What ‘Racism Is a Public Health Issue’ Means

https://www.smithsonianmag.com/science-nature/what-racism-public-health-issue-means-180975326/?utm_source=smithsoniandaily&utm_medium=email&utm_campaign=20200720-daily-responsive&spMailingID=43001584&spUserID=MTA5MDI1MDg0MjgxOQS2&spJobID=1801530184&spReportId=MTgwMTUzMDE4NAS2&fbclid=IwAR027OjpNcyZKM6Jd5aTYhgVaTzaO5lBqI4hCl1xsrKgQRL1bFYH538YIMA

What 'Racism Is a Public Health Issue' Means | Science ...

Epidemiologist Sharrelle Barber discusses the racial inequalities that exist for COVID-19 and many other health conditions.

Throughout the COVID-19 pandemic, whether cases are flaring up, slowing to a simmer, or back on the rise in areas across the United States, the data makes one fact apparent: The viral disease has disproportionally sickened and killed marginalized communities. A New York Times analysis of data from almost 1,000 counties that reported racial breakdowns of COVID-19 cases and fatalities revealed that, compared to white Americans, African Americans and Hispanics were three times more likely to experience and two times more likely to die from the illness. The Navajo Nation has, per capita, more confirmed cases and deaths than any of the 50 states.

Many factors, like access to healthcare and testing, household size, or essential worker status, likely contribute to the pandemic’s outsized toll on communities of color, but experts see a common root: the far-reaching effects of systemic racism.

That racism would have such an insidious effect on health isn’t a revelation to social epidemiologists. For decades, public health experts have discussed “weathering,” or the toll that repeated stressors experienced by people of color take on their health. Studies have demonstrated the link between such chronic stress and high blood pressure, the increased maternal mortality rate among black and indigenous women, and the elevated prevalence of diabetes in black, Latino and especially Native American populations. The pandemic has laid bare these inequities. At the same time, outcry over systemic racism and police brutality against African Americans has roiled the nation, and the phrase, “Racism is a public health issue” has become an internet refrain.

What exactly is the nebulous concept of “public health”? According to Sharrelle Barber, a Drexel University assistant professor of epidemiology, the concept goes beyond the healthcare setting to take a more holistic look at health in different populations. “The charge of public health,” Barber told Smithsonian, “is really to prevent disease, prevent death, and you prevent those things by having a proper diagnosis of why certain groups might have higher rates of mortality, higher rates of morbidity, et cetera.”

Below is a lightly edited transcript of Smithsonian’s conversation with Barber, who studies how anti-black racism impacts health, about the many ways in which racism is a public health crisis:

When people say, “Racism is a public health problem,” what, in broad strokes, do they mean?

We’ve been observing racial inequities in health for decades in this country. W.E.B. DuBois, who was a sociologist, in The Philadelphia Negro showed mortality rates by race and where people lived in the city of Philadelphia at the turn of the 20th century and found striking inequalities based on race. Fast forward to 1985, 35 years ago, and we have the [Department of Health and Human Services-sponsored] Heckler Report, one of the most comprehensive studies the country had undertaken, which again found striking inequalities across a wide range of health outcomes: infant mortality, cancer, stroke, et cetera.

There are various explanations for why these racial inequalities exist, and a lot of those have erroneously focused on either biology or genetics or behavioral aspects, but it’s important to examine the root causes of those inequities, which is structural racism…Racism is a public health problem, meaning racism is at the root of the inequities in health that we see, particularly for blacks in this country. So whether it’s housing, criminal justice, education, wealth, economic opportunities, healthcare, all of these interlocking systems of racism really are the main fundamental drivers of the racial inequities that we see among black Americans.

What are some specific factors or policies that have set the foundations for these health inequities?

Any conversation about racial inequities has to start with a conversation about slavery. We have to go back 400-plus years and really recognize the ways in which the enslavement of African people and people of African descent is the initial insult that set up the system of racism within this country. One of the major drivers that I actually study is the link between racial residential segregation, particularly in our large urban areas, and health inequities. Racial residential segregation is rooted in racist policies that date back at least to the 1930s. Practices such as redlining, which devalued black communities and led to the disinvestment in black communities, were then propped up by practices and policies at the local, the state and federal level, for example, things like restrictive covenants, where blacks were not allowed to move into certain communities; racial terror, where blacks were literally intimidated and run out of white communities when they tried to or attempted to move into better communities; and so many other policies. Even when you get the 1968 Fair Housing Act, the system finds a way to reinvent itself to still perpetuate and maintain racism.

Within segregated communities, you have so many adverse exposures, like poor quality housing or lack of access to affordable, healthy foods, lack of access to quality healthcare, and the list goes on. The chronic stressors within these communities are compounded in segregated communities, which then can lead to a wide array of health outcomes that are detrimental. So for example, in the city of Philadelphia, there’s been work that has shown upwards of a 15-year life expectancy difference between racially and economically segregated communities, black communities and wealthier white communities.

I imagine that sometimes you might get pushback from people who ask about whether you can separate the effects of socioeconomic status and race in these differences in health outcomes.

Yeah, that’s a false dichotomy in some ways. Racism does lead to, in many aspects, lower income, education, wealth. So they’re inextricably linked. However, racism as a system goes beyond socioeconomic status. If we look at what we see in terms of racial inequities in maternal mortality for black women, they are three times times more likely to die compared to white women. This disparity or this inequity is actually seen for black women who have a college degree or more. The disparity is wide, even when you control for socioeconomic status.

Let’s talk about the COVID-19 pandemic. How does racism shape the current health crisis?

The COVID-19 pandemic has literally just exposed what me and so many of my colleagues have known for decades, but it just puts it in such sharp focus. When you see the disproportionate impact COVID-19 is having, particularly for blacks, but also we’re seeing emerging data on Indigenous folks, it is just laying bare the ways racism is operating in this moment to produce those inequities.

Essential workers who had to continue to work during periods of stay at home orders across the country were disproportionately black and Latino. These are also often low wage workers. They weren’t given personal protective equipment, paid sick leave, hazard pay, and really had to choose between being exposed and protecting themselves and having an income during this period. So that’s one way racism operates.

Then we know that those individuals aren’t isolated, that they return to homes that often are crowded because of the lack of affordable housing. Again, another system of racism that compounds the effect. Then you think about places like Flint, Michigan, or places that don’t have access to clean water. When we were telling people, “Wash your hands, social distance,” all of those things, there were people who literally could not adhere to those basic public health prevention measures and still can’t.

So many things were working in tandem together to then increase the risk, and what was frustrating for myself and colleagues was this kind of “blame the victim” narrative that emerged at the very onset, when we saw the racial disparities emerge and folks were saying, “Blacks aren’t washing their hands,” or, “Blacks need to eat better so they have better outcomes in terms of comorbidities and underlying chronic conditions,” when again, all of that’s structured by racism. To go back to your original question, that’s why racism is a public health issue and fundamental, because in the middle of a pandemic, the worst public health crisis in a century, we’re seeing racism operate and racism produce the inequities in this pandemic, and those inequities are striking…

If we had a structural racism lens going into this pandemic, perhaps we would have done things differently. For example, get testing to communities that we know are going to be more susceptible to the virus. We would have done that early on as opposed to waiting, or we would have said, “Well, folks need to have personal protective equipment and paid sick leave and hazard pay.” We would have made that a priority…

The framing [of systemic racism as a public health concern] also dictates the solutions you come up with in order to actually prevent death and suffering. But if your orientation is, “Oh, it’s a personal responsibility” or “It’s behavioral,” then you create messages to black communities to say, “Wash your hands; wear a mask,” and all of these other things that, again, do not address the fundamental structural drivers of the inequities. That’s why it’s a public health issue, because if public health is designed to prevent disease, prevent suffering, then you have to address racism to have the biggest impact.

Can you talk about how police brutality fits into the public health picture?

We have to deal with the literal deaths that happen at the hands of the police, because of a system that is rooted in slavery, but I also think we have to pay attention to the collective trauma that it causes to black communities. In the midst of a pandemic that’s already traumatic to watch the deaths due to COVID-19, [communities] then have to bear witness to literal lynchings and murders and that trauma. There’s really good scholarship on the kind of spillover effects of police brutality that impact the lives of whole communities because of the trauma of having to witness this kind of violence that then does not get met with any kind of justice.

It reinforces this idea that one, our lives are disposable, that black lives really don’t matter, because the whole system upholds this kind of violence and this kind of oppression, particularly for black folks. I’ve done studies on allostatic load [the wear and tear on the body as a result of chronic stress] and what it does, the dysregulation that happens. So just think about living in a society that’s a constant source of stress, chronic stress, and how that wreaks havoc on blacks and other marginalized racial groups as well.

 

 

 

 

What it’s like to be a nurse after 6 months of COVID-19 response

https://www.healthcaredive.com/news/what-its-like-to-be-a-nurse-6-months-coronavirus/581709/

Those on the front lines of the fight against the novel coronavirus worry about keeping themselves, their families and their patients safe.

That’s especially true for nurses seeking the reprieve of their hospitals returning to normal operations sometime this year. Many in the South and West are now treating ICUs full of COVID-19 patients they hoped would never arrive in their states, largely spared from spring’s first wave.

And like many other essential workers, those in healthcare are falling ill and dying from COVID-19. The total number of nurses stricken by the virus is still unclear, though the Centers for Disease Control and Prevention has reported 106,180 cases and 552 deaths among healthcare workers. That’s almost certainly an undercount.

National Nurses United, the country’s largest nurses union, told Healthcare Dive it has counted 165 nurse deaths from COVID-19 and an additional 1,060 healthcare worker deaths.

Safety concerns have ignited union activity among healthcare workers during the pandemic, and also given them an opportunity to punctuate labor issues that aren’t new, like nurse-patient ratios, adequate pay and racial equality.

At the same time, the hospitals they work for are facing some of their worst years yet financially, after months of delayed elective procedures and depleted volumes that analysts predict will continue through the year. Many have instituted furloughs and layoffs or other workforce reduction measures.

Healthcare Dive had in-depth conversations with three nurses to get a clearer picture of how they’re faring amid the once-in-a-century pandemic. Here’s what they said.

Elizabeth Lalasz, registered nurse, John H. Stroger Hospital in Chicago

Elizabeth Lalasz has worked at John H. Stroger Hospital in Chicago for the past 10 years. Her hospital is a safety net facility, catering to those who are “Black, Latinx, the homeless, inmates,” Lalasz told Healthcare Dive. “People who don’t actually receive the kind of healthcare they should in this country.”

Data from the CDC show racial and ethnic minority groups are at increased risk of getting COVID-19 or experiencing severe illness, regardless of age, due to long-standing systemic health and social inequities.

CDC data reveal that Black people are five times more likely to contract the virus than white people.

This spring Lalasz treated inmates from the Cook County Jail, an epicenter in the city and also the country. “That population gradually decreased, and then we just had COVID patients, many of them Latinx families,” she said.

Once Chicago’s curve began to flatten and the hospital could take non-COVID patients, those coming in for treatment were desperately sick. They’d been delaying care for non-COVID conditions, worried a trip to the hospital could risk infection.

A Kaiser Family Foundation poll conducted in May found that 48% of Americans said they or a family member had skipped or delayed medical care because of the pandemic. And 11% said the person’s condition worsened as a result of the delayed care.

When patients do come into Lalasz’s hospital, many have “chest pain, then they also have diabetes, asthma, hypertension and obesity, it just adds up,” she said.

“So now we’re also treating people who’ve been delaying care. But after the recent southern state surges, the hospital census started going down again,” she said.

Amy Arlund, registered nurse, Kaiser Permanente Medical Center in Fresno, California:

Amy Arlund works the night shift at Kaiser Fresno as an ICU nurse, which she’s done for the past two decades.

She’s also on the hospital’s infection control committee, where for years she’s fought to control the spread of clostridium difficile colitis, or C. diff., in her facility. The highly infectious disease can live on surfaces outside the body for months or sometimes years.

The measures Arlund developed to control C. diff served as her litmus test, as “the top, most stringent protocols we could adhere to,” when coronavirus patients arrived at her hospital, she told Healthcare Dive.

But when COVID-19 cases surged in northern states this spring, “it’s like all those really strict isolation protocols that prior to COVID showing up would be disciplinable offenses were gone,” Arlund said.

Widespread personal protective equipment shortages at the start of the pandemic led the CDC and the Occupational Safety and Health Administration to change their longstanding guidance on when to use N95 respirator masks, which have long been the industry standard when dealing with novel infectious diseases.

The CDC also issued guidance for N95 respirator reuse, an entirely new concept to nurses like Arlund who say those changes go against everything they learned in school.

“I think the biggest change is we always relied on science, and we have always relied heavily on infection control protocols to guide our practice,” Arlund said. “Now infection control is out of control, we can no longer rely on the information and resources we always have.”

The CDC says experts are still learning how the coronavirus spreads, though person-to-person transmission is most common, while the World Health Organization recently acknowledged that it wouldn’t rule out airborne transmission of the virus.

In Arlund’s ICU, she’s taken care of dozens of COVID positive patients and patients ruled out for coronavirus, she said. After a first wave in the beginning of April, cases dropped, but are now rising again.

Other changing guidance weighing heavily on nurses is how to effectively treat coronavirus patients.

“Are we doing remdesivir this week or are we going back to the hydroxychloroquine, or giving them convalescent plasma?”Arlund said. “Next week I’m going to be giving them some kind of lavender enema, who knows.”

Erik Andrews, registered nurse, Riverside Community Hospital in Riverside, California:

Erik Andrews, a rapid response nurse at Riverside Community Hospital in California, has treated coronavirus patients since the pandemic started earlier this year. He likens ventilating them to diffusing a bomb.

“These types of procedures generate a lot of aerosols, you have to do everything in perfectly stepwise fashion, otherwise you’re going to endanger yourself and endanger your colleagues,” Andrews, who’s been at Riverside for the past 13 years, told Healthcare Dive.

He and about 600 other nurses at the hospital went on strike for 10 days this summer after a staffing agreement between the hospital and its owner, HCA Healthcare, and SEIU Local 121RN, the union representing RCH nurses, ended without a renewal.

The nurses said it would lead to too few nurses treating too many patients during a pandemic. Insufficient PPE and recycling of single-use PPE were also putting nurses and patients at risk, the union said, and another reason for the strike.

But rapidly changing guidance around PPE use and generally inconsistent information from public officials are now making the nurses at his hospital feel apathetic.

“Unfortunately I feel like in the past few weeks it’s gotten to the point where you have to remind people about putting on their respirator instead of face mask, so people haven’t gotten lax, but definitely kind of become desensitized compared to when we first started,” Andrews said.

With two children at home, Andrews slept in a trailer in his driveway for 12 weeks when he first started treating coronavirus patients. The trailer is still there, just in case, but after testing negative twice he felt he couldn’t spend any more time away from his family.

He still worries though, especially about his coworkers’ families. Some coworkers he’s known for over a decade, including one staff member who died from COVID-19 related complications.

“It’s people you know and you know that their families worry about them every day,” he said. “So to know that they’ve had to deal with that loss is pretty horrifying, and to know that could happen to my family too.”

 

 

 

Diabetes highlights two Americas: One where COVID is easily beaten, the other where it’s often devastating

https://www.usatoday.com/story/news/health/2020/07/27/diabetes-and-covid-two-americas-health-problems/5445836002/?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202020-07-27%20Healthcare%20Dive%20%5Bissue:28706%5D&utm_term=Healthcare%20Dive

What You Need to Know about Diabetes and the Coronavirus | diaTribe

Dr. Anne Peters splits her mostly virtual workweek between a diabetes clinic on the west side of Los Angeles and one on the east side of the sprawling city. 

Three days a week she treats people whose diabetes is well-controlled. They have insurance, so they can afford the newest medications and blood monitoring devices. They can exercise and eat well.  Those generally more affluent West L.A. patients who have gotten COVID-19 have developed mild to moderate symptoms – feeling miserable, she said – but treatable, with close follow-up at home.

“By all rights they should do much worse, and yet most don’t even go to the hospital,” said Peters, director of the USC Clinical Diabetes Programs.

On the other two days of her workweek, it’s a different story.

In East L.A., many patients didn’t have insurance even before the pandemic. Now, with widespread layoffs, even fewer do. They live in “food deserts,” lacking a car or gas money to reach a grocery store stocked with fresh fruits and vegetables. They can’t stay home, because they’re essential workers in grocery stores, health care facilities and delivery services. And they live in multi-generational homes, so even if older people stay put, they are likely to be infected by a younger relative who can’t.

They tend to get COVID-19 more often and do worse if they get sick, with more symptoms and a higher likelihood of ending up in the hospital or dying, said Peters, also a member of the leadership council of Beyond Type 1, a diabetes research and advocacy organization. 

“It doesn’t mean my East Side patients are all doomed,” she emphasized.

But it does suggest COVID-19 has an unequal impact, striking people who are poor and already in ill health far harder than healthier, better off people on the other side of town.

Tracey Brown has known that for years.

“What the COVID-19 pandemic has done is shined a very bright light on this existing and pervasive problem,” said Brown, CEO of the American Diabetes Association. Along with about 32 million others – roughly 1 in 10 Americans – Brown has diabetes herself.

“We’re in 2020, and every 5 minutes, someone is losing a limb” to diabetes, she said. “Every 10 minutes, somebody is having kidney failure.”

Americans with diabetes and related health conditions are 12 times more likely to die of COVID-19 than those without such conditions, she said. Roughly 90% of Americans who die of COVID-19 have diabetes or other underlying conditions. And people of color are over-represented among the very sick and the dead.

Diabetes and COVID: Coronavirus highlights America's health problems

Diabetes increases COVID risk

The data is clear: People with diabetes are at increased risk of having a bad case of COVID-19, and diabetics with poorly controlled blood sugar are at even higher risk, said Liam Smeeth, dean of the faculty of epidemiology and population health at the London School of Hygiene and Tropical Medicine. He and his colleagues combed data on 17 million people in the U.K. to come to their conclusions.

Diabetes often comes paired with other health problems – obesity and high blood pressure, for instance. Add smoking, Smeeth said, and “for someone with diabetes in particular, those can really mount up.”

People with diabetes are more vulnerable to many types infections, Peters said, because their white blood cells don’t work as well when blood sugar levels are high. 

“In a test tube, you can see the infection-fighting cells working less well if the sugars are higher,” she said.

Peters recently saw a patient whose diabetes was triggered by COVID-19, a finding supported by one recent study.

Going into the hospital with any viral illness can trigger a spike in blood sugar, whether someone has diabetes or not. Some medications used to treat serious cases of COVID-19 can “shoot your sugars up,” Peters said.

In patients who catch COVID-19 but aren’t hospitalized, Peters said, she often has to reduce their insulin to compensate for the fact that they aren’t eating as much.

Low income seems to be a risk factor for a bad case of COVID-19, even independent of age, weight, blood pressure and blood sugar levels, Smeeth said. “We see strong links with poverty.”

Some of that is driven by occupational risks, with poorer people unable to work from home or avoid high-risk jobs. Some is related to housing conditions and crowding into apartments to save money. And some, may be related to underlying health conditions.

But the connection, he said, is unmistakable.

Peters recently watched a longtime friend lose her husband. Age 60 and diabetic, he was laid off due to COVID, which cost him his health insurance. He developed a foot ulcer that he couldn’t afford to treat. He ignored it until he couldn’t stand anymore and then went to the hospital.

After surgery, he was released to a rehabilitation facility where he contracted COVID. He was transferred back to the hospital, where he died four days later.

“He died, not because of COVID and not because of diabetes, but because he didn’t have access to health care when he needed it to prevent that whole process from happening,” Peters said, adding that he couldn’t see his family in his final days and died alone. “It just breaks your heart.”

Taking action on diabetes– personally and nationally

Now is a great time to improve diabetes control, Peters added. With many restaurants and most bars closed, people can have more control over what they eat. No commuting leaves more time for exercise.

That’s what David Miller has managed to do. Miller, 65, of Austin, Texas, said he has stepped up his exercise routine, walking for 40 minutes four mornings a week at a nearby high school track. It’s cool enough at that hour, and the track’s not crowded, said Miller, an insurance agent, who has been able to work from home during the pandemic. “That’s more consistent exercise than I’ve ever done.”

His blood sugar is still not where he wants it to be, he said, but his new fitness routine has helped him lose a little weight and bring his blood sugar under better control. Eating less remains a challenge. “I’m one of those middle-aged guys who’s gotten into the habit of eating for two,” he said. “That can be a hard habit to shake.”

Miller said he isn’t too worried about getting COVID-19.

“I’ve tried to limit my exposure within reason,” he said, noting that he wears a mask when he can in public. “I honestly don’t feel particularly more vulnerable than anybody else.”

Smeeth, the British epidemiologist, said even though they’re at higher risk for bad outcomes, people with diabetes should know that they’re not helpless. 

“The traditional public health messages – don’t be overweight, give up smoking, keep active  – are still valid for COVID,” he said. Plus, people with diabetes should prioritize getting a flu vaccine this fall, he said, to avoid compounding their risk.

(For more practical recommendations for those living with diabetes during the pandemic, go to coronavirusdiabetes.org.)

In Los Angeles, Peters said, the county has made access to diabetes medication much easier for people with low incomes. They can now get three months of medication, instead of only one. “We refill everybody’s medicine that we can to make sure people have the tools,” she said, adding that diabetes advocates are also doing what they can to help people get health insurance.

Controlling blood sugar will help everyone, not just those with diabetes, Peters said. Someone hospitalized with uncontrolled blood sugar takes up a bed that could otherwise be used for a COVID-19 patient. 

Brown, of the American Diabetes Association, has been advocating for those measures on a national level, as well as ramping up testing in low-income communities. Right now, most testing centers are in wealthier neighborhoods, she said, and many are drive-thrus, assuming that everyone who needs testing has a car.

Her organization is also lobbying for continuity of health insurance coverage if someone with diabetes loses their job, as well as legislation to remove co-pays for diabetes medication.

“The last thing we want to have happen is that during this economically challenged time, people start rationing or skipping their doses of insulin or other prescription drugs,” Brown said. That leads to unmanaged diabetes and complications like ulcers and amputations. “Diabetes is one of those diseases where you can control it. You shouldn’t have to suffer and you shouldn’t have to die.”

 

 

U.S. Coronavirus Response: We blew it

https://www.axios.com/coronavirus-america-blew-it-b3d84ea3-78b3-4fe0-8dce-1c4ed0ec0a4c.html

We blew it: Why America still hasn't gotten the coronavirus under ...

America spent the spring building a bridge to August, spending trillions and shutting down major parts of society. The expanse was to be a bent coronavirus curve, and the other side some semblance of normal, where kids would go to school and their parents to work.

The bottom line: We blew it, building a pier instead.

There will be books written about America’s lost five months of 2020, but here’s what we know:

We blew testing. President Trump regularly brags and complains about the number of COVID-19 tests conducted in the U.S., but America hasn’t built the infrastructure necessary to process and trace the results.

  • Quest Diagnostics says its average turnaround time for a COVID-19 test has lengthened to “seven or more days” — thus decreasing the chance that asymptomatic or mildly symptomatic carriers will self-quarantine.
  • The testing delays also make it harder for public health officials to understand current conditions, let alone implement effective contact tracing.
  • Speaking of contact tracing, it remains a haphazard and uncoordinated process in many parts of the country.

We blew schools. Congress allocated $150 billion for state and local governments as part of the CARES Act, but that was aimed at maintaining status quo services in the face of plummeting tax revenue.

There was no money earmarked for schools to buy new safety equipment, nor to hire additional teachers who might be needed to staff smaller class sizes and hybrid learning days.

  • U.S. Education Secretary Betsy DeVos was not among the 27 officials included in the White House Coronavirus Task Force.
  • The administration insists that schools should reopen this fall because kids are less likely to get very sick from the virus, but it has not yet offered detailed plans to protect older teachers, at-risk family members, or students with pre-existing respiratory or immune conditions.
  • Silicon Valley provided some free services to schools, but there was no coordinated effort to create a streamlined virtual learning platform. There also continue to be millions of schoolkids without access to broadband and/or Internet-connected devices.

We blew economics. The CARES Act was bold and bipartisan, a massive stimulus to meet the moment.

  • It’s running out, without an extension plan not yet in place.
  • Expanded unemployment benefits expire in days. Many small businesses have already exhausted their Paycheck Protection Program loans, including some that reopened but have been forced to close again.
  • There has been no national effort to pause residential or commercial evictions, nor to give landlords breathing room on their mortgage payments.

We blew public health. There’s obviously a lot here, but just stick with face masks. Had we all been directed to wear them in March — and done so, even makeshift ones while manufacturing ramped up — you might not be reading this post.

We blew goodwill. Millions of Americans sheltered in place, pausing their social lives for the common good.

  • But many millions of other Americans didn’t. Some were essential workers. Some were deemed essential workers but really weren’t. Some just didn’t care, or didn’t believe the threat. Some ultimately decided that protesting centuries of racial injustice was a worthy trade-off.
  • All of this was complicated by mixed messages from federal and state leaders. Top of that list was President Trump, who claimed to adopt a wartime footing without clearly asking Americans to make sacrifices necessary to defeat the enemy.
  • Five months later, many of those who followed the “rules” are furious at what they perceive to be the selfishness of others.

The bottom line: America has gotten many things right since March, including the development of more effective hospital treatments for COVID-19 patients.

  • But we’re hitting daily infection records, daily deaths hover around 900, and many ICUs reports more patients than beds. It didn’t have to be this way.

 

 

 

 

What happens if Covid-19 symptoms don’t go away? Doctors are trying to figure it out.

https://www.vox.com/2020/7/14/21324201/covid-19-long-term-effects-symptoms-treatment

Covid-19 long-term effects: People with persistent symptoms ...

People with long-term Covid-19 complications are meanwhile struggling to get care.

In late March, when Covid-19 was first surging, Jake Suett, a doctor of anesthesiology and intensive care medicine with the National Health Service in Norfolk, England, had seen plenty of patients with the disease — and intubated a few of them.

Then one day, he started to feel unwell, tired, with a sore throat. He pushed through it, continuing to work for five days until he developed a dry cough and fever. “Eventually, I got to the point where I was gasping for air literally doing nothing, lying on my bed.”

At the hospital, his chest X-rays and oxygen levels were normal — except he was gasping for air. After he was sent home, he continued to experience trouble breathing and developed severe cardiac-type chest pain.

Because of a shortage of Covid-19 tests, Suett wasn’t immediately tested; when he was able to get a test, 24 days after he got sick, it came back negative. PCR tests, which are most commonly used, can only detect acute infections, and because of testing shortages, not everyone has been able to get a test when they need one.

It’s now been 14 weeks since Suett’s presumed infection and he still has symptoms, including trouble concentrating, known as brain fog. (One recent study in Spain found that a majority of 841 hospitalized Covid-19 patients had neurological symptoms, including headaches and seizures.) “I don’t know what my future holds anymore,” Suett says.

Some doctors have dismissed some of his ongoing symptoms. One doctor suggested his intense breathing difficulties might be related to anxiety. “I found that really surprising,” Suett says. “As a doctor, I wanted to tell people, ‘Maybe we’re missing something here.’” He’s concerned not just for himself, but that many Covid-19 survivors with long-term symptoms aren’t being acknowledged or treated.

Suett says that even if the proportion of people who don’t eventually fully recover is small, there’s still a significant population who will need long-term care — and they’re having trouble getting it. “It’s a huge, unreported problem, and it’s crazy no one is shouting this from rooftops.”

In the US, a number of specialized centers are popping up at hospitals to help treat — and study — ongoing Covid-19 symptoms. The most successful draw on existing post-ICU protocols and a wide range of experts, from pulmonologists to psychiatrists. Yet even as care improves, patients are also running into familiar challenges in finding treatment: accessing and being able to pay for it.

What’s causing these long-term symptoms?

Scientists are still learning about the many ways the virus that causes Covid-19 impacts the body — both during initial infection and as symptoms persist.

One of the researchers studying them is Michael Peluso, a clinical fellow in infectious diseases at the University of California San Francisco, who is currently enrolling Covid-19 patients in San Francisco in a two-year study to study the disease’s long-term effects. The goal is to better understand what symptoms people are developing, how long they last, and eventually, the mechanisms that cause them. This could help scientists answer questions like how antibodies and immune cells called T-cells respond to the virus, and how different individuals might have different immune responses, leading to longer or shorter recovery times.

At the beginning of the Covid-19 pandemic, “the assumption was that people would get better, and then it was over,” Peluso says. “But we know from lots of other viral infections that there is almost always a subset of people who experience longer-term consequences.” He explains these can be due to damage to the body during the initial illness, the result of lingering viral infection, or because of complex immunological responses that occur after the initial disease.

“People sick enough to be hospitalized are likely to experience prolonged recovery, but with Covid-19, we’re seeing tremendous variability,” he says. It’s not necessarily just the sickest patients who experience long-term symptoms, but often people who weren’t even initially hospitalized.

That’s why long-term studies of large numbers of Covid-19 patients are so important, Peluso says. Once researchers can find what might be causing long-term symptoms, they can start targeting treatments to help people feel better. “I hope that a few months from now, we’ll have a sense if there is a biological target for managing some of these long-term symptoms.”

Lekshmi Santhosh, a physician lead and founder of the new post-Covid OPTIMAL Clinic at UCSF, says many of her patients are reporting the same kinds of problems. “The majority of patients have either persistent shortness of breath and/or fatigue for weeks to months,” she says.

Additionally, Timothy Henrich, a virologist and viral immunologist at UCSF who is also a principal investigator in the study, says that getting better at managing the initial illness may also help. “More effective acute treatments may also help reduce severity and duration of post-infectious symptoms.”

In the meantime, doctors can already help patients by treating some of their lingering symptoms. But the first step, Peluso explains, is not dismissing them. “It is important that patients know — and that doctors send the message — that they can help manage these symptoms, even if they are incompletely understood,” he says. “It sounds like many people may not be being told that.”

Long-term symptoms, long-term consequences

Even though we have a lot to learn about the specific damage Covid-19 can cause, doctors already know quite a bit about recovery from other viruses: namely, how complex and challenging a task long-term recovery from any serious infection can be for many patients.

Generally, it’s common for patients who have been hospitalized, intubated, or ventilated — as is common with severe Covid-19 — to have a long recovery. Being bed-bound can cause muscle weakness, known as deconditioning, which can result in prolonged shortness of breath. After a severe illness, many people also experience anxiety, depression, and PTSD.

A stay in the ICU not uncommonly leads to delirium, a serious mental disorder sometimes resulting in confused thinking, hallucinations, and reduced awareness of surroundings. But Covid-19 has created a “delirium factory,” says Santhosh at UCSF. This is because the illness has meant long hospital stays, interactions only with staff in full PPE, and the absence of family or other visitors.

Theodore Iwashyna, an ICU physician-scientist at the University of Michigan and VA Ann Arbor, is involved with the CAIRO Network, a group of 40 post-intensive care clinics on four continents. In general, after patients are discharged from ICUs, he says, “about half of people have some substantial new disability, and half will never get back to work. Maybe a third of people will have some degree of cognitive impairment. And a third have emotional problems.” And it’s common for them to have difficulty getting care for their ongoing symptoms after being discharged.

In working with Covid-19 patients, says Santhosh, she tells patients, “We believe you … and we are going to work on the mind and body together.”

Yet it’s currently impossible to predict who will have long-lasting symptoms from Covid-19. “People who are older and frailer with more comorbidities are more likely to have longer physical recovery. However, I’ve seen a lot of young people be really, really sick,” Santhosh says. “They will have a long tail of recovery too.”

Who can access care?

At the new OPTIMAL Clinic at UCSF, doctors are seeing patients who were hospitalized for Covid-19 at the UCSF health system, as well as taking referrals of other patients with persistent pulmonary symptoms. For ongoing cough and chest tightness, the clinic is providing inhalers, as well as pulmonary rehabilitation, including gradual aerobic exercise with oxygen monitoring. They’re also connecting patients with mental health resources.

“Normalizing those symptoms, as well as plugging people into mental health care, is really critical,” says Santhosh, who is also the physician lead and founder of the clinic. “I want people to know this is real. It’s not ‘in their heads.’”

Neeta Thakur, a pulmonary specialist at Zuckerberg San Francisco General Hospital and Trauma Center who has been providing care for Covid-19 patients in the ICU, just opened a similar outpatient clinic for post-Covid care. Thakur has also arranged a multidisciplinary approach, including occupational and physical therapy, as well as expedited referrals to neurology colleagues for rehabilitation for the muscles and nerves that can often be compressed when patients are prone for long periods in the ICU. But she’s most concerned by the cognitive impairments she’s seeing, especially as she’s dealing with a lot of younger patients.

These California centers join new post-Covid-19 clinics in major cities across the country, including Mount Sinai in New York and National Jewish Health Hospital in Denver. As more and more hospitals begin to focus on post-Covid care, Iwashyna suggests patients try to seek treatment where they were hospitalized, if possible, because of the difficulty in transferring sufficient medical records.

Santosh recommends that patients with persistent symptoms call their closest hospital, or nearest academic medical center’s pulmonary division, and ask if they can participate in any clinical trials. Many of the new clinics are enrolling patients in studies to try to better understand the long-term consequences of the disease. Fortunately, treatment associated with research is often free, and sometimes also offers financial incentives to participants.

But otherwise, one of the biggest challenges in post-Covid-19 treatment is — like so much of American health care — being able to pay for it.

Outside of clinical trials, cost can be a barrier to treatment. It can be tricky to get insurance to cover long-term care, Iwashyna notes. After being discharged from an ICU, he says, “Recovery depends on [patients’] social support, and how broke they are afterward.” Many struggle to cover the costs of treatment. “Our patient population is all underinsured,” says Thakur, noting that her hospital works with patients to try to help cover costs.

Lasting health impacts can also affect a person’s ability to go back to work. In Iwashyna’s experience, many patients quickly run through their guaranteed 12 weeks of leave under the Family Medical and Leave Act, which isn’t required to be paid. Eve Leckie, a 39-year-old ICU nurse in New Hampshire, came down with Covid-19 on March 15. Since then, Leckie has experienced symptom relapses and still can’t even get a drink of water without help.

“I’m typing this to you from my bed, because I’m too short of breath today to get out,” they say. “This could disable me for the rest of my life, and I have no idea how much that would cost, or at what point I will lose my insurance, since it’s dependent on my employment, and I’m incapable of working.” Leckie was the sole wage earner for their five children, and was facing eviction when their partner “essentially rescued us,” allowing them to move in.

These long-term burdens are not being felt equally. At Thakur’s hospital in San Francisco, “The population [admitted] here is younger and Latinx, a disparity which reflects who gets exposed,” she says. She worries that during the pandemic, “social and structural determinants of health will just widen disparities across the board.” People of color have been disproportionately affected by the virus, in part because they are less likely to be able to work from home.

Black people are also more likely to be hospitalized if they get Covid-19, both because of higher rates of preexisting conditions — which are the result of structural inequality — and because of lack of access to health care.

“If you are more likely to be exposed because of your job, and likely to seek care later because of fear of cost, or needing to work, you’re more likely to have severe disease,” Thakur says. “As a result, you’re more likely to have long-term consequences. Depending on what that looks like, your ability to work and economic opportunities will be hindered. It’s a very striking example of how social determinants of health can really impact someone over their lifetime.”

If policies don’t support people with persistent symptoms in getting the care they need, ongoing Covid-19 challenges will deepen what’s already a clear crisis of inequality.

Iwashyna explains that a lot of extended treatment for Covid-19 patients is “going to be about interactions with health care systems that are not well-designed. The correctable problems often involve helping people navigate a horribly fragmented health care system.

“We can fix that, but we’re not going to fix that tomorrow. These patients need help now.”

 

 

 

The burden on teachers

https://www.axios.com/teachers-worry-school-reopening-coronavirus-4f173e1b-f48f-49ad-a319-0b053ddd7295.html

The burden on teachers in reopening the schools - Axios

The debate over whether and how much to re-open schools in the fall has put teachers in the precarious position of choosing between their own safety and the pressures from some parents and local officials.

Why it matters: Teachers are the core of K-12 education. The people we depend on to educate our society’s children may end up bearing the brunt of both the risk and the workload.

What’s happening: With coronavirus cases spiking in many parts of the U.S., districts are weighing the feasibility of keeping classes all virtual, as Los Angeles and San Diego are doing, or conducting a rotation of in-person and remote lessons.

While all back-to-school options have pros and cons, there are specific worries for teachers.

1. Exposure: Despite a child’s overall low health risk if they contract COVID-19, scientists still do not conclusively know if schools could become hotspots for more vulnerable populations.

  • Schools are on a time and money crunch for better ventilation, more disinfectant and masks and proper social distancing techniques. If a cluster of cases do occur, teachers and parents are short on answers about how to isolate students and contact trace.
  • Districts were already facing staffing shortages before the pandemic. And nearly 1.5 million teachers have a condition that puts them at increased risk of serious illness from coronavirus, per a Kaiser Family Foundation study. A separate KFF study out today found that 3.3 million adults age 65 or older live in a household with school-age children.
  • A study in Germany found that infections in schools had not led to outbreaks in the community. But an analysis of a surge of cases in Israel found that nearly half the reported cases in June were traced back to illness in schools.

“We as teachers prepare for active shooters, tornadoes, fires and I’m fully prepared to take a bullet or shield a child from falling debris during a tornado. But if I somehow get it and I’m asymptomatic and I get a student sick and something happens to them or one of their family members, that’s a guilt I would carry with me forever.”

— Michelle Albright, a second grade teacher from northwest Indiana

2. Difficulty of a hybrid approach: Many school districts like New York City are opting to split school between in-person and online to minimize exposure. That’s an effective but more burdensome approach for teachers, top teachers union chief Randi Weingarten told Axios’ Dan Primack Monday.

  • In-person contact with a teacher can make a big difference for students struggling with a concept or who need one-on-one time.
  • But many teachers will have to prepare virtual and in-person lessons and ensure the same learning outcomes for students in both settings — a tall order.

3. Child care availability: Teachers with children of their own are concerned about how to care for them when they are teaching.

  • States could choose to provide child care services for educators as essential employees, but it’s unclear what non-school child care options will be available in areas with high infection rates or where day care centers have struggled to stay in business.

4. Concerns of other school staff: Bus drivers, custodians, classroom aides, administrative staff, cafeteria workers, school nurses and substitute teachers may come in contact with more children throughout the day because they are less likely than teachers to be confined to a single classroom.

What to watch: School districts ought to be finding other roles for teachers who are not comfortable returning to the classroom, such as reassigning them to virtual-only roles or providing one-on-one online tutoring sessions with students, said John Bailey, visiting fellow at the American Enterprise Institute and former domestic policy adviser during the George W. Bush administration.

  • But there’s not much time to sort that out on top of getting teachers the professional development they need for effective remote learning.
  • “What I worry about is that we squandered the few months we had to make sure we can think through these challenges,” Bailey said. “This was one of the most obvious challenges facing schools with reopening and we should have been thinking about that for the last several months. Instead it’s creeping up on districts.”

The bottom line: Due to the unprecedented nature of this pandemic, teachers are worried about the uncertainties and, in some cases, lack of clear planning should conditions worsen. That may drive some to quit teaching altogether.

  • “You’ve got 25% of teachers who may be in either a high-risk situation because of pre-existing conditions or because of age, and a lot of them, if they can, they may just check out and say ‘nobody’s taking care of me. I can’t go back,'” Weingarten said.

 

 

 

 

More young people are getting — and spreading — the coronavirus

https://www.axios.com/coronavirus-young-people-spread-5a0cd9e0-1b25-4c42-9ef9-da9d9ebce367.html

More young people are getting — and spreading — the coronavirus ...

More young people are being infected with the coronavirus, and even though they’re less likely to die from it, experts warn the virus’ spread among young adults may further fuel outbreaks across the United States.

Why it matters: Some people in their 20s and 30s face serious health complications from COVID-19, and a surge in cases among young people gives the virus a bigger foothold, increasing the risk of infection for more vulnerable people.

  • We may see a pattern of younger people being affected initially, but then, in a number of weeks from now, we’re going to see a more deadly pandemic spreading to elderly people,” says Alison Galvani, an epidemiologist at Yale University.

People can transmit the virus without knowing they have it, and younger people, in particular, could be unknowingly spreading the disease.

  • A study in Italy, yet to be peer reviewed, found the probability of having symptoms increased with age and that among 20–39-year-olds only about 22% had a fever or respiratory symptoms (compared to about 35% of 60–79-year-olds).
  • About half of the clusters in a study in Japan were traced back to people ages 20–39 at karaoke bars, offices and restaurants — and 41% of them did not have symptoms at the time.
  • “Younger people are at lower risk for serious COVID outcomes but are disproportionately responsible for asymptomatic transmission,” says Galvani, who published a study earlier this week that found the majority of COVID-19 transmission is from silent carriers who are pre-symptomatic or asymptomatic.

By the numbers: From Arizona to Allegheny County, Pa., young people increasingly account for COVID-19 cases.

  • In the county of Los Angeles, nearly 50% of cases are now in people under 40 (compared to about 30% in April), per the LA Times.
  • In Harris County, Texas, home to Houston, 43% of the 40,000 cases are in people ages 20–39, as of yesterday.
  • In Florida, the median age of confirmed cases is hovering in the mid- to late-30s, compared to age 65 in March.

And the proportion of young people hospitalized for COVID-19 has also grown.

  • 40% of hospitalizations for COVID-19 at the end of June were for people 18–49-years-old, compared to 26% at the end of March, according to the COVID-NET database of hospitalizations in 14 states that represent about 10% of the U.S. population.

Between the lines: Yes, young people are going to bars and parties — but also to work.

  • 42% of people ages 18–39 said they had socialized without social distancing compared to 26% of people over 40, in a survey last month from the Democracy Fund + UCLA Nationscape.
  • 64% of frontline workers (grocery store clerks, health care workers, delivery drivers and other essential workers) are under 50.
  • There’s a need for better education so that young people choose to take steps to prevent infection, says Lauren Ancel Meyers, a mathematical epidemiologist at UT Austin.
  • “But it also might come down to policies or regulations that get employers to ensure they are providing a safe workplace or resources to protect 20, 30 and other age groups that are working for them.”

Where it stands: Young people are still much less likely to be hospitalized or die from the virus than people older than 60.

  • Yes, but: They can and do get very sick with the disease — from dangerous blood clots in their lungs to inflammation of the heart, lungs and even brain.
  • And the long-term consequences are unknown.
  • The risk is higher for young people of color: For example, the majority of coronavirus hospitalizations among Latino/Hispanic Americans are in people ages 18–49, my Axios colleague Caitlin Owens reported.

“The death rate among the young is not zero, and it is particularly not zero for people who have at least one co-morbid condition. This is not a completely benign disease of the young.”

— Joshua Schiffer, of the Fred Hutchinson Cancer Center

What to watch: “If hospitals are strained now dealing with younger cases, they are going to be all the more taxed when the age distribution of infections shifts to the elderly,” Galvani says.

 

 

 

 

 

U.S. sets one-day record with more than 60,500 COVID cases; Americans divided

https://www.reuters.com/article/us-health-coronavirus-usa/u-s-sets-one-day-record-with-more-than-60500-covid-cases-americans-divided-idUSKBN24A28B?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202020-07-10%20Healthcare%20Dive%20%5Bissue:28416%5D&utm_term=Healthcare%20Dive

Texas, Florida and Arizona see increase in COVID-19 deaths | Daily ...

More than 60,500 new COVID-19 infections were reported across the United States on Thursday, according to a Reuters tally, setting a one-day record as weary Americans were told to take new precautions and the pandemic becomes increasingly politicized.

The total represents a slight rise from Wednesday, when there were 60,000 new cases, and marks the largest one-day increase by any country since the pandemic emerged in China last year.

As infections rose in 41 of the 50 states over the last two weeks, Americans have become increasingly divided on issues such as the reopening of schools and businesses. Orders by governors and local leaders mandating face masks have become particularly divisive.

“It’s just disheartening because the selfishness of (not wearing a mask) versus the selflessness of my staff and the people in this hospital who are putting themselves at risk, and I got COVID from this,” said Dr. Andrew Pastewski, ICU medical director at Jackson South Medical Center in Miami.

“You know, we’re putting ourselves at risk and other people aren’t willing to do anything and in fact go the other way and be aggressive to promote the disease. It’s really, it’s really hard,” he said.

Stephanie Porta, 41, a lifelong Orlando, Florida, resident, said only about half the shoppers at her grocery store wore masks, though that was more than she saw two weeks ago.

“They’re trying to make everything seem normal, when it’s not. People are dying, people are getting sick. It’s insane,” she said.

Florida on Thursday announced nearly 9,000 new cases and 120 new coronavirus deaths, a record daily increase in lives lost. Governor Ron DeSantis called the rising cases a “blip” and urged residents not to be afraid.

“I know we’ve had a lot of different blips,” DeSantis said. “We’re now at a higher blip than where we were in May and the beginning of June.”

Florida is one of the few states that does not disclose the number of hospitalized COVID patients. But more than four dozen Florida hospitals reported their intensive care units reached full capacity earlier this week.

In Texas a group of bar owners sued Governor Greg Abbott, a Republican, saying his June 26 order closing them down violates the state constitution, the Dallas Morning News reported.

Dr. Robert Redfield, director of the U.S. Centers for Disease Control and Prevention, said Thursday that keeping schools closed would be a greater risk to children’s health than reopening them.

California and Texas, the two most populous states, announced record increases in COVID deaths on Wednesday.

California has seen cases and hospitalizations surge, even though it imposed one of the strictest lockdowns. After several lawmakers and staffers at the state Capitol in Sacramento were infected, lawmakers said the legislature would not return from summer break until July 27.

Riverside University Health System, east of Los Angeles, expanded its 44-bed intensive care unit after it filled up with patients.

“It’s been very consistent every day in the last couple of weeks. Every day has been like a full moon,” Riverside emergency room physician Stephanie Loe said, referring to doctors’ beliefs that a full moon brings more patients to the emergency room.

Governors in California, Florida and Texas have either ruled out forced business closures and quarantines or called them a last resort. But Los Angeles Mayor Eric Garcetti warned he would impose a new stay-at-home order in two weeks if the latest surge did not ease.

The rise in infections also weighed on the stock market Thursday on fears of new lockdowns, which would take a toll on the economic recovery. The Dow .DJI and the S&P 500 .SPX ended down about 1%.

 

 

 

 

Cases skyrocketing among communities of color

https://www.axios.com/newsletters/axios-vitals-e9aa531d-4ef5-46ec-aedb-56f2bc9a77c9.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Coronavirus cases skyrocketing among communities of color - Axios

Counties populated by larger numbers of people of color tend to have more coronavirus cases than those with higher shares of white people.

What we’re watching: As the outbreak worsens throughout the South and the West, caseloads are growing fastest in counties with large communities of color.

The big picture: The southern and southwestern parts of the U.S. — the new epicenters of the outbreak — have higher Black and Latino or Hispanic populations to begin with.

  • People of color have seen disproportionate rates of infection, hospitalization and death throughout the pandemic.

Between the lines: These inequities stem from pre-existing racial disparities throughout society, and have been exacerbated by the U.S. coronavirus response.

  • Black and Hispanic or Latino communities have had less access to diagnostic testing, and people of color are also more likely to be essential workers. That means the virus is able to enter and spread throughout a community without adequate detection, often with disastrous results.

The bottom line: Until we plug the huge holes in the American coronavirus response — like inadequate testing and contact tracing and a lack of protection for essential workers — people of color will continue to bear the brunt of the pandemic.

Go deeper: People of color have less access to coronavirus testing