States With Few Coronavirus Restrictions Are Spreading the Virus Beyond Their Borders

Lax states are attracting shoppers and students from stricter neighbors — and sending back COVID-19 cases. The imbalance underscores the lack of a national policy.

For months after Washington state imposed one of the earliest and strictest COVID-19 lockdowns in March, Jim Gilliard didn’t stray far from his modular home near Waitts Lake, 45 miles north of Spokane.

The retiree was at high risk from the coronavirus, both because of his age, 70, and his medical condition. Several years ago, he had a defibrillator implanted. So he mainly ventured out during the pandemic to shop for food.

There wasn’t much else to do anyway. Gatherings in his county were limited to no more than 10 people, there was a mask mandate, movie theaters were closed and many nightclubs and concert venues were shuttered because of a state ban on all live entertainment, indoors and out.

An hour away in Idaho, life was more normal. The state left key COVID-19 regulations up to localities, many of which made masks optional. Even in places that required face coverings, enforcement was laxer than in Washington. High school sports, canceled for the fall in Washington, were on full display in Idaho. Most Idaho schools welcomed back students in person, in contrast to the remote learning prevailing in Washington. Businesses reopened earlier and with fewer restrictions. There were concerts and dances.

Weary of Washington’s restrictions, thousands of residents made the easy drive over the border to vacation, shop and dine in Idaho. Gilliard resisted temptation until he learned that the annual Panhandle Bluesfest would go on as scheduled near Priest River, Idaho, on Sept. 12. A keyboardist who used to own a blues club just outside Coeur d’Alene, Idaho, Gilliard was buoyed after months of relative isolation by the prospect of hanging out with friends while listening to music on a remote mountainside surrounded by soaring pine trees and thick hemlocks. He decided to go.

A friend took a picture of Gilliard at the festival. Wearing a bandanna fashioned as a headband, a cut-off T-shirt and dark glasses, he was perched on a tree stump and pointing back at the camera. As was permitted by local regulations at the time, he was not wearing a mask, nor were about 10 people sitting together in the background.


As the number of COVID-19 cases skyrockets nationwide, the extent of the public health response varies from one state — and sometimes one town — to the next. The incongruous approaches and the lack of national standards have created confusion, conflict and a muddled public health message, likely hampering efforts to stop the spread of the virus. The country’s top infectious disease expert, Dr. Anthony Fauci, said last month that the country needs “a uniform approach” to fighting the virus instead of a “disjointed” one.

Nowhere are these regulatory disparities more counterproductive and jarring than in the border areas between restrictive and permissive states; for example, between Washington and Idaho, Minnesota and South Dakota, and Illinois and Iowa. In each pairing, one state has imposed tough and sometimes unpopular restrictions on behavior, only to be confounded by a neighbor’s leniency. Like factories whose emissions boost asthma rates for miles around, a state’s lax public health policies can wreak damage beyond its borders.

“In some ways, the whole country is essentially living with the strategy of the least effective states because states interconnect and one state not doing a good job will continue to spread the virus to other states,” said Dr. Ashish Jha, dean of the Brown University School of Public Health. “States can’t wall themselves off.”

A motorcycle rally in August in Sturgis, South Dakota, with half a million attendees from around the country spread COVID-19 to neighboring Minnesota and beyond, according to Melanie Firestone, an epidemic intelligence service officer for the Centers for Disease Control and Prevention, who co-authored a report on the event’s impact.

South Dakota “didn’t have policies regarding mask use or event size, and we see that there was an impact in a state that did have such policies,” Firestone said. “The findings from this outbreak support having consistent approaches across states. We are all in it together when it comes to stopping the spread of COVID-19.”

Viruses don’t respect geographic boundaries. While some states require visitors, especially from high-risk areas, to be tested or quarantined, others like South Dakota have no such restrictions. Many people who are tired of strict COVID-19 measures in their states have escaped to areas where everyday life more closely resembles pre-pandemic times. There, with fewer protections, they’re at risk of contracting the virus and bringing it back home.

After the Idaho concert, Gilliard started feeling ill and was diagnosed with the coronavirus. For about a week, he stayed in bed. As his condition worsened, he was admitted to a Spokane hospital and placed on a ventilator. He died on Oct. 15. His death certificate lists COVID-19 as the underlying cause.

Going to the Idaho festival likely killed Gilliard, his ex-wife, Robin Ball, said.

“If he had been wearing a mask, not shaking hands and keeping distance, he could probably be alive,” she said. “He had been careful before that. He shouldn’t have been up there.”


The degree of coronavirus regulation tends to track political lines. President-elect Joe Biden carried blue Washington state with 58% of the vote, while President Donald Trump easily won red Idaho with 64%. Trump has helped to fuel the patchwork response to the pandemic, criticizing the approaches of some states, praising others and at times contradicting the advice of his own coronavirus task force and Fauci.

“What really struck me [is] how hard it is to take the pandemic strategy as laid out by the White House with every state on its own and … implement it because every state is not on its own, they are all interconnected,” Jha said.

Biden has said he wants to implement national standards, such as required mask wearing, to help blunt the spread of COVID-19 while acknowledging the federal government has little power to do so. He hopes to work with governors and local officials to establish consistent standards across the country.

A lack of such consistency is affecting eastern Washington, which appears to be absorbing some of the costs — both human and economic — of Idaho’s more laissez-faire approach to the virus. The rate of new cases in and around Spokane, near the Idaho border, is far higher than in Seattle and western Washington, which experienced one of the earliest outbreaks in the country in February. Although slightly more than half of recent COVID-19 cases in Spokane spread among households or personal contacts, Spokane Regional Health District epidemiologist Mark Springer said, “people bringing back COVID-19 from larger events in Idaho” has been a problem. And with Idaho’s rate of new cases now doubling Washington’s, Idahoans who commute to the Spokane area pose an outsized danger. At the same time, Washington’s shuttered businesses have ceded customers to their Idaho competitors.

Public schools in Washington have also suffered. After opening the school year with remote-only instruction, the Newport School District lost about one-fourth of its 1,200 students. Most of them opted either for specialized online-only programs or for nearby private and public schools across the border in Idaho, which offered in-person learning and sometimes didn’t require masks or social distancing, said Newport Superintendent Dave Smith. The plunge in enrollment has led to a $1.2 million drop in funding, he said.

In early October, Newport began some in-person learning but had to return to remote instruction after a COVID-19 outbreak in the community. The source was traced to a Christian church and school only a few feet from the Washington border in Oldtown, Idaho.

“It’s incredibly frustrating,” Smith said. “I certainly think aligned standards across the nation would have changed our situation.”

Washington Gov. Jay Inslee recently called on “Idaho leaders to show some leadership” and be more aggressive in combating COVID-19. He blamed the virus spread in Idaho for straining Washington hospitals. For their part, some in Idaho have complained that the rise of COVID-19 there has more to do with the influx of Washington residents over the summer and fall than with a lighter regulatory touch.

Many of those Washingtonians headed to Coeur d’Alene (pop. 52,400), the seat of Kootenai County and the largest city in northern Idaho. Despite some cancellations, many tourism activities went on as scheduled. The Spokesman-Review newspaper in Spokane ran a feature headlined, “A nearby escape: Coeur d’Alene Resort offers amenities for singles and families.” The resort, the article noted, was offering special packages for families that include a pizza-making experience, scenic cruise tickets and discount theme park tickets. In the resort garage, most of the license plates were from Idaho or Washington.

“Yes, the coronavirus exists,” the article continued. “However, the luxe Coeur d’Alene Resort is open and taking steps to make an experience as safe as possible.” While employees wore masks, the article said, they were optional for guests and about two-thirds opted not to use them. The resort did not respond to requests for comment.

At a park in downtown Coeur d’Alene, a weekly concert series called Live After 5 attracted crowds all summer. Though attendance was lower than in prior years, it swelled as promoters targeted marketing to tourists, concert organizer Tyler Davis said. At one show in July, a member of the band surveyed the large gathering and said, “Look around you guys, it feels kind of normal tonight.” Groups of people danced in front of the stage, food trucks lined up along one side and vendors set up tents. Masks were “encouraged but not required.”

The day after that show, the Panhandle Health District encompassing five Idaho counties ordered a mask mandate in Kootenai. It required masks in indoor and outdoor public places when a social distance of 6 feet could not be maintained.

Springer, the epidemiologist, watched the flow of Spokane County residents to Idaho with concern. “The issue with Idaho is a somewhat significant one for us in that the restrictions are a pretty stark contrast between what is in Idaho and what we have in Washington,” he said. “Coeur d’Alene is a sister community to us.”


Jim Gilliard was a popular figure in the blues music community around Spokane and northern Idaho. In the 1990s, he operated a music club outside Coeur d’Alene called Mad Daddy’s Blues. He was a talented musician himself, playing keyboards in local blues bands, even after losing a finger and badly injuring two others in a table saw accident.

Gilliard was raised in New York City and Pennsylvania. His father, E. Thomas Gilliard, was an acclaimed ornithologist who served as curator of birds at the American Museum of Natural History and was often gone for months at a time on expeditions to New Guinea. After Gilliard met Ball, the two headed to Colorado and enjoyed life as ski bums, moving from resort to resort for a couple of years before eventually settling in Coeur d’Alene, and having a son. After they divorced two decades ago, she stayed in Coeur d’Alene and he ended up in the village of Valley, Washington. (pop. 164).

Gilliard was one of nearly 300 people who paid $25 each to attend the blues festival, which was held 2 miles up a mountain road outside Priest River, Idaho, a tourist town 6 miles from the Washington border.

Bonner County, where the concert was held, is a rural pocket of defiance against government public health mandates related to the coronavirus. When the local library instituted a mask requirement for users, mask-less demonstrators, some clutching small children, protested and tried to enter the library as staff members stood their ground and explained they were only trying to prevent people from getting sick. The county sheriff wrote to the governor criticizing lockdown orders early in the pandemic, alleging that public health officials misled the public and that “COVID-19 is nothing like the plague.”

Concert organizers Billy and Patty Mullaley said they waited until the end of June before deciding to go ahead with it. The only potential roadblock was getting liability insurance at an affordable price during a pandemic, which they were able to do after shopping around.

“At the time, there were not any restrictions” on events like theirs in Idaho, Patty Mullaley said. “We did not take it lightly, having the event. We really put thought into it.” They bleached outhouses and the area around the concert stage offered plenty of space for social distancing, she said. Among those most grateful they went ahead, she said, were musicians who had been starved for gigs because of coronavirus-related cancellations. Featured acts included Sammy Eubanks, Coyote Kings and Tuck Foster and the Tumbling Dice.

Mullaley said the festival drew Washington residents eager for events banned in their own state. “From my experience, everyone and their dog from Washington was over here,” she said. “Our COVID is probably from people coming over here from Washington.”

Few of the hundreds of people at the festival wore masks and many didn’t stay socially distant, according to attendees. “Part of what made it magical was people were completely free and happy and not fearful at all,” said Sylvia Soucy, who had COVID-19 earlier in the summer. People danced barefoot on the soft sand and mingled with friends, she said.

Mullaley said people socially distanced “as much as possible.” In the end, she said, “these were all adults” who made individual decisions. Soucy agreed. “It was completely a choice all of us made,” she said. The remote setting — no cellphone service, no electricity and surrounded by hundreds of acres of undeveloped forest — added to the temporary joy of escaping from the virus, Soucy said.

Soucy said she talked to Gilliard there and he was in good spirits, “glad that people were not worried about being able to get together there on the mountain.” Gilliard also chatted with other friends, including a former girlfriend, according to Soucy. Ball said the former girlfriend was diagnosed with COVID-19 shortly after the festival and notified Gilliard.

“I don’t know why he let his guard down,” Ball said. “I will never understand that.” In the end, she thinks it had to do with “a long summer of not having a lot of stuff to do. He had been so cautious for those seven or eight months. He just didn’t feel like it was going to be a problem.”

The Mullaleys said they were unaware of anyone else from the concert getting COVID-19 around that time. But some Washington residents who tested positive for the coronavirus told contact tracers that they had attended the blues festival, according to Matt Schanz, the administrator of Northeast Tri County Health District, a public health agency in Washington covering counties near the Idaho border.

That doesn’t definitively mean that they contracted the virus at the festival, he said. “We have 550 cases within three counties, and if you read the summary reports, a decent number of those have some affiliation with Idaho,” Schanz said.


South Dakota has largely remained open for business during the pandemic. Gov. Kristi Noem, an ally of Trump’s, has refused to impose a mask mandate, saying there are questions about its effectiveness. The state has not placed any restrictions on bars and restaurants and officials allowed the 10-day motorcycle rally in Sturgis. Such a rally would have been prohibited in Minnesota. Both Minnesota and South Dakota are in the top five states when it comes to rates of cases per capita over the last week.

The CDC advises that outdoor events are less risky than indoor ones. The Sturgis rally, which featured events in both settings, is now linked to at least 86 COVID-19 cases in Minnesota, including four people who were hospitalized and one death, according to a CDC report released in November. The report said the total is likely an undercount as some of those infected declined to share their close contacts with health officials.

“These findings highlight the far-reaching effects that gatherings in one area might have on another area,” the researchers wrote. They added, “This rally not only had a direct impact on the health of attendees, but also led to subsequent SARS-CoV-2 transmission among household, social, and workplace contacts of rally attendees upon their return to Minnesota.”

Mike Kuhle, the mayor of Worthington, Minnesota, said South Dakota’s approach to the pandemic “is a source of heartburn for me and sleepless nights.” His city is close to both the South Dakota and Iowa borders. In addition to worries about the virus spreading from South Dakota, Kuhle said, “during the lockdown people have gone to Sioux Falls for shopping. It’s ugly for our businesses.”

A similar dynamic has played out in the Quad Cities area at the border of Illinois and Iowa. There, thousands of people cross bridges over the Mississippi River every day to work, visit family and shop in each state.

As cases in Iowa began to surge this summer, Gov. Kim Reynolds dismissed mask mandates as “feel-good” measures that are difficult to enforce. Until recently, Iowa restaurants and gyms were allowed to operate at full capacity as long as social distancing measures were in place. There was no state-imposed limit on the size of social gatherings. Nicknamed “COVID Kim” by her critics, Reynolds changed course in mid-November in the face of surging cases and hospitalizations, requiring masks.

Illinois clamped down earlier and harder, instituting a mask mandate at the end of April. Movie theaters opened in Iowa before those in Illinois. Iowa never closed its golf courses when neighboring states like Illinois did.

For Illinois businesses, the gap between the two states’ regulations has been crushing, said Paul Rumler, the president of the Quad Cities Chamber.

“A river runs through it but otherwise this is one community,” he said. On the Illinois side, “we have retailers and restaurants who want to be responsible corporate citizens and follow the guidelines knowing they are at a disadvantage from a business literally 3 miles away.”

Rumler said the chamber advocated for the two states to have a consistent approach to the pandemic to no avail. “If there was a federal standard, it would eliminate the confusion of our region,” he said. “It would make our life a lot easier.”

Debbie Freiburg, a volunteer contact tracer for the county encompassing the Illinois side of the border, said the looser restrictions in Iowa offered Illinois residents the chance to “take a break” from the virus.

“It’s bad and the differences are huge, unfortunately,” she said. “I can be in Iowa in 10 minutes, and there were a lot of us going shopping in Iowa.”

Freiburg, who retired to the area after working as a pediatric cancer nurse in Washington, D.C., said cases in her Illinois county have been tracked to Iowa, including several from a large wedding at a hotel just over the border.


Tensions between Washington and Idaho over their divergent responses to the pandemic escalated in October. As the count of COVID-19 cases climbed, the board of the Panhandle Health District in Idaho voted 4-3 to rescind the mask order it had imposed on Kootenai County three months before. Officials in Washington were stunned. Inslee, the governor, refused to rule out restrictions on border traffic.

The move by the health board came amid growing resistance in the state to mandatory public health measures to control the virus and skepticism that COVID-19 was even real.

A group of Idaho politicians, including Lt. Gov. Janice McGeachin, appeared in a video in October urging the state to limit restrictions. Sitting in a truck with an American flag draped over the side, McGeachin placed a gun over a Bible. “We recognize that all of us by nature are free and equal and have certain inalienable rights,” she said. A legislator in the video said “the pandemic may or may not be occurring.”

State Rep. Tony Wisniewski, who represents Kootenai and also appeared in the video, urged the health board to make masks optional. He compared the mask mandate to what he said was a requirement in Nazi Germany to tell authorities if a neighbor was Jewish.

Health board member Allen Banks said he was “deeply suspicious” of tests for COVID-19. In an email to a senator who had criticized the board’s mask mandate, he wrote, “I hope you and the legislators who support your effort will continue to stand for truth rather than the fantasy of a phony disease based on a false test.”

Board member Walt Kirby, who had voted in July to approve the mask mandate initially, was the deciding vote. He opposed a mandate because people were “pretty damn nasty” to him for supporting it before, he explained. “I am not going to vote for it, I am just not because no one is wearing the damn masks anyway,” Kirby said, adding that he wears a mask. As for people who ignore the advice of public health experts, he said, “I am just sitting back and watching them catch it and die and hopefully I will live through it. You know I am 90 years old already and I am not getting involved in it anymore.”

Even as the requirement was rescinded, cases in Kootenai were soaring. The rate of hospitalizations in the border area in northern Idaho is nearly double the rate in the Spokane region. Overall, the number of new cases in Idaho per capita is almost twice that of Washington.


With the county mandate overturned, the city of Coeur d’Alene considered in late October whether to adopt one on its own. Mayor Steve Widmyer and the City Council were inundated with hundreds of emails and telephone calls, many from mask opponents.

“This is Idaho, not Washington or California,” wrote one resident. “Let the people decide if they wish to mask up or not.” Another told the city leaders, “If you want to live with a mask ‘muzzle’ on your face move to California or Washington.”

Ball, Gilliard’s ex-wife, urged Widmyer to support a mandate. “People come here so they don’t have to wear a mask and fill our bars and businesses while spreading covid,” she wrote.

In Coeur d’Alene, the mayor only votes to break a tie among the city councilors. Widmyer, who had complained that city officials “shouldn’t have been put into this position,” didn’t have to vote, because the council approved the mandate 4-2 on Oct. 26. Protesters outside chanted, “No more masks, we will not comply,” and the blowback has been swift. A group of residents is pushing to recall the pro-mandate councilors. The mayor did not respond to interview requests.

While Coeur d’Alene adopted a mandate, nearby Post Falls and Hayden rejected similar proposals. All three cities are less than 20 miles from the Washington border. Idaho Gov. Brad Little has also remained steadfast in opposition to the idea, unlike Iowa’s Reynolds. “Idaho’s health officials have been mindful of the challenges of mitigating spread of COVID-19 in border communities since the onset of the pandemic,” a spokeswoman for Little said in an email. The governor’s “priority at this time is mitigating the spread of COVID-19 in Idaho and preserving health care capacity for those in need.”

For the Panhandle health board, however, the situation became too dire to ignore. On Nov. 19 it reversed itself again and passed a mask mandate for all five of its counties, including Bonner, the site of the blues festival. But county sheriffs have ignored enforcing the mandate or made it a low priority, according to local media.

The move came too late to save Gilliard. “Until everyone in this country can do the same thing, all states on the same page, limit crowd size and mask mandates that are enforced, this is going to happen,” said Ball, his ex-wife. “It only makes sense. Because what we have been doing hasn’t been working.”

Now the U.S. Has Lots of Ventilators, but Too Few Specialists to Operate Them

A patient was placed on a ventilator in a hospital in Yonkers, N.Y., in April.

As record numbers of coronavirus cases overwhelm hospitals across the United States, there is something strikingly different from the surge that inundated cities in the spring: No one is clamoring for ventilators.

The sophisticated breathing machines, used to sustain the most critically ill patients, are far more plentiful than they were eight months ago, when New York, New Jersey and other hard-hit states were desperate to obtain more of the devices, and hospitals were reviewing triage protocols for rationing care. Now, many hot spots face a different problem: They have enough ventilators, but not nearly enough respiratory therapists, pulmonologists and critical care doctors who have the training to operate the machines and provide round-the-clock care for patients who cannot breathe on their own.

Since the spring, American medical device makers have radically ramped up the country’s ventilator capacity by producing more than 200,000 critical care ventilators, with 155,000 of them going to the Strategic National Stockpile. At the same time, doctors have figured out other ways to deliver oxygen to some patients struggling to breathe — including using inexpensive sleep apnea machines or simple nasal cannulas that force air into the lungs through plastic tubes.

But with new cases approaching 200,000 per day and a flood of patients straining hospitals across the country, public health experts warn that the ample supply of available ventilators may not be enough to save many critically ill patients.

“We’re now at a dangerous precipice,” said Dr. Lewis Kaplan, president of the Society of Critical Care Medicine. Ventilators, he said, are exceptionally complex machines that require expertise and constant monitoring for the weeks or even months that patients are tethered to them. The explosion of cases in rural parts of Idaho, Ohio, South Dakota and other states has prompted local hospitals that lack such experts on staff to send patients to cities and regional medical centers, but those intensive care beds are quickly filling up.

Public health experts have long warned about a shortage of critical care doctors, known as intensivists, a specialty that generally requires an additional two years of medical training. There are 37,400 intensivists in the United States, according to the American Hospital Association, but nearly half of the country’s acute care hospitals do not have any on staff, and many of those hospitals are in rural areas increasingly overwhelmed by the coronavirus.

“We can’t manufacture doctors and nurses in the same way we can manufacture ventilators,” said Dr. Eric Toner, an emergency room doctor and senior scholar at the Johns Hopkins Center for Health Security. “And you can’t teach someone overnight the right settings and buttons to push on a ventilator for patients who have a disease they’ve never seen before. The most realistic thing we can do in the short run is to reduce the impact on hospitals, and that means wearing masks and avoiding crowded spaces so we can flatten the curve of new infections.”

Medical association message boards in states like Iowa, Oklahoma and North Dakota are awash in desperate calls for intensivists and respiratory therapists willing to temporarily relocate and help out. When New York City and hospitals in the Northeast issued a similar call for help this past spring, specialists from the South and the Midwest rushed there. But because cases are now surging nationwide, hospital officials say that most of their pleas for help are going unanswered.

Dr. Thomas E. Dobbs, the top health official in Mississippi, said that more than half the state’s 1,048 ventilators were still available, but that he was more concerned with having enough staff members to take care of the sickest patients.

“If we want to make sure that someone who’s hospitalized in the I.C.U. with the coronavirus has the best chance to get well, they need to have highly trained personnel, and that cannot be flexed up rapidly,” he said in a news briefing on Tuesday.

Dr. Matthew Trump, a critical care specialist at UnityPoint Health in Des Moines, said that the health chain’s 21 hospitals had an adequate supply of ventilators for now, but that out-of-state staff reinforcements might be unlikely to materialize as colleagues fall ill and the hospital’s I.C.U. beds reach capacity.

“People here are exhausted and burned out from the past few months,” he said. “I’m really concerned.”

The domestic boom in ventilator production has been a rare bright spot in the country’s pandemic response, which has been marred by shortages of personal protective equipment, haphazard testing efforts and President Trump’s mixed messaging on the importance of masks, social distancing and other measures that can dent the spread of new infections.

Although the White House has sought to take credit for the increase in new ventilators, medical device executives say the accelerated production was largely a market-driven response turbocharged by the national sense of crisis. Mr. Trump invoked the wartime Defense Production Act in late March, but federal health officials have relied on government contracts rather than their authority under the act to compel companies to increase the production of ventilators.

Scott Whitaker, president of AdvaMed, a trade association that represents many of the country’s ventilator manufacturers, said the grave situation had prompted a “historic mobilization” by the industry. “We’re confident that our companies are well positioned to mobilize as needed to meet demand,” he said in an email.

Public health officials in Minnesota, Mississippi, Utah and other states with some of the highest per capita rates of infection and hospitalization have said they are comfortable with the number of ventilators currently in their hospitals and their stockpiles.

Mr. Whitaker said AdvaMed’s member companies were making roughly 700 ventilators a week before the pandemic; by the summer, weekly output had reached 10,000. The juggernaut was in part fueled by unconventional partnerships between ventilator companies and auto giants like Ford and General Motors.

Chris Brooks, chief strategy officer at Ventec Life Systems, which collaborated with G.M. to fill a $490 million contract for the Department of Health and Human Services, said the shared sense of urgency enabled both companies to overcome a thicket of supply-chain and logistical challenges to produce 30,000 ventilators over four months at an idled car parts plant in Indiana. Before the pandemic, Ventec’s average monthly output was 100 to 200 machines.

“When you’re focused with one team and one mission, you get things done in hours that would otherwise take months,” he said. “You just find a way to push through any and all obstacles.”

Despite an overall increase in the number of ventilators, some researchers say many of the new machines may be inadequate for the current crisis. Dr. Richard Branson, an expert on mechanical ventilation at the University of Cincinnati College of Medicine and an author of a recent study in the journal Chest, said that half of the new devices acquired by the Strategic National Stockpile were not sophisticated enough for Covid-19 patients in severe respiratory distress. He also expressed concern about the long-term viability of machines that require frequent maintenance.

“These devices were not built to be stockpiled,” he said.

The Department of Health and Human Services, which has acknowledged the limitations of its newly acquired ventilators, said the stockpile — nine times as large as it was in March — was well suited for most respiratory pandemics. “These stockpiled devices can be used as a short-term, stopgap buffer when the immediate commercial supply is not sufficient or available,” the agency said in a statement.

Projecting how many people will end up requiring mechanical breathing assistance is an inexact science, and many early assumptions about how the coronavirus affects respiratory function have evolved.

During the chaotic days of March and April, emergency room doctors were quick to intubate patients with dangerously low oxygen levels. They subsequently discovered other ways to improve outcomes, including placing patients on their stomachs, a protocol known as proning that helps improve lung function. The doctors also learned to embrace the use of pressurized oxygen delivered through the nose, or via BiPAP and CPAP machines, portable devices that force oxygen into a patient’s airways.

Many health care providers initially hesitated to use such interventions for fear the pressurized air would aerosolize the virus and endanger health care workers. The risks, it turned out, could be mitigated through the use of respirator masks and other personal protective gear, said Dr. Greg Martin, the chief of pulmonary and critical care at Grady Health Systems in Atlanta.

“The familiarity of taking care of so many Covid patients, combined with good data, has just made everything we do 100 times easier,” he said.

Some of the earliest data about the perils of intubating coronavirus patients turned out to be incomplete and misleading. Dr. Susan Wilcox, a critical care specialist at Massachusetts General Hospital, said many providers were spooked by data that suggested an 80 percent mortality rate among ventilated coronavirus patients, but the actual death rate turned out to be much lower. The mortality rate at her hospital, she said, was about 25 to 30 percent.

“Some people were saying that we should intubate almost immediately because we were worried patients would crash and have untoward consequences if we waited,” she said. “But we’ve learned to just go back to the principles of good critical care.”

Survival rates have increased significantly at many hospitals, a shift brought about by the introduction of therapeutics like dexamethasone, a powerful steroid that Mr. Trump took when he was hospitalized with the coronavirus. The changing demographics of the pandemic — a growing proportion of younger patients with fewer health risks — have also played a role in the improving survival rates.

Dr. Nikhil Jagan, a critical care pulmonologist at CHI Health, a hospital chain that serves Iowa, Kansas and Nebraska, said many of the coronavirus patients who were arriving at his emergency room now were less sick than the patients he treated in the spring.

“There’s a lot more awareness about the symptoms of Covid-19,” he said. “The first go-around, when people came in, they were very sick right off the bat and in respiratory distress or at the point of respiratory failure and had to be intubated.”

But the promising new treatments and enhanced knowledge can go only so far should the current surge in cases continue unabated. The country passed 250,000 deaths from the coronavirus last week, a reminder that many critically ill patients do not survive. The daily death toll has been rising steadily and is approaching 2,000.

“Ventilators are important in critical care but they don’t save people’s lives,” said Dr. Branson of the University of Cincinnati. “They just keep people alive while the people caring for them can figure out what’s wrong and fix the problem. And at the moment, we just don’t have enough of those people.”

For now, he said there was only one way out the crisis: “It’s not that hard,” he said. “Wear a mask.”

Cartoon – Talk About Super Spreaders

6-02 cartoon | Cartoons | heraldandnews.com

COVID-related controversy and hope amid a week of politics

https://mailchi.mp/95e826d2e3bc/the-weekly-gist-august-28-2020?e=d1e747d2d8

Democracy vs. disease: the role of freedom in facing pandemics | University  of Nevada, Reno

Week two of the 2020 Pre-Recorded Virtual Presidential Convention-thon wrapped up Thursday night, albeit with a decidedly less Zoom-Webex-FaceTimey feel for this week’s Republicans compared to last week’s Democrats. As delegates and VIPs sat cheek-by-jowl at several in-person events, with scarce masking and plenty of loud cheering, the viewer was left hoping that a rigorous attendee COVID testing protocol was being used.

That hope may have been dashed by a significant change to testing guidelines from the Centers for Disease Control and Prevention (CDC), which reversed course on Monday by recommending asymptomatic people who have been exposed to the coronavirus should no longer be tested.

The altered guidance drew sharp rebukes from doctors and infectious disease experts, who worried that it would undermine the ability to track the spread of the virus, which has now claimed more than 181,000 American lives. The flap over testing guidelines came at the same time as Food and Drug Administration (FDA) commissioner Stephen Hahn was forced to apologize for misleading claims he made over the weekend about the efficacy of convalescent plasma in treating COVID patients. In announcing an Emergency Use Authorization (EUA) for the treatment, Hahn dramatically overstated evidence supporting the lifesaving ability of the therapy. The missteps by CDC and FDA officials were undoubtedly an unwelcome distraction for the Trump administration, overshadowing the president’s bold promise in his acceptance speech that a COVID vaccine would be available before the end of the year.

There was hopeful news on the COVID front this week as well. In what was quickly hailed as a “game changer” in solving the nation’s faltering ability to deliver timely test results, Abbott Laboratories was granted its own EUA for a 15-minute, $5 rapid antigen test, which does not require laboratory analysis. The company plans to produce tens of millions of the new BinaxNOW test kits in the next month, and the US government has agreed to acquire nearly all of the 150M tests the company will produce by the end of the year, at a $760M purchase price. Although some antigen tests have been cited for accuracy problems, the FDA said that the new Abbott test delivers correct positive tests 97.1 percent of the time, and correct negative tests 98.5 percent of the time.

Rapid, reliable point-of-care testing could allow for safer return to schools, workplaces, and public gatherings, and if successfully deployed will be an essential tool in managing the impact of the virus until effective vaccines are fully developed, launched, and administered. A genuine ray of hope as the nation looks ahead to the fall and winter.

US coronavirus update: 5.9M cases; 181K deaths; 81.8M tests conducted.

 

 

Patchwork approach to contact tracing hampers national recovery

https://thehill.com/homenews/state-watch/514233-patchwork-approach-to-contact-tracing-hampers-national-recovery

Patchwork approach to contact tracing hampers national recovery | TheHill

A patchwork approach to contact tracing across state health departments is making it increasingly difficult to know where people are getting exposed to COVID-19.

While some states like Louisiana and Washington state publicly track detailed data related to COVID-19 cases in bars, camps, daycares, churches, worksites and restaurants, most states do not, creating obstacles to preventing future cases.

The extensive spread of the virus, combined with the country’s 50-state approach to pandemic response, has led to a dearth of information about where transmissions are occurring. Those shortcomings are in turn complicating efforts to safely open the economy and to understand the risks associated with certain activities and settings.

Experts know COVID-19 spreads in crowded indoor spaces, but more specifics could help state and local lawmakers strike a better balance between public health needs and those of the economy.

“If you want to take a more targeted approach to public health measures, the more information you have the better,” said Joshua Michaud, an associate director for global health policy at the Kaiser Family Foundation and an infectious disease epidemiologist.

“Rather than have a blunt, close-everything-down approach, you could be a bit more targeted and surgical about how you implement certain measures,” he added.

The Hill asked every state for information about the data they collect and share as part of their contact tracing programs, one of the main tools public health officials have to slow the spread of COVID-19.

Most states release information about outbreaks and cases at congregate settings like nursing homes, meatpacking plants, and prisons, which comprise the majority of cases. But there is less information publicly available about the numbers of cases or outbreaks tied to other settings commonly visited by people.

A handful of states including ArkansasColoradoKansasLouisianaMaryland, Michigan, Ohio, Rhode Island and Washington track and publicly release data on the settings where COVID-19 outbreaks are occurring, according to responses from state health departments.

For example, Louisiana has tied 468 cases to bars in the state, but most of the new cases in the past week have been tied to food processing plants.

In The Hill’s review of publicly available state data, other settings for COVID-19 transmission include restaurants, childcare centers, gyms, colleges and schools, churches, retailers, weddings and other private social events. It is not clear how widely those settings contributed to infections because widespread transmission of the virus means many people who get sick do not get interviewed by contact tracers — over the past week, there has been an average of 42,000 confirmed cases, though many more are likely going undetected.

State health departments in Idaho, Illinois, Massachusetts, Mississippi, Missouri, New Hampshire, North Carolina, South Carolina, Tennessee, Texas, Vermont, Virginia and West Virginia told The Hill they don’t track location data.

Utah tracks outbreaks and cases tied to workplaces and schools, but not restaurants or bars.

Arizona, California, Delaware, Indiana, Oregon and Pennsylvania track infection locations, but don’t release it to the public.

“The number of people getting COVID-19 from isolated, identifiable outbreaks, such as those in long term care facilities, is decreasing, and more people are contracting COVID-19 from being out and about in their community, such as when visiting restaurants and bars,” said Maggi Mumma, a spokeswoman for the Pennsylvania Department of Health.

Bars, indoor dining and gyms are still closed in most of New York and New Jersey, so there is no current data to track for those settings.

But the state health departments also don’t release data on outbreaks or cases tied to other settings like childcare or retail stores.

MinnesotaMontanaNorth Dakota and Wisconsin release the number of cases tied to outbreaks in the community but do not go into specifics about possible transmission sites.

For example, Minnesota lists nearly 7,000 cases as being tied to “community” exposure, but that includes settings like restaurants, bars and workspaces.

In Iowa, a state health department spokesperson said the agency is working on extracting and sharing this type of data on its website, while Maine would not say if they track by specific location.

The remaining state health departments did not respond to multiple requests for comment from The Hill and don’t have information about outbreaks or exposure settings on their websites.

Several states said local health departments may be tracking infection locations even if the state is not.

Experts said such a decentralized approach can miss outbreaks if local departments aren’t communicating with each other, meaning any data should be public.

“I do think it would be very valuable for states to make that information public,” said Crystal Watson, assistant professor at Johns Hopkins Bloomberg School of Public Health.

“It helps us collectively get a better understanding as policymakers, as people trying to help in the response. It can also help with personal decision making for people to understand … where it’s most dangerous to go related to getting infected,” Watson said.

The disparities between state health departments are partially due to a lack of federal guidance.

There are no federal requirements on the information contact tracers collect; guidelines vary from state to state, and sometimes from county to county.

Tracking data about where people are getting sick would allow states to take a “cluster busting” approach, experts said, by working backwards from confirmed cases to find where patients might have first contracted the disease, potentially stopping future outbreaks.

That approach requires a change in mindset for contact tracers, who typically focus on reaching close contacts of confirmed cases who might have been exposed to the virus. But research shows between 10 and 20 percent of people are responsible for about 80 percent of new infections, mostly through so-called super-spreader events.

“We know that the way this virus has transmitted is highly clustered groups and anytime you have settings where a lot of people are together in one place,” said Kaiser’s Michaud.

“Collecting good information on this — the cluster busting approach — is a good way to find out where your prevention efforts can have the best bang for your buck,” he said.

At the same time, some state programs are still not operating at full force and are struggling to keep up with widespread infections.

“I think that many parts of the country, especially outside of the Northeast … simply have too many cases to use contact tracing as the primary public health measure to control cases,”  said Stephen Kissler, a research fellow at the Harvard T.H. School of Public Health.

“It’s just not enough,” he said. “We just don’t have enough resources, and in a lot of these places enough contact tracers, to follow up on all of the cases.”

 

 

 

 

 

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.”

 

 

 

New CDC Report Says Nearly Half of U.S. Population Is at Risk of Contracting Severe COVID-19

https://www.cidrap.umn.edu/news-perspective/2020/07/chronic-conditions-put-nearly-half-us-adults-risk-severe-covid-19

Coronavirus Disease 2019 Case Surveillance — United States ...

Chronic conditions put nearly half of US adults at risk for severe COVID-19

About 47% of US adults have an underlying condition strongly tied to severe COVID-19 illness, researchers at the Centers for Disease Control and Prevention (CDC) have found.

The model-based study, published today in the CDC’s Morbidity and Mortality Weekly Report, used self-reported data from the 2018 Behavioral Risk Factor Surveillance System and the US Census.

Researchers analyzed the data for the prevalence of chronic obstructive pulmonary disease (COPD), heart disease, diabetes, chronic kidney disease (CKD), and obesity in residents of 3,142 counties in all 50 states and the District of Columbia. They defined obesity as having a body mass index (BMI) of 30 kg/m2 or higher.

They found that prevalence patterns generally followed population distributions, with high numbers in large cities, but that these conditions were more prevalent in rural than in urban areas. Counties with the highest prevalence of these conditions were generally clustered in the Southeast and Appalachia.

Severe COVID-19 disease, requiring hospitalization, intensive care, and mechanical ventilation or leading to death, is most common in people of advanced age and in those who have at least one of the previously mentioned underlying conditions.

A CDC analysis last month of US COVID-19 patient surveillance data from Jan 22 to May 30 showed that those with underlying conditions were hospitalized six times more often, needed intensive care five times more often, and had a death rate 12 times higher than those without these conditions. But the authors of today’s reported noted that the earlier study defined obesity as a BMI of 40 kg/m2 or higher and included some conditions with mixed or limited evidence of a tie to poor coronavirus outcomes.

Prevalence of underlying conditions in rural, urban counties

Median estimated county prevalence of any underlying illness was 47.2% (range, 22.0% to 66.2%). Numbers of people with any underlying condition ranged from 4,300 in rural counties to 301,744 in large cities.

Prevalence of obesity was 35.4% (range, 15.2% to 49.9%), while it was 12.8% for diabetes (range, 6.1% to 25.6%), 8.9% for COPD (range, 3.5% to 19.9%), 8.6% for heart disease (range, 3.5% to 15.1%), and 3.4% for CKD, 3.4% (range, 1.8% to 6.2%).

Nationwide, the overall weighted prevalence of adults with chronic underlying conditions was 30.9% for obesity, 11.4% for diabetes, 6.9% for COPD, 6.8% for heart disease, and 3.1% for CKD.

The estimated median prevalence of any underlying condition generally increased with increasing county remoteness, ranging from 39.4% in large metropolitan counties to 48.8% in rural ones.

Resource allocation, preventive health measures

The authors noted that access to healthcare resources in some rural counties may be poor, adding to the risk of severe COVID-19 outcomes.

“The findings can help local decision-makers identify areas at higher risk for severe COVID-19 illness in their jurisdictions and guide resource allocation and implementation of community mitigation strategies,” they wrote. “These findings also emphasize the importance of prevention efforts to reduce the prevalence of these underlying medical conditions and their risk factors such as smoking, unhealthy diet, and lack of physical activity.”

The researchers called for future studies to include the weighting of the contribution of each underlying illness according to the risk of serious COVID-19 outcomes and identifying and integrating other factors leading to susceptibility to both infection and serious outcomes to better estimate the number of people at increased risk for COVID-19 infection. 

 

 

 

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.”

 

 

Mask resistance during a pandemic isn’t new – in 1918 many Americans were ‘slackers

https://theconversation.com/mask-resistance-during-a-pandemic-isnt-new-in-1918-many-americans-were-slackers-141687?utm_medium=email&utm_campaign=The%20Weekend%20Conversation%20-%201680716207&utm_content=The%20Weekend%20Conversation%20-%201680716207+Version+A+CID_c211e1b0b6c4b69b3a29a9d1624a2ab6&utm_source=campaign_monitor_us&utm_term=Mask%20resistance%20during%20a%20pandemic%20isnt%20new%20%20in%201918%20many%20Americans%20were%20slackers

Mask resistance during a pandemic isn't new – in 1918 many ...

We have all seen the alarming headlines: Coronavirus cases are surging in 40 states, with new cases and hospitalization rates climbing at an alarming rate. Health officials have warned that the U.S. must act quickly to halt the spread – or we risk losing control over the pandemic.

There’s a clear consensus that Americans should wear masks in public and continue to practice proper social distancing. While a majority of Americans support wearing masks, widespread and consistent compliance has proven difficult to maintain in communities across the country. Demonstrators gathered outside city halls in Scottsdale, ArizonaAustin, Texas; and other cities to protest local mask mandates. Several Washington state and North Carolina sheriffs have announced they will not enforce their state’s mask order.

I’ve researched the history of the 1918 pandemic extensively. At that time, with no effective vaccine or drug therapies, communities across the country instituted a host of public health measures to slow the spread of a deadly influenza epidemic: They closed schools and businesses, banned public gatherings and isolated and quarantined those who were infected. Many communities recommended or required that citizens wear face masks in public – and this, not the onerous lockdowns, drew the most ire.

Mask resistance during a pandemic isn't new – in 1918 many ...

In mid-October of 1918, amidst a raging epidemic in the Northeast and rapidly growing outbreaks nationwide, the United States Public Health Service circulated leaflets recommending that all citizens wear a mask. The Red Cross took out newspaper ads encouraging their use and offered instructions on how to construct masks at home using gauze and cotton string. Some state health departments launched their own initiatives, most notably California, Utah and Washington.

Nationwide, posters presented mask-wearing as a civic duty – social responsibility had been embedded into the social fabric by a massive wartime federal propaganda campaign launched in early 1917 when the U.S. entered the Great War. San Francisco Mayor James Rolph announced that “conscience, patriotism and self-protection demand immediate and rigid compliance” with mask wearing. In nearby Oakland, Mayor John Davie stated that “it is sensible and patriotic, no matter what our personal beliefs may be, to safeguard our fellow citizens by joining in this practice” of wearing a mask.

Health officials understood that radically changing public behavior was a difficult undertaking, especially since many found masks uncomfortable to wear. Appeals to patriotism could go only so far. As one Sacramento official noted, people “must be forced to do the things that are for their best interests.” The Red Cross bluntly stated that “the man or woman or child who will not wear a mask now is a dangerous slacker.” Numerous communities, particularly across the West, imposed mandatory ordinances. Some sentenced scofflaws to short jail terms, and fines ranged from US$5 to $200.

Mask resistance during a pandemic isn't new – in 1918 many ...

Passing these ordinances was frequently a contentious affair. For example, it took several attempts for Sacramento’s health officer to convince city officials to enact the order. In Los Angeles, it was scuttled. A draft resolution in Portland, Oregon led to heated city council debate, with one official declaring the measure “autocratic and unconstitutional,” adding that “under no circumstances will I be muzzled like a hydrophobic dog.” It was voted down.

Utah’s board of health considered issuing a mandatory statewide mask order but decided against it, arguing that citizens would take false security in the effectiveness of masks and relax their vigilance. As the epidemic resurged, Oakland tabled its debate over a second mask order after the mayor angrily recounted his arrest in Sacramento for not wearing a mask.prominent physician in attendance commented that “if a cave man should appear…he would think the masked citizens all lunatics.”

In places where mask orders were successfully implemented, noncompliance and outright defiance quickly became a problem. Many businesses, unwilling to turn away shoppers, wouldn’t bar unmasked customers from their stores. Workers complained that masks were too uncomfortable to wear all day. One Denver salesperson refused because she said her “nose went to sleep” every time she put one on. Another said she believed that “an authority higher than the Denver Department of Health was looking after her well-being.” As one local newspaper put it, the order to wear masks “was almost totally ignored by the people; in fact, the order was cause of mirth.” The rule was amended to apply only to streetcar conductors – who then threatened to strike. A walkout was averted when the city watered down the order yet again. Denver endured the remainder of the epidemic without any measures protecting public health.

Mask resistance during a pandemic isn't new – in 1918 many ...

In Seattle, streetcar conductors refused to turn away unmasked passengers. Noncompliance was so widespread in Oakland that officials deputized 300 War Service civilian volunteers to secure the names and addresses of violators so they could be charged. When a mask order went into effect in Sacramento, the police chief instructed officers to “Go out on the streets, and whenever you see a man without a mask, bring him in or send for the wagon.” Within 20 minutes, police stations were flooded with offenders. In San Francisco, there were so many arrests that the police chief warned city officials he was running out of jail cells. Judges and officers were forced to work late nights and weekends to clear the backlog of cases.

Many who were caught without masks thought they might get away with running an errand or commuting to work without being nabbed. In San Francisco, however, initial noncompliance turned to large-scale defiance when the city enacted a second mask ordinance in January 1919 as the epidemic spiked anew.

Many decried what they viewed as an unconstitutional infringement of their civil liberties. On January 25, 1919, approximately 2,000 members of the “Anti-Mask League” packed the city’s old Dreamland Rink for a rally denouncing the mask ordinance and proposing ways to defeat it. Attendees included several prominent physicians and a member of the San Francisco Board of Supervisors.

It is difficult to ascertain the effectiveness of the masks used in 1918. Today, we have a growing body of evidence that well-constructed cloth face coverings are an effective tool in slowing the spread of COVID-19. It remains to be seen, however, whether Americans will maintain the widespread use of face masks as our current pandemic continues to unfold.

Deeply entrenched ideals of individual freedom, the lack of cohesive messaging and leadership on mask wearing, and pervasive misinformation have proven to be major hindrances thus far, precisely when the crisis demands consensus and widespread compliance.

This was certainly the case in many communities during the fall of 1918. That pandemic ultimately killed about 675,000 people in the U.S. Hopefully, history is not in the process of repeating itself today.

 

 

 

Anticipating a post-pandemic “Renaissance Era”

https://mailchi.mp/da2dd0911f99/the-weekly-gist-july-17-2020?e=d1e747d2d8

The primary measures we’re using to control the spread of COVID-19—masks, social distancing, isolation—have changed little from those used to mitigate the Spanish Flu in 1918, or even the bubonic plague in the Middle Ages. (In fact, the word “quarantine” comes from the Italian quaranta giorni, the forty-day period of time that arriving ships were required to anchor off the Venetian coast to prevent the spread of the Black Death.)

We were intrigued by a recent piece in the New Yorker that looks at another impact of the plague that ravaged the world in the 14th and 15th centuries: the Black Death likely ushered in an era of unprecedented social change and knowledge advancement. Devastated economies recovered to become stronger than before, with greater equality. With half of the population wiped out, workers’ wages rose, leading to the rise of a new class of artisans and innovators. With a shortage of adult men to fill jobs, women found meaningful employment in many trades.

Science and medicine moved from a spiritual and astrological orientation to a more knowledge-based approach. The “quarantine enforcers” birthed a public health infrastructure. And so the Renaissance was born. But the author also points out that great upheavals, whether caused by disease, depression or war, lead to radical social adjustments—which can be a good thing or a bad thing.

Our current pandemic offers glimpses of both possibilities. Will distrust of science, government ineptitude, and political divisiveness become further entrenched? Or will society emerge stronger, with advances in technology and medicine, a stronger economy and a renewed social system that addresses deep-rooted inequality—our own post-pandemic Renaissance? It’s up to us.