‘We Are Looking For Answers’: Treating The COVID Long Haulers

https://www.wnpr.org/post/we-are-looking-answers-treating-covid-long-haulers

Vic Gara, 57, at his home in West Granby Dec. 10, 2020. Gara survived COVID-19 in a hospital ICU bed on a ventilator. Months later, he discovered he was experiencing long-term complications from the virus.

In early March, Vic Gara came down with severe muscle aches, headaches and a rising blood pressure, indicators of COVID-19 that weren’t well understood early on in the pandemic.

“Taking a shower, just the water hurt my body,” he said. “I couldn’t sleep. I slowly became hypoxic. I just couldn’t breathe.” 

Eventually, he was admitted to Hartford Hospital, where he was quarantined immediately and separated from his wife, Laura. 

“My wife was walking in from after parking the car, and I saw her from maybe 15, 20 feet away and I just barely raised my hand and said goodbye to her,” Gara recalled. “And I was there for a month.”

The 57-year-old was intubated and spent 11 days on a ventilator, which helped him breathe, before he regained consciousness. Like so many others who required intensive care, Gara was first transferred to a rehabilitation hospital for a short time before he could return to his home in West Granby.

He thought the worst was behind him. But by midsummer, Gara struggled with exhaustion, his headaches returned, he had poor balance and trouble speaking and “brain fog” had set in. Then he joined an online support group for COVID-19 survivors. 

“Not until I was contacted did I find out, ‘Oh my god, there’s other people like me that are suffering almost identical situations,’” he said.

There is an untold number of COVID-19 survivors worldwide who struggle with long-term symptoms and complications from the virus. Scientists don’t yet know how common this occurs, but what they do know is symptoms can be both physical and mental in nature, and they can delay people from making a full recovery.

As the phenomenon becomes more well-known and researched, health organizations across Connecticut and the country are creating and expanding dedicated COVID-19 recovery programs to help survivors.

“We’re now seeing patients that have had some of those symptoms for eight, nine months,” said Dr. Jerry Kaplan, outpatient medical director at Gaylord Hospital in Wallingford. He runs the organization’s new COVID-19 recovery and rehabilitation program.

The hospital created an online support group over the summer for former COVID-19 rehab patients like Gara. Kaplan said that’s when patients came forward with a wide range of lingering health issues.

Gaylord opened its specialized outpatient program in early fall, and it provides COVID-19 survivors with occupational and physical therapies, nutrition education, psychological treatment and other services.

“Even if you can’t do everything you were doing before, we can get you to the highest possible functional level,” Kaplan said, “and that’s really what the program is designed to do.”

The program has picked up in the last several months as long-term complications from COVID-19 illness become more well-known.

“As we see more patients hospitalized with COVID now, we will continue to see the need for COVID recovery programs in the future,” Kaplan said.

The Post-COVID-19 Recovery Program at Yale Medicine opened several months ago as a Friday clinic with a small patient roster. Dr. Denyse Lutchmansingh said it has now expanded to three days a week as more patients and medical clinicians discover the program.

“I think early on, people would say, give it a couple of weeks and you should feel better,” she said. “And now we’re well past that give-it-a-couple-of-weeks period and people are still having symptoms.”

Lutchmansingh, a pulmonary and critical care physician who leads the Yale recovery program, said she and her colleagues initially expected that patients who had had moderate to severe COVID-19 illness, like Gara, would be the ones needing long-term recovery services the most.

That’s only been partly true.

“Patients who were classified as mild disease have also had persistent symptoms almost as severe as a patient who was hospitalized in an intensive care unit, and that has been quite eye-opening,” she said.

Lutchmansingh said the clinic is also seeing a surprisingly young population. She has patients in their 30s and 40s who were runners, athletically inclined, or generally in good health prior to getting a mild case of COVID-19 “who now struggle to walk up a flight of stairs.”

It’s some of these patients that Lutchmansingh has seen struggle the most mentally with their persistent symptoms.

“Because they expected to recover very quickly and move on,” she said.  

Dr. Serena Spudich is the division chief of neurological infections and global neurology at Yale School of Medicine and leads a designated neuro-COVID clinic, which opened in October.

Her team collaborates with Lutchmansingh and other clinicians in the greater community to get referrals for COVID-19 survivors suffering with tingling and numbness, loss or impaired senses of smell, taste and hearing, headaches, cognitive impairment and other complications.

Many of these patients were never hospitalized or never required intensive care for COVID-19.             

This is where more research can help make sense of the trends that health providers are seeing in their COVID-19 “long hauler” patients, Spudich said.

“I think it’s really important to try to understand why some people get these neurologic issues, and many people don’t seem to,” she said. “I know lots of people who’ve recovered from COVID who seem completely fine.”

Scientists are still trying to estimate exactly how many people in the world ever had COVID-19, including those who never got tested or people who got false negative results — cases that have not been recorded.

Only then might health experts know how common or rare long-term complications are among survivors, Spudich said.

“I think it’s important to be aware of them, to understand them and of course provide treatment for them,” she said. “But I worry that it’s sort of a fire that can take off where all the social media, all the press attention will suddenly make a lot of people think, ‘Oh, I’m having post-COVID problems.’”

“What is really, really important is getting patients who are having symptoms to a provider who can really critically take care of them and try to understand clinically what’s happening with them.”

What patients often want to know is, when will their health get back to what it was prior to COVID-19? And health experts don’t yet have a good answer to that as scientists continue to follow survivors in their recovery.

“We always make it clear to the patients that we don’t have all the answers. We are looking for answers,” Lutchmansingh said. “We remain hopeful, we have seen patients improve and build back to baseline, but it is a long pathway and it is not necessarily an easy pathway.

For Gara, he continues recovery treatment at Gaylord on an outpatient basis. He tries to get outside more and build up his endurance with walks. For the most part, he takes it one day at a time.

“I went into it with an open mind and trying to stay positive,” he said. “I learned how to be more positive and look for the good rather than the bad. It helps.”

A Canadian woman has been sick with covid-19 long-term effects for nearly 9 months: ‘I’m definitely worried it will be permanent’

When Ashley Antonio contracted covid-19 in late March, the Canadian criminal lawyer fought against the common symptoms that come with most cases: fever, body aches, fatigue, headaches.

She would manage her symptoms at home and eventually overcome them, she assured herself. After all, she was a healthy 35-year-old with no underlying conditions who boxed and did strength training four times a week.

Except the symptoms never really went away — they intensified.

Now, 259 days later, Antonio is still suffering the repercussions of a virus that has upended almost every aspect of her life.

She has been in and out of the hospital four times in almost nine months. Her doctors have diagnosed Antonio with arthritis and a condition that causes her heartbeat to dramatically increase when she stands up. Both are long-term effects of the virus, they told her. They also don’t know if, and when, those symptoms will go away.

“Everyone is just told you either recover or you die,” Antonio told The Washington Post on Tuesday. “There’s never talk of all the people that are trapped somewhere in the middle with all of these long-term effects. We’re not recovered. We’re just not covid-positive anymore.”

Antonio is not alone. Doctors still aren’t sure why “long-haulers” continue to suffer the consequences of the disease months later or whether the symptoms will stay with them for the rest of their lives. But public health experts say it’s increasingly clear that many thousands of patients face long-term effects from the virus.

Long-haulers “are in every country, in every language,” Igor J. Koralnik, who started a program for covid-19 neurocognitive problems at Northwestern Memorial Hospital in Chicago, told The Post in October. “It’s going to be a big problem. It’s not going to go away.”

So far, clinicians have learned the long-term effects can impact both the old and the young, regardless of whether the case was mild or required hospitalization. Many long-haulers have turned to social media groups to share their experiences and advice.

Antonio, who lives in Edmonton and whose story was first reported by the CBC, said she had been taking precautions and working from home for a month before she got sick. Her best guess is that she caught the virus on a run to the grocery store. She began feeling symptoms around March 25.

But because she did not have a cough, which doctors and health experts then said was one of covid-19′s main symptoms, Antonio thought she only had a stomach flu.

She stayed home and started to feel like herself again days later. But every time she thought she was recovering, symptoms would return. In the next three months, old symptoms and new, graver ones left Antonio tied to her couch. The fatigue was so bad she could shower only a couple of times a week. Her blood oxygen levels would drop dangerously low whenever she took short steps. One day, her brain was so foggy that she could not remember how to hold a glass.

It wasn’t until mid-May when she was taken to the emergency room for the first time. Alone in her bedroom and fighting a high fever, Antonio began hallucinating. Then, she could not feel half of her body or her face. The hospital tested her for the coronavirus, but her results came back negative so she was sent home. About a week later, she was back. She would return two more times in the following months.

“I had every test you could imagine,” she said. But her doctors could still not figure out what exactly was wrong with her. An emergency room doctor suggested she might have long-term covid-19 effects and referred her to a special clinic.

In June, she tested positive for coronavirus antibodies. In July, doctors at a clinic for coronavirus survivors diagnosed her with arthritis and a condition that causes her heartbeat to raise significantly when standing. “But doctors couldn’t explain why my oxygen was still dropping every time I walked or any other symptoms,” she said.

Antonio turned to other long-haulers for more information, joining a Facebook group where she learned, for example, that she wasn’t alone in smelling cigarettes when no one was smoking near her. Other people experienced random smells too, they told her.

“I had a lot of questions and the doctors didn’t have a lot of answers. It was all so new to everyone,” Antonio said. “I just wanted to see if what I was experiencing was ‘normal.’ It was very comforting to know that I wasn’t alone.”

Although her symptoms persisted, in August, Antonio voluntarily returned to the law firm where she works as a criminal lawyer. Some days, she feels okay. But the increased heart rate, shortness of breath, joint pain and headaches are usually daily ailments. She also still suffers from blurry vision and gets skin rashes. Her doctors have now told her it’s possible that her long-term symptoms will come and go for the rest of her life. For now, Antonio said she is taking it one day at a time.

“I’m definitely worried it will be permanent,” she said. “It’s very overwhelming if I think that this is how the rest of my life is going to be.”

Antonio added: “When I have a good day, I no longer think that it will be over. I know I’ll have bad days again. It makes you feel hopeless.”

COVID-19 long haulers on months of debilitating symptoms: ‘They don’t know how to make me better’

https://www.yahoo.com/lifestyle/covid-19-long-haulers-debilitating-symptoms-210633981.html

COVID-19 'long-haulers' complain of symptoms lasting weeks and ...

SARS-CoV-2, the virus that causes COVID-19, has prompted more questions than science can answer. But of the many puzzles that remain, few are more perplexing — or urgent — than this one: Why do some people get sick and never get better?

This group of individuals, nicknamed the “long haulers,” are people of all ages, races and genders. Survivors of the virus who, months later, find themselves battling a constellation of debilitating side effects that disrupt their ability to function. In a study released by Indiana University School of Medicine this August, in partnership with COVID-19 nonprofit Survivor Corps, long haulers describe nearly 100 side effects, from fatigue and body aches to night sweats and neuropathy.

The study casts doubt on the idea that the COVID-19 is a respiratory illness that lasts only a few weeks, suggesting instead that it may be a vascular disease capable of wreaking havoc on the eyes, skin, heart and brain, long after the sore throat goes away. While some hospitals, such as Mount Sinai in New York, have launched recovery centers for post-COVID care, the Centers for Disease Control and Prevention has released little data on the longterm prognosis for those who survive.

In the interim, it’s the long haulers themselves who are helping demystify their strange new world. Karyn Bishof, a firefighter paramedic in Florida, is one of them. After coming down with sore throat, nausea and fatigue in late March, she tested positive for COVID-19 and was told her case was mild. But as the weeks went on, the symptoms didn’t go away. Over four months later, the fatigue remains constant and along with it, a host of other exhausting side effects.

“I’m dealing with drastic changes in heart rate … My oxygen levels drop into the low 90, sometimes even the low eighties, I’m still dealing with headache, memory issues. I have a lot of trouble recalling things or sometimes finding my words,” Bishof tells Yahoo Life. “I’m still dealing with a runny and stuffy nose on and off. And then just a ton of other neurological issues, cardiac issues, chest pain, shortness of breath. I mean, the list goes on.”

Jessica Hulett, a writer in New York, has been battling similar effects. “The fatigue has been really persistent … All I want to do is go to sleep from like two o’clock on every day, and some days I have to,” says Hulett. “I’ve also started having a lot of like cognitive difficulties. Like I can’t remember things, I can’t focus on things.

Both Hulett and Bishof have struggled to find answers from doctors about what’s happening. “I’ve been talking a lot to my primary care doctor … she has kind of admitted, she’s like, ‘We don’t know, like we don’t know how long you’re going to be sick,’” says Hulett. “We don’t know what’s gonna make you better. We don’t know why you’re still sick.”

Luis Santos, a native-New Yorker who’s been experiencing “crushing fatigue,” cognitive issues and an unexplained spike in his cholesterol since getting COVID-19 in March, is too. “I have a team of about seven or eight doctors … and it’s a very scary thing that all these physicians are saying they don’t know. They don’t know how to make me better,” says Santos. “They’re hoping that with time they get better.”

Natalie Lambert, an associate research professor at IU School of Medicine and the lead author of the long haulers study, says this reaction is common. “I feel like this is a huge problem in health care around the world...We’re just kind of a society where you’re healthy until you can prove that you’re sick,” Lambert tells Yahoo Life. “If you’re experiencing something that’s outside of the standard of medical care, it can be really hard to get answers.”

Lambert, who began talking to patients after seeing a “wide range of COVID-19 symptoms” early on, says she doesn’t blame doctors for the gap in knowledge. “They can only treat you with the appropriate and approved standard treatments,” says Lambert. “They can’t experiment on people — so it’s understandable. But if there’s no answer to your question, what can you do?”

Survivor Corps, a grassroots movement connecting COVID-19 survivors, is trying to figure out just that — hosting webinars, sharing research and creating a Facebook group nearly 100,000 people strong. It’s from this group that Lambert pulled information about side effects, using an open-ended survey that allowed long haulers to add their symptoms.

She says the importance of these individuals, and their stories, can’t be overstated. “They are the world’s experts in the disease at this point in time,” Lambert tells Yahoo Life. “I mean, these patients know more about the disease than the medical community does.”

She hopes her research will serve as validation to long haulers — and proof that they’re not alone. “If you’re experiencing any of these symptoms, lots of people are experiencing these symptoms,” says Lambert. “And if your doctor won’t treat them, continue to advocate for yourself to try to get medical care because some of these can result in very serious health consequences.”

When it comes to the long haulers themselves, they’re urging others not to overlook the seriousness of this virus. “Right now the science for long haulers is showing that [COVID-19] doesn’t care about your age. It doesn’t care about your fitness level,” says Bishof. “It doesn’t care if you’re a firefighter-paramedic, or if you work on your computer from home … Do everything you can to protect yourself and others. This is not just a cold or a flu.”

 

 

 

COVID-19 long-term toll signals billions in healthcare costs ahead

https://www.reuters.com/article/us-health-coronavirus-fallout-insight/long-term-complications-of-covid-19-signals-billions-in-healthcare-costs-ahead-idUSKBN24Z1CM?fbclid=IwAR2f9fSnhgGBVvIe1fKX2EO5kKSG7TwUesAMUGrG0jBSfoBrBYltR1e9Nik

COVID-19 long-term toll signals billions in healthcare costs ahead ...

Late in March, Laura Gross, 72, was recovering from gall bladder surgery in her Fort Lee, New Jersey, home when she became sick again.

Her throat, head and eyes hurt, her muscles and joints ached and she felt like she was in a fog. Her diagnosis was COVID-19. Four months later, these symptoms remain.

Gross sees a primary care doctor and specialists including a cardiologist, pulmonologist, endocrinologist, neurologist, and gastroenterologist.

“I’ve had a headache since April. I’ve never stopped running a low-grade temperature,” she said.

Studies of COVID-19 patients keep uncovering new complications associated with the disease.

With mounting evidence that some COVID-19 survivors face months, or possibly years, of debilitating complications, healthcare experts are beginning to study possible long-term costs.

Bruce Lee of the City University of New York (CUNY) Public School of Health estimated that if 20% of the U.S. population contracts the virus, the one-year post-hospitalization costs would be at least $50 billion, before factoring in longer-term care for lingering health problems. Without a vaccine, if 80% of the population became infected, that cost would balloon to $204 billion.

Some countries hit hard by the new coronavirus – including the United States, Britain and Italy – are considering whether these long-term effects can be considered a “post-COVID syndrome,” according to Reuters interviews with about a dozen doctors and health economists.

Some U.S. and Italian hospitals have created centers devoted to the care of these patients and are standardizing follow-up measures.

Britain’s Department of Health and the U.S. Centers for Disease Control and Prevention are each leading national studies of COVID-19’s long-term impacts. An international panel of doctors will suggest standards for mid- and long-term care of recovered patients to the World Health Organization (WHO) in August.

YEARS BEFORE THE COST IS KNOWN

More than 17 million people have been infected by the new coronavirus worldwide, about a quarter of them in the United States.

Healthcare experts say it will be years before the costs for those who have recovered can be fully calculated, not unlike the slow recognition of HIV, or the health impacts to first responders of the Sept. 11, 2001 attacks on the World Trade Center in New York.

They stem from COVID-19’s toll on multiple organs, including heart, lung and kidney damage that will likely require costly care, such as regular scans and ultrasounds, as well as neurological deficits that are not yet fully understood.

A JAMA Cardiology study found that in one group of COVID-19 patients in Germany aged 45 to 53, more than 75% suffered from heart inflammation, raising the possibility of future heart failure.

A Kidney International study found that over a third of COVID-19 patients in a New York medical system developed acute kidney injury, and nearly 15% required dialysis.

Dr. Marco Rizzi in Bergamo, Italy, an early epicenter of the pandemic, said the Giovanni XXIII Hospital has seen close to 600 COVID-19 patients for follow-up. About 30% have lung issues, 10% have neurological problems, 10% have heart issues and about 9% have lingering motor skill problems. He co-chairs the WHO panel that will recommend long-term follow-up for patients.

“On a global level, nobody knows how many will still need checks and treatment in three months, six months, a year,” Rizzi said, adding that even those with mild COVID-19 “may have consequences in the future.”

Milan’s San Raffaele Hospital has seen more than 1,000 COVID-19 patients for follow-up. While major cardiology problems there were few, about 30% to 40% of patients have neurological problems and at least half suffer from respiratory conditions, according to Dr. Moreno Tresoldi.

Some of these long-term effects have only recently emerged, too soon for health economists to study medical claims and make accurate estimates of costs.

In Britain and Italy, those costs would be borne by their respective governments, which have committed to funding COVID-19 treatments but have offered few details on how much may be needed.

In the United States, more than half of the population is covered by private health insurers, an industry that is just beginning to estimate the cost of COVID-19.

CUNY’s Lee estimated the average one-year cost of a U.S. COVID-19 patient after they have been discharged from the hospital at $4,000, largely due to the lingering issues from acute respiratory distress syndrome (ARDS), which affects some 40% of patients, and sepsis.

The estimate spans patients who had been hospitalized with moderate illness to the most severe cases, but does not include other potential complications, such as heart and kidney damage.

Even those who do not require hospitalization have average one-year costs after their initial illness of $1,000, Lee estimated.

‘HARD JUST TO GET UP’

Extra costs from lingering effects of COVID-19 could mean higher health insurance premiums in the United States. Some health plans have already raised 2021 premiums on comprehensive coverage by up to 8% due to COVID-19, according to the Kaiser Family Foundation.

Anne McKee, 61, a retired psychologist who lives in Knoxville, Tennessee and Atlanta, had multiple sclerosis and asthma when she became infected nearly five months ago. She is still struggling to catch her breath.

“On good days, I can do a couple loads of laundry, but the last several days, it’s been hard just to get up and get a drink from the kitchen,” she said.

She has spent more than $5,000 on appointments, tests and prescription drugs during that time. Her insurance has paid more than $15,000 including $240 for a telehealth appointment and $455 for a lung scan.

“Many of the issues that arise from having a severe contraction of a disease could be 3, 5, 20 years down the road,” said Dale Hall, Managing Director of Research with the Society of Actuaries.

To understand the costs, U.S. actuaries compare insurance records of coronavirus patients against people with a similar health profile but no COVID-19, and follow them for years.

The United Kingdom aims to track the health of 10,000 hospitalized COVID-19 patients over the first 12 months after being discharged and potentially as long as 25 years. Scientists running the study see the potential for defining a long-term COVID-19 syndrome, as they found with Ebola survivors in Africa.

“Many people, we believe will have scarring in the lungs and fatigue … and perhaps vascular damage to the brain, perhaps, psychological distress as well,” said Professor Calum Semple from the University of Liverpool.

Margaret O’Hara, 50, who works at a Birmingham hospital is one of many COVID-19 patients who will not be included in the study because she had mild symptoms and was not hospitalized. But recurring health issues, including extreme shortness of breath, has kept her out of work.

O’Hara worries patients like her are not going to be included in the country’s long-term cost planning.

“We’re going to need … expensive follow-up for quite a long time,” she said.

 

 

 

 

Coronavirus’s painful side effect is deep budget cuts for state and local government services

https://theconversation.com/coronaviruss-painful-side-effect-is-deep-budget-cuts-for-state-and-local-government-services-141105

Coronavirus's painful side effect is deep budget cuts for state ...

Nationwide, state and local government leaders are warning of major budget cuts as a result of the pandemic. One state – New York – even referred to the magnitude of its cuts as having “no precedent in modern times.”

Declining revenue combined with unexpected expenditures and requirements to balance budgets means state and local governments need to cut spending and possibly raise taxes or dip into reserve funds to cover the hundreds of billions of dollars lost by state and local government over the next two to three years because of the pandemic.

Without more federal aid or access to other sources of money (like reserve funds or borrowing), government officials have made it clear: Budget cuts will be happening in the coming years.

And while specifics are not yet available in all cases, those cuts have already included reducing the number of state and local jobs – from firefighters to garbage collectors to librarians – and slashing spending for education, social services and roads and bridges.

In some states, agencies have been directed to cut their budget as much as 15% or 20% – a tough challenge as most states prepared budgets for a new fiscal year that began July 1.

As a scholar of public administration who researches how governments spend money, here are the ways state and local governments have reduced spending to close the budget gap.

Cutting jobs

State and local governments laid off or furloughed 1.5 million workers in April and May.

They are also reducing spending on employees. According to surveys, government workers are feeling personal financial strain as many state and local governments have cut merit raises and regular salary increases, frozen hiring, reduced salaries and cut seasonal employees.

Washington state, for example, cut both merit raises and instituted furloughs.

survey from the National League of Cities shows 32% of cities will have to furlough or lay off employees and 41% have hiring freezes in place or planned as a result of the pandemic.

Employment reductions have met some resistance. In Nevada, for example, a state worker union filed a complaint against the governor to the state’s labor relations board for violating a collective bargaining statute by not negotiating on furloughs and salary freezes.

Most of the employee cuts have been made in education. Teachers, classroom aids, administrators, staff, maintenance crews, bus drivers and other school employees have seen salary cuts and layoffs.

The job loss has hurt public employees beyond education, too: librarians, garbage collectors, counselors, social workers, police officers, firefighters, doctors, nurses, health aides, park rangers, maintenance crews, administrative assistants and others have been affected.

Residents also face the consequences of these cuts: They can’t get ahold of staff in the city’s water and sewer departments to talk about their bill; they can’t use the internet at the library to look for jobs; their children can’t get needed services in school.

Most of these cuts have been labeled temporary, but with the extensions to stay-at-home orders and a mostly closed economy, it will be some time before these employees are back to work.

Suspending road, bridges, building and water system projects

As another way to reduce costs quickly, a National League of Cities survey shows 65% of the municipalities surveyed are stopping temporarily, or completely, capital expenditure and infrastructure projects like roads, bridges, buildings, water systems or parking garages.

In New York City, there is a US$2.3 billion proposed cut to the capital budget, a fund that supports large, multiyear investments from sidewalk and road maintenance, school buildings, senior centers, fire trucks, sewers, playgrounds, to park upkeep. There are potentially serious consequences for residents. For example, New York housing advocates are concerned that these cuts will hurt plans for 21,000 affordable homes.

Suspending these big money projects will save the government money in the short term. But it will potentially harm the struggling economy, since both public and private sectors benefit from better roads, bridges, schools and water systems and the jobs these projects create.

Delaying maintenance also has consequences for the deteriorating infrastructure in the U.S. The costs of unaddressed repairs could increase future costs. It can cost more to replace a crumbling building than it does to fix one in better repair.

Cities and towns hit

In many states, the new budgets severely cut their aid to local governments, which will lead to large local cuts in education – both K-12 and higher education – as well as social programs, transportation, health care and other areas.

New York state’s budget proposes that part of its fiscal year 2021 budget shortfall will be balanced by $8.2 billion in reductions in aid to localities. This is the state where the cuts were referred to in the budget as “not seen in modern times.” This money is normally spent on many important services that residents need everyday –mass transit, adult and elderly care, mental health support, substance abuse programs, school programs like special education, children’s health insurance and more. Lacking any of these support services can be devastating to a person, especially in this difficult time.

Fewer workers, less money

As teachers and administrators figure out how to teach both online and in person, they and their schools will need more money – not less – to meet students’ needs.

Libraries, which provide services to many communities, from free computer use to after-school programs for children, will have to cut back. They may have fewer workers, be open for fewer hours and not offer as many programs to the public.

Parks may not be maintained, broken playground equipment may stay that way, and workers may not repave paths and mow lawns. Completely separate from activists’ calls to shift police funding to other priorities, police departments’ budgets may be slashed just for lack of cash to pay the officers. Similar cuts to firefighters and ambulance workers may mean poorly equipped responders take longer to arrive on a scene and have less training to deal with the emergency.

To keep with developing public safety standards, more maintenance staff and materials will be needed to clean and sanitize schools, courtrooms, auditoriums, correctional facilitiesmetro stations, buses and other public spaces. Strained budgets and employees will make it harder to complete these new essential tasks throughout the day.

To avoid deeper cuts, state and local government officials are trying a host of strategies including borrowing money, using rainy day funds, increasing revenue by raising tax rates or creating new taxes or fees, ending tax exemptions and using federal aid as legally allowed.

Colorado was able to hold its budget to only a 3% reduction, relying largely on one-time emergency reserve funds. Delaware managed to maintain its budget and avoided layoffs largely through using money set aside in a reserve account.

Nobody knows how long the pandemic, or its economic effects, will last.

In the worst-case scenario, budget officials are prepared to make steeper cuts in the coming months if more assistance does not come from the federal government or the economy does not recover quickly enough to restore the flow of money that governments need to operate.