From Health and Fitness

‘Is This When I Drop Dead?’ Two Doctors Report From the COVID Front Lines

Health workers across the country looked on in horror when New York became the global epicenter of the coronavirus. Now, as physicians in cities such as Houston, Phoenix and Miami face their own COVID-19 crises, they are looking to New York, where the caseload has since abated, for guidance.

The Guardian sat in on a conversation with two emergency room physicians — one in New York and the other in Houston — about what happened when COVID-19 arrived at their hospitals.

Dr. Cedric Dark, Houston: When did you start worrying about how COVID-19 would impact New York?

Dr. Tsion Firew, New York: Back in February, I traveled to Sweden and Ethiopia for work. There was some sort of screening for COVID-19 in both places. On Feb. 22, I came to New York City, and nothing — no screening. At that point, I thought, “I don’t think this country’s going to handle this well.”

Dark: On Feb. 26, at a department meeting, one of my colleagues put coronavirus on the agenda. I thought to myself, “Why do we even need to bother with this here in Houston? This is in China; maybe it’s in Europe?”

Firew: On March 1, we had our first case in New York City, which was at my hospital. Fast-forward 15 days and I get a call saying, “Hey, you were exposed to COVID-positive patients.” I was told to stay home.

Dark: My anxiety grew as I saw what was happening in Italy, a country I’ve visited several times. I remember seeing images of people dying in their homes and mass graves. I started to wonder, “Is this what we’ll see over here? Are my colleagues going to be dying? Is this something that’s going to get me or my wife, who’s also an ER doctor? Are we going to bring it home to our son?”

In March, we repurposed our urgent care pod, which has eight beds, into our coronavirus unit. And for a while, that was enough.

Firew: In late March, health workers without symptoms were told to come back to work. It felt like a tsunami hit. I’ve practiced in very low-resource settings and even in a war zone, and I couldn’t believe what I was witnessing in New York.

The emergency department was silent — there were no visitors, and patients were very sick. Many were on ventilators or getting oxygen. The usual human interactions were gone. Everybody was wearing a mask and gowns and there were so many people who came to help from different places that you didn’t know who was who. I spent a lot more time on the phone talking to family members about end-of-life care decisions, conversations you’d normally have face-to-face.

In New York, the severity of the crisis really depended on what hospital you were at. Columbia has two hospitals — one at 168th and one at 224th — and the difference was night and day. The one on 224th is smaller and just across the bridge from the Bronx, which was hit hard by the virus.

There, people were dying in ambulances while waiting for care. The emergency department was overwhelmed with patients who needed oxygen. Its hallways were crowded with patients on portable oxygen tanks. We ran out of monitors and oxygen for the portable tanks. Staff members succumbed to COVID-19, exacerbating shortages of nurses and doctors.

My friends who work in Lower Manhattan couldn’t believe some of the things we saw.

Dark: I went to medical school at NYU and have a lot of friends in New York I was checking in with at the time. I thought that in Houston, a city that’s almost as big, we had the conditions for a similar crisis: It’s a large city with an international airport, it attracts a lot of business travelers, and thousands of people come here each March for the rodeo.

In late March, a guy about my age came into the hospital. It was the first day we got coronavirus tests. A few days later, a nurse texted me that the patient had tested positive. He hadn’t traveled anywhere — it was proof to me that we had community transmission in Houston before any officials admitted it.

You became infected, right?

Firew: In early April, I became sick, along with my husband. I never imagined that in 2020 I would be writing out a living will detailing my life insurance policy to my family. Walking from my bed to the kitchen would make my heart race; I often wondered: Is this when I drop dead like my patient the other day?

A few days before I got sick, the president had said that anybody who wanted a test could get one. But then I was on the phone with my workplace and with the department of health begging for a test.

It was also around that time that a brown-skinned physician who was about my age died from COVID-19. So I knew being in my mid-30s wouldn’t protect me. I was even more worried when my husband became ill because, as a Black man, his chances of dying from this disease were much higher than mine. We both recovered, but I still have some fatigue and shortness of breath.

When did cases pick up in Houston?

Dark: We saw a gradual increase in cases throughout April, but it stayed relatively calm because the city was shut down. The hospital was kind of a ghost town because no one was having elective procedures. Things were quiet until Texas reopened in May.

I remember when I lost my first COVID patient. He started to crash right in front of me. We started CPR and I ran the algorithms through my mind trying to think how we could bring him back, but kept ending up at the same conclusion: This is COVID and there’s nothing I can do.

It’s like serving on the front lines of a war. We initially struggled to find our own personal protective equipment while the hospitals worked to secure the supply chain. Although that situation has stabilized, a lot of patients who come in for non-COVID reasons wind up testing positive. COVID is everywhere.

Our patient population is heavily Latino and Black and, for a time, our hospital had some of the highest numbers of COVID cases among the nearly two dozen hospitals in the Texas Medical Center network. It’s revealed the fault lines of a preexisting issue in terms of inequities in health care.

As area hospitals fill up, they reallocate additional floors to COVID patients. Who knows, if we don’t get this under control, maybe one day the whole hospital will be COVID.

Firew: Now I’m just chronically angry. The negligence came from the top all the way down. Our leaders do not lead with evidence — we knew what was going to happen when states reopened so quickly.

Dark: Yeah, this was completely avoidable, had the governor [Texas Gov. Greg Abbott] decided not to open up the economy too fast.

How are things in New York now?

Firew: There have been several days where I’ve seen zero COVID cases. If I do see a case, it’s usually someone who has traveled from abroad or other states.

People are coming in for non-COVID reasons. Recently, a woman in her early 40s came in with a massive lesion on her breast. She’d started experiencing some pain three months ago, during the peak of the pandemic, and was too frightened to come to the hospital. To make matters worse, she didn’t have insurance and couldn’t afford the telehealth that many had access to.

By the time she made it to our hospital, the mass had metastasized to her spine and lungs. Even with aggressive treatment, she likely only has a few months to live. This is one of the many cases we’re seeing now that we are back to “normal” — complications of chronic illnesses and delayed diagnoses of cancer. The burden of the pandemic layered with a broken health care system.

Dr. Tsion Firew is an assistant professor of emergency medicine at Columbia University and special adviser to the minister of health of Ethiopia.

Dr. Cedric Dark is an assistant professor of emergency medicine at Baylor College of Medicine and a board member for Doctors for America.

This conversation was condensed and edited by Danielle Renwick.

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Public Health States

COVID Data Failures Create Pressure for Public Health System Overhaul

After terrorists slammed a plane into the Pentagon on 9/11, ambulances rushed scores of the injured to community hospitals, but only three of the patients were taken to specialized trauma wards. The reason: The hospitals and ambulances had no real-time information-sharing system.

Nineteen years later, there is still no national data network that enables the health system to respond effectively to disasters and disease outbreaks. Many doctors and nurses must fill out paper forms on COVID-19 cases and available beds and fax them to public health agencies, causing critical delays in care and hampering the effort to track and block the spread of the coronavirus.

“We need to be thinking long and hard about making improvements in the data-reporting system so the response to the next epidemic is a little less painful,” said Dr. Dan Hanfling, a vice president at In-Q-Tel, a nonprofit that helps the federal government solve technology problems in health care and other areas. “And there will be another one.”

There are signs the COVID-19 pandemic has created momentum to modernize the nation’s creaky, fragmented public health data system, in which nearly 3,000 local, state and federal health departments set their own reporting rules and vary greatly in their ability to send and receive data electronically.

Sutter Health and UC Davis Health, along with nearly 30 other provider organizations around the country, recently launched a collaborative effort to speed and improve the sharing of clinical data on individual COVID cases with public health departments.

But even that platform, which contains information about patients’ diagnoses and response to treatments, doesn’t yet include data on the availability of hospital beds, intensive care units or supplies needed for a seamless pandemic response.

The federal government spent nearly $40 billion over the past decade to equip hospitals and physicians’ offices with electronic health record systems for improving treatment of individual patients. But no comparable effort has emerged to build an effective system for quickly moving information on infectious disease from providers to public health agencies.

In March, Congress approved $500 million over 10 years to modernize the public health data infrastructure. But the amount falls far short of what’s needed to update data systems and train staff at local and state health departments, said Brian Dixon, director of public health informatics at the Regenstrief Institute in Indianapolis.

The congressional allocation is half the annual amount proposed under last year’s bipartisan Saving Lives Through Better Data Act, which did not pass, and much less than the $4.5 billion Public Health Infrastructure Fund proposed last year by public health leaders.

“The data are moving slower than the disease,” said Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists. “We need a way to get that information electronically and seamlessly to public health agencies so we can do investigations, quarantine people and identify hot spots and risk groups in real time, not two weeks later.”

The impact of these data failures is felt around the country. The director of the California Department of Public Health, Dr. Sonia Angell, was forced out Aug. 9 after a malfunction in the state’s data system left out up to 300,000 COVID-19 test results, undercutting the accuracy of its case count.

Other advanced countries have done a better job of rapidly and accurately tracking COVID-19 cases and medical resources while doing contact tracing and quarantining those who test positive. In France, physicians’ offices report patient symptoms to a central agency every day. That’s an advantage of having a national health care system.

“If someone in France sneezes, they learn about it in Paris,” said Dr. Chris Lehmann, clinical informatics director at UT Southwestern Medical Center in Dallas.

Coronavirus cases reported to U.S. public health departments are often missing patients’ addresses and phone numbers, which are needed to trace their contacts, Hamilton said. Lab test results often lack information on patients’ races or ethnicities, which could help authorities understand demographic disparities in transmission and response to the virus.

Last month, the Trump administration abruptly ordered hospitals to report all COVID-19 data to a private vendor hired by the Department of Health and Human Services rather than to the long-established reporting system run by the Centers for Disease Control and Prevention. The administration said the switch would help the White House coronavirus task force better allocate scarce supplies.

The shift disrupted, at least temporarily, the flow of critical information needed to track COVID-19 outbreaks and allocate resources, public health officials said. They worried the move looked political in nature and could dampen public confidence in the accuracy of the data.

An HHS spokesperson said the transition had improved and sped up hospital reporting. Experts had various opinions on the matter but agreed that the new system doesn’t fix problems with the old CDC system that contributed to this country’s slow and ineffective response to COVID-19.

“While I think it’s an exceptionally bad idea to take the CDC out of it, the bottom line is the way CDC presented the data wasn’t all that useful,” said Dr. George Rutherford, a professor of epidemiology at the University of California-San Francisco.

The new HHS system lacks data from nursing homes, which is needed to ensure safe care for COVID patients after discharge from the hospital, said Dr. Lissy Hu, CEO of CarePort Health, which coordinates care between hospitals and post-acute facilities.

Some observers hope the pandemic will persuade the health care industry to push faster toward its goal of smoother data exchange through computer systems that can easily talk to one another — an objective that has met with only partial success after more than a decade of effort.

The case reporting system launched by Sutter Health and its partners sends clinical information from each coronavirus patient’s electronic health record to public health agencies in all 50 states. The Digital Bridge platform also allows the agencies for the first time to send helpful treatment information back to doctors and nurses. About 20 other health systems are preparing to join the 30 partners in the system, and major digital health record vendors like Epic and Allscripts have added the reporting capacity to their software.

Sutter hopes to get state and county officials to let the health system stop sending data manually, which would save its clinicians time they need for treating patients, said Dr. Steven Lane, Sutter’s clinical informatics director for interoperability.

The platform could be key in implementing COVID-19 vaccination around the country, said Dr. Andrew Wiesenthal, a managing director at Deloitte Consulting who spearheaded the development of Digital Bridge.

“You’d want a registry of everyone immunized, you’d want to hear if that person developed COVID anyway, then you’d want to know about subsequent symptoms,” he said. “You can only do that well if you have an effective data system for surveillance and reporting.”

The key is to get all the health care players — providers, insurers, EHR vendors and public health agencies — to collaborate and share data, rather than hoarding it for their own financial or organizational benefit, Wiesenthal said.

“One would hope we will use this crisis as an opportunity to fix a long-standing problem,” said John Auerbach, CEO of Trust for America’s Health. “But I worry this will follow the historical pattern of throwing a lot of money at a problem during a crisis, then cutting back after. There’s a tendency to think short term.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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California Health Industry Public Health

Back to Life: COVID Lung Transplant Survivor Tells Her Story

Mayra Ramirez remembers the nightmares.

During six weeks on life support at Northwestern Memorial Hospital in Chicago, Ramirez said, she had terrifying nightmares that she couldn’t distinguish from reality.

“Most of them involve me drowning,” she said. “I attribute that to me not being able to breathe, and struggling to breathe.”

On June 5, Ramirez, 28, became the first known COVID-19 patient in the U.S. to undergo a double lung transplant. She is strong enough now to begin sharing the story of her ordeal.

Mysterious Exposure

When the COVID-19 pandemic hit, Mayra Ramirez began working from home. She’s unsure how she contracted COVID-19.(Northwestern Medicine)

Before the pandemic, Ramirez worked as a paralegal for an immigration law firm in Chicago. She enjoyed walking her dogs and running 5K races.

Ramirez had been working from home since mid-March, hardly leaving the house, so she has no idea how she contracted the coronavirus. In late April, she started experiencing chronic spasms, diarrhea, loss of taste and smell, and a slight fever.

“I felt very fatigued,” Ramirez said. “I wasn’t able to walk long distances without falling over. And that’s when I decided to go into the emergency room.”

From the ER to a Ventilator

The staff at Northwestern checked her vitals and found her oxygen levels were extremely low. She was given 10 minutes to explain her situation over the phone to her mother in North Carolina and appoint her to make medical decisions on her behalf.

Ramirez knew she was about to be placed on a ventilator, but she didn’t understand exactly what that meant.

“In Spanish, the word ‘ventilator’ — ventilador — is ‘fan,’ so I thought, ‘Oh, they’re just gonna blow some air into me and I’ll be OK. Maybe have a three-day stay, and then I’ll be right out.’ So I wasn’t very worried,” Ramirez said.

In fact, she would spend the next six weeks heavily sedated on that ventilator and another machine — known as ECMO, or extracorporeal membrane oxygenation — pumping and oxygenating her blood outside of her body.

In this photo taken before the transplant, Mayra Ramirez is being monitored by the ECMO team at Northwestern Memorial Hospital in Chicago.(Northwestern Medicine)

One theory about why Ramirez became so sick is that she has a neurological condition that is treated with steroids, drugs that can suppress the immune system.

By early June, Ramirez was at risk of further decline. She began showing signs that her kidneys and liver were starting to fail, with no improvement in her lung function. Her family was told she might not make it through the night, so her mother and sisters caught the first flight from North Carolina to Chicago to say goodbye.

When they arrived, the doctors told Ramirez’s mother, Nohemi Romero, that there was one last thing they could try.

Ramirez was a candidate for a double lung transplant, they said, although the procedure had never been done on a COVID patient in the U.S. Her mother agreed, and within 48 hours of being listed for transplant, a donor was found and the successful procedure was performed on June 5.

At a recent news conference held by Northwestern Memorial, Romero shared in Spanish that there were no words to describe the pain of not being by her daughter’s side as she struggled for her life.

She thanked God all went well, and for giving her the strength to make it through.

‘I Just Felt Like a Vegetable’

Dr. Ankit Bharat, Northwestern Medicine’s chief of thoracic surgery, performed the 10-hour procedure.

“Most patients are quite sick going into [a] lung transplant,” Bharat said in an interview in June. “But she was so sick. In fact, I can say without hesitation, the sickest patient I ever transplanted.”

Bharat said most COVID-19 patients will not be candidates for transplants because of their age and other health conditions that decrease the likelihood of success. And early research shows that up to half of COVID patients on ventilators survive the illness and are likely to recover on their own.

But for some, like Ramirez, Bharat said, a transplant can be a lifesaving option of last resort.

When Ramirez woke up after the operation, she was disoriented, could barely move her body and couldn’t speak.

“I just felt like a vegetable. It was frustrating, but at the time I didn’t have the cognitive ability to process what was going on,” Ramirez said.

She recalled being sad that her mother wasn’t with her in the hospital, not understanding that visitors weren’t allowed because of the pandemic.

Her family had sent photos to post by her hospital bed, and Ramirez said she couldn’t recognize anyone in the pictures.

“I was actually sort of upset about it, [thinking,] ‘Who are these strangers and why are their pictures in my room?’” Ramirez said. “It was weeks later, actually, that I took a second look and realized, ‘Hey, that’s my grandmother. That’s my mom and my siblings. And that’s me.”

After a few weeks, Ramirez said, she finally understood what happened to her. When COVID-19 restrictions loosened at the hospital in mid-June, her mother was finally able to visit.

“The first thing I did was just tear up,” Ramirez said. “I was overjoyed to see her.”

The Long Road to Recovery

After weeks of inpatient rehabilitation, Ramirez was discharged home. She’s now receiving in-home nursing assistance as well as physical and occupational therapy, and she’s working on finding a psychologist.

Ramirez eagerly looks forward to being able to spend more time with her family, her boyfriend and her dogs and serving the immigrant community through her legal work.

But for now, her days are consumed by rehab. Her doctors say it will be at least a year before she can function independently and be as active as before.

Ramirez is slowly regaining strength and learning how to breathe with her new lungs.

She takes more than 17 pills, four times a day, including medicines to prevent her body from rejecting the new lungs. She also takes anxiety meds and antidepressants to help her cope with daily nightmares and panic attacks.

The long-term physical and mental health tolls on Ramirez and other COVID-19 survivors remain largely unknown, since the virus is so new.

While most people who contract the virus are left seemingly unscathed, for some patients, like Ramirez, the road to recovery is full of uncertainty, said Dr. Mady Hornig, a physician-scientist at the Columbia University Mailman School of Public Health.

Some patients can experience post-intensive care syndrome, or PICS, which can consist of depression, memory issues and other cognitive and mental health problems, Hornig said. Under normal circumstances, ICU visits from loved ones are encouraged, she said, because the human interaction can be protective.

“That type of contact would normally keep people oriented … so that it doesn’t become as traumatic,” Hornig said.

Hopes for the Future

COVID-19 has disproportionately harmed Latino communities, as Latinos are overrepresented in jobs that expose them to the virus and have lower rates of health insurance and other social protections.

Ramirez has health insurance, although that hasn’t spared her from tens and thousands of dollars’ worth of medical bills.

And even though she still ended up getting COVID-19, she counts herself lucky for having a job that allowed her to work from home when the pandemic struck. Many Latino workers don’t have that luxury, she said, so they’re forced to risk their lives doing low-wage jobs deemed essential at this time.

Ramirez’s mother is a breast cancer survivor, making her particularly vulnerable to COVID-19. She had been working at a meatpacking plant in North Carolina, for a company that Ramirez said has had hundreds of COVID-19 cases among employees.

So Ramirez is relieved to have her mom in Chicago, helping take care of her.

“I’m glad this is taking her away from her position,” Ramirez said.

Friends and family in North Carolina have been fundraising to help pay her medical bills, selling raffle tickets and setting up a GoFundMe page on her behalf. Ramirez is also applying for financial assistance from the hospital.

Her experience with COVID-19 has not changed who she is as a person, she said, and she looks forward to living her life to the fullest.

If she ever gets the chance to speak with the family of the person whose lungs she now has, she said, she will thank them “for raising such a healthy child and a caring person [who] was kind enough to become an organ donor.”

Her life may never be the same, but that doesn’t mean she won’t try. She laughs as she explains how she asked her surgeon to take her skydiving someday.

“Dr. Bharat actually used to work at a skydiving company when he was younger,” Ramirez said. “And so he promised me that, hopefully within a year, he could get me there.”

And she has every intention of holding him to that promise.

This story is part of a reporting partnership that includes Illinois Public Media, Side Effects Public Media, NPR and KHN.

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States

When Will Long-Term Care Facilities Reopen to Visitors?

Three years ago, Cathy Baum helped both her mother and her mother-in-law move into memory care in an assisted living facility in Reston, Va. Because Ms. Baum lived nearby, she could visit four to five days a week and keep a watchful eye on them.

“I’d check the bathrooms to be sure they’d had a shower when they were supposed to,” said Ms. Baum, 69. She stuck around at lunchtime to help cut their food or see that a staff member did. She made sure that her mother-in-law got the right clothing back from the laundry.

Then the coronavirus struck. On March 10 the facility, like nursing homes and assisted living complexes across the country, shut down and barred family visits. Ms. Baum did not see her 98-year-old mother or her 82-year-old mother-in-law until administrators again permitted visitors on June 30.

Even then, the experience proved frustrating. At first, employees escorted residents into an outdoor courtyard, where family members could talk to them over a wrought-iron fence. When the weather became too hot, the facility rigged a plastic curtain at an entrance, so that residents could sit in the air-conditioning while relatives visited.

Ms. Baum isn’t sure how much the two women understand when she, her husband or her brother try to communicate through the barrier. Cognitive impairment makes phone calls and video chats unworkable, too.

“They appear to be well,” she said, noting that the women didn’t seem to have lost weight and had visited the recently reopened beauty salon. Distanced dining room service has resumed.

But Ms. Baum is having trouble sleeping. “When I could check on things, I could go home and not worry,” she said. “Now, I can’t check.”

In the early weeks of the pandemic, a shutdown made sense to experts. “We faced so much risk,” said David Grabowski, a health care researcher at Harvard Medical School. “It was a crisis.” More than 40 percent of those who have died from Covid-19 were long-term care residents or staff members, a New York Times database shows.

Given such uncertainty about the new virus, Dr. Grabowski and others think the federal Centers for Medicare and Medicaid Services made the right initial call in banning outsiders, a policy that most assisted living facilities (which are not federally regulated) also adopted.

“We felt they were being responsive and protecting residents,” he said.

Now, a number of geriatricians, researchers and advocates — and frantic family members — fear that months of restrictive visiting policies have become injurious.

“It’s not just Covid that’s killing residents in long-term care,” said Dr. Jason Karlawish, a geriatrician at the University of Pennsylvania. “It’s the isolation, the loneliness.” Studies have repeatedly shown that isolated older adults have higher rates of heart disease, stroke and dementia and increased mortality rates comparable to those linked to smoking.

Moreover, Dr. Karlawish said, “Covid exposes a secret everyone knows” — that such facilities are chronically understaffed, with relatives often filling the gap. “The family were covert caregivers,” he said, providing not just connection and stimulation but hands-on help with dressing, walking, eating and monitoring residents’ health.

In a study Dr. Grabowski co-authored, nursing home residents with dementia received better quality care at the end of life if a family member visited regularly.

Could nursing homes and assisted living facilities start to resume family visits? Some already have, most commonly scheduling brief contacts outdoors or encounters through windows, sometimes supplemented by video chat and phone calls.

But the response has not been universal. “We are hearing that many facilities are refusing to permit visits even if they are allowed to do so,” Robyn Grant, director of public policy and advocacy for the National Consumer Voice, said in an email.

ImageCathy Baum and her husband, Mark, whose mother also lives at Tall Oaks. Ms. Baum dreads “the idea that one of them might pass without one of us next to them,” she said.
Cathy Baum and her husband, Mark, whose mother also lives at Tall Oaks. Ms. Baum dreads “the idea that one of them might pass without one of us next to them,” she said.Credit…Alyssa Schukar for The New York Times

Moreover, scheduled outdoor visits don’t give family caregivers the same ability to participate in residents’ care or monitor their conditions. Suzanne Thomas, who has been able to visit her mother only through the front window of her assisted living facility near Charlotte, N.C., wonders if anyone inside remembers that her mother, who is 81 and has dementia, needs her hearing aid batteries changed every other day.

And soon, winter weather will make outdoor visits impractical in many locations, as summer heat does now in some places.

“Some have termed this isolation ‘involuntary confinement,’” said Dr. Christian Bergman, a geriatrician and internist at Virginia Commonwealth University. “We can’t continue down this path for another six months.”

In May, Medicare officials issued recommendations for state and local officials on phased reopening for nursing homes. It includes expanded visiting with masks and distancing when a home has entered Phase 3, meaning that it has had no new Covid cases for 28 days and can provide adequate testing and protective equipment, with no staff shortages.

Dr. Bergman, who heads a panel of health care professionals who are developing reopening guidelines for long-term care, estimated that fewer than 5 percent of facilities nationally have reached that point.

Thirty-four states have issued guidelines for nursing home visits and 27 for assisted living, according to LeadingAge, which represents nonprofit senior service providers. But individual facilities can decide whether to permit visitors and under what conditions.

For nursing homes, Medicare “left it to the discretion of the states, and the states essentially left it to the discretion of the providers,” said Dee Pekruhn, an executive at LeadingAge. With no central federal authority, assisted living providers arguably have more leeway, but as an industry, their approach to visiting is even less clear.

A study in 26 nursing homes in the Netherlands, demonstrating that families can visit without causing new Covid infections, has encouraged advocates. Perhaps, they say, in areas with low community infection rates, when facilities have sufficient protective equipment and testing capacity, family caregivers can be cautiously reintroduced.

But many long-term-care facilities still can’t meet those conditions. Dr. Bergman, whose group expects to publish its recommendations next month, pointed out that some still report shortages of protective equipment, particularly N95 masks in appropriate sizes. In many regions, bottlenecks in testing have so delayed results that they are useless for screening visitors.

Moreover, Dr. Karlawish said, “one thing that haunts long-term care is fear of litigation.”

Medicare vowed last month to send a rapid testing kit to each of the nation’s 15,000 nursing homes, prioritizing those with outbreaks or in Covid hot spots; so far it has allocated about 2,400. But these antigen tests produce more false negative than the slower but more reliable P.C.R. tests, experts said; facility administrators also worry about the cost of supplies the kits require.

“Providers are eager but cautious to welcome visitors and volunteers back into their buildings,” the American Health Care Association/National Center for Assisted Living said in an email. “That is why we need public health officials to direct resources — testing, PPE and funding — to long-term care on an ongoing basis.”

There’s always a reason to delay, and facilities where residents and staff members have already suffered and died from Covid-19 understandably fear a recurrence. But they could exercise judgment, Dr. Karlawish said, and at least allow visitors for residents who clearly struggling with the isolation. “Nursing homes care for a group of people for whom high-stakes ethical decisions are part of life,” he said.

Almost by definition, long-term care residents have limited life spans; nursing home residents are particularly fragile. Do they so value safety over quality of life that they want to spend their last months or years separated from their loved ones? Has anyone asked them?

Ms. Baum keeps visiting her mother and mother-in-law from a distance, but she is haunted by “the idea that one of them might pass, without one of us next to them,” she said. “I don’t know what I would do.”

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How Young People Can Own Their Health Care (Even if They Still See a Pediatrician)

Owning your health care is a key life skill for young people, like doing laundry, voting and making ramen — and it’s one you can start learning, even (or especially) while living under your parents’ roof.

Adolescent medicine specialists want you to embrace your own medical care, and now might be the perfect time. Dr. Hina J. Talib, the adolescent medicine medical director of Children’s Hospital at Montefiore, identifies the pandemic as a “golden opportunity” for teenagers to practice self-care and self-advocacy skills.

The National Alliance to Advance Adolescent Health offers advice and resources on a website, gottransition.org, including setting up a “Medical ID” app on your phone.

Following are some of the foundational elements of transitioning to self-care.

Get private, confidential time with your doctor

Adolescent medicine specialists recommend starting at around age 13 or 14 — or even younger as needed. This alone time gives you a chance to share private mental-health concerns, high-risk behaviors, or personal issues related to sex, sexuality, gender and substances. Dr. Cora Breuner, a professor of pediatrics and adolescent medicine at Seattle Children’s Hospital and the University of Washington, uses this time not only for more revelatory and trusting conversations, but also so that young people can practice talking — and listening — to doctors, without their parents butting in.

Do understand that, before you turn 18, the issue of confidentiality is tricky and varies by state. It tends to cover conversations about reproductive, sexual and mental health — but if the doctor determines anything to be life-threatening or dangerous (a big gray area), they can talk to your parents about it.

If you have questions about what is and isn’t confidential, and what a minor can and can’t consent to in terms of birth control, vaccinations for sexually transmitted infections and other aspects of sexual or reproductive care, don’t hesitate to ask for clarification. Dr. Breuner also recommends a visit to the Guttmacher Institute website, which breaks down reproductive health consent issues by state. Even if a procedure or lab test is confidential, a charge for it may show up on a bill your parents receive, so ask about that too.

And if you want to loop your parents in, but aren’t sure how, Dr. Ellen Rome, head of the Center for Adolescent Medicine at Cleveland Clinic Children’s Hospital, recommends asking your provider: “How do I have a healthy conversation about this with my parents?”

And a Covid-era issue: If you’re doing a telehealth appointment from home, ask everyone in the house to respect your privacy before it starts (or, a tip from Dr. Talib, conduct it from the bathroom).

Understand adult privacy and consent issues

Once you turn 18, your health information is yours alone. If you’ve ever seen the acronym HIPAA (Health Insurance Portability and Accountability Act) on any forms you’ve filled out, that’s one of the things it refers to. If a parent wants to be part of the conversation, they must ask you; this is true even if they pay for your health insurance or health care. If you want to, you can sign a waiver allowing your doctor or health center to talk to them about your health.

Make your own appointments, and cancel them if needed

If your doctor’s office has a health care portal such as MyChart, you may be able to schedule an appointment online; otherwise, you’ll need to actually call (I know!) and have a calendar handy. (While you’re at it, put your doctor’s name and number in your phone.) If you’re having an urgent health crisis — mental or physical — say so and ask for advice; if it’s after hours, you’ll talk to an answering service who will have the doctor call you back to discuss next steps — going to the emergency room, for example.

And a plea from Dr. Talib: “If my teen patients would actually cancel appointments, I would love that so much — they just don’t show up.” Plus, you can be charged for a missed appointment that you don’t cancel.

Daunted? Don’t be! Call as if you’re making an appointment, then say, “Hi, this is [you]. I was supposed to see Dr. Healthperson on [date], but I need to cancel that appointment.” They’ll likely ask if you’d like to reschedule, and you can take it from there.

If you have a cognitive, physical or developmental difference or disability, then your individualized education program — I.E.P. — or 504 plan may be a useful starting point for figuring out the accommodations you might need to become medically independent.

Manage chronic conditions and prescriptions

With some conditions, this can be a lot of work (one friend of ours took a gap year before college to learn to manage his diabetes independently), so transition gradually. Ask a parent to walk you through everything that’s been happening behind the scenes, such as the appointments or labs they routinely schedule, and any prescriptions they’ve been managing. Know what you take and why, how often you need to pick it up, if you have to call the pharmacy first, and if your doctor will need to call in a refill.

Have a parent, doctor, or pharmacist teach you how to read the label on your medication: the number of refills left, the dosage, the possible side effects. And make sure to build in plenty of lead time; you don’t want to end up in the E.R. simply because you, say, forgot to pick up your inhaler.

Any questions? Ask the pharmacist. Dr. Talib describes them as a “wonderful and underutilized resource for taking care of people.”

Understand your health insurance

Ask a parent to explain how co-payments (the amount you pay out of pocket) work for office visits, emergency care and prescription medications; get in the habit of saving receipts for any payments you make; learn how to get a referral to a specialist; look at a bill with your parents and start to learn what gets covered and why — and when and how to contest an erroneous charge.

If you’re going to college, decide with your family whether to enroll in your college’s health plan or waive the coverage. And plan, far in advance, for the age of 26, when you’ll get bumped from your parents’ plan.

Coronavirus and college

If you’re going away to school this fall, have a family conversation about what would happen if you got sick, familiarize yourself with the location and hours of your health center, and memorize your parents’ telephone numbers in case you are ever separated from your phone.

Bring along some supplies for self-care. Beyond masks and hand sanitizer, Dr. Rome recommends packing up a thermometer, Advil and Tylenol, and Benadryl (in case of an allergic reaction). And Dr. Breuner recommends regularly checking the website of the Centers for Disease Control and Prevention for updates on the virus because, as she says — and as you already know — “knowledge is power.”

Remember that independence doesn’t mean you have to do everything on your own. As Dr. Talib puts it, “We’re not saying you need to have a parentectomy at age 18.” Always ask for help, company or advice when you need it. That’s what smart adults do.

Where to call in a crisis:

  • 911 if you or a friend are having a life-threatening emergency of any type, including a drug overdose.

  • The National Suicide Prevention Lifeline: 1-800-784-2433 if you or someone you know is thinking about self-harm or suicide.

  • The Safe Place hotline: 1-888-290-7233 or visit the website if you need help with bullying, suicidal thoughts, homelessness, abuse or neglect.

  • The Trevor Project hotline: 1-866-488-7386 or visit the website if you need LGBTQ+ support or suicide prevention assistance related to gender identity, transgender issues or sexuality.

  • The National Runaway Switchboard: 1-800-621-4000 for referrals to hospitals, soup kitchens, drug abuse centers, S.T.I./H.I.V. information and testing facilities, and free bus tickets home.

  • Planned Parenthood: 1-800-230-7526 (business hours only) for information about birth control, the morning-after pill, reproductive health, relationship safety, sexually transmitted infections, pregnancy and abortions.

Catherine Newman is the author of the teen skill-building book “How to Be a Person.”


The Particular Pain of Pandemic Grief

“Don’t thank me, love. It’s just my job.” The nurse’s words were clear, firm, efficient. Just like her, in the two hours I had known her.

“He’s all right. He’s peaceful now.” That was the end of my conversation with the British National Health Service nurse in charge of the Covid-19 ward where my father was at the end of his life in England, half a world away from my home in California.

Hanging up the phone meant it was over. And so I stood, motionless, staring through now-blurry eyes into the vast expanse of what lay ahead. “All right” meant my father was dying; “peaceful” meant he was sedated. This was what I was supposed to hope for, just four days after his hospitalization with Covid-19. A peaceful death.

Her words echo still in my mind.

My father had always been a solitary soul, and yet here he was, forced into this final, unwilling form of solitude as the coronavirus overwhelmed his body in a rapid and irreparable takeover of his lungs. The work of the virus was complete, though his life was not.

The nurse had offered to arrange for a final goodbye with my father using the one donated iPad the hospital had for families of Covid patients to communicate with our loved ones — a piece of nonmedical equipment allowed into my father’s contaminated room.

I could see her blond hair and barely 30-something face, a ray of life beneath the long plastic face-mask that protected her from my father. Her arm, outstretched, was covered in her white translucent surgical gown, a thin veil keeping her in this world while ensuring that dad’s passage to what lay beyond was humane. The comfort she offered to him and to me put her in the proximity of this deadly virus.

By the time we said goodbye, my father was dying, preverbal once more, eyes sunken and searching. He labored on his outbreath, groaning in the slow, rhythmic soundtrack of a life ending.

But even when there are no words, there is goodbye.

He had always been a man of few words, at least through the humdrum of daily life. Dad loved the remote Scottish loch where I spent my childhood; more, it seemed, than me, or anyone in his life for that matter. Children were superfluous, an added track of daily spirit and motion atop the steady lap of the loch’s waters, the gray layers of mountain backdrop, the hauntings of the pub he ran for years.

He would, however, come to life with a bottle of gin and the ears of the local pub-goers. Daily, one of the regulars would make the trek miles along the one-lane, winding road down the loch to the pub, in full Scottish regalia — kilt, sporran and long, knee high kilt-socks with the red fleck of a garter peeking below the seam — and linger until the late-night hours, when I would hear the tenor of Gaelic expletives, a sure sign of a few too many drams.

In my preschool days I learned to count with the small five-pence tips I was given after delivering shots of whiskey to the regulars. I sat in the window sill, overlooking a view so breathtaking it makes me speechless to this day, counting my pennies, lulled by Dad’s presence and the singsong of a language now lost to me.

I marveled at how Dad would spin stories endlessly with the locals. I wanted to feature in these stories, or at least to understand them, but they remained elusive — a point of entry to worlds past, a space where he seemed that much more comfortable.

As I grew up and attended schooling of a more formal kind, Dad taught me how to drive — windows down, music blaring, my hand on his hand. Always a bit too fast on the winding, one-lane Scottish open road. He taught me how to cook — simple, slow foods, before it was a thing; to savor slowly the delights of the earth, to crack the pepper always a bit too generously, to keep the fat and the crisps close at hand too.

He taught me my manners and to be a rebel, all in one. Somehow these contradictions all made sense with him.

I took Dad’s rebel streak to heart one winter day at school when faced with the injustice of a headmistress who violently admonished me for stealing off with her son’s toboggan. When I dared speak back to tell her she was wrong, she yelled viciously.

I will never forget the gentle pride in Dad’s voice when he told me later that she had rung to say something just had to be done about my talking back. Of course, I did complete the 1,000 lines I was assigned — “I will not talk back” — as I was my father’s daughter, well-mannered and all. But I made sure my handwriting was unimpressive, barely legible; subversive in the only way I knew how.

I moved to Berkeley, Calif., in 1986 when I was 13, after my mother remarried. I would travel to spend summers with my Dad and his family in Scotland and — more recently since becoming a parent myself — had taken my partner and children to spend time. Scotland is still very much home for me, even though Dad moved to England a few years ago to retire.

In the final chapter of our life’s conversation, I spoke softly, calmly, tears streaming down my face as my Dad’s eyes revealed a distant place. His eyes gently lifted as I spoke, my voice shaking through the phone. “I love you, Dad.”

I had never told my father I loved him until he lay dying, body wrecked with coronavirus.

It had come so quickly, this window onto our life together. I said it again and again. In some ways, I was preverbal too.

Navigating the spoken and unspoken rules of a rigid society by finding ways to narrate and challenge its edges was something my father had demonstrated with deft wit and wisdom. Articulating love was not part of this. But it didn’t mean it was not there.

Now here I was, trying to narrate this closing chapter. He had given me the power of words, and now was the time to use them.

“You aren’t alone. We are with you.” There was nothing and a lifetime of unspoken words to say.

Pandemic death is particularly cruel. It preys on the vulnerable. We all hold a collective grief and loss in this pandemic.

But what happens when death comes? When the circles of Covid-19 close in so tightly that it wrings your heart?

The daily acts of service — “just work” — on the part of our nurses and doctors, janitors and funeral workers change the lives of those of us left behind even as they support dignity for our dying and dead. Those who make final words possible, even when there are no words.

Our rituals of grief are no more. These are now mediated through distance and must emerge in new forms as we feel the cut-me-to-the-core pain of grief in isolation, as we see masked coffin-bearers revealed over video livestream funerals.

We yearn for human comfort, yet we know all too well the excruciating cost that lifting distance too early could engender.

As we reconfigure meaning in our now-pandemic lives and dare to envision the necessity of a reconfigured post-pandemic world, perhaps we will understand anew what matters most.

I hope Dad has found a home for his gentle, rebel soul. Meanwhile, I will carry his spirit on as best I can. Perhaps by beginning with a story.

Sonja Mackenzie is an associate professor of public health at Santa Clara University and lives in Berkeley, Calif., with her partner and two children.

Weekly Health Quiz: Pesticides, Cancer and Coronavirus

1 of 7

The current coronavirus pandemic is known to have killed about how many people worldwide?

75,000

750,000

7.5 million

75 million

2 of 7

More than 166,000 Americans have died from Covid-19, but the number of excess deaths since the pandemic began suggests the number of coronavirus-related deaths may be closer to:

200,000

300,000

500,000

1 million

3 of 7

People with this sleep/wake behavior tended to move 20 to 30 minutes more throughout the day:

Early risers

Day types

Night owls

Chronotype had little overall effect on daily movement

4 of 7

Pyrethroids, a group of insecticides commonly used to repel mosquitoes, ticks and other pests, were linked to an increased risk of death from this illness, though the study cannot prove cause and effect:

Cancer

Heart disease

Parkinson’s disease

Amyotrophic lateral sclerosis

5 of 7

The Environmental Protection Agency approved a new chemical called nookatine that repels and kills ticks and mosquitoes. The substance appears to be safe enough to eat and is found in this fruit:

Apples

Bananas

Grapefruits

Kiwis

6 of 7

Symptoms of the inflammatory condition known as GPA, or granulomatosis with polyangiitis, include all of the following except:

Red, swollen ears

Chronic sinusitis

Muscle aches

Fever

7 of 7

Gum disease was linked to an increased risk of this form of cancer:

Throat cancer

Breast cancer

Colon cancer

Prostate cancer

I Exchanged Notes With Elena Ferrante. Sort of.

Times Insider explains who we are and what we do, and delivers behind-the-scenes insights into how our journalism comes together.

When you read The New York Times, you can be assured that everything you’re seeing is nonfiction — with noted special exceptions. The Books department frequently publishes short excerpts from new fiction and, since 2016, an editorial team known as NYT Mag Labs has, among other projects, been publishing print-only adaptations from upcoming novels of note.

The first such excerpt was from Colson Whitehead’s “The Underground Railroad,” a book that went on to win both a National Book Award and a Pulitzer Prize. So from the start, the bar for these excerpts has been extremely high.

As senior editor for the Labs team, I’m responsible for identifying potential excerpts, and when our team learned in September that Elena Ferrante, the popular Italian author, had a novel scheduled to be published in English in 2020, we immediately made inquiries.

Not only is Ms. Ferrante critically lauded, but she’s also become a global phenomenon. Her Neapolitan quartet of novels have been published in 48 countries and have sold 16 million copies worldwide. Dozens of publications, including The Times, had named her upcoming novel, “The Lying Life of Adults,” as one of the most anticipated books of 2020. In short, a new novel from Ms. Ferrante is news — and precisely the kind of special reading experience that we at Labs hope to bring to weekend print subscribers.

We also understood that, even among celebrity authors, Ms. Ferrante was a singular case. While most authors are inclined — either through temperament or the coercion of their publishers — to undertake every opportunity to publicize a book, she is famously averse to attention. “Elena Ferrante” is a pseudonym for an anonymous author whose real name is a well-protected secret.

She rarely grants interviews (and those must be conducted by email) and is so mysterious that, in the earliest days of her success, some observers wondered if she existed at all. Others have speculated that the author is, in fact, a man, and a few critics and scholars have undertaken baroque investigations in an attempt to unveil her identity. Her publisher, Europa Editions, was happy to cooperate with a potential excerpt, but her U.S. editor warned us that Ms. Ferrante’s involvement might range from limited to nonexistent.

After making first contact in December 2019, we began negotiations over the excerpt that continued for months. The novel, about a young girl in Naples who discovers a trove of family secrets, was originally set to be published in early June, but the pandemic prompted a delay until fall. For Labs, the notion of providing a sneak peek of an anticipated new book by a beloved author seemed all the more enticing during a national lockdown, so we agreed to postpone the excerpt to coincide with the book’s U.S. publication on Sept. 1.

Next, there was the question of the excerpt itself. The selections published by Mag Labs are lengthy — often 15,000 words or more. Creating a compelling and coherent reading experience at that length demands a certain level of editorial intervention; for example, the excision of story lines and subplots that may fit perfectly in the longer novel but that don’t pay off (or even make sense) within an excerpt.

Traditionally, in crafting these excerpts, we work fairly closely with the authors. In this case, the author is an anonymous recluse accessible only through emails sent to her English-language publishers.

When our edit was ready, we sent it for Ms. Ferrante’s approval. All correspondence with her was routed through her English-language publisher, who forwarded it to her Italian editors, who sent it along to her, then relayed her response. We never had direct contact with her. (Her celebrated translator, Ann Goldstein, who has also been interviewed in our section, works the same way — she has never met or interacted with Ms. Ferrante directly.)

A note came back explaining that, while she was happy overall, she had never before acquiesced to such extensive editorial intervention. She asked that ellipses be placed everywhere in the text where we had made an editorial change. This was an unusual request, one I had never encountered before.

We communicated to her publisher that the inclusion of ellipses would probably confuse readers and might leave the excerpt reading like a series of disparate, abandoned trains of thought. Or, worse, like one of those … heavily edited … movie … blurbs. (Or, for those who remember them, the rambling newspaper columns of Larry King.)

So we proposed a compromise: We would insert an asterisk, along with a simple explanatory note, in the spots where major excisions had occurred. And that is how you’ll find our excerpt from “The Lying Life of Adults,” which will be published as a print-only section this weekend.

Readers can ignore the unobtrusive asterisks entirely and enjoy the story. Or, if you’re so inclined, grab the book once it’s available on Sept. 1 and compare the original to our edited excerpt. We promise that the novel is an excellent read — even the parts that, by necessity, we had to leave out.

A Glance (and a Rooster) That Changed Everything

A wooden spoon. A green onion. A pot with three legs. One bottle of Florida water. Another of Champagne Andre. Three candles. A bag of “poud pa janbe” (“don’t-cross-here powder”). And most important, a young rooster.

I had been warned not to haggle over the rooster.

The merchant had five birds. One was old and orange. Three were adolescents, good for fighting but not much else. The last was energetic, almost enthusiastic. His red feathers looked gold in the sunlight.

“How much for him?” I asked.

She picked him up. “300 gourdes,” she said (a little over seven U.S. dollars). I paid her, tucked the bird under my arm and walked home.

It was April 2010. Four months earlier, an earthquake had killed hundreds of thousands of my fellow Haitians. My family and I were homeless again, sleeping behind a Mormon church, and I needed something to change.

Born in a town on Haiti’s west coast, I had lived with my father and mother and seven siblings in Ti Gine, the fisherman’s quarter, until our house was washed away in a flood. We slept on the floor of an aunt’s house, and then in a Baptist church. My father was a good man who could never get ahead. He left our family when I was 17.

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My mother sold patties at a local school; we survived on her daily wages, which I now know were less than one U.S. dollar a day. Finding money for school was an ordeal. My sisters and I always wanted what we couldn’t have — dolls, shoes, a backpack or cellphone.

As the oldest sibling, I felt responsible for the others. I moved to Port-au-Prince for college, which I attended when I could get the money to pay for it, and I was there when the earthquake struck, on a bus on my way to class. I later learned that the school building collapsed, killing many of my classmates.

It took me 12 hours to journey by foot through the ruined downtown to my uncle’s house in Aviation, a neighborhood near the old airport. My aunt was among the first to make camp on the old runway, where she was joined by thousands.

With the cellphone towers destroyed, I couldn’t reach my family. For five days, my mother thought I was dead. It took me that long to travel the 67 kilometers (almost 42 miles) to Petit Goave. The highway bridges were out; we had to exit the busses and wade to the other side. I returned home to find my family sleeping in the street.

The next months were a nightmare. I slept as much as I could because I was hungry all the time. Finally, in the depths of despair, I accompanied a friend to visit his spiritual guide, a Vodou priest in the town of Leogane.

As soon as he saw me, he knew what was wrong: “There’s a shadow over your life.”

“What do you mean?”

“You might be the first in a room, but you’re the last to be seen.”

He wrote a prescription — green onion, wooden spoon, young rooster — and told me to return when I had gathered the items.

When I asked my mother for the money, she said, “I taught you the way of light. This is the way of darkness.” As a devout Christian, she disapproves of Vodou.

I told her that this was a deeper darkness than any I had faced, that I was desperate for change, and finally she gave in. I filled the prescription and left for the priest’s house with my sister.

The rooster was killed, and I was painted in his blood. Afterward, I bathed in water infused with citrus leaves and Florida water. When I offered my sister a piece of the cooked rooster, the priest said, “You eat your fill before anyone else.”

This accomplished, I was to go home and place a glass of water under the moon. Then I would wake before anyone else, take the water in my mouth and spit in the cardinal directions. The priest said I would be washed and bright as a new penny.

He was right.

A month later, when “the whites” arrived — aid workers, mostly from Europe — I was hired by Oxfam International to work as a hygiene specialist in the tent camps. I made more money in one month than my mother made in a year. In October, when the cholera epidemic started, I was transferred to the public health campaign, and went into the camps with iodine tabs and bars of soap, teaching prevention.

The hygienists were invited to tour the new cholera treatment center when it opened. We found a series of tents set up over white gravel. The incoming patients were stripped naked and then sprayed with a blast of chlorine mist. What I remember most about that day is not the smell of the place or even the morgue they were building — it was the man I saw exiting the tent carrying a five-gallon bucket; he was handsome and enthusiastic, blonde under the sunlight.

I had not expected my rooster to be white.

We made eye contact; that was all. When I got home, I told my sister I had seen my rooster and was afraid I would never see him again. But we did see each other again, at a concert. His name was Xander. When he asked, in Creole, for my phone number, I gave it to him.

I woke to find he had texted me to say good morning.

“Are you married?” I wrote.

No.

“You have kids?”

No.

My grandmother lived in the mountains. Every few weeks she would come see my family in the city, bringing cocoa and coffee she grew herself. Everyone called her Madam Ti Klis, or Mrs. Small Seed, because she was only 4 feet 10. When she came to see us over Christmas, she was amazed to hear I had gotten a job.

“The job’s not all she got,” my mother said, mentioning my white boyfriend.

My grandmother said she had never associated with a white person outside of church, and she didn’t think they were all that friendly.

She returned a few weeks later with her boyfriend, Emwa. They had been dating for 20 years and she wanted him to hear the story. Afterward, she insisted I bring Xander to their house for a visit. Emwa was worried about the bad road, the long hike and the sorry state of the house, which had become infested with termites.

“If he truly cares for her,” my grandmother said, “he’ll come.”

The invitation was a test, one I worried Xander would fail, not wanting to trek into the mountains to visit my poor grandmother. But he said he would come.

On Sunday, we left town in a “taptap” (a little truck) and made our way to my grandmother’s house. I was ashamed of the dirt floor, but Xander didn’t seem to care.

Our relationship deepened as the strife around us grew worse. Cholera ravaged the tent camps. Hundreds got sick, filling the morgue. Xander and I would meet for lunch, scrubbing our hands with Clorox soap, and then he would put his head in my lap, and I would play with his hair. He extended his stay once, and again, until his visa was about to expire.

The first thing Xander did when he landed in Miami, before he called his own family, was to call me. After that, we spoke for hours every day. Neighbors told me he would never return, that I was just a way to pass the time. But on the phone, he asked if I wanted to come live with him. I didn’t know if he was serious. I had never left Haiti or even flown on a plane.

“Why would he bring you to America?” my friends said.

But he did return, with a ring. He got on one knee and asked me to marry him.

That was 10 years ago.

In American movies, couples almost always have so much in common. Xander and I didn’t even speak the same language — he was still learning Creole when we met, and although I now speak English fluently, I didn’t then. But we know something that American cinema doesn’t: Love has its own language.

I was born in the tropics, a Black girl in the poorest country in the Western Hemisphere. My husband was born in the north, a white man from the richest country on earth. But from the day we first saw each other at the cholera treatment center, all of that fell away, and we were naked to each other as Naomie and Xander.

Ever since, for thousands of nights, we have said “I love you” to each other in the dark, and then we have fallen asleep, marveling that it took an earthquake, an epidemic, a rooster and a passing glance to bring us together.

Naomie Brinvilus lives with her husband, Xander Miller, a novelist (“Zo”) and physician assistant, in Hershey, Penn., where they are writing a joint memoir from alternating points of view.

Modern Love can be reached at modernlove@nytimes.com.

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Young Adults Report Rising Levels of Anxiety and Depression in Pandemic

The collateral damage from the pandemic continues: Young adults, as well as Black and Latino people of all ages, describe rising levels of anxiety, depression and even suicidal thoughts, and increased substance abuse, according to findings reported by the Centers for Disease Control and Prevention.

In a research survey, U.S. residents reported signs of eroding mental health in reaction to the toll of coronavirus illnesses and deaths, and to the life-altering restrictions imposed by lockdowns.

The researchers argue that the results point to an urgent need for expanded and culturally sensitive services for mental health and substance abuse, including telehealth counseling. In the online survey completed by some 5,400 people in late June, the prevalence of anxiety symptoms was three times as high as those reported in the second quarter of 2019, and depression was four times as high.

The effects of the coronavirus outbreaks were felt most keenly by young adults ages 18 to 24. According to Mark Czeisler, a psychology researcher at Monash University in Melbourne, Australia, nearly 63 percent had symptoms of anxiety or depression that they attributed to the pandemic and nearly a quarter had started or increased their abuse of substances, including alcohol, marijuana and prescription drugs, to cope with their emotions.

“It’s ironic that young adults who are at lower risk than older adults of severe illness caused by Covid-19 are experiencing worse mental health symptoms,” said Mr. Czeisler.

A survey of about 5,000 people done in April, during the earlier days of the pandemic, Mr. Czeisler said, suggested that tremors in the mental health firmament were beginning to surface.

Already in April, high percentages of respondents reported they were spending more time on screens and less time outside than before the pandemic, which translated into more virtual interactions and far fewer in person. They noted upheavals to family, school, exercise and work routines, and to their sleeping patterns. All of these are factors that can contribute to the robustness of mental health.

But why do young adults appear to be crumbling at rates far greater than older people?

Mr. Czeisler said that the team hoped to conduct more research along those lines. He mentioned one direction of inquiry that could prove especially illuminating: measuring the extent to which people can tolerate uncertainty, or “the ability to accept the unknown, because now there are so many questions, especially for young people, about relative risk, duration of the pandemic and what their futures will look like.”

In this latest survey, nearly 41 percent overall reported symptoms of at least one adverse reaction, ranging from anxiety and depression to post-traumatic stress disorder. Nearly 11 percent said they had suicidal thoughts in the month leading up to the survey, with the greatest clusters being among Black and Latino people, essential workers and unpaid caregivers for adults. Men were more likely to express such feelings than women were.

The researchers, who represent a joint effort largely between Monash University and Brigham and Women’s Hospital in Boston, said the symptoms were less pronounced in older groups, perhaps an indication that their longer life experience has been beneficial to helping them ride out the current turbulence.

Don’t Like What You See on Zoom? Get a Face-Lift and Join the Crowd.

A growing number of people, stuck at home and tired of staring at their own haggard faces on Zoom, are finding a fix: face and eye lifts, chin and tummy tucks and more.

At a time when many medical fields are reeling from lockdowns when lucrative electives work was postponed, cosmetic surgery procedures are surging, practitioners say, driven by unexpected demand from patients who have found the coronavirus pandemic a perfect moment for corporeal upgrades.

“I have never done so many face-lifts in a summer as I’ve done this year,” said Dr. Diane Alexander, a plastic surgeon in Atlanta. She said she had performed 251 procedures through the end of July from May 18, when her clinic opened back up for elective surgery. “Pretty much every face-lift patient that comes in says: ‘I’ve been doing these Zoom calls and I don’t know what happened but I look terrible.’ ”

“This is the weirdest world I live in,” Dr. Alexander added. “The world is shut down, we’re all worried about global crisis, the economy is completely crashing and people come in and still want to feel good about themselves.”

One of her patients, a 55-year-old woman named Joanne who asked that her last name not be used because she feared seeming vain, said she considered getting work done on her face for years. But the pandemic finally made it possible because she could conceal the bruising and swelling during her recovery period.

“Knowing everybody is staying in, wearing a face mask, not coming out due to social distancing, made it the spot-on right time,” she said. “Not one friend knows I’ve done it. Family members don’t know and my sister and mom don’t even know.”

The trend is, in many ways, surprising in a tough economy. Cosmetic surgery generally isn’t covered by insurance, so procedures can cost as much as $25,000 for a full body makeover — tummy, breasts, face — and less for piecemeal work, like $3,300 for eyelid surgery and $10,000 for breast lift and enhancement. Patients say they’re diverting funds they might have spent on travel, concert, sports tickets, or other pleasures in their pre-pandemic lives.

Since insurers generally don’t pay, it’s difficult to track the precise number of cosmetic procedures being done. Dr. Lynn Jeffers, president of the American Society of Plastic Surgeons, said nationwide “demand is definitely busier than what we had expected,” though she added: “What we don’t know is if the pent-up demand is transitory, and will go back to normal, or will even dip.”

Before Covid-19, invasive cosmetic procedures like face-lifts had been declining in favor of more minimal enhancements, like Botox injections, fillers and other skin-tighteners. Since 2000, such injectable procedures rose 878 percent, according to the plastic surgeons society, while eyelid surgeries fell 36 percent and face-lifts dropped 8 percent over that period.

Colleen Nolan, executive director of the American Academy of Cosmetic Surgery, another professional organization, said she’d heard from surgeons around the country that patients were opting for more invasive procedures now than in the recent past.

“They were going for fillers and Botox because they didn’t have any down time,” she said of patients. “Now they realize they can have the procedure and privately experience it.”

The solitude of quarantine was precisely what motivated Patrice Solorzano, 62, who spent $20,000 on a procedure known in the business as a “mommy makeover” — a tummy tuck, and breast lift and enhancement. She underwent surgery on June 26, followed by a two-week recovery in her home outside Dayton, Ohio.

By the second week, she said, “I was fine. I popped myself up, got to the workstation and went back online.”

Ms. Solorzano, who oversees 160 people in 25 locations around the world as a military contractor working on account management for the Air Force, said the expense wasn’t a financial burden in part because she wasn’t spending as she otherwise might. “I definitely don’t spend it on gas,” she said. “We don’t go to the mall and don’t really go shopping.”

She spent another $10,000 on a breast lift and enhancement for her daughter, Jena Solorzano, 24, who said she was heading off to law school and thought this moment was ideal to tackle a body-image issue that has nagged at her for years. She partly blamed social media for wanting the work done.

“It doesn’t help that every single social media page has a gorgeous woman or a beautiful man on it,” she said, adding: “Covid-19 actually gave us the perfect opportunity to get a more drastic surgery.”

The loneliness of quarantine has also motivated some people. A second patient of Dr. Alexander in Atlanta said that she got a face-lift not only because she had time to recover but also because she had come face-to-face during Covid-19 with a solitary life.

“I have great girlfriends but they have husbands, and it does get lonely. I realized I really want to meet somebody,” said the woman, 57, who is divorced. She asked that her name not be used in a newspaper article because “it feels very vain to being going in and doing something cosmetically when so many people are struggling.”

Some plastic surgeons said some patients tell them that they want their faces now to match newly in-shape bodies since they’ve had time, for instance, to take 10,000 steps each day. Other surgeons said that they’ve gotten a lot of interest from people who spent the early part of the pandemic sitting inside and snacking on junk food.

Dr. Amy Alderman, another plastic surgeon in Atlanta, said that many of her patients have gained 10 to 20 pounds while shut in at home. “It’s a common theme,” she said. “I don’t know if that’s what’s driving them here. They’re saying: ‘As long as you’re doing my breasts, could you do a little lipo?’”

Dr. Alderman said she’s been shocked that the industry, and her practice, hasn’t seen an economic backlash. She said she figured “patients would be a little hesitant spending between $6,000 and $25,000.”

“But I can’t keep up with the demand,” she said. “I haven’t had an unfilled minute in the operating room. And I’m booked through September.”

KHN’s ‘What the Health?’: Kamala Harris on Health

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California Sen. Kamala Harris, the newly named running mate for presumptive Democratic presidential nominee Joe Biden, doesn’t have a lot of background in health policy. But that’s unlikely to prevent Republicans from using her on-again, off-again support for “Medicare for All” against her in the fall campaign.

Meanwhile, with talks between Congress and the Trump administration over the next round of COVID-19 relief at a standstill, President Donald Trump is trying to fill the void with executive orders. What’s unclear is whether the president has the authority to do some of what he is proposing — or whether it will work to help people in dire economic and health straits.

This week’s panelists are Julie Rovner of KHN, Kimberly Leonard of Business Insider, Joanne Kenen of Politico and Mary Agnes Carey of KHN.

Among the takeaways from this week’s podcast:

  • Although Harris isn’t closely associated with health care issues, one created problems for her last fall during her failed presidential bid. She was an original co-sponsor of the Medicare for All bill put forward by Sen. Bernie Sanders (I-Vt).
  • Trump’s executive order to suspend payroll taxes is causing consternation. It’s not clear if the order applies to both Social Security and Medicare or whether employers will follow the order. There is no indication that Congress would accept the president’s plan — and, if lawmakers don’t, workers and companies would owe the back taxes by the end of the year.
  • The tax suspension also has handed Democrats a club for the fall campaign. They are charging that the lack of revenue would endanger the Social Security and Medicare trust funds and could affect consumer benefits. Trump has replied that money from the federal government’s general fund would be used to fill the gap, but with the pandemic causing an economic upheaval, there’s no guarantee the government could afford that.
  • The president has promised he will shortly issue an executive order to protect coverage for people with medical conditions. The Affordable Care Act, which Trump has repeatedly pledged to abolish, already carries that protection, so this could be an attempt to offer Republicans a shield if the case before the Supreme Court overturns the law or some of its provisions. Previous vows by the president to offer health care plans have largely gone unfulfilled.
  • The administration is seeking to change the U.S. reliance on foreign nations, largely China and India, for prescription drugs and is moving to mandate that the government buy only U.S.-manufactured medications. Although the effort enjoys bipartisan support, it could end up increasing drug prices.
  • The recent announcement that the federal government is offering Kodak a $765 million loan to begin making chemicals that could be used in drug manufacturing triggered new scrutiny of the company. Stock trades made before the announcement, major escalation of the company’s lobbying efforts in Washington and a leak about the pending deal are all being analyzed.
  • The KHN-Guardian spotlight on the deaths of health care workers from COVID-19 points to a longer-term issue: shortages of medical professionals in key care fields.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Julie Rovner: The Wall Street Journal’s “Covid-19 Data Reporting System Gets Off to Rocky Start,” by Robbie Whelan

Joanne Kenen: The Texas Tribune and ProPublica’s “ICE Is Making Sure Migrant Kids Don’t Have COVID-19 — Then Expelling Them to ‘Prevent the Spread’ of COVID-19,” by Dara Lind and Lomi Kriel

Kimberly Leonard: The Philadelphia Inquirer’s “Coronavirus Is Changing Childbirth in the Philadelphia Region, Including Boosting Scheduled Inductions,” by Sarah Gantz

Mary Agnes Carey: The New York Times’ “Inside the Fight to Save Houston’s Most Vulnerable,” by Sheri Fink, Emily Rhyne and Erin Schaff

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Tu restaurant o tienda favorita están abiertas. ¿Cómo saber si está bien ir?

El hecho de que muchas empresas vuelvan a abrir no significa que la pandemia haya terminado. El coronavirus todavía anda suelto, en realidad aumentando en muchos lugares, lo que significa que las personas tienen que tomar decisiones serias sobre su salud cada día.

Nada en la vida está exento de riesgos y, en última instancia, las decisiones dependen de balances individuales. Pero, según expertos en salud pública consultados, hay pasos que puedes tomar, y señales que debes buscar, que te pueden ayudar a abrir la puerta y entrar… o no.

En primer lugar, evalúa tu situación personal.

Las personas con ciertas afecciones de salud, desde enfermedades cardíacas hasta diabetes u obesidad, pacientes bajo tratamiento por cáncer o personas mayores, o que viven con parientes mayores, por ejemplo, deben limitar sus salidas en un grado mucho mayor que los que no están en categorías de riesgo.

“Algunas personas no deberían correr ese riesgo en absoluto”, dijo el doctor Georges Benjamin, director ejecutivo de la Asociación Americana de Salud Pública. “No significa que no puedas salir a la calle o ir a algún lugar donde puedas relajarte. Pero hazlo lejos de otras personas “.

El consejo que has estado escuchando desde hace tiempo sigue vigente: cuando salgas, usa máscara, manténte alejado de los demás y evita las multitudes.

También debes observar las reglas sobre el uso de mascarillas en las tiendas y restaurantes que quieras visitar. En general, los expertos estuvieron de acuerdo: sin máscara, sin clientes. Los empleados, propietarios, gerentes y clientes deben usarlas. Si no las usan, ni entres, dijeron expertos, especialmente en las regiones en donde su uso es mandatorio. Además, busca letreros en la puerta que indiquen a las personas que deben usar máscaras.

A continuación, se incluyen consideraciones adicionales para situaciones que pueden presentarse:

Tiendas: es bueno que un empleado controle que cada persona que entra tenga su máscara. Otras cosas a tener en cuenta, que haya desinfectante de manos, que se limite la cantidad de personas adentro y que haya flechas que dirijan el tráfico.

“Si el negocio se ha tomado la molestia de marcar lugares para que la gente haga fila a 6 pies de distancia signifca que se está tomando las cosas en serio”, dijo el doctor Marcus Plescia, director médico de la Asociación de Funcionarios de Salud Estatales y Territoriales.

Más a favor, las tiendas que están tomando medidas para mejorar sus sistemas de ventilación y filtración. Las áreas grandes o al aire libre son una señal positiva. Pero las tiendas más pequeñas también pueden organizar sus productos de manera que apoyen el distanciamiento social.

Restaurantes: busca mesas bien separadas. El exterior triunfa sobre el interior. “Ve a un lugar donde puedas hacer una reserva afuera”, dijo Benjamin, en espacios interiors “hay problemas con el flujo de aire, por lo que el exterior es mejor”.

Salones de belleza: las áreas comunes deben limpiarse regularmente y el número de clientes debe ser limitado. Elije los salones que hagan citas. Mejor si puedes esperar afuera hasta que te llamen o te envíen un mensaje de texto para avisarte que es tu turno.

Gimnasios/piscinas: busca instalaciones espaciosas. Los suministros de limpieza deben ser abundantes. Los requisitos de la máscara son mejores que no, pero algunas actividades dificultan su uso. Las clases al aire libre son mejores que en el interior. Las piscinas deben limitar el número de personas e instruir a los nadadores para que eviten amontonarse en los bordes u otras áreas.

Limpieza/reparación del hogar: Tara Kirk Sell, investigadora principal del Centro Johns Hopkins para la seguridad de la salud, señaló que existen diferencias en las consideraciones para alguien, como la persona que repara, que es un visitante ocasional o poco común, y alguien que llega regularmente, para hacer la limpieza. “Tener un diálogo abierto sobre las prácticas a seguir y las posibles enfermedades con alguien que está habitualmente en su casa es ideal”, dijo.

Un consejo para el día de limpieza: planee salir o estar en otra parte de la casa, tal vez al segundo piso mientras limpian el primero, para minimizar la exposición.

Para situaciones más ocasionales, como reparaciones, los trabajadores deben usar máscaras cuando hablen con usted o entren a su casa. Si toda la actividad se realiza al aire libre, como la jardinería o la reparación de una cerca, los revestimientos faciales no son una preocupación.

Plescia dijo que es mejor hacer esas preguntas o indicar sus requisitos al programar la cita. “Si te comunicas con anticipación y aparecen sin máscara, puedes decir: ‘Hablamos de esto’”. Para mejorarlo, pregunte sobre la salud del trabajador. ¿Han estado enfermos? ¿Cómo se sienten? ¿Han dado positivo o han estado cerca de alguien que lo haya hecho?

También es importante ser cortés, dijo Sell. “El propietario también debe usar una máscara cuando se encuentra en el mismo espacio que el trabajador. Y, obviamente, no querría concertar una visita de este tipo si estuviera enfermo “.

Guardería/campamento para niños: si la instalación está adentro, verifica si los consejeros/cuidadores usan máscaras. En el interior, idealmente, los niños también deberían usarlas. Otras preguntas importantes que debes hacerte: ¿Se realizan pruebas periódicas al personal para detectar el coronavirus? Pregunte sobre la política de licencia por enfermedad. ¿Tienen uno? Si es un lugar pequeño, es posible que no exista una política formal. Pero pregunte sobre la capacidad de los trabajadores para quedarse en casa sin perder sus trabajos si están enfermos o dan positivo en la prueba, dijo Sell.

Hoteles: Las habitaciones deben limpiarse a fondo y, en el mejor de los casos, desocuparlas al menos varias horas antes de su llegada. Otros elementos tangibles que pueden aportar tranquilidad: separadores de plástico duro entre usted y el personal de recepción y límites a los grupos de personas que se reúnen en los vestíbulos. Es incluso mejor si tienen un check-in “sin contacto”. Una vez en su habitación, limpie las áreas de la superficie: mesas, interruptores de luz y, especialmente, el control remoto de la televisión. Considere llevar tu propia almohada.

Qué evitar: Los tres expertos dijeron que se deben evitar las barras, especialmente en interiores, ya que es casi imposible distanciarse adecuadamente de los demás o usar máscaras. “Vas a los bares porque disfrutas del hecho de que hay otras personas allí y, cuando hay mucha gente, es difícil mantener una distancia de 6 pies”, dijo Plescia. “Cuando la gente bebe, pierde algo de juicio y es más probable que baje la guardia”. Los eventos deportivos, donde las personas “están una encima de la otra”, es otro tabú, dijo Benjamin. Venta recomendada contra fiestas en casa u otras reuniones grandes.

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Dying Young: The Health Care Workers in Their 20s Killed by COVID-19

Jasmine Obra believed that if it wasn’t for her brother Joshua, she wouldn’t exist. When 7-year-old Josh realized that his parents weren’t going to live forever, he asked for a sibling so he would never be alone.

By spring 2020, at ages 29 and 21, Josh and Jasmine shared a condo in Anaheim, California, not far from Disneyland, which they both loved.

Both worked at a 147-bed locked nursing facility that specialized in caring for elderly people with cognitive issues such as Alzheimer’s, where Jasmine, a nursing student, was mentored by Josh, a registered nurse.

Both got tested for COVID-19 on the same day in June.

Both tests came back positive.

Yet only one of them survived.

While COVID-19 takes a far deadlier toll on elderly people than on young adults, an investigation of front-line health care worker deaths by the Guardian and KHN has uncovered numerous instances when staff members under age 30 were exposed on the job and also succumbed.

In our database of 167 confirmed front-line worker deaths, 21 medical staffers, or 13% of the total, were under 40, and eight (5%) fatalities were under 30. The median age of a COVID-19 death in the general population is 78, while the median age of health care worker deaths in the database is 57. This is in part because we are, by definition, including only people of working age who were treating patients during the pandemic — but it is also because, as health workers, they are far more exposed to the virus.

Young health care workers are at a “stage in their career and a stage of life at which they have so much more to offer,” said Andrew Chan, a physician at Massachusetts General Hospital and epidemiologist at Harvard Medical School. “Lives lost among any young people related to COVID really should be considered something that’s unacceptable to us as a society.”

As coronavirus cases surge — and dire shortages of lifesaving protective gear like N95 masks, gowns and gloves persist — the nation’s health care workers face disproportionate risk. Chan’s research has found that health care workers of any age are at least three times more likely to become infected than the general population, and the risk is greater if they are people of color or have to work without adequate personal protective equipment. People of color are also likelier to have inadequate access to PPE.

In interviews, relatives and friends of these younger victims described a particular and wrenching sorrow. Everything lay ahead for these front-line workers. They were just embarking on their careers. Some still lived in the family home; others were looking forward to getting married or had young children. Several parents of victims contacted by the Guardian and KHN said they were simply unable to talk about what had happened, so immense was their grief.

Valeria Viveros, a 20-year-old nursing assistant, was “barely blooming,” said her uncle, Gustavo Urrea. She made ceviche for her patients at a nursing home in Riverside, California, and Urrea could see her visibly growing in self-confidence. When she first fell sick from the virus, she went to the hospital but was sent home with Tylenol. She returned several days later in an ambulance — her final journey.

“We’re all destroyed,” Urrea said. “I can’t even believe it.”

Dulce Garcia, 29, an interpreter at a medical facility in Chapel Hill, North Carolina, died in May. “It just doesn’t feel real,” said friend Brittany Mathis. Garcia was the one who wouldn’t let friends drive if they’d had too many drinks, and she loved going out to dance to bachata, merengue and reggaeton. “There were so many things she had unfinished,” Mathis said.

While people of any age with underlying conditions such as diabetes and obesity are at higher risk of a severe COVID-19 infection, the particular impacts of the virus on young adults are only now becoming clear.

Doctors in New York noticed that more younger patients than usual were presenting with strokes, to the point that “the average age of our stroke patients with large-vessel strokes” — the most devastating kind — “has come down,” said Thomas Oxley, a Mount Sinai medical system neurosurgeon. COVID-19 infections cause inflammation, and often blood clots, in blood vessels as well as the lungs.

Angela Padula and Dennis Bradt became engaged in early February. On May 13, Bradt died of a heart attack as doctors tried to coax him off a ventilator.(Angela Padula)

Angela Padula thought that she and Dennis Bradt had done everything right.

Padula, 27, and Bradt, 29, became engaged on Feb. 8. She was a special-education teacher, and he was an addiction technician at Conifer Park, a private addiction treatment facility in Glenville, New York.

The couple wanted to save up for a few years for their wedding, but by early April, they had already purchased her engagement and wedding rings. Bradt, who had the sweeter tooth, had chosen a raspberry-swirl wedding cake.

After the pandemic hit, Bradt started showering when he got home from work. He and Padula wore masks when they went out, which was usually only for groceries or gas. They stopped visiting their immunocompromised parents.

On April 5, Bradt came down with a fever, stomach-bug symptoms and achiness, and went to the hospital. His COVID-19 test came back negative. Soon he couldn’t breathe. Another test proved positive. On April 16 he was put on a ventilator. In the process, he choked on his own vomit, which caused his lung to collapse.

Padula assumes Bradt was infected at work, and is unsure whether he had sufficient PPE. Conifer Park did not respond to queries, but according to local health authorities, 12 employees and six patients at the facility tested positive for COVID-19. Padula herself had symptoms so severe that she was taken to the emergency room in an ambulance.

She was not allowed to visit Bradt, and was quarantined alone at home, where she spent her 28th birthday, taking anxiety medication prescribed by her doctor.

On May 13, as doctors tried to coax Bradt off the ventilator, he suffered a heart attack, Padula said. She and Bradt’s mother were permitted to say goodbye to him. But “he was gone by the time we got there,” Padula said in an interview. “He didn’t look like himself,” swollen and festooned with tubes.

Today Padula is still sick. Pain in her arms, legs and back wakes her at night. She feels as though the virus has taken over her life.

“I have my days where it’s just too much to think about,” she said. “I’ll see people getting engaged on Facebook — it makes me mad. I want to be happy for them, but it’s very difficult for me to be happy. We were planning on having kids in a couple years.”

“It’s been a tough month for all of us,” Josh Obra wrote in an Instagram caption less than two months before he fell ill. “It’s just mentally exhausting thinking each night when I come home that I may be having symptoms the next day.”(The Obra family)

Less than two months before Josh and Jasmine Obra fell ill, Josh posted two pictures to Instagram: One was a photo of a fireworks display at Disneyland; the other was a picture of himself in medical scrubs, wearing a face mask, giving the peace sign.

“Heeeeeyo! It’s been a minute,” he wrote in the caption. “It’s been a tough month for all of us.” He worked with a vulnerable population, he said, and “it’s just mentally exhausting thinking each night when I come home that I may be having symptoms the next day.”

Even so, Josh was the kind of helpful, empathetic nurse who “makes things easier for everybody,” said colleague Sarah Depayso. He knew how to talk to patients and was attuned to others’ stress levels. “We were so busy, and it was ‘I’ll buy you lunch, I’ll buy you dinner, I’ll buy you boba.’”

It had been about 35 days since Disneyland closed its gates, Josh noted in his post. Josh’s photos — of the Sleeping Beauty castle framed by tabebuia blossoms, or of himself in an attention-grabbing Little Mermaid sweater — and corny jokes endeared him to thousands of followers on Instagram. “He had a way of capturing magic,” said his friend Brandon Joseph. The pictures were joyful, like memories of childhood.

Josh’s last post was on June 10, announcing that Disneyland planned to reopen in July. At some point the virus had reached his nursing home, infecting 49 staff members and 120 residents and ultimately killing 14 people. Approximately 41% of all U.S. coronavirus deaths are linked to nursing homes, where frail people live in close quarters, according to The New York Times.

After taking the virus test on June 12, his health deteriorated. On June 15, he messaged Joseph that he couldn’t take a full breath of air without feeling like he was being knifed in the chest. On June 20, he texted that he was at the hospital and that he had a particularly bad case.

The final time Josh spoke with his family, before he was put on a ventilator, was on June 21. “On our last video call together, I was isolated in Anaheim, quarantined, and our parents were at home,” Jasmine said. It was Father’s Day, “and I remembered crying and crying because this was the reality of what our family was.”

Josh’s family was not permitted to visit him in the hospital, and he died on July 6.

By coincidence, Josh, like his grandparents, was buried in the same cemetery as Walt Disney — Forest Lawn Memorial Park in Glendale, California.

Before the funeral, Jasmine walked over to Disney’s grave, she said. “I was like, ‘Hi, Walt. I hope you and my brother found each other.’”

Every night since he died, Jasmine has watched Southern California’s spectacular sunsets, the pinks and yellows that Josh kept returning to in his pictures. “And every time I feel like he’s with me. I look at the sky and sometimes I start talking to it, and I feel like I’m talking to my brother, and that he’s painting beautiful skies.”

Melissa Bailey, Eli Cahan, Shoshana Dubnow and Anna Sirianni contributed to this report.

This story is part of “Lost on the Frontline,” an ongoing project by The Guardian and KHN (Kaiser Health News) that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Contact Tracers in Massachusetts Might Order Milk or Help With Rent. Here’s Why.

It’s a familiar moment. The kids want their cereal and the coffee’s brewing, but you’re out of milk. No problem, you think — the corner store is just a couple of minutes away. But if you have COVID-19 or have been exposed to the coronavirus, you’re supposed to stay put.

Even that quick errand could make you the reason someone else gets infected. But making the choice to keep others safe can be hard to do without support.

For many — single parents or low-wage workers, for instance — staying in isolation is difficult as they struggle with how to feed the kids or pay the rent. Recognizing this problem, Massachusetts includes a specific role in its COVID-19 contact-tracing program that’s not common everywhere: a care resource coordinator.

Luisa Schaeffer spends her days coordinating resources for a densely packed, largely immigrant community in Brockton, Massachusetts.

On her first call of the day recently, a woman was poised at her apartment door, debating whether to take that quick walk to get groceries. The woman had COVID-19. Schaeffer’s job is to help clients make the best choice for the public — sometimes, the help she offers is as basic, and important, as the delivery of a jug of milk.

“That’s my priority. I have to put milk in her refrigerator immediately,” Schaeffer said.

“Most of the time it’s the simple things, the simple things can spread the virus.”

The woman who needed milk was one of eight cases referred to Schaeffer through the state government’s Community Tracing Collaborative. Contact tracers make daily calls to people in isolation because they’ve tested positive or those in quarantine because they’ve been exposed to the coronavirus and must wait 14 days to see if they develop an infection. The collaborative estimates that between 10% and 15% of cases request assistance. Those requests are referred to Schaeffer and other care resource coordinators.

“So many people are on this razor-thin edge, and it’s often a single diagnosis like COVID that can tip them over,” said John Welch, director of operations and partnerships for Partners in Health’s Massachusetts Coronavirus Response, which manages the state’s contact-tracing program.

He said a role such as resource coordinator becomes essential in getting people back to “a sense of health, a sense of wellness, a sense of security.”

With milk on its way, Schaeffer dialed a woman who needed to find a primary care doctor, make an appointment and apply for Medicaid. That call was in Spanish.

With her third client, Schaeffer switched to her native language, Cape Verdean Creole. The man on the other end of the line and his mother had both been sick and out of work. He applied for food stamps and was denied. Schaeffer texted the regional head of a state office that manages that program. A few minutes later, the director texted back that he was on the case.

Schaeffer, who has deep roots in the community, is on temporary loan to the state’s contact-tracing collaborative and will later return to her job, helping patients understand and follow their prescribed treatments at the Brockton Neighborhood Health Center.

The collaborative said most client requests are for food, medicine, masks and cleaning supplies. COVID-19 patients who are out of work for weeks or who don’t have salaried jobs may need help applying for unemployment or help with rental assistance — available to qualified Massachusetts residents.

Care resource coordinators even connect people with legal support when they need it. An older woman employed in the laundry room at a nursing home was told she wouldn’t be paid while out sick. Schaeffer got in touch with the Community Tracing Collaborative’s attorney, who reminded the company that paid sick leave is required of most employers during the pandemic.

“So, now, everything’s in place. She started getting paid,” Schaeffer said.

There are glitches as the care resource coordinators try to support people isolating at home. Some workers who are undocumented return to work because they fear losing their jobs. When the local food bank runs out, Schaeffer has had to scramble to find a local grocer to help. The free canned goods or vegetables can be like foreign cuisine for Schaeffer’s clients, some of whom are from Cape Verde and Peru. In those cases, she can reach out to a nutritionist and set up a cooking lesson via conference call.

“I love the three-way calls,” she said, beaming.

Schaeffer and other care resource coordinators have responded to more than 10,500 requests for help so far through Massachusetts’ contact-tracing program. Demand is likely greater in cities such as Brockton, with higher infection rates than most of the state and a 28.7% lower median household income.

Massachusetts has carved out care resource coordination as a separate job in this project. But the role is not new. Local health departments routinely include what might be called support or wrap-around services when tracing contacts. With cases of tuberculosis, for example, a public health worker might make sure patients have a doctor, get to frequent appointments and have their medications.

“You can’t have one without the other,” said Sigalle Reiss, president of the Massachusetts Health Officers Association.

Partners in Health’s Welch, who is advising other states on contact tracing, said the importance of having someone assist with food and rent while residents isolate isn’t getting enough attention.

“I don’t see that as a universal approach with other contact-tracing programs across the U.S.,” he said.

Some contact-tracing programs that schools, employers or states have erected during the pandemic cover only the basics.

“They’re focused on: Get your positive case, find the contacts, read the script, period, the end,” said Adriane Casalotti, chief of government and public affairs at the National Association of City and County Health Officials. “And that’s really not how people’s lives work.”

Casalotti acknowledged that the support role — and services for people isolating or in quarantine — adds to the cost of contact tracing. She urges more federal funding to help with this expense as well as a federal extension of the paid sick time requirement, and more money for food banks so that people exposed to the coronavirus can make sure they don’t give it to anyone else.

“Individuals’ lives can be messy and complicated, so helping them to be able to drop everything and keep us all safe — we can help them through the challenges they might have,” Casalotti said.

This story is part of a partnership that include WBUR, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Turning Anger Into Action: Minority Students Analyze COVID Data on Racial Disparities

As the coronavirus swept into Detroit this spring, Wayne State University junior Skye Taylor noticed something striking. On social media, many of her fellow Black classmates who live or grew up in the city were “posting about death, like, ‘Oh, I lost this family member to COVID-19,’” said Taylor.

The picture was different in Beverly Hills, a mostly white suburb 20 miles away. “People I went to high school with aren’t posting anything like that,” Taylor said. “They’re doing well, their family is doing OK. And even the ones whose family members have caught it, they’re still alive.”

How do COVID-19 infection rates and outcomes differ between these ZIP codes? she wondered. How do their hospitals and other resources compare? This summer, as part of an eight-week research collaborative developed by San Francisco researchers and funded by the National Institutes of Health, Taylor will look at that question and other effects of the pandemic. She’s one of 70 participants from backgrounds underrepresented in science who are learning basic coding and data analysis methods to explore disparity issues.

Data to address racial discrepancies in care and outcomes has been spotty during the pandemic, and it isn’t available for most of these students’ communities, which disproportionately bear the brunt of the virus. The participants are “asking questions from a perspective that we desperately need, because their voices aren’t really there in the scientific community,” said Alison Gammie, who directs the division of training, workforce development and diversity at the National Institute of General Medical Sciences.

Wayne State University student Skye Taylor wants to take a closer look at how mental health issues affect susceptibility to COVID-19 — “especially in the Black community, because mental health isn’t really talked about,” she says. (Joy Taylor)

Scientists from Black, Hispanic, Native American and other minority backgrounds have long been underrepresented in biomedicine. By some measures, efforts to diversify the field have made progress: The number of these minorities who earned life science doctoral degrees rose more than ninefold from 1980 to 2013. But this increase in Ph.D.s has not moved the needle at the faculty level.

Instead, the number of minority assistant professors in these fields has dipped in recent years, from 347 in 2005 to 341 in 2013. And some of those who have entered public health endure racial aggression and marginalization in the workplace — or, after years in a toxic environment, quietly leave.

“We really need to focus on making sure people are supported and find academic and research jobs sufficiently desirable that they choose to stay,” said Gammie. “There have been improvements, but we still have a long way to go.”

In 2014, the NIH launched the Building Infrastructure Leading to Diversity initiative. It offers grants to 10 undergraduate campuses that partner with scores of other institutions researching how to get poor and minority students to pursue biomedical careers.

Students in the program receive stipends and typically spend summers working in research labs. But when COVID-19 hit, many labs and their experiments shut down. “People were like, what do we do? How do we do that remotely?” said biologist Leticia Márquez-Magaña, who heads the initiative’s team at San Francisco State University.

She and University of California-San Francisco epidemiologist Kala Mehta sketched out a plan for students to work remotely with bioinformatics, population health and epidemiology researchers to collect and analyze COVID-19 data for marginalized populations.

Gammie encouraged the Bay Area team to expand the summer opportunity to participants across the nation. From June 22 to Aug. 13, students spend two to three hours online four days a week in small groups led by master’s-level mentors. They learn basic bioinformatics — computational methods for analyzing biological and population health data — and R, a common statistical programming language, to collect and analyze data from public data sets. “I think of basic bioinformatics and R coding as an empowerment tool,” said Mehta. “They’re going to become change agents in their communities, fighting back with data.”

Niquo Ceberio recently earned a master’s in biology at San Francisco State University and is leading a team of mentors in a summer program to help college students explore COVID-19’s impact on communities facing health disparities. (Julio Ceberio) / After spending much of her childhood in foster care, psychology major Willow Weibel is studying how COVID-19 restrictions affect the mental health of former foster youth and other young adults with traumatic backgrounds. (Le Anna Jacobson)

Bench science often takes years, whereas data crunching to solve problems offers a sense of immediacy, said Niquo Ceberio, who recently earned a master’s in biology at SFSU and leads the team of mentors. “There was this sort of limitlessness about it that really appealed to me,” she said.

Raymundo Aragonez, a University of Texas-El Paso biology major participating in the summer program, sees data analysis as a way to address confusion in the Hispanic community — including some of his family members who think the pandemic “is all a hoax.” Dismayed by misleading YouTube videos and rampant misinformation shared on social media, Aragonez, who aims to be the first in his family to finish college, said he hopes to gain skills to “understand the data and how infections are actually happening, so I can explain it to my family.”

He hopes to explore whether COVID-19 infection rates differ among people living in El Paso, those living in the Mexican city of Juárez, and those who frequently cross the

University of Texas-El Paso biology major Raymundo Aragonez sees data analysis as a way to address COVID confusion in the Hispanic community. He’s one of about 70 college students participating in a summer program funded by the National Institutes of Health, aimed at exploring the virus’s impact on communities facing health disparities. (Miriam Aragonez)

border between the cities — like many of his friends and classmates.

Willow Weibel, an SFSU psychology major, is studying how COVID-19 restrictions affect the mental health of former foster youth and other young adults with traumatic backgrounds. Weibel spent much of her childhood in foster care before getting adopted into a Southern California family at age 17. “I’ve grown to really care about what other people go through in the system,” she said.

Mental health is a common thread in the research questions proposed by several students in Weibel’s group, including Skye Taylor, who is majoring in psychology with a minor in public health. While curious about disparities in Detroit-area COVID-19 outcomes, she also wants to examine how mental health issues affect COVID-19 susceptibility — “especially in the Black community, because mental health isn’t really talked about,” she said.

Having the chance to explore their own research questions is unusual for undergraduates, and particularly meaningful to students of color. “It feels like science is something that’s been done to us or on us,” said Ceberio, who is Black and Latina, and grew up in Los Angeles, Miami and Las Vegas before moving to the Bay Area. “This experience allows them to do research that they feel is relevant based on the way they’re viewing the world. I’m trying to get them to trust their instincts.”

Trainees from underrepresented groups will more likely stay in biomedicine if they feel they are giving back to their communities or doing something with a tangible purpose, said Gammie. This summer, participants “have an opportunity to engage in science that does both,” she said. “Our hope is that this will inspire students to go on to be independent scientists.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Managing Pandemic Health Risks on College Campuses

College life was designed around community and togetherness. Now we are attempting to retrofit it for the opposite — with physical distancing, fewer people and the elimination of most in-person gatherings.

The final days of summer offer an opportunity for incoming students and their families to prepare for a semester anchored by public health principles.

As an infectious disease expert and chief health officer for the University of Michigan, I’ve spent the past four months deeply involved in planning efforts to bring thousands of young people back to a campus as safely as possible. I have talked with public health and student services colleagues at many other colleges, and while each school may have a different approach to testing or allowing students to move into residence halls with roommates, certain aspects of campus life will be broadly similar. Following are suggestions for how to minimize the health risks on and around campuses this fall.

Travel and Move In

Since the number of people who can assist with the actual move-in process and the time allotted for unloading will be limited at most schools, pack efficiently and take care of longer goodbyes ahead of time.

Once students are on campus, nonessential travel (especially out of state) will be discouraged. Most schools have canceled fall breaks and will wrap up in-person learning before Thanksgiving, with any remainder of the semester completed remotely.

Parent and family weekends are among the many events that will not happen. With limitations on in-person visits, students should plan on alternative ways to stay connected. Create a schedule for regular video chat check-ins to provide support but also allow for independence.

Your Room Is Your Home

Students living in residence halls can expect limits on movement (to connecting halls, for example), use of common areas, and guests. Because of the need to maintain physical distance, most students will spend a lot of time in their rooms, especially if libraries and other gathering places are closed or have capacity limits. Your room will be your “home” and the place you study, sleep, eat and attend class virtually.

Think carefully about what you need to be comfortable and productive, but resist bringing excess stuff. You will appreciate the extra space, and packing up will be easier whenever you leave. If you have a roommate, the circumstances of this semester present unique pressures. You will spend far more time in your room than ever before, and you are each vulnerable to the risks the other takes, so you need to have an honest conversation to set expectations and boundaries. Open communication, respect, kindness and patience will go a long way.

Although policies may vary, face coverings will be part of your uniform anytime you leave your room. Face coverings provide protection only if worn correctly, so try different types of cloth masks to find one that fits well and is comfortable to wear for several hours. You should be able to talk and move around without the mask requiring frequent adjustment. Think of face coverings like underwear — have several pairs, wash them often and don’t share.

Eating on the Run

Campus dining halls will continue to offer meals, but dine-in options will be limited and may require reservations. The alternative will be takeout meals consumed in designated eating areas or in your room.

Because of capacity limits and a screening process for entry, getting food may require more time. Students should have some shelf-stable snacks and meals that can be prepared with minimal equipment in their rooms, such as instant oatmeal, canned soup, dried fruit, peanut butter and crackers. A refrigerator and microwave will help. Since access to a full-service grocery store may be limited, consider options to restock, including delivery services and convenience stores.

Classrooms

With large, introductory classes being fully remote on most campuses, in-person learning will likely be limited to small groups and activities that cannot be done remotely such as science labs, studio work and performance programs. Explore opportunities to get extra help for classwork via office hours, review sessions and tutoring resources, all of which may be done virtually. Successful remote learning means having the right technology and ensuring stable access to broadband. Many schools have laptop programs and other ways to support students who do not have reliable equipment.

Staying Healthy

Investigate the local health resources and have a plan for what to do if you develop symptoms suggestive of Covid-19. Larger institutions are more likely to have a full-service health center on campus, while smaller schools might have longstanding relationships with health care providers in the community.

With more than 6,600 cases of coronavirus already linked to colleges by the end of July, many campus health centers have gained considerable experience managing infections and are well positioned to provide compassionate, student-focused care for mild to moderate illness. The medical staff can facilitate transfers to emergency departments if needed. Most colleges have designated living space for students who become ill or require quarantine after close exposure to someone with Covid-19. If home is within a few hours and students can safely travel by car, this may be a good option.

While student health fees often cover routine services, this is not the same as health insurance. Be sure to review policies about out-of-network coverage for your health insurance plan. Depending on restrictions, it may be prudent to purchase insurance plans offered by the school. Depending on the state, low-income students may qualify for Medicaid coverage.

Covid-19 health kits should include a functional thermometer and basic, over-the-counter medications (such as acetaminophen, cough drops, cough suppressants). Hand sanitizer and disinfecting wipes can help keep the living space clean. Fingertip pulse oximeters, which are growing in popularity, can be used to measure blood oxygen levels should symptoms of Covid-19 develop. This type of monitoring can be an early warning sign, before a patient has difficulty breathing, that urgent medical evaluation is needed.

Getting a flu shot will be especially important this year, with concerns that concurrent outbreaks of Covid-19 and influenza will quickly overwhelm health system capacity. The flu vaccine this year is expected to be available starting in September.

Depending on state restrictions, indoor fitness centers will likely remain closed. Develop a regular exercise routine, ideally with activities that can be done outdoors or with minimal equipment in your room.

Promoting Social Well-Being

Even before Covid-19, loneliness has been epidemic on college campuses. Social and emotional well-being is essential to overall health. Young adults need face-to-face interaction with other young adults. The focus should be on picking the safest options, making good decisions and managing social expectations.

Meeting in person means sticking with small numbers (10 or less), wearing masks and being outdoors whenever possible. Be open to different types of interactions — take a walk, play video games remotely, sit in a circle outside. There will be less mixing but perhaps more potential for deep friendships.

Taking care of yourself means getting enough sleep and making good decisions about drugs, alcohol, vaping and sexual activity, all of which pose health concerns during normal times and can also increase Covid-19 risk. For some, seeing pictures of other students at parties is likely to increase FOMO — the fear of missing out — but some colleges regard hosting parties as a violation that could result in being thrown out of school.

In This Together

Starting college during a pandemic means taking on both shared risk and shared responsibility. While testing has a role, consistent adherence to basic public health measures — wearing a mask, washing your hands and physical distancing — is the most important aspect of prevention. A successful fall semester requires a social contract of sorts, since your behavior affects everyone around you as well as everyone they are exposed to. Ultimately behavior (not the academic calendar) will determine how long the semester lasts.

Dr. Preeti Malani is chief health officer and a professor in the division of infectious diseases at the University of Michigan.


Back to the Future: Trump’s History of Promising a Health Plan That Never Comes

Ever since he was a presidential candidate, President Donald Trump has been promising the American people a “terrific,” “phenomenal” and “fantastic” new health care plan to replace the Affordable Care Act.

But, in the 3½ years since he set up shop in the Oval Office, he has yet to deliver.

In his early days on the campaign trail, circa 2015, he said on CNN he would repeal Obamacare and replace it with “something terrific,” and on Sean Hannity’s radio show he said the replacement would be “something great.” Fast-forward to 2020. Trump has promised an Obamacare replacement plan five times so far this year. And the plan is always said to be just a few weeks away.

The United States is also in the grips of the COVID-19 pandemic, which has resulted in more than 163,000 U.S. deaths. KFF estimates that 27 million Americans could potentially lose their employer-sponsored insurance and become uninsured following their job loss due to the pandemic. (KHN is an editorially independent program of the Kaiser Family Foundation.) All of this makes health care a hot topic during the 2020 election.

This record is by no means a comprehensive list, but here are some of the many instances when Trump promised a new health plan was coming soon.

2016: The Campaign Trail

Trump tweeted in February that he would immediately repeal and replace Obamacare and that his plan would save money and result in better health care.

By March, a blueprint, “Healthcare Reform to Make America Great Again,” was posted on his campaign website. It echoed popular GOP talking points but was skimpy on details.

During his speech accepting the Republican nomination in July, Trump again promised to repeal Obamacare and alluded to ways his replacement would be better. And, by October, Trump promised that within his first 100 days in office he would repeal and replace Obamacare. During his final week of campaigning, he suggested asking Congress to come in for a special session to repeal the health care law quickly.

2017: The First Year in Office

January and February:

Trump told The Washington Post in a January interview that he was close to completing his health care plan and that he wanted to provide “insurance for everybody.”

He tweeted Feb. 17 that while Democrats were delaying Senate confirmation of Tom Price, his pick to lead the Department of Health and Human Services, the “repeal and replacement of ObamaCare is moving fast!”

And, on Feb. 28, in his joint address to Congress, Trump discussed his vision for replacing Obamacare. “The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we are going to do,” he said.

March: Eyes on Congress — And Twitter

House Republicans, with backing from the White House, were the ones to introduce new health legislation, the American Health Care Act (AHCA). The repeal-and-replace bill kept in place some of the more popular provisions of the ACA. Some conservative Republicans said the bill didn’t go far enough, deriding it as “Obamacare Lite” and refusing to vote on it.

On March 9, Trump tweeted, “Despite what you hear in the press, healthcare is coming along great. We are talking to many groups and it will end in a beautiful picture!”

Later that month, as efforts to pass the AHCA continued to stall, Trump updated his earlier promise.

“And I never said — I guess I’m here, what, 64 days? I never said repeal and replace Obamacare. You’ve all heard my speeches. I never said repeal it and replace it within 64 days. I have a long time,” said Trump in his remarks from the Oval Office on March 24. (Which was true; he had said within 100 days.) “But I want to have a great health care bill and plan, and we will. It will happen. And it won’t be in the very distant future.”

April and May: A Roller-Coaster Ride of Legislation and Celebration, Then …

After an intraparty dust-up, the House narrowly passed the AHCA on May 4. Despite tepid support in the Republican-controlled Senate, Trump convened a Rose Garden celebratory event to mark the House’s passage, saying he felt “so confident” about the measure. He also congratulated Republican lawmakers on what he termed “a great plan” and “incredibly well-crafted.”

Nonetheless, Senate Republicans first advanced their own replacement bill, the Better Care Reconciliation Act, but ultimately voted on a “skinny repeal” that would have eliminated the employer mandate and given broad authority to states to repeal sections of the ACA. It failed to gain passage when Sen. John McCain (R-Ariz.) gave it a historic thumbs-down in the wee hours of July 28.

September and October: Moving On … But Not

Trump began September by signaling in a series of tweets that he was moving on from health reform.

But on Oct. 12, he signed an executive order allowing for health care plans to be sold that don’t meet the regulatory standards set up in the Affordable Care Act. The next day, Trump tweeted, “ObamaCare is a broken mess. Piece by piece we will now begin the process of giving America the great HealthCare it deserves!”

Roughly two weeks later, on Oct. 29, Trump got back to the promise with this tweet: “… we will … have great Healthcare soon after Tax Cuts!”

2019: More Talk, More Tweets

March and April: A Moving Target

It seems that 2018 was a quiet time — at least for presidential promises regarding a soon-to-be-unveiled health plan. It was reported that conservative groups were working on an Obamacare replacement plan. But in 2019, Trump again took up the health plan mantle with this March 26 tweet: “The Republican Party will become ‘The Party of Healthcare!’” Two days later, in remarks to reporters before boarding Marine One, Trump said that “we’re working on a plan now,” but again updated the timeline, saying, “There’s no very great rush from the standpoint” because he was waiting on the court decision for Obamacare. This was a reference to Texas v. U.S., the lawsuit brought by a group of Republican governors to overturn the ACA. It is currently pending before the Supreme Court.

Backtracking from his earlier promises to repeal and replace Obamacare within his first 100 days in office, Trump on April 3 tweeted: “I was never planning a vote prior to the 2020 Election on the wonderful HealthCare package that some very talented people are now developing for me & the Republican Party. It will be on full display during the Election as a much better & less expensive alternative to ObamaCare…”

June 16:

In an interview with ABC News, Trump again said a health care plan would be coming shortly.

“We’re going to produce phenomenal health care. And we already have the concept of the plan. And it’ll be much better health care,” Trump told George Stephanopoulos. When Stephanopoulos asked if he was going to tell people what the plan was, Trump responded: “Yeah, we’ll be announcing that in two months, maybe less.”

June 26:

But then, timing again changed as Trump promised a sweeping health plan after the 2020 election. “If we win the House back, keep the Senate and keep the presidency, we’ll have a plan that blows away ObamaCare,” Trump said in a speech to the Faith and Freedom Coalition’s Road to the Majority conference.

Oct. 3:

He reiterated this post-2020 election pledge in a speech to Florida retirees. “If the Republicans take back the House, keep the Senate, keep the presidency — we’re gonna have a fantastic plan,” Trump said.

Oct. 25:

Trump told reporters that Republicans have a “great” health care plan. “You’ll have health care the likes of which you’ve never seen,” he said.

2020: ‘Two Weeks’

Feb. 10:

During a White House business session with governors, Trump commented on the Republican governors’ lawsuit to undo the ACA and whether protections for preexisting conditions would be lost: “If a law is overturned, that’s OK, because the new law’s going to have it in.”

May 6:

During the signing of a proclamation to honor National Nurses Day, Trump again said Obamacare would be replaced “with great healthcare at a lesser price, and preexisting conditions will be included and you won’t have the individual mandate.”

July 19:

Trump told Chris Wallace in a Fox News interview that a health care plan would be unveiled within two weeks: “We’re signing a health care plan within two weeks, a full and complete health care plan that the Supreme Court decision on DACA gave me the right to do.”

July 31:

With no sign of a plan yet, reporters asked Trump about it at a Florida event. Trump responded that a “very inclusive” health care plan was coming and “I’ll be signing it sometime very soon.”

Aug. 3:

Pushing the timeline once again, Trump said during a press briefing that the health care plan would be introduced “hopefully, prior to the end of the month.”

Aug. 7:

Citing his two-week timeline once again, Trump said during a press briefing that he would pursue a major executive order in the next two weeks “requiring health insurance companies to cover all preexisting conditions for all customers.” Trump also said that covering preexisting conditions had “never been done before,” despite the ACA provisions outlining protections for people who have preexisting conditions being among the law’s most popular components. The Trump administration has backed the effort to overturn the ACA — including these protections — now pending before the Supreme Court.

Aug. 10:

In response to a reporter’s question about why he was planning to issue an executive order when the ACA already protects those with preexisting conditions, Trump said: “Just a double safety net, and just to let people know that the Republicans are totally strongly in favor of … taking care of people with preexisting conditions. It’s a second platform. We have: Preexisting conditions will be taken care of 100% by Republicans and the Republican Party.”

Just before publication, we asked the White House for more information regarding when exactly the plan might be unveiled. The press office did not respond to our request for comment.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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My Boyfriend Is Mad At His White Parents for Me. But I Don’t Care.

I am a young Black woman who’s been quarantining with my white boyfriend for months. It’s been mostly great for us as a couple. When we visit his family nearby, they often ask me about the Black Lives Matter protests, in which we’re participating. I find them genuinely interested, respectful and curious about why expressions like “All Lives Matter” are racist. I’m happy to engage. But my boyfriend gets furious with them! He turns simple questions into big fights. What am I missing?

NIKKI

I love your willingness to talk about race with people who may not have considered it much before our current reckoning, in the wake of George Floyd’s horrible death. But I’ve received many letters from readers of color who feel legitimately burdened by their white friends’ newfound and seemingly insatiable interest in racism.

Your boyfriend may feel protective of you or embarrassed that his family is treating you like an expert witness on Blackness. They could do some work too, right? A simple Google search would explain how the phrase “All Lives Matter” robs the protests against anti-Black racism of the specific point. It’s not your job to educate this family.

Still, I bet you’re having a big influence on them. Thanks to you, they may develop a deeper sensitivity and, in fairness, it’s only recently that many white people have been willing to acknowledge that a “colorblind” approach to racism (treating everyone the same despite our long history of inequality) only further entrenches the problem.

As for your boyfriend’s anger, tell him you’re happy, for now, to invest this energy in his family because you love him and want to help them know you better. And promise you’ll let him know when you tire of being their great Black resource. (And make sure you do!)

Childcare Cameos

My colleagues and I are working remotely during the pandemic. Our boss has an 8-years-old daughter who delights in making daily appearances in our Zoom meetings. She holds up handmade signs for us to read or climbs onto her mother’s lap and waves at the camera while her mother runs our meetings. I feel pressure to delight in her supposed adorableness. I understand the hardships working parents face now. But most of the people in these meetings have young children who do not make cameos. I find our boss’s child hard to take. Any suggestions?

ANONYMOUS

Of course I have suggestions! That’s my job. And incidentally, those suggestions must be broadly acceptable to my boss, or I’d be fired. It’s called working for a company. Here, I suggest holding your fire about your boss’s kid. Not every grievance needs to be aired, especially not petty ones involving our superiors at work.

Let the little girl have her 30 seconds of attention. It’s probably inappropriate, as you suggest. But letting this slide means that when you have a serious issue to bring to your boss, she won’t see you as the whiner who shut down her daughter’s harmless fun. Consider muting Zoom, averting your face and shouting into a pillow, instead.

Image
Credit…Christoph Niemann

Blame Shame

My wife and I are an older couple. We were terrified of Covid-19 and very careful about masks, social distancing and staying at home when possible. Still, I got the virus anyway. I didn’t have to be hospitalized, and my wife was fine. We quarantined at home. I have no issue talking about our experience, but my wife doesn’t want me to. She believes people will think less of us, that we were careless about the pandemic. You?

HUSBAND

It breaks my heart that on top of the fear and illness you’ve already suffered, your wife is now grappling with shame. Neither of you is to blame for getting sick. The novel coronavirus is highly contagious, and it sounds as if you took reasonable precautions.

Sadly, victim-blaming and shame over illness are nothing new. Read Susan Sontag’s essay, “Illness as a Metaphor,” for a deeper dive. I can’t tell you and your wife what to do. But let me float an idea: By showing your friends the responsible face of Covid patients (yours!), you may encourage extra vigilance in them. A great result!

Present Company

More than once, at different people’s homes, I have been served chocolates or wine I gave as host gifts months or even a year before. I know that once given, a gift is no longer under my control. But I feel rejected when this happens, as if my gifts weren’t worth consuming or serving to other guests. Am I oversensitive, or are my hosts being rude?

STUART

Let’s wheel back to the bigger picture. Host gifts are tokens of thanks for often larger gestures of hospitality, like feeding us dinner or inviting us for the weekend. The circuit is complete when the gift is made and the visit ends. Why inject a note of pettiness about the gifts’ use? Maybe your hosts don’t care for the chocolates or wine you brought. No crime there! Isn’t it doubly thoughtful of them to remember that you do?


For help with your awkward situation, send a question to SocialQ@nytimes.com, to Philip Galanes on Facebook or @SocialQPhilip on Twitter.

Listen: Will Telemedicine Outlast the Pandemic?

Julie Rovner, KHN’s chief Washington correspondent, on Tuesday joined WDET’s “Detroit Today” host Stephen Henderson and Dr. George Kipa, the deputy chief medical officer at Blue Cross Blue Shield of Michigan, to talk about the future of telemedicine and whether Medicare and private insurers will continue to pay for those services. You can listen to the discussion here.

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El coronavirus prolifera entre trabajadores latinos en un condado rico de California

En una cálida tarde de finales de junio, la gente acudió en masa a las mesas al aire libre de la calle principal de esta ciudad para tomar sauvignon blanc, comer pizza cocinada en horno de leña y celebrar “Dining Under the Lights”, uno de los pasatiempos favoritos de los residentes del condado de Marin.

A una milla de allí, Crisalia Calderón estaba acurrucada en su apartamento, enfrentando una noche de insomnio mientras lidiaba con los primeros síntomas de COVID-19.

La empleada doméstica, de 29 años, tenía dificultades para respirar.  “Cada vez que intentaba dormir, sentía que me ahogaba”, contó durante una entrevista reciente. Su esposo, Henry, trabajador de la construcción, sufría un terrible dolor de espalda.

Unos días antes, Henry la había llamado sollozando desde una sala de emergencias después de dar positivo para el coronavirus. La pareja y sus tres hijos pequeños comparten un apartamento del barrio del Canal con la hermana de Crisalia y los cuatro miembros de su familia. “Él no quería volver a casa”, dijo ella. “¿Pero qué podíamos hacer? ¿A dónde podría ir?”

En casa, Henry trató de aislarse en la litera de arriba de una de las camas de sus hijos. Pero era demasiado tarde. En una semana, todas las personas de la vivienda, excepto dos, dieron positivo para COVID-19.

Las comunidades de color de bajos ingresos, especialmente los latinos, sufren cada vez más el peso de la pandemia de coronavirus en California, donde la propagación de infecciones entre los trabajadores pobres del sector servicios, que viven en condiciones de hacinamiento, ha resaltado el aumento de las desigualdades raciales y económicas.

Estas disparidades son particularmente marcadas en la idílica Marin, donde el aumento de nuevos casos de COVID-19, concentrados en un superpoblado vecindario latino, ha ayudado a que el condado figure en la lista de vigilancia de pandemias del estado.

Los latinos, que constituyen el 16% de la población del condado, representan el 75% de las infecciones por coronavirus —cerca del 90% desde mediados de junio—, según el doctor Matt Willis, funcionario de salud pública del condado de Marin. Después de registrar sólo un puñado de casos en los primeros meses de la pandemia, el condado tiene ahora la tasa per cápita más alta del Área de la Bahía.

“Se trata de nuestra fuerza de trabajo esencial”, explicó Willis. “Esto no es el resultado de la socialización casual durante los ‘happy hour’”.

El Canal, llamado así por la vía fluvial en su frontera norte que una vez fue el paseo marítimo comercial de San Rafael, es un distrito llano y densamente poblado en un suburbio del Área de la Bahía famoso por sus aldeas sobre las laderas de las colinas y sus vistas multimillonarias.

Las dos millas y media cuadradas del Canal están salpicadas de talleres de automóviles, palmeras descuidadas e hileras de edificios de apartamentos de baja altura ocupados por inmigrantes de México, Guatemala y El Salvador. La llegada de jóvenes latinos casi ha triplicado la población del barrio desde los años 90.

“Es como un pueblo hispano donde todos se conocen”, explicó Jennifer Tores, de 22 años, nativa del Canal y empleada en una tienda de ropa de descuento.

Los trabajadores del Canal están a un mundo de distancia y, al mismo tiempo, íntimamente conectados con pueblos ricos como San Anselmo y Tiburón, donde limpian mansiones, enceran Teslas y sirven cafés con leche a $6 la taza.

Más de la mitad de las familias de esta comunidad ganan menos de $35,000 al año, en un condado donde el ingreso promedio es casi el triple. Con frecuencia, dos o tres familias deben vivir juntas en un apartamento para poder pagar los infames altos alquileres de Marin. Los Calderón viven de paga en paga para cubrir la mitad de los $2,100 de alquiler mensual, y se las arreglan para enviar dinero a sus familiares en Guatemala.

Willis dijo que tales arreglos de vivienda “pueden fácilmente traducir un caso de COVID-19 en cinco o diez”.

Aún más contagiosa que el virus es la información errónea que se ha propagado entre la comunidad latina, incluyendo el rumor de que en los lugares donde se hacen las pruebas la gente acababa infectándose, o que la cerveza es una cura.

Confundida y aislada en su casa en cuarentena durante varias semanas con toda su familia, Crisalia Calderón comenzó a preocuparse. “Me estaba asustando mucho”, dijo. “Nos estábamos quedando sin comida y sin dinero”.

Pasó horas llamando a funcionarios del condado y a las organizaciones locales sin fines de lucro, pero nadie le devolvió la llamada. Finalmente, alguien de una organización comunitaria prometió entregar comida a la familia, pero todo lo que llegó al día siguiente fue algo de carne molida caducada y unas cuantas papas.

Así que Calderón recurrió a la misma red de seguridad informal en la que había confiado en la aldea que dejó, con 16 años, para emigrar al norte.

Una vecina guatemalteca fue a Costco y le trajo ibuprofeno para los dolores y la fiebre, y pañales y PediaSure para los niños, que tienen 5, 3 y 2 años. Alguien más le trajo verduras, leche y frijoles. Después de tres horas al teléfono, Calderón logró calificar para $500 en ayuda estatal para coronavirus dirigida a los residentes indocumentados.

Willis dijo que los funcionarios están trabajando con Canal Alliance, una organización vecinal, para brindar apoyo a los residentes que contraen el virus, en forma de dinero en efectivo y habitaciones de hotel para aislar a los infectados. El condado está reclutando rastreadores de contacto bilingües de la comunidad latina.

Crisalia Calderon con sus hijos, de izq. a der., Neymar, Daisy y Katy. Toda la familia dio positivo para COVID a fines de junio pero ya se han recuperado. (Photo by Rachel Scheier)

Marin es uno de los condados más saludables, ricos y educados de California, y uno de los más segregados. A lo largo de los años, el condado ha preservado su belleza natural y sus amplios espacios abiertos, a menudo a costa del transporte público y la vivienda asequible.

Un informe sobre el condado de Marin realizado en 2012 por el American Human Development Project mostró que menos de la mitad de los adultos del Canal tenían un diploma de secundaria. Clasificó a los casi 12,000 residentes del vecindario en el último lugar de los 51 distritos del condado, en cuanto a  bienestar y oportunidades.

A la luz de estas disparidades, no sorprende que personas como Calderón sean olvidadas, comentó Omar Carrera, CEO de Canal Alliance.

“Estas personas solo sobrevivían antes de COVID-19”, dijo Carrera. La gente ha estado haciendo cola desde las 7 de la mañana para hacerse pruebas de coronavirus gratuitas que comienzan a la 1 de la tarde. Los funcionarios de salud tratan de seguir el ritmo de la demanda de pruebas, ya que las infecciones han aumentado y los empleadores, como gasolineras y tiendas de comestibles, han comenzado a exigir que los trabajadores se hagan pruebas regularmente.

Un promedio del 20% de las pruebas del Canal dan positivo. Algunos días, la tasa de positividad ha sido tan alta como el 40%, señaló Willis. Con muchos de los infectados mostrando pocos o ningún síntoma, el virus se ha propagado rápido por esta comunidad relativamente joven.

Pero la gente tiene que trabajar, así que la vida sigue igual en el Canal. Los jornaleros todavía se reúnen en los estacionamientos al amanecer; los vendedores se instalan en las esquinas de las calles bajo sombrillas de colores para vender maíz tostado o bolsas de fruta.

Las teorías conspirativas continúan multiplicándose. Una que circula en español en las redes sociales sostiene que el virus es una trampa del gobierno. Otra dice que los sitios de pruebas locales están reutilizando los hisopos sucios para infectar deliberadamente a la gente. Los rumores han alimentado un clima de miedo y silencio en torno al virus.

Una residente dijo que los vecinos pintaron una “X” en la puerta de la casa de un amigo de su esposo para hacer público que estaba infectado.

Crisalia Calderón y su familia se han recuperado y desde entonces los resultados de sus pruebas de COVID-19 han dado negativo, pero aún así “hay vecinos que se escapan de nosotros”, comentó. Espera la noche para lavar la ropa en su edificio, cuando los vecinos duermen.

El otro día, Calderón decidió que había llegado la hora de pedirle a su casero que fuera a al apartamento a arreglar un problema de plomería y algunos quemadores estropeados. Pero el casero le dijo que no podía ir. Estaba en casa enfermo con COVID-19.

Esta historia de KHN se publicó primero en California Healthline, un servicio de la California Health Care Foundation.

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Gum Disease Tied to Colon Cancer Risk

Gum disease may increase your risk of colorectal cancer.

A new study, published in Cancer Prevention Research, included 42,486 men and women participating in two large continuing health surveys. Over the past several decades, the participants had periodically reported information on health and diet, including reports of gingivitis and tooth loss.

The researchers reviewed pathology reports from colonoscopies, documenting the incidence of two types of intestinal lesions that are precursors of colon cancer: serrated polyps and conventional adenomas. Removal of these lesions reduces colon cancer risk substantially.

Compared with people with no history of periodontal disease, those who had gum disease had a 17 percent increased relative risk of having a serrated polyp and an 11 percent increased risk of a conventional adenoma. The scientists also found that the loss of four or more teeth was associated with a 20 percent increased risk for having a serrated polyp.

The study controlled for smoking, body mass index, aspirin use and physical activity, among other known risks for colon cancer.

“We don’t know exactly how much poor oral health increases the risk for colorectal cancer,” said the senior author, Mingyang Song, an assistant professor of epidemiology at the Harvard T.H. Chan School of Public Health. “We need further studies to determine how the oral microbiome and the gut microbiome may interact to influence cancer risk.”

In Health-Conscious Marin County, Virus Runs Rampant Among ‘Essential’ Latino Workers

SAN RAFAEL, Calif. — On a warm evening in late June, people flocked to alfresco tables set up along this town’s main drag to sip sauvignon blanc and eat wood-oven pizza for Dining Under the Lights, an event to welcome Marin County residents back to one of their favorite pastimes.

About a mile away, Crisalia Calderon was hunkered down in her apartment facing a sleepless night as she grappled with the early symptoms of COVID-19.

The 29-year-old house cleaner and her husband, Henry, a construction worker, both suffered terrible back pain, and she struggled to breathe. “Every time I tried to sleep, I felt like I was drowning,” she said recently, speaking in Spanish through an interpreter.

A few days earlier, Henry had called her sobbing from a hospital emergency room after testing positive for the coronavirus. The couple and their three small children share their Canal neighborhood flat with Crisalia’s sister and her four family members. “He didn’t want to come home,” she said. “But what could we do? Where could he go?”

At home, Henry tried to isolate himself in the top bunk of one of their kids’ beds. But it was too late. Within about a week, all but two of the 10 people in the household had tested positive for COVID-19.

Low-income communities of color — especially Latinos — are increasingly bearing the brunt of the coronavirus pandemic in California, where spreading infections among poor service workers living in crowded conditions has highlighted widening racial and economic inequities. These disparities are particularly stark in idyllic Marin, where a surge of new COVID-19 cases concentrated in one crowded Latin American neighborhood has helped land the county on the state’s pandemic watchlist.

Latinos, who are 16% of the county’s population, account for 75% of coronavirus infections — closer to 90% since mid-June, according to Dr. Matt Willis, the public health officer for Marin County. After recording only a handful of coronavirus cases in the early months of the pandemic, the county now has the highest per capita rate in the Bay Area.

“This is our essential workforce,” said Willis. “This isn’t the result of casual socializing at happy hour.”

The Canal, named for the waterway on its northern border that was once San Rafael’s commercial waterfront, is a flat, densely populated district in a Bay Area suburb famous for its wooded hillside hamlets and multimillion-dollar vistas. The Canal’s 2½ square miles are dotted by auto shops, scruffy palm trees and rows of low-slung apartment buildings occupied by immigrants from countries such as Mexico, Guatemala and El Salvador. An influx of young Latinos has nearly tripled the neighborhood’s population since the 1990s.

“It’s like a Hispanic village where everybody knows everybody else,” said Jennifer Tores, 22, a Canal native who works at a discount clothing store.

The laborers of the Canal are both a world away from and intimately connected to well-heeled towns like San Anselmo and Tiburon, where they clean mansions, wax Teslas and steam milk for $6 lattes.

More than half of families in the neighborhood earn less than $35,000 a year, in a county where the median income is almost triple that. People are often squeezed two or three families to an apartment in order to afford Marin’s infamously high rents. The Calderons live paycheck-to-paycheck to cover their half of the $2,100 monthly rent while also managing to send money back home to relatives in Guatemala.

Willis said such living arrangements “can easily translate one case of COVID-19 into five or 10.”

Even more contagious than the virus is the misinformation that’s spread quickly through the Latino community, including a rumor that local testing sites were infecting people and claims that beer is a cure.

Confused and isolated at home in quarantine for several weeks with her entire family, Crisalia Calderon began to worry. “I was getting really scared,” she said. “We were running out of food and money.”

She spent hours dialing county officials and local nonprofits, but no one called back. Finally, someone at a community organization promised to deliver meals to the family, but all that arrived the next day was some expired ground meat and a few potatoes.

So Calderon turned to the same informal safety net she’d relied on in the rural village she left at 16 to migrate north. A fellow Guatemalan neighbor went to Costco and brought her ibuprofen for the aches and fever, and diapers and PediaSure for the kids, who are 5, 3, and 2. Someone else brought vegetables, milk and beans from  . After three hours on the phone, Calderon managed to qualify for $500 in state coronavirus aid for undocumented residents.

Willis said officials are working with Canal Alliance, a neighborhood group, to provide support to residents who contract the virus — in the form of cash and hotel rooms to isolate the infected. The county is recruiting bilingual contact tracers from the Latino community.

Crisalia Calderon with her children, Neymar (left), Daisy and Katy. The whole family tested positive for COVID-19 in late June but have since recovered. (Photo by Rachel Scheier)

Marin is one of California’s healthiest, wealthiest and best-educated counties, and  one of the most segregated. The county has fiercely preserved its natural beauty and wide-open spaces over the years — often at the cost of public transit and affordable housing.

A 2012 report on Marin County by the American Human Development Project showed that fewer than half of adults in the Canal had a high school diploma. It ranked the neighborhood’s nearly 12,000 residents dead last among the county’s 51 census tracts for community well-being and opportunity.

In light of these disparities, it’s not surprising that people like Calderon are falling through the cracks, said Omar Carrera, Canal Alliance’s CEO.

“These people were in survival mode before COVID-19,” Carrera said on a recent afternoon, standing before a mural that adorns the group’s headquarters. People had been lining up since 7 a.m. for free coronavirus testing that began at 1 p.m. Health officials are scrambling to keep pace with demand for tests as infections have surged and employers such as gas stations and grocery stores have started requiring workers to be tested regularly.

An average of 20% of Canal tests are coming back positive. Some days, the positivity rate has been as high as 40%, said Willis. With many of the infected showing few or no symptoms, the virus has raced through this relatively young community.

But people around here have to go to work, so life continues mostly as usual in the Canal. Day laborers still gather in the parking lots at dawn; vendors set up at street corners beneath colorful umbrellas to hawk roasted corn or bags of fruit.

Conspiracy theories continue to multiply; one circulating in Spanish on social media holds that the virus was a government conspiracy. Another says local testing sites are reusing dirty test swabs to deliberately infect people. The rumors have fed a climate of fear and silence around the virus.

One resident said neighbors painted an “X” on the front door of a friend of her husband’s to warn others he was infected.

Crisalia Calderon and her family have all recovered and since tested negative for COVID-19, but still, “there are neighbors who run away from us,” she said. She waits until late at night to do the laundry in her building, when no one else is around.

The other day, Calderon decided it was finally time to ask her landlord to come to her apartment to fix a long-festering plumbing problem and some broken burners. But he said he couldn’t come. He was home sick with COVID-19.

Bereaved Families Are ‘the Secondary Victims of COVID-19’

Every day, the nation is reminded of COVID-19’s ongoing impact as new death counts are published. What is not well documented is the toll on family members.

New research suggests the damage is enormous. For every person who dies of COVID-19, nine close family members are affected, researchers estimate based on complex demographic calculations and data about the coronavirus.

Many survivors will be shaken by the circumstances under which loved ones pass away — rapid declines, sudden deaths and an inability to be there at the end — and worrisome ripple effects may linger for years, researchers warn.

If 190,000 Americans die from COVID complications by the end of August, as some models suggest, 1.7 million Americans will be grieving close family members, according to the study. Most likely to perish are grandparents, followed by parents, siblings, spouses and children.

“There’s a narrative out there that COVID-19 affects mostly older adults,” said Ashton Verdery, a co-author of the study and a professor of sociology and demography at Pennsylvania State University. “Our results highlight that these are not completely socially isolated people that no one cares about. They are integrally connected with their families, and their deaths will have a broad reach.”

Because of family structures, Black families will lose slightly more close family members than white families, aggravating the pandemic’s disproportionate impact on African American communities. (Verdery’s previous research modeled kinship structures for the U.S. population, dating to 1880 and extending to 2060.)

The potential consequences of these losses are deeply concerning, with many families losing important sources of financial, social and caregiving support. “The vast scale of COVID-19 bereavement has the potential to lower educational achievement among youth, disrupt marriages, and lead to poorer physical and mental health across all age groups,” Verdery and his co-authors observe in their paper.

Holly Prigerson, co-director of the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York City, sounds a similar alarm, especially about the psychological impact of the pandemic, in a new paper on bereavement.

“Bereaved individuals have become the secondary victims of COVID-19, reporting severe symptoms of traumatic stress, including helplessness, horror, anxiety, sadness, anger, guilt, and regret, all of which magnify their grief,” she and co-authors from Memorial Sloan Kettering Cancer Center in New York noted.

In a phone conversation, Prigerson predicted that people experiencing bereavement will suffer worse outcomes because of lockdowns and social isolation during the pandemic. She warned that older adults are especially vulnerable.

“Not being there in a loved one’s time of need, not being able to communicate with family members in a natural way, not being able to say goodbye, not participating in normal rituals — all this makes bereavement more difficult and prolonged grief disorder and post-traumatic stress more likely,” she noted.

Organizations that offer bereavement care are seeing this unfold as they expand services to meet escalating needs.

Typically, 5% to 10% of bereaved family members have a “trauma response,” but that has “increased exponentially — approaching the 40% range — because we’re living in a crisis,” said Yelena Zatulovsky, vice president of patient experience at Seasons Hospice & Palliative Care, the nation’s fifth-largest hospice provider.

Since March, Seasons has doubled the number of grief support groups it offers to 29, hosted on virtual platforms, most of them weekly. All are free and open to community members, not just families whose loved ones received care from Seasons. (To find a virtual group in your time zone, call 1-855-812-1136, Season’s 24/7 call center.)

“We’re noticing that grief reactions are far more intense and challenging,” Zatulovsky said, noting that requests for individual and family counseling have also risen.

Medicare requires hospices to offer bereavement services to family members for up to 13 months after a client’s death. Many hospices expanded these services to community members before the pandemic, and Edo Banach, president and CEO of the National Hospice and Palliative Care Organization, hopes that trend continues.

“It’s not just the people who die on hospice and their families who need bereavement support at this time; it’s entire communities,” he said. “We have a responsibility to do even more than what we normally do.”

In New York City, the center of the pandemic in its early months, the Jewish Board is training school administrators, teachers, counselors and other clinicians to recognize signs of grief and bereavement and provide assistance. The health and human services organization serves New Yorkers regardless of religious affiliation.

“There is a collective grief experience that we are all experiencing, and we’re seeing the need go through the roof,” said Marilyn Jacob, a senior director who oversees the organization’s bereavement services, which now includes two support groups for people who have lost someone to COVID-19.

“There’s so much loss now, on so many different levels, that even very seasoned therapists are saying, ‘I don’t really know how to do this,’” Jacob said. In addition to losing family members, people are losing jobs, friends, routines, social interactions and a sense of normalcy and safety.

For many people, these losses are sudden and unexpected, which can complicate grief, said Patti Anewalt, director of Pathways Center for Grief & Loss in Lancaster, Pennsylvania, affiliated with the state’s largest not-for-profit hospice. The center recently created a four-week group on sudden loss to address its unique challenges.

The day before Julie Cheng’s 88-year-old mother was rushed to the hospital in early July, she had been singing songs with Cheng’s sister over the phone at her Irvine, California, nursing home. The next morning, a nurse reported that the older woman had a fever and was wheezing badly. At the hospital, COVID-19 was diagnosed and convalescent plasma therapy tried. Within two weeks, after suffering a series of strokes, Cheng’s mother died.

Since then, Cheng has mentally replayed the family’s decision not to take her mother out of the nursing home and to refuse mechanical ventilation at the hospital — something she was sure her mother would not have wanted.

“There have been a lot of ‘what ifs?’ and some anger: Someone or something needs to be blamed for what happened,” she said, describing mixed emotions that followed her mother’s death.

But acceptance has sprung from religious conviction. “Mostly, because of our faith in Jesus, we believe that God was ready to take her and she’s in a much better place now.”

Coping with grief, especially when it is complicated by social isolation and trauma, takes time. If you are looking for help, call a local hospice’s bereavement department and ask what kind of services it provides to people in the community. Funeral directors should also have a list of counselors and grief support programs. One option is GriefShare, offered by churches across the country.

Many experts believe the need for these kinds of services will expand exponentially as more family members emerge from pandemic-inspired shock and denial.

“I firmly believe we’re still at the tip of the iceberg, in terms of the help people need, and we won’t understand the full scope of that for another six to nine months,” said Diane Snyder-Cowan, leader of the bereavement professionals steering committee of the National Council of Hospice and Palliative Professionals.

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