Into the COVID fray again, or for the first time

https://mailchi.mp/45f15de483b9/the-weekly-gist-october-9-2020?e=d1e747d2d8

Addressing Workforce Needs for COVID-19 | University at Albany

While it sometimes seems like the coronavirus has been with us forever, it’s worth remembering that there are still parts of the country that are only now experiencing their first big spike in cases—that’s the nature of a “patchwork” pandemic working its way across a vast country.

One of our health system members in the Midwest, with whom we recently spent time, is in just this situation: they’re seeing their highest inpatient COVID census to date, just this month. As they shared with us, there are advantages and drawbacks to being a “late follower” on the epidemic curve. The good news is that they’re ready.

Back in March, like most systems, they stood up an “incident command center”, and began preparing for a wave of COVID patients, designating a floor of the hospital as a “hot zone”, creating negative pressure rooms, cross-training staff, developing treatment protocols, stockpiling protective equipment, and securing a pipeline of critical therapeutics and testing supplies. There was a moderate but manageable number of cases across the late spring and summer, but never to an extent that stressed the system.
 
Eventually, recognizing that they couldn’t ask their doctors, nurses, and administrators to stay on high alert indefinitely, they “stood down” to a more normal operational tempo, only to watch with dismay as the surrounding community seemingly forgot about the virus, and lessened precautions (masking, distancing, and so forth), wanting life to return to “normal”. And now, the post-Labor Day, post-return-to-school spike has arrived.

The challenge now is getting everyone, inside and outside the system, to stop talking about COVID in the past tense, as though they’ve already “gotten through it.” The preparations they’ve made are paying off now. Hospital operations continue to run smoothly even with a high COVID census, but the workforce is exhausted, and citizens aren’t stepping outside to bang gratefully on pots every night anymore.

Asking the team to return to war footing is no easy task, given the fatigue of the past seven months. A question looms: what is the trigger to restart “incident command”? As cases begin to increase again in some of the original COVID hot spots—New York, New England, the Pacific Northwest—healthcare leaders there will need to learn from the experiences of their colleagues in the newly-hit Midwest, about how to take an already virus-weary clinical workforce back onto the battlefield.

Pandemic spurs national union activity among hospital workers

https://www.healthcaredive.com/trendline/labor/28/?utm_source=HD&utm_medium=Library&utm_campaign=Vituity&utm_term=Healthcare%20Dive#story-1

When COVID-19 cases swelled in New York and other northern states this spring, Erik Andrews, a rapid response nurse at Riverside Community Hospital in southern California, thought his hospital should have enough time to prepare for the worst.

Instead, he said his hospital faced staffing cuts and a lack of adequate personal protective equipment that led around 600 of its nurses to strike for 10 days starting in late June, just before negotiating a new contract with the hospital and its owner, Nashville-based HCA Healthcare.

“To feel like you were just put out there on the front lines with as minimal support necessary was incredibly disheartening,” Andrews said. Two employees at RCH have died from COVID-19, according to SEIU Local 121RN, the union representing them.

A spokesperson for HCA told Healthcare Dive the “strike has very little to do with the best interest of their members and everything to do with contract negotiations.”

Across the country, the pandemic is exacerbating labor tensions with nurses and other healthcare workers, leading to a string of disputes around what health systems are doing to keep front-line staff safe. The workers’ main concerns are adequate staffing and PPE. Ongoing or upcoming contract negotiations could boost their leverage.

But many of the systems that employ these workers are themselves stressed in a number of ways, above all financially, after months of delayed elective procedures and depleted volumes. Many have instituted furloughs and layoffs or other workforce reduction measures.

Striking a balance between doing union action at hospitals and continuing care for patients could be an ongoing challenge, Patricia Campos-Medina, co-director of New York State AFL-CIO/Cornell Union Leadership Institute.

“The nurses association has been very active since the beginning of the crisis, demanding PPE and doing internal activities in their hospitals demanding proper procedures,” Campos-Medina said. “They are front-line workers, so they have to be thoughtful in how they continue to provide care but also protect themselves and their patients.”

At Prime Healthcare’s Encino Hospital Medical Center, just outside Los Angeles, medical staff voted to unionize July 5, a week after the hospital laid off about half of its staff, including its entire clinical lab team, according to SEIU Local 121RN, which now represents those workers.

One of the first things the newly formed union will fight is “the unjust layoffs of their colleagues,” it said in a statement.

A Prime Healthcare spokesperson told Healthcare Dive 25 positions were cut. “These Encino positions were not part of front-line care and involved departments such as HR, food services, and lab services,” the system said.

Hospital service workers elsewhere who already have bargaining rights are also bringing attention to what they deem as staffing and safety issues.

In Chicago, workers at Loretto Hospital voted to authorize a strike Thursday. Those workers include patient care technicians, emergency room technicians, mental health staff and dietary and housekeeping staff, according to SEIU Healthcare Illinois, the union that represents them. They’ve been bargaining with hospital management for a new contract since December and plan to go on strike July 20.

Loretto Hospital is a safety-net facility, catering primarily to “Black and Brown West Side communities plagued with disproportionate numbers of COVID illnesses and deaths in recent months,” the union said.

The “Strike For Black Lives” is in response to “management’s failure to bargain in good faith on critical issues impacting the safety and well-being of both workers and patients — including poverty level wages and short staffing,” according to the union.

A Loretto spokesperson told Healthcare Dive the system is hopeful that continuing negotiations will bring an agreement, though it’s “planning as if a strike is eminent and considering the best options to continue to provide healthcare services to our community.”

Meanwhile in Joliet, Illinois, more than 700 nurses at Amita St. Joseph Medical Center went on strike July 4.

The Illinois Nurses Association which represents Amita nurses, cited ongoing concerns about staff and patient safety during the pandemic, namely adequate PPE, nurse-to-patient ratios and sick pay, they want addressed in the next contract. They are currently bargaining for a new one, and said negotiations stalled. The duration of the strike is still unclear.

However, a hospital spokesperson told Healthcare Dive, “Negotiations have been ongoing with proposals and counter proposals exchanged.”

The hospital’s most recent proposal “was not accepted, but negotiations will continue,” the system said.

INA is also upset with Amita’s recruitment of out-of-state nurses to replace striking ones during the COVID-19 pandemic.

It sent a letter to the Illinois Department of Financial and Professional Regulation, asserting the hospital used “emergency permits that are intended only for responding to the pandemic for purposes of aiding the hospital in a labor dispute.”

 

 

 

 

Covid-19 has killed more police officers this year than all other causes combined, data shows

https://www.washingtonpost.com/business/2020/09/02/coronavirus-deaths-police-officers-2020/?utm_campaign=wp_main&utm_medium=social&utm_source=facebook&fbclid=IwAR3KWZcuMmVXy_R7mDh_m58_BLdQkz6rw5iU9nsii950Bx46lwc0nbfC3p4

By one estimate, coronavirus deaths among law enforcement are likely to surpass those of 9/11.

In a speech this week in Pittsburgh, Joe Biden linked the Trump administration’s mismanagement of the coronavirus to its handling of protests and riots with a surprising statistic: “More cops have died from covid this year than have been killed on patrol,” he said.

The Democratic presidential nominee’s claim is true, according to data compiled by the Officer Down Memorial Page and the National Law Enforcement Officers Memorial Fund, two nonprofits that have tracked law enforcement fatalities for decades.

As of Sept. 2, on-the-job coronavirus infections were responsible for a least 100 officer deaths, more than gun violence, car accidents and all other causes combined, according to the Officer Down group. NLEOMF reported a nearly identical number of covid-related law enforcement deaths.

NLEOMF reported a nearly identical number of covid-related law enforcement deaths. It also noted that fatalities due to non-covid causes are actually down year-over-year, undermining President Trump’s claims that “law enforcement has become the target of a dangerous assault by the radical left.”

Both organizations only count covid deaths “if it is determined that the officer died as a result of exposure to the virus while performing official duties,” as the National Law Enforcement Officers Memorial Fund put it. “Substantive evidence will be required to show the death was more than likely due to the direct and proximate result of a duty-related incident.”

In addition to the 100 confirmed coronavirus fatalities listed on the Officer Down website, the nonprofit said it is in the process of verifying an additional 150 officer deaths due to covid-19 and presumed to have been contracted in the line of duty, said Chris Cosgriff, executive director of ODMP, in an email.

“By the end of this pandemic, it is very likely that COVID will surpass 9/11 as the single largest incident cause of death for law enforcement officers,” he wrote. Seventy-one officers were killed in the attacks on the twin towers, one officer was killed on United Flight 93, and more than 300 have passed away since then as a result of cancer contracted in the wake of the attacks, according to ODMP.

At the state level, Texas stands out for having the highest number of law enforcement covid fatalities with at least 21, according to NLEOMF. At least 16 of those represent officers with the Texas Department of Criminal Justice, which manages the state’s correctional facilities. Louisiana has 12 covid-related officer deaths. Florida, New Jersey and Illinois round out the top five with eight each.

According to both organizations, officers in correctional facilities account for a substantial number of covid-related law enforcement deaths, reflecting the dire epidemiological situation in many of the nation’s prisons and jails.

“Corrections officers and Corrections Departments have been hit harder than regular police agencies,” Cosgriff said. According to the Marshall Project, a nonprofit criminal justice news site, more than 100,000 U.S. prison inmates have tested positive for coronavirus and at least 928 have died. There have been an additional 24,000 cases and 72 deaths among prison staff.

ODMP’s tally includes police officers, sheriff’s deputies, correctional officers, federal law enforcement officers and military police officers killed outside of military conflict. NLEOMF’s inclusion criteria are similar.

This year, Trump signed the Safeguarding America’s First Responders Act of 2020, which guarantees law enforcement officers and their survivors federal benefits if the officer is killed or disabled by covid. For legal purposes, the legislation presumes that covid cases among officers were contracted in the line of duty.

 

 

 

 

San Francisco’s lonely war against Covid-19

https://www.vox.com/future-perfect/2020/7/30/21331369/london-breed-coronavirus-covid-san-francisco-california-trump

On June 25, San Francisco Mayor London Breed was excited the city’s zoo would finally reopen after closing down for months in response to Covid-19. She visited the facilities, posting photos on social media with a mask on and giraffes in the background.

“I know people are eager to get back to some sense of normalcy, especially families and children,” she tweeted. And it looked like her city was taking a step toward it.

The day after the visit, Breed had to announce the sad news: San Francisco’s reopening plan — for the zoo and various other facilities, including hair salons and indoor museums — would have to be put on hold.

“COVID-19 cases are rising throughout CA. We’re now seeing a rise in cases in SF too. Our numbers are still low but rising rapidly,” she tweeted. “As a result, we’re temporarily delaying the re-openings that were scheduled for Monday.”

While state and local leaders nationwide were pushing ahead with reopening, Breed pulled back. “I listened to our public health experts,” she told me. “It’s hard. The last thing I want to do is go out there and say one thing and then have to say something else. But I think it’s important that people understand things can change. This is a fluid situation.”

The decision — taken weeks before California Gov. Gavin Newsom’s move to shut down risky indoor venues statewide in July — was emblematic of San Francisco’s cautious approach throughout the coronavirus crisis. The city joined a regional stay-at-home order in March, before the rest of the state and New York, which became a Covid-19 epicenter, imposed their own orders. It was also slower to reopen: When California started to close down indoor venues again, the order largely didn’t affect San Francisco — because the city never reopened bars and indoor dining, among other high-risk venues, in the first place.

By and large, the approach — aided by regional cooperation, with leadership from Santa Clara County Health Officer Sara Cody, and widespread social distancing and mask-wearing by the public — has kept cases of Covid-19 manageable. In the spring, California and the Bay Area saw some of the first coronavirus cases, but quick action since then has let San Francisco and the surrounding region avoid turning into a major hot spot.

The increase in cases this summer has exceeded the April peak and fallen particularly hard on marginalized groups, especially Latin communities. But that, too, seems to be turning around: New cases started to fall by July 20 — almost a week before the state as a whole began to plateau. San Francisco has maintained less than 60 percent the Covid-19 cases per capita as California, and less than 30 percent the deaths per capita. Its caseload and death toll are lower than other large cities, including Washington, DC, and Columbus, Ohio, and far lower than current hot spots like Arizona and Florida.

“It’s doing as well as it can, given what’s going on around it,” Peter Chin-Hong, an infectious disease expert at the University of California San Francisco, told me.

Experts and local officials say the summer increase in cases doesn’t take away from what San Francisco has done. What it shows, instead, is the limits of what a local government can do — and the risk of relying on a county-by-county, state-by-state approach to a truly national crisis.

“We have to accept that we are all interrelated in a pandemic,” Kirsten Bibbins-Domingo, an epidemiologist at UCSF, told me. “We have to help each other out.”

The city’s leaders agree, pointing to some of the problems that have addled their response to the pandemic as the federal government did little — from a lack of personal protective equipment for health care workers to continued shortfalls in tests for Covid-19.

“We are not isolated; we are interconnected,” Grant Colfax, director of the San Francisco Department of Public Health, told me. “The virus exploits that very interconnectedness of our society. Without a consistent, robust, and sustained federal response that is driven by science … eventually things cannot be sustained.

This is why, experts argue, federal leadership is so key: The federal government is the one entity that could address these problems on a large scale. But President Donald Trump has ceded his role to the states and private actors — what his administration called the “state authority handoff” and the New York Times described as “perhaps one of the greatest failures of presidential leadership in generations.”

That’s left cities and states to fend for themselves. San Francisco has made the best of it, with the kind of model that experts argued could have prevented the current coronavirus resurgence if it had been followed nationally.

“There’s a value to being cautious,” Bibbins-Domingo said. “Any type of reopening is going to come with some increase in cases. That’s what we are learning in the pandemic. That’s what the infectious disease experts told us was going to happen. Places that thought they could just reopen without caution have really paid the price for it.”

San Francisco’s leaders were ahead on Covid-19

Breed started to really worry about the coronavirus in February, when she saw a glimpse of the future.

Stories of overwhelmed hospitals in Wuhan, China, showed that Covid-19 could cripple health care systems. But Breed believed, she said, that San Francisco’s larger, more advanced health care system could handle the blow. Then her advisers and experts told her differently — that a situation like Wuhan’s really could happen in San Francisco if she didn’t act.

“The shock I got,” Breed said. “We have all these hospitals, all these places where we have some of the most incredible doctors and research institutions. So in my mind, I’ve always thought this is where you want to be if something happens. To be told that here’s what our capacity is, here’s what happens if we do nothing, and what we need to prepare for, it really did blow my mind.”

At that point, she concluded, “We need to shut the city down to make sure this doesn’t happen.”

The virus has been the biggest challenge yet for Breed, who first became mayor in 2017 when her predecessor died, before she was elected to the role in 2018, having previously served on the Board of Supervisors.

But Breed, with the guidance of the Bay Area’s public health officials, has consistently kept the city ahead on Covid-19. The day before Trump claimed, falsely, that coronavirus cases would go from 15 to nearly zero in the US, Breed on February 25 declared a local state of emergency over the virus. Three days before California imposed a stay-at-home order and nearly a week before New York state did, San Francisco County, with Breed’s full backing, on March 16 joined the five other Bay Area counties in issuing the country’s first regional stay-at-home order.

Breed was ahead of not just much of the nation, but her progressive peers as well. On March 2, she warned on Twitter that the public should “prepare for possible disruption from an outbreak,” advising people to stock up on essential medications, make a child care plan in case a caregiver gets sick, and plan for school closures. The same day, New York City Mayor Bill de Blasio, a fellow Democrat, tweeted that he was “encouraging New Yorkers to go on with your lives + get out on the town despite Coronavirus.”

New York City would go on to suffer one of the worst coronavirus outbreaks in the world, with its total death rate standing, as of July 29, at 272 per 100,000 people — more than 45 times as high as San Francisco’s rate of 6 per 100,000. (De Blasio’s office didn’t respond to a request for comment.)

San Francisco’s death toll is also fairly low compared to that of some other areas in California — a fraction of Los Angeles County’s 45 per 100,000 and Imperial County’s 103. San Mateo County, a Bay Area county that reopened more aggressively, has more than double the death rate, at 15 per 100,000. San Francisco looks even better compared to cities and counties beyond California — with less than a tenth the deaths per capita as Washington, DC, and about a sixth as many as Franklin County, Ohio, where Columbus is, and Fulton County, Georgia, where most of Atlanta is.

At the time of the initial stay-at-home order, Chin-Hong said, people wondered if Breed was overreacting. “Of course, in hindsight, she was very prescient. She knew what was coming.”

There’s good reason to believe that San Francisco’s early action, particularly its lockdown, helped. The research indicates that stay-at-home orders and similar measures worked, with one preliminary Health Affairs study concluding:

Adoption of government-imposed social distancing measures reduced the daily growth rate by 5.4 percentage points after 1–5 days, 6.8 after 6–10 days, 8.2 after 11–15 days, and 9.1 after 16–20 days. Holding the amount of voluntary social distancing constant, these results imply 10 times greater spread by April 27 without SIPOs (10 million cases) and more than 35 times greater spread without any of the four measures (35 million).

That’s not to say San Francisco performed flawlessly.

Even the experts who praised Breed simultaneously raised alarms about how the virus had disproportionately affected minority populations — with about half of confirmed Covid-19 cases affecting Latin people, even though they comprise about 15 percent of the local population. The city’s large homeless population is also a major point of concern, with a big outbreak at the largest local homeless shelter. These are the kinds of blind spots with Covid-19 that have shown up across the country — as minority groups, in particular, are more likely to work in the kind of job deemed “essential” — and San Francisco isn’t immune to them.

“Myself, just taking care of patients, I know that some of those patients are going back to work sick if they don’t have to be hospitalized,” Yvonne Maldonado, an infectious disease expert at Stanford, told me. “They can’t afford not to work.”

Local officials point out they have taken aggressive action to shield marginalized populations — creating support programs for them, fielding contact tracing calls in Spanish, and setting up more than 2,500 hotel rooms for the vulnerable, including homeless people. And the disproportionate case count for Latin people is from a baseline of cases that’s lower than other parts of the state and country with similar disparities. Out of 57 Covid-19 deaths in the city, only one was a homeless person.

Breed acknowledged the challenge, describing the city’s response to Covid-19 as a work in progress as she and other officials struggle with the uncertainty that surrounds a virus that’s still relatively new to humans.

“That’s hard,” Breed said. “We have to make the hard decisions. What we hope people will understand is why. We keep trying to call attention to what’s happening or could happen to any of us. It’s a constant struggle.”

That’s especially compounded by the massive sacrifices that people have to make as they’re forced to stay at home, potentially giving up income, child care, and social connections.

Breed is aware this is no easy task. On a personal level, she said, “I’m tired of being in the house. I’ll tell you that much.” She acknowledged that the shutdown has left many people struggling, “because their livelihoods are at stake, their ability to take care of themselves is at stake.”

But the alternative, she suggested, is much worse. It’s not just more Covid-19 cases, hospitalizations, and deaths — but harm to the economy if a major outbreak forces cities and states to shut down all over again. As a preliminary study of the 1918 flu pandemic found, the cities that came out economically stronger back then took more aggressive action that hindered economies in the short term but better kept infections and deaths down overall.

Experts echoed a similar sentiment. “Dead people don’t shop. They don’t spend money. They don’t invest in things,” Jade Pagkas-Bather, an infectious disease expert and doctor at the University of Chicago, told me. “When you fail to invest in the health of your population, then there are longitudinal downstream effects.”

Breed had a key ally in San Francisco: The public

Chin-Hong, who lives and works in the Bay Area, recalled a recent experience he had at the grocery store. With the place at full capacity, people were waiting outside the store in a line. One person joined the line without a mask on. People began to eye him disapprovingly. He grew visibly nervous, at one point pulling his shirt over his mouth. After a while, a store staff member came out and gave him a mask, which he quickly put on.

The story is emblematic of one of Breed’s key advantages as she has pushed forward with aggressive actions against the coronavirus: San Francisco’s public is by and large on board, with a lot of solidarity built around social distancing and masking.

“The politician is only as good as her constituents,” Chin-Hong said. “It’s a key factor in all of this.”

In some ways, the public was even ahead of Breed. In the weeks before Bay Area counties issued a stay-at-home order, major tech companies in the region, like Google and Microsoft, told employees to work from home. That partly reflects tech employees’ ability to work from home with fewer disruptions, but also a greater sense of vigilance for an industry with close ties to the countries in East Asia that saw Covid-19 cases earlier.

It wasn’t just the tech sector. Restaurant data from OpenTable shows San Francisco was starting to avoid dining out by the first week of March, while most other cities in the US saw at best small decreases, if any changes: On March 1, dining out via OpenTable was down 18 percent in San Francisco, compared to down 3 percent in Los Angeles, down 2 percent in New York City, up 2 percent in Houston, and up 21 percent in Philadelphia. From that point forward, San Francisco’s numbers steadily dropped, while much of the US fluctuated before the depth of the outbreak became clearer nationwide.

San Francisco has also been better than much of the country about mask-wearing.New York Times analysis found there’s a roughly 60 to 90 percent chance, depending on the part of the city, that everyone is masked in five random encounters in San Francisco. In other parts of the US, including cities, the percent chance can drop to as low as 20, 10, or the single digits.

Even in California, it wasn’t guaranteed things would go like this. Orange County’s chief health officer resigned in June due to public resistance against a mask-wearing order. Sheriffs in Orange, Riverside, Fresno, and Sacramento counties said they wouldn’t enforce Gov. Newsom’s June order requiring masks in public and high-risk areas. With Trump and other Republicans suggesting that social distancing and masking requirements were part of a broader overreaction to the pandemic and an attempt at government overreach, and people genuinely suffering due to the economic downturn, San Francisco could have taken a very different direction.

We don’t know for certain why San Francisco’s public is more aggressive about precautions against Covid-19. One advantage San Franciscans have is many of them, particularly those in the tech sector and other office jobs, can work from home much more easily than, say, “essential” agricultural employees. The city also has close ties to East Asia, including China, potentially offering personal connections — and an early warning — to the first coronavirus outbreaks and the value of masking. San Francisco is also very progressive and Democratic, which helps as physical distancing, masking, and related measures have become politically polarized. Perhaps Breed’s more aggressive communication paid off.

Whatever the cause, there’s good reason to believe the public embrace of precautions helped the city. A review of the research published in The Lancet found that “evidence shows that physical distancing of more than 1 m is highly effective and that face masks are associated with protection, even in non-health-care settings.”

Again, it’s not perfect. Breed told me of a recent trip to a local store that was clearly far above the city’s reduced standards of capacity, with some of the staff and customers not wearing masks. “I was like, ‘What the heck is this? This is ridiculous,’” she said. “I called [the San Francisco Department of] Public Health, and they put a stop to it.”

More recently, Breed had to get tested for coronavirus after she went to an event attended by someone who reportedly knew they were positive. She used the moment to lightly admonish those who didn’t follow the recommended precautions: “I know people want to be out in public right now, but this disease is killing people. It’s simply reckless for those who have tested positive [to] go out and risk the lives of others,” she tweeted. “I cannot stress this enough: if you test positive, it’s on you to stay home and not expose others.” (Breed tested negative.)

But San Francisco’s public is seemingly better than much of the country at following the recommended precautions. Beyond Breed’s actions, that’s a potent explanation for why San Francisco has done relatively well — and why other parts of the state and country haven’t.

Local governments can only do so much about a pandemic

As successful as San Francisco has been relative to other parts of California and the US, it hasn’t escaped the recent rise in Covid-19 cases untouched. As of July 22 (the most recent reliable local data available), the city hit a seven-day average of 98 new cases a day — down from a peak of 120 several days prior but up from the previous peak of 48 in mid-April.

More than reflecting San Francisco’s own failures, experts said the upward swing in cases reflects the limits of what a local government can do when a virus spreads nationally and globally. When a virus can cross borders, there’s only so much San Francisco can do if its residents can drive an hour or two to a county where bars and indoor dining are open for service, or to meet with family members in an area that’s hit much harder by Covid-19.

“When you have different rules for different counties, it’s very confusing,” Maldonado said. “People lose the message.”

There are similar limitations to what even California can do. It can impose its own lockdown, but it has less control over cases from Arizona, Nevada, Mexico, or other parts of the globe. While the state has taken steps to build up its testing capacity — surpassing the benchmark of 150 tests per 100,000, which is the equivalent of 500,000 tests nationwide — it can only go so far if there are constraints around the country for testing.

The testing problem is especially acute now: With new outbreaks across the US, demand for tests climbed as supply constraints reappeared. That’s led to waiting periods of up to weeks for getting results back — making tests practically useless for confirming, tracing, and containing infections before they have time to spread.

But there are limits to what San Francisco or California can do if the bottlenecks for testing are originating in other parts of the country or world — whether they’re due to epidemics in Arizona and Florida, or because factories in the Northeast and South can’t produce enough swabs to collect samples or reagents to run tests.

“We need a national plan,” Cyrus Shahpar, a director at the global health advocacy group Resolve to Save Lives, told me. “In terms of the structures to improve the supply chain or procure more stuff for the whole country, that’s a federal level of support. You need that to be in place.”

The Trump administration, however, has explicitly left most of these issues for states to solve. The White House’s testing plan declared that the federal government is merely a “supplier of last resort,” leaving it to local and state governments and private actors to fix choke points along the testing supply chain. The New York Times explained this was part of a broader “state authority handoff” plan that would “shift responsibility for leading the fight against the pandemic from the White House to the states.”

To the extent the federal government has provided support, Trump has actively undermined it. When the federal government released a phased plan for state reopenings, Trump called on states to reopen faster — to supposedly “LIBERATE” them from economic calamity. After the Centers for Disease Control and Prevention recommended people in public wear masks, Trump said it was a personal choice, refused for months to wear a mask in public, and even suggested that people wear masks to spite him (although a recent tweet seemed to support masking). (The White House didn’t return a request for comment.)

In my interviews, local officials, health care workers, and experts repeatedly complained about the problems caused by federal inaction. Breed lamented that San Francisco, and California, couldn’t rely on federal support to get personal protective equipment for health care workers, particularly in the early stages of the pandemic. A San Francisco Department of Public Health spokesperson told me that testing took time to scale up while the federal government did little to address supply constraints, commenting that the mixed messaging and inaction from the federal government “are hampering local efforts to be as effective as we would like to be.”

Over time, even the once-proactive California let its guard down. As Gov. Newsom faced pressure from local governments and businesses to reopen the state quickly, he allowed counties to reopen at a quicker pace if they met certain metrics. That led to new outbreaks, particularly in Central and Southern California — each of which presented a risk of bleeding over to the Bay Area. As Bibbins-Domingo said, county-by-county variations “have not been helpful” for suppressing the virus in San Francisco or statewide.

California Health and Human Services Secretary Mark Ghaly said that, like everyone else, the state was still learning how to properly combat the pandemic. But he argued it does make sense to tailor local responses to Covid-19 to what’s happening locally — and that’s what the state tried to do as it let some counties move quicker than others, while keeping some oversight by enforcing certain criteria before counties moved ahead.

The state is still “figuring out … the balance between hundreds of different things,” Ghaly told me. That includes, he added, “how you support counties making local decisions while maintaining some level of cohesiveness at a regional and statewide level so we don’t erode gains.”

Still, the fractured nature of federalism doesn’t help for fighting a virus that ignores local, state, and national borders.

A recent study in Science backed that up. Running simulations for Europe, researchers concluded that better-coordinated action within the European Union can help suppress Covid-19 better than different countries acting in different ways. Drawing on that finding, the authors concluded:

The implications of our study extend well beyond Europe and COVID-19, broadly demonstrating the importance of communities coordinating easing of various [non-pharmaceutical interventions] for any potential pandemic. In the United States, [non-pharmaceutical interventions] have been generally implemented at the state-level, and because states will be strongly interconnected, our results emphasize national coordination of pandemic preparedness efforts moving forward.

That the US has by and large stuck to a state-by-state and county-by-county approach to public health — an approach that predates the coronavirus pandemic — can help explain, then, why the country has continued to fail to control Covid-19 in the same way countries with strong national plans and, in some cases, international cooperation haven’t. To this day, America reports among the highest rates of coronavirus cases and deaths in the world.

In that context, with outbreaks raging around San Francisco and California, there’s only so much any single local or state government could do. “When you look at success stories of countries on Covid, you had a strong central voice,” Chin-Hong said.

So while San Francisco has done a lot right, it will take the rest of the country adopting a similar approach for the city, the broader Bay Area, or anywhere else in the US to really be safe from the coronavirus.

 

 

 

 

U.S. advisory group lays out detailed recommendations on how to prioritize Covid-19 vaccine

U.S. advisory group lays out detailed recommendations on how to prioritize Covid-19 vaccine

A new report that aims to prioritize groups to receive Covid-19 vaccine lays out detailed recommendations on who should be at the front of the line, starting with health care workers in high-risk settings, followed by adults of any age who have medical conditions that put them at significantly higher risk of having severe disease.

Also toward the front of the line would be older adults living in long-term care homes or other crowded settings.

The draft report, which runs 114 pages, was released Tuesday by the National Academies of Sciences, Engineering, and Medicine, which was tasked with the work by Francis Collins, director of the National Institutes of Health, and Robert Redfield, director of the Centers for Disease Control and Prevention.

A virtual public meeting on the recommendations will be held Wednesday afternoon, and the committee’s final report will be submitted later in September.

When Covid-19 vaccines are approved for use, initial supplies will be tight — potentially in the tens of millions of doses. Most of the vaccines under development will require two doses per person: a priming dose followed by a booster either three or four weeks later.

The report suggests that a second phase of vaccinations should involve critical risk workers — people in industries essential to the functioning of society — as well as teachers and school staff; people of all ages with an underlying health problem that increases the risk of severe Covid-19; all older adults not vaccinated in the first phase; people in homeless shelters and group homes, and prisons; and staff working in these facilities.

Young adults, children, and workers in essential industries not vaccinated previously would make up the third priority group. Remaining Americans who were not vaccinated in the first three groups would be offered vaccine during a fourth and final phase.

The report is meant to serve as a guide for more detailed prioritization plans on the order in which Americans will be offered vaccine. That more granular work is already being conducted by the Advisory Committee on Immunization Practices, an expert panel that crafts vaccination guidance for the CDC, and by state, local, and tribal health authorities, who must identify the actual people in their regions who fall into the priority groups.

There has been discussion of prioritizing people of color, who have been disproportionately badly hit in this pandemic. But the report does not recommend that Black, Hispanic, Latinx people, or American Indians or Alaskan natives be treated as a distinct priority group.

The committee suggested that there does not appear to be a biological reason for why these communities are more seriously affected by the pandemic. Instead, it argues, the high rates of infections and deaths in these communities are due to systemic racism that leads to higher levels of poor health and socioeconomic factors such as working in jobs that cannot be done from home or living in crowded settings.

The report therefore prioritized other factors — people with underlying medical problems, people living in crowded environments, for instance — rather than creating priority categories for racial or ethnic groups.

The ACIP’s recommendations will go to the CDC. It remains unclear, however, whether the CDC, Operation Warp Speed — the task force set up to fast-track development of Covid-19 vaccines, drugs and diagnostics — or the White House will make the final determinations on who will be vaccinated first.

The task of determining who should be at the front of the vaccines line is not an easy one, and must be made without key pieces of information. It’s not yet known how many vaccines will prove to be successful, when they will be approved for use and in what quantities. Critically, some vaccines may prove to be more effective in key groups — the elderly, for instance — than others. Knowing that in advance could influence the recommendations, but people working on the priority groups cannot wait for that information to become available.

Initial discussions suggest large numbers of Americans would qualify as members of priority groups, a reality that will likely require additional tough decisions to be made.

CDC estimates that there are between 17 million and 20 million health care workers in the country, and roughly 100 million people with medical conditions that put them at increased risk of severe illness if they contract Covid-19. There are roughly 53 million Americans aged 65 and older and 100 million people in jobs designated as essential services. There is some overlap among these groups — health workers, for instance, are also essential workers.

report released last month by the Johns Hopkins Center for Health Security recommended dividing priority groups into two tiers, with health workers and others essential to the Covid-19 response in the first tier and other health workers in the second.

In that report, people at greatest risk and their caregivers, and workers most essential to maintaining core societal functions would also be designated to be in the first tier.

 

 

 

 

Medicaid Is Essential for Workers

Medicaid Is Essential for Workers

Earlier this year, when public schools in Kansas City, Missouri, shut down in-person instruction because of the COVID-19 pandemic, Nika Cotton quit her job in social work to start her own business. She has two young children — ages 8 and 10 — and no one to watch them if she were to continue working a traditional job.

It was a big decision, made weightier by the loss of her employer-sponsored health insurance. But on August 5, Cotton awoke to the news that Missouri voters had narrowly approved the expansion of the state’s Medicaid program via ballot initiative, making it the second politically right-leaning state to do so during the pandemic. The expansion opens Medicaid eligibility to individuals and families with incomes up to 138% of the federal poverty guidelines, which are $12,760 for an individual and $21,720 for a family of three, allowing Cotton’s family of three to qualify.

“It takes a lot of stress off of my shoulders with having to think about how I’m going to take care of myself, how I’m going to be able to go and see a doctor and get the health care I need while I’m starting my business,” she told Alex Smith of KCUR, the NPR affiliate in Kansas City.

Nearly 1,264,000 voters weighed in on the measure, with 53% voting for it and 47% against it. Missouri’s Republican governor Mike Parson opposed it, arguing that the state could not afford the coverage expansion — even though the federal government pays 90% of the costs and a fiscal analysis (PDF) by the Center for Health Economics and Policy at Washington University estimated that the state would save $39 million if it implemented Medicaid expansion in 2020.

The ballot measure requires the state to expand Medicaid by July 2021, and an estimated 230,000 residents with low incomes will become eligible for affordable health coverage.

Voters Signal Support

In late June, Oklahoma voters also approved Medicaid expansion by ballot measure, eking out a victory by less than one percentage point.

“It is difficult to ignore that these ballot initiatives passed in right-leaning states in the middle of the coronavirus pandemic, when millions of Americans have lost their jobs and, with them, their employer-sponsored health insurance,” Dylan Scott wrote in Vox. “This is partly a coincidence — the signatures were collected to put the Medicaid expansion questions on the ballot long before COVID-19 ever arrived in the US — but the relatively narrow margins made me wonder if the pandemic and its economic and medical consequences proved decisive.”

Earlier this year, Scott spoke to Cynthia Cox, MPH, director of the Peterson-Kaiser Health System Tracker, about the potential impact of the pandemic on health care politics. “Many of the biggest coverage expansions both in the US and in similar countries happened in the context of wars and social upheavals, as well as financial crises,” Cox said. “One theory is that those circumstances redefine social solidarity, thus expanding views of the role of government.”

Between February and May, Missouri’s Medicaid program saw enrollment rise nearly 9%, one of the largest increases nationwide during the pandemic, Rachel Roubein reported in Politico. During that same period, Oklahoma’s Medicaid program saw enrollment increase by about 6%.

States that implemented Medicaid expansion are better positioned to respond to COVID-19, according to a report by the Center on Budget and Policy Priorities (CBPP). These states entered the health crisis and resulting economic downturn with lower uninsured rates, which is important for public health “because people who are uninsured may forgo testing or treatment for COVID-19 due to concerns that they cannot afford it, endangering their health while slowing detection of the virus’ spread,” the authors wrote.

CBPP and KFF estimate that 3.6 to 4.4 million uninsured adults would become eligible for Medicaid coverage if the 12 states that have not yet expanded the program did so. Those states are Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming.

Coverage for Frontline Essential Workers

Medicaid is particularly important for frontline essential workers — such as those working in grocery stores, meat processing plants, and nursing homes — during the pandemic. Their jobs require them to report in person, increasing their risk of getting sick with the coronavirus as they interact with coworkers and, in many cases, with customers and patients. Essential workers are often paid low wages and not offered employer-sponsored health insurance or can’t afford the premiums for it.

About 5 million essential workers nationwide get health coverage through Medicaid, “including nearly 1.8 million people working in frontline health care services and 1.6 million in other frontline essential services including transportation, waste management, and child care,” Matt Broaddus, senior research analyst at CBPP, wrote on the center’s blog.

In California, over 950,000 essential workers are enrolled in Medi-Cal, the state’s Medicaid program. People of color are overrepresented in many categories of essential jobs. According to a UC Berkeley Labor Center analysis of the 15 largest frontline essential occupations, Latinx workers are overrepresented in agriculture, construction, and food preparation, among other occupations. Asian workers are overrepresented among registered nurses and personal care aides; and Black workers are overrepresented among personal care aides, laborers and material movers, and office clerks.

In addition to low-wage workers, Medi-Cal continues to bridge the coverage gap for other key populations amid the COVID-19 crisis, which is magnifying historical health inequities. (Medi-Cal covers nearly 40% of the state’s children, half of Californians with disabilities, and over one million seniors. For a refresher on the program, see CHCF’s Medi-Cal Explained series.)

Medicaid Saves Lives

Research has shown time and time again the varied benefits of Medicaid expansion: lower mortality rates among older adults with low incomes, declines in infant mortality, reductions in racial disparities in the care of cancer patients, and fewer personal bankruptcies, just to name a few.

Even though Missouri’s Medicaid expansion won’t take effect for another year, Nika Cotton remains excited. “It’s better late than never,” she said. “The fact that it’s coming is better than nothing” — perhaps a takeaway for the remaining 12 states.

 

 

 

 

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.”