was put on a ventilator.
Across the U.S., state and local public health officials such as Coleman have found themselves at the center of a political storm as they combat the worst pandemic in a century. Amid a fractured federal response, the usually invisible army of workers charged with preventing the spread of infectious diseases has become a public punching bag. Their expertise on how to fight the coronavirus is often disregarded.
Some have become the target of far-right activists, conservative groups and anti-vaccination extremists, who have coalesced around common goals — fighting mask orders, quarantines and contact tracing with protests, threats and personal attacks.
The backlash has moved beyond the angry fringe. In the courts, public health powers are being undermined. Lawmakers in at least 24 states have crafted legislation to weaken public health powers, which could make it more difficult for communities to respond to other health emergencies in the future.
“What we’ve taken for granted for 100 years in public health is now very much in doubt,” said Lawrence Gostin, an expert in public health law at Georgetown University in Washington, D.C.
It is a further erosion of the nation’s already fragile public health infrastructure. At least 181 state and local public health leaders in 38 states have resigned, retired or been fired since April 1, according to an ongoing investigation by The Associated Press and KHN. According to experts, this is the largest exodus of public health leaders in American history. An untold number of lower-level staffers has also left.
“I’ve never seen or studied a pandemic that has been as politicized, as vitriolic and as challenged as this one, and I’ve studied a lot of epidemics,” said Dr. Howard Markel, a medical historian at the University of Michigan. “All of that has been very demoralizing for the men and women who don’t make a great deal of money, don’t get a lot of fame, but work 24/7.”
One in 8 Americans — 40 million people — lives in a community that has lost its local public health department leader during the pandemic. Top public health officials in 20 states have left state-level departments, including in North Dakota, which has lost three state health officers since May, one after another.
Many of the state and local officials left due to political blowback or pandemic pressure. Some departed to take higher-profile positions or due to health concerns. Others were fired for poor performance. Dozens retired.
KHN and AP reached out to public health workers and experts in every state and the National Association of County and City Health Officials; examined public records and news reports; and interviewed hundreds to gather the list.
Collectively, the loss of expertise and experience has created a leadership vacuum in the profession, public health experts say. Many health departments are in flux as the nation rolls out the largest vaccination campaign in its history and faces what are expected to be the worst months of the pandemic.
“We don’t have a long line of people outside of the door who want those jobs,” said Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas, who is retiring from his job earlier than planned because, he said, he’s burned out. “It’s a huge loss that will be felt probably for generations to come.”
The departures accelerate problems that had already weakened the nation’s public health system. AP and KHN reported that per capita spending for state public health departments had dropped by 16%, and for local health departments by 18%, since 2010. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.
Those diminishing resources were already prompting high turnover. Before the pandemic, nearly half of public health workers said in a survey they planned to retire or leave in the next five years. The top reason given was low pay.
Such reduced staffing in departments that have the power and responsibility to manage everything from water inspections to childhood immunizations left public health workforces ill-equipped when COVID-19 arrived. Then, when pandemic shutdowns cut tax revenues, some state and local governments cut their public health workforces further.
“Now we’re at this moment where we need this knowledge and leadership the most, everything has come together to cause that brain drain,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.
Coleman, a Christian and a Republican, said that’s just what happened in Linn County. “A lot of people are shamed into not wearing a mask … because you’re considered a Democrat,” she said. “I’ve been called a ‘sheep.’”
The politicization has put some local governments at odds with th