Category Archives: Evidence-Based Care

COVID-related controversy and hope amid a week of politics

Posted on by • Posted in 2020 Election Issues, Centers for Disease Control & Prevention (CDC), Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Economic Crisis, Economic Recovery, Evidence-Based Care, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, Food and Drug Administration (FDA), Infection Control, Infection Control Plan, Infectious Virus, Mislead, Misleading, Mistake, Mistrust, Mixed Message, Mortality, National Strategy, Pandemic, Public Health, Public Opinion, Public Perception, Public Safety, Public Schools, Public Trust, Quarantine, School Reopening, Scientists, Social Distancing, Superspreader, Superspreader Event, Superspreader Facilities, Superspreading Events • Leave a comment

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

Posted on by • Posted in 2020 Election Issues, Asymptomatic Transmission, Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Data Analytics, Data Control, Data Gathering, Data Governance, Data Integrity, Data Interpretation, Data Management, Data Privacy, Data Transparency, Evidence-Based Care, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, Expert, Expert Opinion, Failed, Failed Repeatedly, Failure, Infection Control, Infection Control Plan, Infectious Virus, Leadership Decentralized, Mortality, National Strategy, Pandemic, Public Health, Public Opinion, Public Perception, Public Safety, Public Schools, Public Trust, Quarantine, School Reopening, Scientists, Social Distancing, Superspreader, Superspreader Event, Superspreader Facilities, Superspreading Events • Leave a comment

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 Arkansas, Colorado, Kansas, Louisiana, Maryland, 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.

Minnesota, Montana, North 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

Posted on by • Posted in 2020 Election Issues, Centers for Disease Control & Prevention (CDC), Clinical Testing, Contact Tracing, Coronavirus, Coronavirus Treatment, Crisis, Crisis Management, Deferred Healthcare, Economic Crisis, Elective Procedures, Elective Surgery, Employee Protections, Employer-Based Health Insurance, Essential Health Benefits, Essential Workers, Evidence-Based Care, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, Expert, Expert Opinion, Front Lines, Health Insurance Coverage Adequacy, Healthcare Providers, Infection Control, Infection Control Plan, Infectious Virus, Labor Union, Mortality, National Strategy, Nurses, Nurses Union, Out of Pocket Expenses, Pandemic, Personal Protective Equipment (PPE), Preexisting Conditions, Primary Care, Public Health, Public Safety, Quarantine, Scientists, Social Determinants of Health, Social Distancing, Supply Chain, Underinsured, Unemployment, Unemployment Insurance, Uninsured, Ventilators, Worker Protection, Worker Rights, World Health Organization (WHO) • Leave a comment

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

Posted on by • Posted in 2020 Election Issues, Centers for Disease Control & Prevention (CDC), Chronic Care Management, Chronic Conditions, Chronic Diseases, Clinical Testing, Contact Tracing, Coronavirus, Evidence-Based Care, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, Health Insurance Coverage Adequacy, Infection Control, Infection Control Plan, Infectious Virus, Mortality, National Strategy, Pandemic, Preexisting Conditions, Public Health, Public Safety, Social Determinants of Health, Underinsured, Unemployment, Unemployment Insurance, Uninsured • Leave a comment

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

Posted on by • Posted in Access & Quality of Healthcare, Chronic Care Management, Chronic Conditions, Chronic Diseases, Coronavirus, Coronavirus Long-Term Complications, Coronavirus Treatment, Diabetes, Essential Health Benefits, Essential Workers, Evidence-Based Care, Health Insurance Coverage Adequacy, Mortality, Out of Pocket Expenses, Pandemic, Preexisting Conditions, Primary Care, Social Determinants of Health, Underinsured, Unemployment, Unemployment Insurance, Uninsured, Vulnerable Populations • Leave a comment

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

Posted on by • Posted in 2020 Election Issues, Change, Change Management, Changing Behavior, Clinical Testing, Contact Tracing, Coronavirus, Crisis, Crisis Management, Economic Crisis, Economy Reopening, Evidence-Based Care, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, False Hope, False Narrative, History, Infection Control, Infection Control Plan, Infectious Virus, Leadership Decentralized, Misinformation, Misinterpret, Mislead, Misleading, Mistake, Mistrust, Mixed Message, Mortality, National Strategy, Pandemic, Partisanship, Personal Protective Equipment (PPE), Public Health, Public Safety, Quarantine, Scientists, Social Distancing, Social Responsibility, Wishful Thinking • Leave a comment

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, Arizona; Austin, 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. A 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”

Posted on by • Posted in Change, Change Agent, Change Management, Coronavirus, Evidence-Based Care, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, Leadership, Mortality, Pandemic, Quarantine, Scientists, Social Distancing • Leave a comment

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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.

 

 

 

Nearly one-third of children tested for COVID in Florida are positive.

Posted on by • Posted in Asymptomatic Transmission, Chronic Care Management, Clinical Testing, Contact Tracing, Coronavirus, Coronavirus Long-Term Complications, Coronavirus Treatment, Evidence-Based Care, Evidence-based Leadership, Evidence-Based Plan, Evidence-Based Policy, Pandemic, Public Health, Public Safety, Quarantine, Social Distancing • Leave a comment

https://www.sun-sentinel.com/coronavirus/fl-ne-pbc-health-director-covid-children-20200714-xcdall2tsrd4riim2nwokvmsxm-story.html

Nearly One-Third Of Children Tested For COVID In Florida Are ...

Palm Beach County’s health director warns of risk of long-term damage.

Nearly one-in-three children tested for the new coronavirus in Florida has been positive, and a South Florida health official is concerned the disease could cause lifelong damage even for children with mild illness.

Dr. Alina Alonso, Palm Beach County’s health department director, warned county commissioners Tuesday that much is unknown about the long-term health consequences for children who catch COVID-19.

X-rays have revealed the virus can cause lung damage even in people without severe symptoms, she said.

“They are seeing there is damage to the lungs in these asymptomatic children. … We don’t know how that is going to manifest a year from now or two years from now,” Alonso said. “Is that child going to have chronic pulmonary problems or not?”

Her comments stand in contrast to Gov. Ron DeSantis’ messaging that children are at low risk, and classrooms need to be reopened in the fall. DeSantis has said he would be comfortable sending his children to school if they were old enough to attend.

Some studies suggest that children are less likely to catch COVID-19 than adults. Children are also far less likely to die of the disease. About 17,000 of Florida’s roughly 287,800 cases have been people younger than 18. Of the 4,514 COVID-19 deaths reported by Florida as of Tuesday, four have been younger than 18.

Still, it’s possible COVID-19 could have long-term consequences that will take time to understand, Alonso said.

“This is not the virus you bring everybody together to make sure you catch it and get it over with,” she said. “This is something serious, and we are learning new information about this virus every day.”

State statistics also show the percentage of children testing positive is much higher than the population as a whole. Statewide, about 31% of 54,022 children tested have been positive. The state’s positivity rate for the entire population is about 11%.

Researchers have linked a serious and potentially deadly inflammatory condition with COVID-19 in children. The condition, called pediatric multisystem inflammatory syndrome, doesn’t appear to be widespread. The Florida Department of Health lists 13 confirmed cases of the syndrome.

Dr. Jorge Perez, co-founder of Kidz Medical Services, said it’s too early to say how common and severe long-term damage could be from COVID-19, but early evidence suggests some children infected with the virus could have lasting damage.

“We are learning something every day,” said Perez, who operates pediatric offices throughout South Florida. “We have to be knowledgeable about this and continue to monitor to see what effects it has in children.”

DeSantis told talk radio host Rush Limbaugh last week that the risk to children is “very low.”

“I’ve got a 3-year-old daughter, 2-year-old son, and a newborn daughter,” DeSantis said in the radio interview. “And I can tell you if they were school age, I would have zero concern sending them.”

 

 

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

Posted on by • Posted in 2020 Election Issues, Centers for Disease Control & Prevention (CDC), Clinical Testing, Clinical Trials, Contact Tracing, Coronavirus, Coronavirus Long-Term Complications, Coronavirus Treatment, Deconditioning, Delirium, Essential Businesses, Essential Workers, Evidence-Based Care, Health Insurance Coverage Adequacy, Health Policy, Health System, Hospital, Hospital Industry, Infection Control, Infection Control Plan, Infectious Virus, Intensive Care (ICU), Lingering Symptoms, Long-Term Consequences, Mortality, Out of Pocket Expenses, Pandemic, Post-Covid Care, Preexisting Conditions, Public Health, Public Safety, Quarantine, Scientists, Social Distancing, Underinsured, Uninsured • Leave a comment

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

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

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

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

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

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

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

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

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

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

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

What’s causing these long-term symptoms?

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

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

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

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

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

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

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

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

Long-term symptoms, long-term consequences

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

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

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

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

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

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

Who can access care?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

 

Fauci has been an example of conscience and courage.

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Opinion | Fauci has been an example of conscience and courage ...

When historians try to identify the most shameful documents from the Trump administration, a few are likely to stand out. For unconstitutional bigotry, it is hard to beat the initial executive order banning travel to the United States from Muslim countries. For cruelty and smallness, there is the “zero tolerance” directive to federal prosecutors that led to family separations at the border. For naked corruption, there is the transcript of the quid-pro-quo conversation between President Trump and the president of Ukraine.

But for rash, foolish irresponsibility, I’d nominate the opposition research paper recently circulated by the White House in an attempt to discredit the National Institute of Allergy and Infectious Diseases’ Anthony S. Fauci. As reported by The Post, the document recounted a number of instances — on community transmission, asymptomatic transmission and mask wearing in particular — where Fauci’s views have shifted over time. As far as I know, this official record is unique: A White House attack on the government’s leading infectious-disease specialist during a raging pandemic. It indicates an administration so far gone in rage, bitterness and paranoia that it can no longer be trusted to preserve American lives.

From a purely political standpoint, it is understandable that the administration would want to divert attention from its covid-19 record. Trump’s policy of reopening at any cost is exacting a mounting cost. Five months into the greatest health crisis of modern U.S. history, there are still serious problems with supply chains for protective equipment. There are still long wait times for testing results in many places. The contact tracing process in many communities remains (as one health expert described it to me) “a joke.” More than 132,000 Americans have died.

Rather than addressing these failures, Trump has chosen to sabotage a public official who admits their existence. Rather than confronting these problems, Trump wants to ensure his whole administration lies about them in unison. The president has surveyed America’s massive spike in new infections and thinks the most urgent matter is . . . message discipline.

It is true that a number of Fauci’s views on the novel coronavirus have evolved (though some of the administration’s charges against him are distorted). But attacking a scientist for making such shifts is to willfully misunderstand the role of science in the fight against disease. We do not trust public health officials during an emerging pandemic because they have fully formed scientific views from the beginning. We trust them because 1) they are making judgments based on the best available information and 2) they have no other motive than the health of the public. If, say, health officials were initially mistaken about the possibility of asymptomatic transmission, it is not failure when they change their views according to better data. It is the nature of the scientific method and the definition of their duty.

In the inch-deep world of politics, amending your view based on new information is a flip-flop. In epidemiology, it is known as, well, epidemiology.

Meanwhile, the president is failing according to both requirements of public trust. Trump is not making judgments based on the best available information. And he clearly has political goals that compete with (and often override) his commitment to public health. The president is hoping against hope that the public will forget about the virus until November, or at least about the federal role in fighting it. To apply a veneer of normalcy, he is holding public events that endanger his staff and his audience and is planning a Republican convention that will double as a petri dish.

It now seems likely that the most decisive moment of the American pandemic took place in mid-April when new cases began to stabilize around 25,000 a day. Even four or six more weeks of firm presidential leadership — urging the tough, sacrificial application of stay-at-home orders — might have reduced the burden of disease to more sustainable levels, as happened in Western Europe. And this would have relieved stress on systems of testing, tracing and treatment.

But Trump’s nerve failed him. Instead of holding firm, he began siding with populist demands for immediate opening, pressuring governors to take precipitous steps and encouraging skepticism about basic public health information and measures. This may well have been the defining moment of the Trump presidency. And he was weak, weak, weak.

It is typical for Trump to shift blame. But in this case, the president has selected his fall guy poorly. Fauci has been an example of conscience and courage in an administration that values neither. When Trump encourages a contrast to his own selfishness and cravenness, he only damages himself.