From Health and Fitness

Weekly Health Quiz: Better Masks, a Sleep Benefit and Another Coronavirus Vaccine

1 of 7

For better protection against coronavirus, experts recommend all of the following measures for masks except:

Having multiple layers of material

Using soft materials rather than stiff ones

Having ties rather than ear loops

Wearing a face shield rather than a mask

2 of 7

Over the past week, this state has had the highest number of Covid-19 deaths per 100,000 population:

Wisconsin

Texas

North Dakota

South Dakota

3 of 7

The drug maker AstraZeneca announced promising results from a new coronavirus vaccine that is made from a cold virus that affects these animals:

Dogs

Cats

Chimpanzees

Bats

4 of 7

All of the following sleep habits were tied to a decreased risk of heart failure except:

Getting seven to eight hours of sleep a night

Rarely or never snoring

Being a “night owl”

Feeling refreshed during the day

5 of 7

People who ate this style of diet were at the lowest risk of bone fractures:

Vegetarian

Vegan

Fish but no meat

Meat eaters

6 of 7

True or false? Teenagers can become addicted to the nicotine in e-cigarette products.

True

False

7 of 7

Girls born very prematurely, before 28 weeks of gestation, were at higher risk of this mental health disorder as young adults:

Bipolar disorder

Depression

Anorexia nervosa

Schizophrenia

Modern Love: Junk Food Was Our Love Language

It’s autumn again, the eighth since my father died, and I’m craving chicken nuggets.

When the pandemic began, I craved foods that happened to feel more virtuous. I was a frequent takeout customer at local San Francisco restaurants in economic peril: beef noodle soup from a mom-and-pop on Irving, refried beans from a taqueria on 24th Street, a pork chop from the beloved neighborhood spot on Divisadero. Every action I took was fraught with the concept of doing good. I purchased stacks of books from independent bookstores, researched gardening gloves, donated, downloaded a workout app, started reading “War and Peace.”

And then: depression, Zoom fatigue, a major life milestone passing without the ability to celebrate it, the deaths of public figures, the deaths of frontline workers, the death of a friend’s father, the deaths of migrants detained at the border, the death of a friend’s father, the death of another friend’s father.

Six months later, I was moving 800 miles in an attempt to outrun a suffocating sense of doom, driving across state lines, every stop an exercise in anxiously navigating shared airspace and inconsistent mask policies, and all I wanted was the ease of a drive-through chicken nugget.

My father would have understood.

I don’t remember him saying, “I love you,” which isn’t a common phrase in Mandarin, his preferred language. We always had a bit of a communication issue. But his love language was the simple pleasure of processed food.

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I have a photo of the two of us, taken when I was 2, at the gleaming flagship McDonald’s in Beijing. The franchise had just arrived in China, and its “M” at the time was a signal of luxury, a marker of the cosmopolitan upper-middle class that my young parents hoped to break into. In the photo, I’m feeding my father a fry. We both beam. Everywhere the light falls in that faded print, it is as golden as the arches.

My father was the fun parent, the indulgent one. He introduced me to fries, Cool Whip straight from the tub, fizzy drinks. After we emigrated to America, where McDonald’s franchises were ubiquitous rather than luxurious, he drove for an hour on the weekend to deliver us, triumphant, to some generic, all-you-can-eat buffet with actual crab on silver chafing trays.

I sucked down soft serve after soft serve until I threw up. My father never reprimanded me for overindulgence as my mother did. He laughed. It didn’t seem to matter, then, that his English wasn’t fluent, or that my Mandarin was already slipping away.

Our language of junk food evolved into one of secrets. A conspiratorial Happy Meal on our fishing trip alone. Two liters of Coke guzzled together before my mother came home. I felt honored until I began to understand that my father kept secrets from me, too.

In third grade, I came home newly evangelized to the dangers of cigarettes and threw away my father’s packs. He raged, then promised to quit, but I kept smelling smoke in his clothes and car.

My father was not virtuous. He was a man of vices and quick pleasures. Processed foods, nicotine, trashy Chinese science fiction, gambling, adultery. The hit of dopamine, the rush of blood sugar. I didn’t ask why he turned to these — that wasn’t how our family operated, and anyhow, language remained a barrier.

Instead, I began to distance myself. By the time I graduated from my Ivy League university, newly educated in class and its trappings, I knew the person I aimed to be. That person was not reflected in my broken-English, gambling-addict, divorced, blue-collar father. He had become a shameful artifact to me, one I wanted to leave behind. I grew increasingly distant as I focused on my new life with the impersonal callousness of youth.

My father died two years after I graduated. He was 49. I was 22. His death came like a shaft falling from the heavens, marking the central tragedy of my life. I grieved his passing, and then I grieved the fact that I never fully knew him. There were questions I had never thought to ask and nuances I hadn’t been able to articulate in my language or in his.

I can see now that my father’s death was a tragedy but not a surprise. If he hadn’t died in 2012 of probable heart failure, he would have died in another year from diabetes or high cholesterol or Covid-19. I used to blame him for the weakened body that killed him — a product, I thought, of his weakened virtue. There was a kind of solace in the stark language of “good” and “bad.”

But the older I get, the more I see myself compromising, too. I live less perfectly at 30 than I imagined I would when I was 10. The world is hard and unforgiving, to some much more than others.

And so, each autumn, I think: Now I’m the age at which my father had to care for a newborn daughter; now I’m at the age at which he followed his spouse to a country where he didn’t speak the language; now I’m at the age at which he was fired from his job and took a minimum-wage gig; now I’m at the age at which he, low and dreary, found his first online gambling website, as irresistible to him as the dumb games on my phone are to me.

Friends of mine have, as adults, gotten to know their parents as people with whom they swap intimacies and truths. I can’t have that. The only intimacies I have are the years of my life that overlap with the years of my father’s life, and at each intersection, I think: The age I am is far too young for the responsibilities he bore. How can I resent my father for being the product of such a staggeringly unfair world, one that systemically suffocates some people more than others?

And I can imagine, too, the giddy power my father must have felt upon moving to America in the ’90s to discover that McDonald’s was now the stuff of everyday. Cheaper than fish, more accessible than fresh fruit, simpler than a long-distance phone call to Beijing in which he felt compelled to hide his difficulties, his loneliness and alienation.

I can imagine the balm of preternaturally smooth processed meat to a tongue made clumsy by translation; how sugar might soothe an ego bruised by rejection, racism and the need to ask if a store accepts food stamps. I can imagine how, when language for the above is difficult, it might be easier to hand your child a golden nugget — how the gesture is a promise of abundance and pleasure, however short-lived.

Autumn is a time when the skin of the world feels thin, perhaps permeable; it is the season in which my father was born and died. This autumn, we’re eight months into a pandemic that too many public officials, including the current president, have called the “Chinese virus,” a dangerous characterization that shimmers with xenophobia and implied blame. I know a taste of the uncertainty that my father, with his thick accent and expired visa, knew. No number of years lived in this country, no degrees or good deeds, can protect me from the anxiety of having a Chinese face in a year that has seen a surge in hate crimes against Asian-Americans.

Under such conditions, the demand for perfect virtue feels impossible, even cruel. And so I binge bad television when I can’t handle good books. I smoke one cigarette a week. And on occasion, I get the damn chicken nuggets. There are vices we must allow ourselves, even if they theoretically shorten our lives by a day or a week or a year — because first we have to get through this day, this week, this year.

Is it wrong to compare my father to a processed piece of deep-fried food, that unholy creation that is like a chicken translated again and again until it achieves a new form of existence? Because I think of him whenever I bite into one. If that sounds weird — OK. It’s a more faithful representation than the usual metaphors of fathers as safe harbors, rocks or teachers. None of those ring true when it comes to my father. A chicken nugget, then. Some religions, after all, think of Christ in a piece of bread.

The next time the urge strikes, and the air feels particularly thin, I’ll have another nugget or two or four. There will be the rush of additives, the hit of engineered pleasure, and — though I know I can’t comprehend a dead man in all his contradictions, and I admit that to imagine my father’s motivations is not to know them — in that moment, in a communion across a golden crust, I will understand my father completely.

C Pam Zhang is a writer whose debut novel, published this year, is “How Much of These Hills Is Gold.”

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

To find previous Modern Love essays, Tiny Love Stories and podcast episodes, visit our archive.

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Travel Insurance During Coronavirus Pandemic: What To Know

When the pandemic struck, many travel insurance policies failed to cover Covid-19-related trip interruptions and cancellations, often because they excluded pandemics. But in the intervening months, the travel insurance industry has introduced a spate of new policies covering the disease just as many foreign destinations begin to require them.

“We’ve seen progress in that many plans will now treat Covid like any other unexpected sickness or illness,” said Stan Sandberg, a co-founder of the comparison website Travelinsurance.com. “If you have a trip and travel insurance and came down with Covid-19, which made it impossible to travel, that would fall under cancellation coverage as an unexpected illness that prevents you from traveling.”

Likewise, policies now including Covid-19 would cover holders in the event that a doctor diagnosed them with the virus while traveling under the trip interruption benefit.

Not all travel insurance excluded pandemics when the coronavirus began to spread early this year; Berkshire Hathaway Travel Protection was one exception. But the broader change partially arises from consumer demand, a better understanding of the virus — including mortality rates and hospital costs — and the industry’s eagerness for travel to resume.

“People who are traveling are more conscious of their risks and thinking about protecting themselves and their investment,” said Jeremy Murchland, the president of the travel insurer Seven Corners. The company launched policies that included Covid-19 coverage in June; they now account for more than 80 percent of sales.

But, like all insurance, the devil is in the details when it comes to understanding travel insurance, including what’s covered, destinations where it’s required, and the inevitable caveats, as follows.

How travel insurance covers Covid-19

The new Covid-inclusive insurance generally covers travelers from the day after purchase until their return home. During that period, if you become sick and a doctor determines you cannot travel (because of the virus or another illness), trip cancellation and trip interruption benefits would kick in.

These benefits vary by policy, but a search to insure a $2,000 weeklong trip to Costa Rica in December on Travelinsurance.com turned up a $69.75 Generali Global Assistance Standard policy with Covid-19 benefits that would be triggered if you, your host at your destination, a travel companion or a family member tested positive for the virus.

If this happened before your departure, the policy would cover your prepaid travel expenses. If you or your travel companion contracted Covid-19 during the trip and were diagnosed by a physician, it would reimburse prepaid arrangements, such as lodgings, and cover additional airfare to return home — once a doctor deems it safe to travel — up to $2,500. Should you be required to quarantine and can’t travel, travel delay coverage for lodging, meals and local transportation would pay up to $1,000. The policy also covers medical expenses for up to one year, even after you return home, up to $50,000 — though the policy also states that a holder would have to exhaust their own health insurance benefits before seeking coverage under the travel insurance plan.

Travelers should read these policies carefully to understand the benefits (for example, some rules vary by your state of residence), but brokers like TravelInsurance.com, InsureMyTrip and Squaremouth are making them easier to find through filters, F.A.Q.s and flags.

The new more comprehensive policies don’t necessarily cost more. On a Squaremouth search for insurance for two 40-year-olds on a two-week trip costing $5,000, the site turned up a variety of policies with or without coronavirus exclusions from $130 to $300, with no apparent premium for Covid-19 coverage.

Not every Covid-19-related expense is covered by many of these policies, including tests for the virus that many destinations require before arrival (those may be covered by private insurance).

Many policies include medical evacuation to a nearby facility, but won’t necessarily transport you home. For those concerned about treatment abroad, Medjet, a medical evacuation specialist, now offers Covid-19-related evacuations in the 48 contiguous United States, Canada, Mexico and the Caribbean that will transport you to the hospital of your choice in your home country (trip coverage starts at $99; annual memberships start at $189).

“Covid-19 requires special transport pods to protect the crew and others, which adds logistical issues,” said John Gobbels, the vice president and chief operating officer for Medjet.

In addition to the Medjet plan, travelers would need separate travel insurance with medical benefits to cover treatment costs and trip interruption.

Destination insurance requirements

Travelers aren’t the only ones worried about health. A growing list of countries are mandating medical coverage for Covid-19 as a prerequisite for visiting, often along with other measures like pre-trip virus testing and health screenings for symptoms on arrival.

Many Caribbean islands are among those requiring travel medical insurance, including Turks and Caicos and the Bahamas. St. Maarten requires health insurance coverage and strongly recommends additional travel insurance covering Covid-19.

Farther-flung countries also require policies that cover Covid-19, including French Polynesia and the Maldives.

Some destinations specify the required plan as a way to ensure travelers have the correct coverage and to expedite treatment. Aruba requires visitors to buy its Aruba Visitors Insurance, regardless of any other plans you may have.

“Insurance through a destination typically only covers Covid and infection while you’re there,” said Kasara Barto, a spokeswoman for Squaremouth.com. “If you catch Covid before, they don’t offer cancellation coverage. If you break a leg, the policy may only cover Covid medication. It varies by country.”

Costa Rica also requires insurance that includes an unusual benefit stipulating a policy cover up to $2,000 in expenses for a potential Covid-19 quarantine while in the country.

In response to the new requirement, which Costa Rica announced in October, insurers, including Trawick International, have begun introducing policies that meet the standard.

“It was a pretty quick and nimble reaction,” Mr. Sandberg of TravelInsurance.com said.

Normally, travel insurance varies by factors including the age of the traveler, destination, trip length and cost (most range from 4 to 10 percent of the trip cost). But some destinations are providing it at a flat fee, with most policies spelling out coverage limits and terms for emergency medical services, evacuation and costs associated with quarantines.

Jamaica, which will require insurance, but has not said when the new rule will go into effect, plans to charge $40 for each traveler. The Bahamas will include the insurance in the cost of its Travel Health Visa, an application that requires negative Covid-19 test results, which runs $40 to $60 depending on length of stay (free for children 10 and younger). The Turks and Caicos is offering a policy for $9.80 a day, and Costa Rica’s policies, if purchased locally, cost roughly $10 a day.

Expect this list of destinations to grow. In January, the Spanish region of Andalusia plans to require travel medical insurance and is working on finding a provider to make it easy for travelers to buy it.

Gaps in travel insurance

Policies that cover Covid-19 as a medical event that may cause trip cancellation or disruption, or those that provide coverage for medical treatment and evacuation still don’t necessarily cover travelers who have a change of heart when they learn they will have to quarantine upon arrival, even if they don’t have the virus. Nor are policies necessarily tied to conditions on the ground, like a spike in infections, State Department travel warnings, a government travel ban or the cessation of flights to and from a destination.

For those events, there’s Cancel For Any Reason, or CFAR, an upgrade to plans that generally only returns 50 to 75 percent of your nonrefundable trip costs.

“Prior to the pandemic, we wouldn’t necessarily recommend CFAR because most of travelers’ concerns were covered by standard plans,” Ms. Barto of Squaremouth.com said. “It’s about 40 percent more expensive and we didn’t want travelers to pay for additional coverage.” Now, she added, there’s been a surge in interest in the upgrade, including in 22 percent of policies sold at the site since mid-March.

Industry experts predict some of these outstanding issues may work their way into policies of the future as they adapt to enduring realities, much as they did after 9/11 in covering travelers in case of terrorist events, which was not the norm before.

The pandemic “was unprecedented, but once it happened, the industry has been pretty quick to react and create coverage, and that’s in the spirit of how this industry is trying to define itself, to be one of those subtle but valuable assets,” Mr. Sandberg said. “Once the world opens back up, we expect travel insurance to be much more top of mind with travelers.”


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Their Teeth Fell Out. Was It Another Covid-19 Consequence?

Earlier this month, Farah Khemili popped a wintergreen breath mint in her mouth and noticed a strange sensation: a bottom tooth wiggling against her tongue.

Ms. Khemili, 43, of Voorheesville, N.Y., had never lost an adult tooth. She touched the tooth to confirm it was loose, initially thinking the problem might be the mint. The next day, the tooth flew out of her mouth and into her hand. There was neither blood nor pain.

Ms. Khemili survived a bout with Covid-19 this spring, and has joined an online support group as she has endured a slew of symptoms experienced by many other “long haulers”: brain fog, muscle aches and nerve pain.

There’s no rigorous evidence yet that the infection can lead to tooth loss or related problems. But among members of her support group, she found others who also described teeth falling out, as well as sensitive gums and teeth turning gray or chipping.

She and other survivors unnerved by Covid’s well-documented effects on the circulatory system, as well as symptoms such as swollen toes and hair loss, suspect a connection to tooth loss as well. But some dentists, citing a lack of data, are skeptical that Covid-19 alone could cause dental symptoms.

“It’s extremely rare that teeth will literally fall out of their sockets,” said Dr. David Okano, a periodontist at the University of Utah in Salt Lake City.

But existing dental problems may worsen as a result of Covid-19, he added, especially as patients recover from the acute infections and contend with its long-term effects.

And some experts say that doctors and dentists need to be open to such possibilities, especially because more than 47 percent of adults 30 years or older have some form of periodontal disease, including infections and inflammation of the gums and bone that surround teeth, according to a 2012 report from the Centers for Disease Control and Prevention.

“We are now beginning to examine some of the bewildering and sometimes disabling symptoms that patients are suffering months after they’ve recovered from Covid,” including these accounts of dental issues and teeth loss, said Dr. William W. Li, president and medical director of the Angiogenesis Foundation, a nonprofit that studies the health and disease of blood vessels.

While Ms. Khemili had become more diligent about her dental care, she had a history of dental issues before contracting the coronavirus. When she went to the dentist the day after her tooth came out, he found that her gums were not infected but she had significant bone loss from smoking. He referred Ms. Khemili to a specialist to handle a reconstruction. The dental procedure is likely to cost her just shy of $50,000.

The same day Ms. Khemili’s tooth fell out, her partner went on Survivor Corp, a Facebook page for people who have lived through Covid-19. There, he found that Diana Berrent, the page’s founder, was reporting that her 12-year-old son had lost one of his adult teeth, months after he had a mild case of Covid-19. (Unlike Ms. Khemili, Ms. Berrent’s son had normal and healthy teeth with no underlying disease, according to his orthodontist.)

Others in the Facebook group have posted about teeth falling out without bleeding. One woman lost a tooth while eating ice cream. Eileen Luciano of Edison, N.J., had a top molar pop out in early November when she was flossing.

“That was the last thing that I thought would happen, that my teeth would fall out,” Ms. Luciano said.

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Teeth falling out without any blood is unusual, Dr. Li said, and provides a clue that there might be something going on with the blood vessels in the gums.

The new coronavirus wreaks havoc by binding to the ACE2 protein, which is ubiquitous in the human body. Not only is it found in the lungs, but also on nerve and endothelial cells. Therefore, Dr. Li says, it’s possible that the virus has damaged the blood vessels that keep the teeth alive in Covid-19 survivors; that also may explain why those who have lost their teeth feel no pain.

It’s also possible that the widespread immune response, known as a cytokine storm, may be manifesting in the mouth.

“If a Covid long hauler’s reaction is in the mouth, it’s a defense mechanism against the virus,” said Dr. Michael Scherer, a prosthodontist in Sonora, Calif. Other inflammatory health conditions, such as cardiovascular disease and diabetes, he said, also correlate with gum disease in the same patients.

“Gum disease is very sensitive to hyper-inflammatory reactions, and Covid long haulers certainly fall into that category,” Dr. Scherer said.

Dentists haven’t seen many of these cases, and some dismiss these individual claims. But physicians like Dr. Li say Covid-19’s surprises require that the profession be on the lookout for unexpected consequences of the disease.

“Patients may be bringing in new findings,” he said, and physicians and dentists need to cooperate on understanding the effects of long-term Covid-19 on teeth.

For now, Ms. Khemili hopes her story may serve as a cautionary tale. If people aren’t taking the proper precautions to protect themselves from the coronavirus, “they could be looking at something like this.”

What You Need to Know Now About Travel Insurance

When the pandemic struck, many travel insurance policies failed to cover Covid-19-related trip interruptions and cancellations, often because they excluded pandemics. But in the intervening months, the travel insurance industry has introduced a spate of new policies covering the disease just as many foreign destinations begin to require them.

“We’ve seen progress in that many plans will now treat Covid like any other unexpected sickness or illness,” said Stan Sandberg, a co-founder of the comparison website Travelinsurance.com. “If you have a trip and travel insurance and came down with Covid-19, which made it impossible to travel, that would fall under cancellation coverage as an unexpected illness that prevents you from traveling.”

Likewise, policies now including Covid-19 would cover holders in the event that a doctor diagnosed them with the virus while traveling under the trip interruption benefit.

Not all travel insurance excluded pandemics when the coronavirus began to spread early this year; Berkshire Hathaway Travel Protection was one exception. But the broader change partially arises from consumer demand, a better understanding of the virus — including mortality rates and hospital costs — and the industry’s eagerness for travel to resume.

“People who are traveling are more conscious of their risks and thinking about protecting themselves and their investment,” said Jeremy Murchland, the president of the travel insurer Seven Corners. The company launched policies that included Covid-19 coverage in June; they now account for more than 80 percent of sales.

But, like all insurance, the devil is in the details when it comes to understanding travel insurance, including what’s covered, destinations where it’s required, and the inevitable caveats, as follows.

How travel insurance covers Covid-19

The new Covid-inclusive insurance generally covers travelers from the day after purchase until their return home. During that period, if you become sick and a doctor determines you cannot travel (because of the virus or another illness), trip cancellation and trip interruption benefits would kick in.

These benefits vary by policy, but a search to insure a $2,000 weeklong trip to Costa Rica in December on Travelinsurance.com turned up a $69.75 Generali Global Assistance Standard policy with Covid-19 benefits that would be triggered if you, your host at your destination, a travel companion or a family member tested positive for the virus.

If this happened before your departure, the policy would cover your prepaid travel expenses. If you or your travel companion contracted Covid-19 during the trip and were diagnosed by a physician, it would reimburse prepaid arrangements, such as lodgings, and cover additional airfare to return home — once a doctor deems it safe to travel — up to $2,500. Should you be required to quarantine and can’t travel, travel delay coverage for lodging, meals and local transportation would pay up to $1,000. The policy also covers medical expenses for up to one year, even after you return home, up to $50,000 — though the policy also states that a holder would have to exhaust their own health insurance benefits before seeking coverage under the travel insurance plan.

Travelers should read these policies carefully to understand the benefits (for example, some rules vary by your state of residence), but brokers like TravelInsurance.com, InsureMyTrip and Squaremouth are making them easier to find through filters, F.A.Q.s and flags.

The new more comprehensive policies don’t necessarily cost more. On a Squaremouth search for insurance for two 40-year-olds on a two-week trip costing $5,000, the site turned up a variety of policies with or without coronavirus exclusions from $130 to $300, with no apparent premium for Covid-19 coverage.

Not every Covid-19-related expense is covered by many of these policies, including tests for the virus that many destinations require before arrival (those may be covered by private insurance).

Many policies include medical evacuation to a nearby facility, but won’t necessarily transport you home. For those concerned about treatment abroad, Medjet, a medical evacuation specialist, now offers Covid-19-related evacuations in the 48 contiguous United States, Canada, Mexico and the Caribbean that will transport you to the hospital of your choice in your home country (trip coverage starts at $99; annual memberships start at $189).

“Covid-19 requires special transport pods to protect the crew and others, which adds logistical issues,” said John Gobbels, the vice president and chief operating officer for Medjet.

In addition to the Medjet plan, travelers would need separate travel insurance with medical benefits to cover treatment costs and trip interruption.

Destination insurance requirements

Travelers aren’t the only ones worried about health. A growing list of countries are mandating medical coverage for Covid-19 as a prerequisite for visiting, often along with other measures like pre-trip virus testing and health screenings for symptoms on arrival.

Many Caribbean islands are among those requiring travel medical insurance, including Turks and Caicos and the Bahamas. St. Maarten requires health insurance coverage and strongly recommends additional travel insurance covering Covid-19.

Farther-flung countries also require policies that cover Covid-19, including French Polynesia and the Maldives.

Some destinations specify the required plan as a way to ensure travelers have the correct coverage and to expedite treatment. Aruba requires visitors to buy its Aruba Visitors Insurance, regardless of any other plans you may have.

“Insurance through a destination typically only covers Covid and infection while you’re there,” said Kasara Barto, a spokeswoman for Squaremouth.com. “If you catch Covid before, they don’t offer cancellation coverage. If you break a leg, the policy may only cover Covid medication. It varies by country.”

Costa Rica also requires insurance that includes an unusual benefit stipulating a policy cover up to $2,000 in expenses for a potential Covid-19 quarantine while in the country.

In response to the new requirement, which Costa Rica announced in October, insurers, including Trawick International, have begun introducing policies that meet the standard.

“It was a pretty quick and nimble reaction,” Mr. Sandberg of TravelInsurance.com said.

Normally, travel insurance varies by factors including the age of the traveler, destination, trip length and cost (most range from 4 to 10 percent of the trip cost). But some destinations are providing it at a flat fee, with most policies spelling out coverage limits and terms for emergency medical services, evacuation and costs associated with quarantines.

Jamaica, which will require insurance, but has not said when the new rule will go into effect, plans to charge $40 for each traveler. The Bahamas will include the insurance in the cost of its Travel Health Visa, an application that requires negative Covid-19 test results, which runs $40 to $60 depending on length of stay (free for children 10 and younger). The Turks and Caicos is offering a policy for $9.80 a day, and Costa Rica’s policies, if purchased locally, cost roughly $10 a day.

Expect this list of destinations to grow. In January, the Spanish region of Andalusia plans to require travel medical insurance and is working on finding a provider to make it easy for travelers to buy it.

Gaps in travel insurance

Policies that cover Covid-19 as a medical event that may cause trip cancellation or disruption, or those that provide coverage for medical treatment and evacuation still don’t necessarily cover travelers who have a change of heart when they learn they will have to quarantine upon arrival, even if they don’t have the virus. Nor are policies necessarily tied to conditions on the ground, like a spike in infections, State Department travel warnings, a government travel ban or the cessation of flights to and from a destination.

For those events, there’s Cancel For Any Reason, or CFAR, an upgrade to plans that generally only returns 50 to 75 percent of your nonrefundable trip costs.

“Prior to the pandemic, we wouldn’t necessarily recommend CFAR because most of travelers’ concerns were covered by standard plans,” Ms. Barto of Squaremouth.com said. “It’s about 40 percent more expensive and we didn’t want travelers to pay for additional coverage.” Now, she added, there’s been a surge in interest in the upgrade, including in 22 percent of policies sold at the site since mid-March.

Industry experts predict some of these outstanding issues may work their way into policies of the future as they adapt to enduring realities, much as they did after 9/11 in covering travelers in case of terrorist events, which was not the norm before.

The pandemic “was unprecedented, but once it happened, the industry has been pretty quick to react and create coverage, and that’s in the spirit of how this industry is trying to define itself, to be one of those subtle but valuable assets,” Mr. Sandberg said. “Once the world opens back up, we expect travel insurance to be much more top of mind with travelers.”


Follow New York Times Travel on Instagram, Twitter and Facebook. And sign up for our weekly Travel Dispatch newsletter to receive expert tips on traveling smarter and inspiration for your next vacation.

For Parents, Every Day Is Bird School

Me, my wife, our teenager and our 5-year old, we knew nothing about birds before the lockdown sent us inside in March. Our cramped home was suburban-convenient before the pandemic hit, nestled a few blocks from a school we don’t go in and a train downtown we won’t ride, and now it is just small.

It was a bedroom short and had nothing a person could call work space beyond the dining room table even before it became our entire lives. But it did have windows, sunny and bright in the morning, that looked out on the worn patch of yard just outside so I bought a bird feeder and some cheap seed and mounted it just outside our dining room window. We needed a distraction.

The birds came in swarms, tiny brown ones at first that constantly pecked at each other over the absolute trash seed we’d put out. It was like we’d opened an avian fight club. Then came the cardinals, regal and red, and the goldfinches, a hallucinatory yellow. They all fought, too, but they were beautiful.

The 5-year-old kept telling us he’d seen a blue jay, but it would always fly off, he’d claim, when we turned around. We thought it was a way of getting attention after losing his preschool, his swim lessons, his friends — everything his tiny world encompassed — to the pandemic. A phantom bird for attention, a way of controlling the tiny slice of world that existed outside our window. When I saw it for the first time, its iridescent blue tail catching the late spring sunlight, I screamed. He was right.

Credit…Dan Sinker

The pandemic required full days of work to become half days, our time now split down the middle between work and child care. We began drawing birds, my son and I, making a poster a week, one bird a day. He and I drew in the mornings, and he would study the birds with his mother in the afternoons. The time split was inconvenient, but how long could it possibly last, we asked.

Spring turned into summer and we were still inside. That one feeder became two and then three. A suction-cup feeder on the window. A thistle feeder on the fence. When the 5-year-old and I were kicking a soccer ball in our tiny mud patch of a yard and a hummingbird flew overhead, that was the next feeder we hung.

Remote school ended for our teenage son, and summer break meant more of the same. We were forever indoors, but the world was alive in our tiny yard that was more weeds and dirt than grass.

I bought a pole that could hold six feeders at a time. We’ve only gotten drive-through twice in the last eight months, but kept our fly-up fully stocked at all times. Two kinds of suet. A feeder built for woodpeckers. One that could hold whole peanuts for the blue jays; it became a prize the neighborhood squirrels dedicated their lives to claim. A second hummingbird feeder went up after we read they were highly territorial.

The five-year-old got a children’s guide to birds for his birthday, a birthday celebrated inside. He spent hours poring over it, teaching himself to read by sheer desire, calling out for help with words that grew longer and more complex as the weeks wore on. He memorized page after page.

The posters we draw line the walls of our dining room now — 25 at this point, one a week, the number always increasing. His tiny hand was unsure at first, lines and lettering halting and hesitant, but as weeks became months, he’s grown more confident and ambitious. Backyard birds. Sea birds. Exotics, Crayola bright. They reach the ceiling. We’re running out of space.

A new school year started and we were still inside. The teenager retreated to high school in his bedroom while we crammed a tiny desk into the corner of our dining room. Zoom kindergarten unfolded on a tablet screen, birds swarming the feeders just outside. For show and tell the 5-year-old flipped the camera and let the other kids see the birds. Zoom school isn’t all bad.

School’s start gave way to fall, leaves glowing in yellows and reds. We prepare for the unknowns of the “dark winter” ahead, holding on to fall like a rope above a pit. Cases are up everywhere, over a million in just a week. The numbers — the numbers are people, I remind myself when I check them every day — seem impossible, yet experts warn they’ll grow even larger when winter comes.

Things are changing, rapidly. We stay inside and look out.

The feeders are changing too. Migratory birds visit for stopovers unexpectedly, gone as quickly as they come. Woodpeckers, once a novelty, are now regulars; their usual supply of insects have disappeared with the onset of cold. The red-bellied woodpecker, whose head sports a shocking red stripe and whose wings are an op-art dream of black-and-white polka dots, now regularly gets in fights with the little trash birds, throwing his sharp beak in their direction when they swarm too close.

We knock ice off the bird bath — just a plastic tray on an upside-down flower pot — most mornings now. I make a mental note to research warmers. It’s been 255 days since the boys were last in school. It was a cold day that last day, and it’s cold days again now. Whole seasons inside.

“That’s a dark-eyed junco” the 5-year-old announced excitedly one morning a week or two ago (what’s time anymore?), pointing at a bird that, to my eyes, looked just like the trash birds we get by the hundreds. It was maybe a little darker, its beak a little lighter. Its only distinguishing mark was a little flick of a white tail I never would have noticed. He noticed.

This time I didn’t question him. I just looked it up in his bird book and there it was, exactly as he said, a dark-eyed junco. They only come in winter.

The Weekend of Personal Leftovers

Welcome. The weekend after Thanksgiving is, for many of us, time for leftovers, when the turkey and sides are summoned for their encore: as sandwich fixings, as stuffing croutons, as turkey pho. Of course, Thanksgiving was likely a smaller affair this year, so leftovers might be in short supply in the kitchen.

But even if you’ve polished off the turkey, it’s still a good time to finish up your personal leftovers. Just pull on your “hangaround bangarounds,” as my friend Alice calls them, the cozy indoor clothes that for a good number of us have become our only clothes the past several months, and get to work. Finish the book you’ve been meaning to get back to but kept casting aside for a cable news fix. Wrap up the card game, the Zoom convo, the jigsaw puzzle that’s been half-done for months (or just put the puzzle away without finishing it; you could use the table space).

I’ll be getting back to “All My Puny Sorrows,” a terrific novel by the Canadian writer Miriam Toews about sisters growing up in a Mennonite family. Catching up on the crossword, finally finishing “The Last Dance,” the 10-part documentary series about Michael Jordan and the Chicago Bulls; I think I have two episodes left. I’ll water the plants, parched since we turned the heat on, get the humidifier out of storage to keep them happy until spring. Small things, life’s leftovers.

If you find yourself with some time this weekend, I highly recommend this profile of Adriene Mishler of “Yoga With Adriene” fame. (When we talked about our exercise routines during the pandemic, Mishler’s videos were the ones mentioned most frequently by At Home readers.) What do her fans love about her? According to Molly Young, whose writing I always admire, it’s “a level of empathy so forceful it almost seems like brain damage.”

Speaking of very good writing, I read and then immediately reread “Happiness Won’t Save You,” a devastatingly beautiful essay by Jennifer Senior about the social psychologist Philip Brickman who conducted foundational studies on happiness but, for all his scholarship, couldn’t soothe his own troubled psyche.

And Hurray for the Riff Raff’s mesmerizing performance at Lincoln Center from 2014 is just as emotionally affecting. Check it out.

Tell us.

What personal leftovers are you tending to this weekend? What unfinished business will you finally wrap up? Write to us: athome@nytimes.com. We’re here to help you lead a good, cultured life at home, and we’re always looking for suggestions for how to do so ourselves, so drop us a line! We’re At Home and we’d love to hear from you. More ideas for how to pass the time this weekend appear below. See you next week.


How to pass the time.

Credit…Illustration by Ana Pérez López
  • “When days were long, doctors’ visits were discouraging and the future was uncertain, crossword puzzles gave me a sense of accomplishment, comfort and stability.” Read this lovely essay about how doing puzzles helped a woman during her husband’s long illness.

  • If you’re itching for a ski vacation, we’ve got a bunch of under-the-radar resorts that provide both challenging slopes and room for social distancing.

  • And among the new books coming in December are “Bag Man” by Rachel Maddow and Michael Yarvitz, about Richard Nixon’s vice president Spiro Agnew, and a new novel from Jane Smiley.


What to watch.

In Netflix’s “Dolly Parton’s Christmas on the Square,” Regina (Christine Baranski), who has been trying to evict townspeople, is visited by an angel (Dolly Parton).Credit…Netflix
  • You’ll want to watch “Christmas in the Square” starring Dolly Parton, even though, as Wesley Morris writes, “It’s bad, the sort of bad that knows what it is — campy rather than camp. ‘Campy’ is camp with a diploma and a martini. And ‘Christmas on the Square’ is a drunk.” It may not be high art but with “a little of everything from the music buffet: Rodgers and Hammerstein, treacle, Ike and Tina,” it sounds like it might be just the family entertainment called for this holiday weekend.

  • On the occasion of the broadcast debut of “Gilmore Girls: A Year in the Life,” we spoke with the creator Amy Sherman-Palladino and other vets of the series about why its appeal endures.

  • And definitely don’t miss Manohla Dargis and A.O. Scott’s interactive feature on the 25 greatest actors of the 21st century (so far).


How to deal.

Credit…Glenn Harvey

Like what you see?

Sign up to receive the At Home newsletter. You can always find much more to read, watch and do every day on At Home. And let us know what you think!

Doctors and Nurses Are Running on Empty

About 2 a.m. on a sweltering summer night, Dr. Orlando Garner awoke to the sound of a thud next to his baby daughter’s crib. He leapt out of bed to find his wife, Gabriela, passed out, her forehead hot with the same fever that had stricken him and his son, Orlando Jr., then 3, just hours before. Two days later, it would hit their infant daughter, Veronica.

Nearly five months later, Dr. Garner, a critical care physician at the Baylor College of Medicine in Houston, is haunted by what befell his family last summer: He had inadvertently shuttled the coronavirus home, and sickened them all.

“I felt so guilty,” he said. “This is my job, what I wanted to do for a living. And it could have killed my children, could have killed my wife — all this, because of me.”

With the case count climbing again in Texas, Dr. Garner has recurring nightmares that one of his children has died from Covid. He’s returned to 80-hour weeks in the intensive care unit, donning layers of pandemic garb including goggles, an N95 respirator, a protective body suit and a helmet-like face shield that forces him to yell to be heard.

As he treats one patient after another, he can’t shake the fear that his first bout with the coronavirus won’t be his last, even though reinfection is rare: “Is this going to be the one who gives me Covid again?”

Frontline health care workers have been the one constant, the medical soldiers forming row after row in the ground war against the raging spread of the coronavirus. But as cases and deaths shatter daily records, foreshadowing one of the deadliest years in American history, the very people whose life mission is caring for others are on the verge of collective collapse.

In interviews, more than two dozen frontline medical workers described the unrelenting stress that has become an endemic part of the health care crisis nationwide. Many related spikes in anxiety and depressive thoughts, as well as a chronic sense of hopelessness and deepening fatigue, spurred in part by the cavalier attitudes of many Americans who seem to have lost patience with the pandemic.

“This is my job, what I wanted to do for a living. And it could have killed my children, could have killed my wife — all this, because of me,” said Dr. Orlando Garner, a critical care physician in Houston.
“This is my job, what I wanted to do for a living. And it could have killed my children, could have killed my wife — all this, because of me,” said Dr. Orlando Garner, a critical care physician in Houston.Credit…Michael Starghill Jr. for The New York Times

Surveys from around the globe have recorded rising rates of depression, trauma and burnout among a group of professionals already known for high rates of suicide. And while some have sought therapy or medications to cope, others fear that engaging in these support systems could blemish their records and dissuade future employers from hiring them.

“We’re sacrificing so much as health care providers — our health, our family’s health,” said Dr. Cleavon Gilman, an emergency medicine physician in Yuma, Ariz. “You would think that the country would have learned its lesson” after the spring, he said. “But I feel like the 20,000 people that died in New York died for nothing.”

Many have reached the bottom of their reservoir, with little left to give, especially without sufficient tools to defend themselves against a disease that has killed more than 1,000 of them.

“I haven’t even thought about how I am today,” said Dr. Susannah Hills, a pediatric head and neck surgeon at Columbia University. “I can’t think of the last time somebody asked me that question.”

Dreading the darkness of winter

For Dr. Shannon Tapia, a geriatrician in Colorado, April was bad. So was May. At one long-term care facility she staffed, 22 people died in 10 days. “After that number, I stopped counting,” she said.

A bit of a lull coasted in on a wave of summer heat. But in recent weeks, Dr. Tapia has watched the virus resurge, sparking sudden outbreaks and felling nursing home residents — one of the pandemic’s most hard-hit populations — in droves.

“This is much, much worse than the spring,” Dr. Tapia said. “Covid is going crazy in Colorado right now.”

Dr. Tapia bore witness as long-term care facilities struggled to keep adequate protective equipment in stock, and decried their lack of adequate tests. As recently as early November, diagnostic tests at one home Dr. Tapia regularly visits took more than a week to deliver results, hastening the spread of the virus among unwitting residents.

Some nursing home residents in the Denver area are getting bounced out of full hospitals because their symptoms aren’t severe, only to rapidly deteriorate and die in their care facilities. “It just happens so fast,” Dr. Tapia said. “There’s no time to send them back.”

The evening of Nov. 17, Dr. Tapia fielded phone call after phone call from nursing homes brimming with the sick and the scared. Four patients died between 5 p.m. and 8 a.m. “It was the most death pronouncements I’ve ever had to do in one night,” she said.

Before the pandemic, nursing home residents were already considered a medically neglected population. But the coronavirus has only exacerbated a worrisome chasm of care for older patients. Dr. Tapia is beleaguered by the helplessness she feels at every turn. “Systematically, it makes me feel like I’m failing,” she said. “The last eight months almost broke me.”

At the end of the summer, Dr. Tapia briefly considered leaving medicine — but she is a single parent to an 11-year-old son, Liam. “I need my M.D. to support my kid,” she said.

Dr. Shannon Tapia, a geriatrician based in Denver, mourns the nursing home residents she cares for. “It just happens so fast,” Dr. Tapia said of patients whose conditions deteriorated after being discharged from hospitals. “There’s no time to send them back.”Credit…Daniel Brenner for The New York Times

It goes on and on and on

For others, the slog has been relentless.

Dr. Gilman, the emergency medicine physician in Yuma, braced himself at the beginning of the pandemic, relying on his stint as a hospital corpsman in Iraq in 2004.

“In the military, they train you to do sleep deprivation, hikes, marches,” he said. “You train your body, you fight an enemy. I began running every day, getting my lungs strong in case I got the virus. I put a box by the door to put my clothes in, so I wouldn’t spread it to my family.”

The current crisis turned out to be an unfamiliar and formidable foe that would follow him from place to place.

Dr. Gilman’s first coronavirus tour began as a resident at New York-Presbyterian at the height of last spring. He came to dread the phone calls to families unable to be near their ailing relatives, hearing “the same shrill cry, two or three times per shift,” he said. Months of chaos, suffering and pain, he said, left him “just down and depressed and exhausted.”

“I would come home with tears in my eyes, and just pass out,” he said.

The professional fallout of his Covid experience then turned personal.

Dr. Gilman canceled his wedding in May. His June graduation commenced on Zoom. He celebrated the end of his residency in his empty apartment next to a pile of boxes.

“It was the saddest moment ever,” he said.

Within weeks, he, his fiancée, Maribel, their two daughters and his mother-in-law had relocated to Arizona, where caseloads had just begun to swell. Dr. Gilman hunkered down anew.

They have weathered the months since in seclusion, keeping the children out of school and declining invitations to mingle, even as their neighbors begin to flock back together and buzz about their holiday plans.

There are bright spots, he said. The family’s home, which they moved into this summer, is large, and came with a pool. They recently adopted a puppy. Out in the remoteness of small-town Arizona, the desert has delighted them with the occasional roadrunner sighting.

Since the spring, Dr. Gilman has become a social media tour de force. To document the ongoing crisis, he began publishing journal entries on his website. His Twitter wall teems with posts commemorating people who lost their lives to Covid-19, and the health workers who have dedicated the past nine months to stemming the tide.

It’s how he has made sense of the chaos, Dr. Gilman said. What he’s fighting isn’t just the virus itself — but a contagion of disillusionment and misinformation, amid which mask-wearing and distancing continue to flag. “It’s a constant battle, it’s a never-ending war,” he said.

Reaching the breaking point

Nurses and doctors in New York became all too familiar with the rationing of care last spring. No training prepared them for the wrath of the virus, and its aftermath. The month-to-month, day-to-day flailing about as they tried to cope. For some, the weight of the pandemic will have lingering effects.

Shikha Dass, an emergency room nurse at Mount Sinai Queens, recalled nights in mid-March when her team of eight nurses had to wrangle some 15 patients each — double or triple a typical workload. “We kept getting code after code, and patients were just dying,” Ms. Dass said. The patients quickly outnumbered the available breathing support machines, she said, forcing doctors and nurses to apportion care in a rapid-fire fashion.

“We didn’t have enough ventilators,” Ms. Dass said. “I remember doing C.P.R. and cracking ribs. These were people from our community — it was so painful.”

“We’re there to save a person, save a life, stabilize a person so they can get further management,” said Shikha Dass, an emergency room nurse at Mount Sinai Queens. “And here I am, not able to do that.”Credit…Kholood Eid for The New York Times

Ms. Dass wrestled with sleeplessness and irritability, sniping at her husband and children. Visions of the dead, strewn across emergency room cots by the dozens, swam through her head at odd hours of the night. Medical TV dramas like Grey’s Anatomy, full of the triggering sounds of codes and beeping machines, became unbearable to watch. She couldn’t erase the memory of the neat row of three refrigerated trailers in her hospital parking lot, each packed with bodies that the morgue was too full to take.

One morning, after a night shift, Ms. Dass climbed into her red Mini Cooper to start her 20-minute drive home. Her car chugged onto its familiar route; a song from the 2017 film “The Greatest Showman” trickled out. For the first time since the pandemic began, Ms. Dass broke down and began to cry. She called her husband, who was on his way to work; he didn’t pick up. Finally, she reached her best friend.

“I told her, ‘These people are not going to make it, these people are not going to survive this,’” she said. “We’re there to save a person, save a life, stabilize a person so they can get further management. And here I am, not able to do that.”

Shortly after, she phoned a longtime friend, Andi Lyn Kornfeld, a psychotherapist who said Ms. Dass was in the throes of “absolute and utter acute PTSD.”

“I have known Shikha for 13 years,” Ms. Kornfeld said. “She is one of the strongest women I have ever met. And I had never heard her like this.”

The sounds of silence

Long gone are the raucous nightly cheers, loud applause and clanging that bounced off buildings and hospital windows in the United States and abroad — the sounds of public appreciation at 7 each night for those on the pandemic’s front line.

“Nobody’s clapping anymore,” said Dr. Jessica Gold, a psychiatrist at Washington University in St. Louis. “They’re over it.”

Health workers, once a central part of the coronavirus conversation, have in many ways faded into the background. Some, like Dr. Gilman, in Arizona, have had their salaries slashed as hospitals weigh how to cover costs.

Many have guiltily recoiled from the “hero” label emblazoned in commercials or ad campaigns, burdened by the death march of the people they could not save and the indiscriminate path of the coronavirus.

The word “hero” evokes bravery and superhuman strength but leaves little room for empathy, said Dr. Nicole Washington, a psychiatrist in Oklahoma. When portrayed as stalwart saviors, health workers “don’t have the room or right to be vulnerable.”

But the trope of invincibility has long been ingrained into the culture of medicine.

Dr. Tapia, the Colorado geriatrician, began taking an antidepressant in September after months of feeling “everything from angry to anxious to furious to just numb and hopeless.” The medication has improved her outlook. But she also worries that these decisions could jeopardize future employment.

Many state medical boards still ask intrusive questions about physicians’ history of mental health diagnoses or treatments in applications to renew a license — a disincentive to many doctors who might otherwise seek professional help.

“I don’t want to be a hero,” said Dr. Cleavon Gilman, an emergency medicine physician in Yuma, Ariz. “I want to be alive.”Credit…Caitlin O’Hara for The New York Times

Being on the front lines doesn’t make health workers stronger or safer than anyone else. “I’m not trying to be a hero. I don’t want to be a hero,” Dr. Gilman said. “I want to be alive.”

As social bubbles balloon nationwide in advance of the chilly holiday months, health care workers fret on the edges of their communities, worried they are the carriers of contagion.

Dr. Marshall Fleurant, an internal medicine physician at Emory University, has the sense that his young children, 3 and 4 years old, have grown oddly accustomed to the ritual of his disrobing out of work clothes, from his scrubs to his sneakers, before entering his home.

“I do not touch or speak to my children before I have taken a shower,” Dr. Fleurant said. “This is just how it is. You do not touch Daddy when he walks in the door.”

A week of vacation with his family startled him, when he could scoop the little ones up in his arms without fear. “I think they must have thought that was weird,” he said.

Bracing for the next wave

Trapped in a holding pattern as the coronavirus continues to burn across the nation, doctors and nurses have been taking stock of the damage done so far, and trying to sketch out the horizon beyond. On the nation’s current trajectory, they say, the forecast is bleak.

Jina Saltzman, a physician assistant in Chicago, said she was growing increasingly disillusioned with the nation’s lax approach to penning in the virus.

While Illinois rapidly reimposed restrictions on restaurants and businesses when cases began to rise, Indiana, where Ms. Saltzman lives, was slower to respond. In mid-November, she was astounded to see crowds of unmasked people in a restaurant as she picked up a pizza. “It’s so disheartening. We’re coming here to work every day to keep the public safe,” she said. “But the public isn’t trying to keep the public safe.”

Since the spring, Dr. Gilman has watched three co-workers and a cousin die from the virus. Ms. Dass lost a close family friend, who spent three weeks at Mount Sinai Queen’s under her care. When Dr. Fleurant’s aunt died of Covid, “We never got to bury her, never got to pay respects. It was a crushing loss.”

In state after state, people continue to flood hospital wards, where hallways often provide makeshift beds for the overflow. More than 12 million cases have been recorded since the pandemic took hold in the United States, with the pace of infection accelerating in the last couple months.

Jill Naiberk, a nurse at the University of Nebraska Medical Center, has spent more of 2020 in full protective gear than out of it. About twice a day, when Ms. Naiberk needs a sip of water, she must completely de-gown, then suit up again.

Otherwise, “you’re hot and sweaty and stinky,” she said. “It’s not uncommon to come out of rooms with sweat running down your face, and you need to change your mask because it’s wet.”

It’s her ninth straight month of Covid duty. “My unit is 16 beds. Rarely do we have an open one,” she said. “And when we do have an open bed, it’s usually because somebody has passed away.”

Many of her I.C.U. patients are young, in their 40s or 50s. “They’re looking at us and saying things like, ‘Don’t let me die’ and ‘I guess I should have worn that mask,’” she said.

Sometimes she cries on her way home, where she lives alone with her two dogs. Her 79-year-old mother resides just a couple houses away.

They have not hugged since March.

“I keep telling everybody the minute I can safely hug you again, get ready,” she said. “Because I’m never letting go.”

After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion

Adam Woodrum was out for a bike ride with his wife and kids on July 19 when his then 9-year-old son, Robert, crashed.

“He cut himself pretty bad, and I could tell right away he needed stitches,” said Woodrum.

Because they were on bikes, he called the fire department in Carson City, Nevada.

“They were great,” said Woodrum. “They took him on a stretcher to the ER.”

Robert received stitches and anesthesia at Carson Tahoe Regional Medical Center. He’s since recovered nicely.

Then the denial letter came.

The Patient: Robert Woodrum, covered under his mother’s health insurance plan from the Nevada Public Employees’ Benefits Program

Total Bill: $18,933.44, billed by the hospital

Service Provider: Carson Tahoe Regional Medical Center, part of not-for-profit Carson Tahoe Health

Medical Service: Stitches and anesthesia during an emergency department visit

What Gives: The Aug. 4 explanation of benefits (EOB) document said the Woodrum’s claim had been rejected and their patient responsibility would be the entire sum of $18,933.44.

This case involves an all-too-frequent dance between different types of insurers about which one should pay a patient’s bill if an accident is involved. All sides do their best to avoid paying. And, no surprise to Bill of the Month followers: When insurers can’t agree, who gets a scary bill? The patient.

The legal name for the process of determining which type of insurance is primarily responsible is subrogation.

Could another policy — say, auto or home coverage or workers’ compensation — be obligated to pay if someone was at fault for the accident?

Subrogation is an area of law that allows an insurer to recoup expenses should a third party be found responsible for the injury or damage in question.

Health insurers say subrogation helps hold down premiums by reimbursing them for their medical costs.

About two weeks after the accident, Robert’s parents — both lawyers — got the EOB informing them of the insurer’s decision.

The note also directed questions to Luper Neidenthal & Logan, a law firm in Columbus, Ohio, that specializes in helping insurers recover medical costs from “third parties,” meaning people found at fault for causing injuries.

The firm’s website boasts that “we collect over 98% of recoverable dollars for the State of Nevada.”

Another letter also dated Aug. 4 soon arrived from HealthScope Benefits, a large administrative firm that processes claims for health plans.

The claim, it said, included billing codes for care “commonly used to treat injuries” related to vehicle crashes, slip-and-fall accidents or workplace hazards. Underlined for emphasis, one sentence warned that the denied claim would not be reconsidered until an enclosed accident questionnaire was filled out.

Adam Woodrum, who happens to be a personal injury attorney, runs into subrogation all the time representing his clients, many of whom have been in car accidents. But it still came as a shock, he said, to have his health insurer deny payment because there was no third party responsible for their son’s ordinary bike accident. And the denial came before the insurer got information about whether someone else was at fault.

“It’s like deny now and pay later,” he said. “You have insurance and pay for years, then they say, ‘This is denied across the board. Here’s your $18,000 bill.’”

Although Adam Woodrum is a personal injury attorney, he says it still came as a shock to have his health insurer deny the claim after his son, Robert, got stitches in July following a bike crash. (Maggie Starbard for KHN)
Woodrum and his son, Robert, get ready to bike near their home in Carson City, Nevada, on Nov. 7. (Maggie Starbard for KHN)

When contacted, the Public Employees’ Benefits Program in Nevada would not comment specifically on Woodrum’s situation, but a spokesperson sent information from its health plan documents. She referred questions to HealthScope Benefits about whether the program’s policy is to deny claims first, then seek more information. The Little Rock, Arkansas-based firm did not return emails asking for comment.

The Nevada health plan’s documents say state legislation allows the program to recover “any and all payments made by the Plan” for the injury “from the other person or from any judgment, verdict or settlement obtained by the participant in relation to the injury.”

Attorney Matthew Anderson at the law firm that handles subrogation for the Nevada health plan said he could not speak on behalf of the state of Nevada, nor could he comment directly on Woodrum’s situation. However, he said his insurance industry clients use subrogation to recoup payments from other insurers “as a cost-saving measure,” because “they don’t want to pass on high premiums to members.”

Despite consumers’ unfamiliarity with the term, subrogation is common in the health insurance industry, said Leslie Wiernik, CEO of the National Association of Subrogation Professionals, the industry’s trade association.

“Let’s say a young person falls off a bike,” she said, “but the insurer was thinking, ‘Did someone run him off the road, or did he hit a pothole the city didn’t fill?’”

Statistics on how much money health insurers recover through passing the buck to other insurers are hard to find. A 2013 Deloitte consulting firm study, commissioned by the Department of Labor, estimated that subrogation helped private health plans recover between $1.7 billion and $2.5 billion in 2010 — a tiny slice of the $849 billion they spent that year.

Medical providers may have reason to hope that bills will be sent through auto or homeowner’s coverage, rather than health insurance, as they’re likely to get paid more.

That’s because auto insurers “are going to pay billed charges, which are highly inflated,” said attorney Ryan Woody, who specializes in subrogation. Health insurers, by contrast, have networks of doctors and hospitals with whom they negotiate lower payment rates.

Resolution: Because of his experience as an attorney, Woodrum felt confident it would eventually all work out. But the average patient wouldn’t understand the legal quagmire and might not know how to fight back.

“I hear the horror stories every day from people who don’t know what it is, are confused by it and don’t take appropriate action,” Woodrum said. “Then they’re a year out with no payment on their bills.” Or, fearing for their credit, they pay the bills.

After receiving the accident questionnaire, Woodrum filled it out and sent it back. There was no liable third party, he said. No driver was at fault.

His child just fell off his bicycle.

HealthScope Benefits reconsidered the claim. It was paid in September, two months after the accident. The hospital received less than half of what it originally billed, based on rates negotiated through his health plan.

The insurer paid $7,414.76 of the cost, and the Woodrums owed $1,853.45, which represented their share of the deductibles and copays.

Adam Woodrum and his son, Robert, bike near their home in Carson City, Nevada, on Nov. 7.(Maggie Starbard for KHN)

The Takeaway: The mantra of Bill of the Month is don’t just write the check. But also don’t ignore scary bills from insurers or hospitals.

It’s not uncommon for insured patients to be questioned on whether their injury or medical condition might have been related to an accident. On some claim forms, there is even a box for the patient to check if it was an accident.

But in the Woodrums’ case, as in others, it was an automatic process. The insurer denied the claim based solely on the medical code indicating a possible accident.

If an insurer denies all payment for all medical care related to an injury, suspect that some type of subrogation is at work.

Don’t panic.

If you get an accident questionnaire, “fill it out, be honest about what happened,” said Sean Domnick, secretary of the American Association for Justice, an organization of plaintiffs lawyers. Inform your insurer and all other parties of the actual circumstances of the injury.

And do so promptly.

That’s because the clock starts ticking the day the medical care is provided and policyholders may face a statutory or contractual requirement that medical bills be submitted within a specific time frame, which can vary.

“Do not ignore it,” said Domnick. “Time and delay can be your enemy.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

It’s Time for a Digital Detox. (You Know You Need It.)

When is enough enough?

Even though the presidential election is over, we’re still doomscrolling through gloomy news about the coronavirus surge. The rest of your daily routine is probably something like mine while stuck at home in the pandemic: Divided among streaming movies on Netflix, watching home improvement videos on YouTube and playing video games. All of these activities involve staring at a screen.

There has to be more to life than this. With the holiday season upon us, now is a good time to take a breather and consider a digital detox.

No, that doesn’t mean quitting the internet cold turkey. No one would expect that from us right now. Think of it as going on a diet and replacing bad habits with healthier ones to give our weary eyes some much needed downtime from tech.

“There’s lots of great things to do online, but moderation is often the best rule for life, and it’s no different when it comes to screens,” said Jean Twenge, a psychology professor at San Diego State University and the author of “iGen,” a book about younger generations growing up in the smartphone era.

Too much screen time can take a toll on our mental health, depriving us of sleep and more productive tasks, experts said. I, for one, am experiencing this. Before the pandemic, my average daily screen time on my phone was three and a half hours. Over the last eight months, that has nearly doubled.

So I turned to psychology experts for their advice. From setting limits to finding alternatives to being glued to our phones, here’s what we can do.

Come Up With a Plan

Not all screen time is bad — after all, many students are attending school via videoconferencing apps. So Step One is assessing which parts of screen time feel toxic and make you unhappy. That could be reading the news or scrolling through Twitter and Facebook. Step Two is creating a realistic plan to minimize consumption of the bad stuff.

You could set modest goals, such as a time limit of 20 minutes a day for reading news on weekends. If that feels doable, shorten the time limit and make it a daily goal. Repetition will help you form new habits.

That’s easier said than done. Adam Gazzaley, a neuroscientist and co-author of the book “The Distracted Mind: Ancient Brains in a High-Tech World,” recommended creating calendar events for just about everything, including browsing the web and taking breaks. This helps create structure.

For example, you could block off 8 a.m. to read the news for 10 minutes, and 20 minutes from 1 p.m. for riding the exercise bike. If you feel tempted to pick up your phone during your exercise break, you would be aware that any screen time would be violating the time you dedicated to exercise.

Most important, treat screen time as if it were a piece of candy that you occasionally allow yourself to indulge. Don’t think of it as taking a break as that may do the opposite of relaxing you.

“Not all breaks are created equal,” Dr. Gazzaley said. “If you take a break and go into social media or a news program, it can get hard to get out of that rabbit hole.”

Create No-Phone Zones

We need to recharge our phones overnight, but that doesn’t mean the devices need to be next to us while we sleep. Many studies have shown that people who keep phones in their bedrooms sleep more poorly, according to Dr. Twenge.

Smartphones are harmful to our slumber in many ways. The blue light from screens can trick our brains into thinking it’s daytime, and some content we consume — especially news — can be psychologically stimulating and keep us awake. So it’s best not to look at phones within an hour before bed. What’s more, the phone’s proximity could tempt you to wake up and check it in the middle of the night.

“My No. 1 piece of advice is no phones in the bedroom overnight — this is for adults and teens,” Dr. Twenge said. “Have a charging station outside the bedroom.”

Outside of our bedrooms, we can create other No-Phone Zones. The dinner table, for example, is a prime opportunity for families to agree to put phones away for at least 30 minutes and reconnect.

Resist the Hooks

Tech products have designed many mechanisms to keep us glued to our screens. Facebook and Twitter, for example, made their timelines so that you could scroll endlessly through updates, maximizing the amount of time you spend on their sites.

Adam Alter, a marketing professor at New York University’s Stern School of Business and author of the book “Irresistible: The Rise of Addictive Technology and the Business of Keeping Us Hooked,” said that tech companies employed techniques in behavioral psychology that make us addicted to their products.

He highlighted two major hooks:

  • Artificial goals. Similar to video games, social media sites create goals to keep users engaged. Those include the number of likes and followers we accrue on Facebook or Twitter. The problem? The goals are never fulfilled.

  • Friction-free media. YouTube automatically plays the next recommended video, not to mention the never-ending Facebook and Twitter scrolling. “Before there was a natural end to every experience,” like reading the last page of a book, he said. “One of the biggest things tech companies have done was to remove stopping cues.”

What to do? For starters, we can resist the hooks by making our phones less intrusive. Turn off notifications for all apps except those that are essential for work and keeping in touch with people you care about. If you feel strongly addicted, take an extreme measure and turn the phone to grayscale mode, Dr. Alter said.

There’s also a simpler exercise. We can remind ourselves that outside of work, a lot of what we do online doesn’t matter, and it’s time that can be better spent elsewhere.

“The difference between getting 10 likes and 20 likes, it’s all just meaningless,” Dr. Alter said.

Why Employers Find It So Hard to Test for COVID

Brandon Hudgins works the main floor at Fleet Feet, a running-shoe store chain, for more than 30 hours a week. He chats with customers, measuring their feet and dashing in and out of the storage area to locate right-sized shoes. Sometimes, clients drag their masks down while speaking. Others refuse to wear masks at all.

So he worries about COVID-19. And with good reason. Across the U.S., COVID hospitalizations and deaths are hitting record-shattering new heights. The nation saw 198,633 new cases on Friday alone.

Unlike in the early days of the pandemic, though, many stores nationwide aren’t closing. And regular COVID-19 testing of those working remains patchy at best.

“I’ve asked, what if someone on staff gets symptoms? ‘You have to stay home,’” said Hudgins, 33, who works in High Point, North Carolina. But as an hourly employee, staying home means not getting paid. “It’s stressful, especially without regular testing. Our store isn’t very big, and you’re in there all day long.”

To the store’s credit, Hudgins said the manager has instituted a locked-door policy, where employees determine which customers can enter. They sanitize the seating area between customers and administer regular employee temperature checks. Still, there’s no talk of testing employees for COVID-19. Fleet Feet did not respond to multiple requests to talk about its testing policies.

The federal Centers for Disease Control and Prevention issued guidance to employers to include COVID testing, and it advised that people working in close quarters be tested periodically. However, the federal government does not require employers to offer those tests.

But the board overseeing the California Division of Occupational Safety and Health, known as Cal/OSHA, on Thursday approved emergency safety rules that are soon likely to require the state’s employers to provide COVID testing to all workers exposed to an outbreak on the job at no cost to the employees. Testing must be repeated a week later, followed by periodic testing.

California would be the first state to mandate this, though the regulation doesn’t apply to routine testing of employees. That is up to individual businesses.

Across the nation, workplaces have been the source of major coronavirus outbreaks: meat-processing plants, grocery stores, farms, schools, Amazon warehouses — largely among the so-called essential workers who bear the brunt of COVID infections and deaths.

The U.S. Occupational Safety and Health Administration inspects workplaces based on workers’ complaints — over 40,000 of which related to COVID-19 have been filed with the agency at the state and federal levels.

Workers “have every right to be concerned,” said Dr. Peter Chin-Hong, an epidemiologist at the University of California-San Francisco. “They are operating in a fog. There is little economic incentive for corporations to figure out who has COVID at what sites.”

Waiting for symptoms to emerge before testing is ill-considered, Chin-Hong noted. People can exhibit no symptoms while spreading the virus. A CDC report found that, among people with active infections, 44% reported no symptoms.

Yet testing alone cannot protect employees. While workplaces can vary dramatically, Chin-Hong emphasized the importance of enforcing safety guidelines like social distancing and wearing face masks, as well as being transparent with workers when someone gets sick.

Molly White, who works for the Missouri state government, was required to return to the office once a week starting in July. But White, who is on drugs to suppress her immune system, feared her employer’s “cavalier attitude toward COVID and casual risk taking.” Masks are encouraged for employees but are not mandatory, and there’s no testing policy or even guidance on where to get tested, she said. White filed for and received an Americans With Disabilities Act exception, which lasts through the end of the year, to avoid coming into the office.

After a cluster of 39 COVID cases emerged in September in the building where she normally works, White was relieved to at least get an email notifying her of the outbreak. A few days later, Gov. Mike Parson visited the building, and he tested positive for COVID-19 soon after.

Following pressure from labor groups, Amazon reported in a blog post last month that almost 20,000 employees had tested positive or been presumed positive for COVID-19 since the pandemic began. To help curb future outbreaks, the online retailing giant, which also owns Whole Foods, built its own testing facilities, hired lab technicians and said it planned to conduct 50,000 daily tests across 650 sites by this month.

The National Football League tests players and other essential workers daily. An NFL spokesperson said the league conducts 40,000 to 45,000 tests a week through New Jersey-based BioReference Laboratories, though both organizations declined to share a price tag. Reports over the summer estimated the season’s testing program would cost about $75 million.

Not all companies, particularly those not in the limelight, have the interest — or the money — to regularly test workers.

“It depends on the company how much they care,” said Gary Glader, president of Horton Safety Consultants in Orland Park, Illinois. Horton works with dozens of companies in the manufacturing, construction and transportation industries to write exposure control plans to limit the risk of COVID-19 outbreaks and avoid OSHA citations. “Some companies could care less about their people, never have.”

IGeneX, a diagnostic testing company in Milpitas, California, gets around 15 calls each day from companies across the country inquiring about its employer testing program. The lab works with about 100 employers — from 10-person outfits to two pro sports teams — mainly in the Bay Area. IGeneX tests its own workers every other week.

One client is Tarana Wireless, a nearby telecommunications company that needs about 30 employees in the office at a time to operate equipment. In addition to monthly COVID tests, the building also gets cleaned every two hours, and masks are mandatory.

“It’s definitely a burden,” said Amy Beck, the company’s director of human resources. “We are venture-backed and have taken pay cuts to make our money extend longer. But we do this to make everyone feel safe. We don’t have unlimited resources.”

IGeneX offers three prices, depending on how fast a company wants the results: $135 for a polymerase chain reaction (PCR) test with a 36- to 48-hour turnaround — down to around $100 a test for some higher-volume clients; one-day testing costs $250, and it’s $400 for a six-hour turnaround.

In some cases, IGeneX is able to bill the companies’ health insurance plan.

“Absolutely, it’s expensive,” said IGeneX spokesperson Joe Sullivan. “I don’t blame anyone for wanting to pay as little as possible. It’s not ‘one and done,’ which companies are factoring in.”

Plus, cheaper, rapid options like Abbott’s antigen test, touted by the Trump administration, have come under fire for being inaccurate.

For those going into work, Chin-Hong recommends that companies test their employees once a week with PCR tests, or twice a week with the less sensitive antigen tests.

Ideally, Chin-Hong said, public health departments would work directly with employers to administer COVID testing and quash potential outbreaks. But, as KHN has reported extensively, these local agencies are chronically underfunded and overworked. Free community testing sites can sometimes take days to weeks to return results, bogged down by extreme demand at commercial labs like Quest Diagnostics and LabCorp and supply chain problems.

Hudgins, who receives his health insurance through North Carolina’s state exchange, tries to get a monthly COVID test at CVS on his own time. But occasionally, his insurance — which requires certain criteria to qualify — has declined to pay for it, he said.

“Being in the service industry in a state where numbers are ridiculously high,” he said in an email, “I see volumes of people every day, and I think getting tested is the smart and considerate thing to do.”

Related Topics

Public Health States

How Exercise Changes Our Blood

While we exercise, we raise and lower the levels of hundreds of molecules in our bloodstreams that are related to our metabolic health, even if we work out for only a few minutes, according to a complex and encouraging new study of the molecular effects of being active. The study, which involved more than 1,000 men and women, adds to growing evidence that exercise improves our health in large part by transforming the numbers and types of cells inside of us.

There is at this point, of course, no reasonable debate about whether exercise is good for us. It is. Countless studies show that people who are active are less likely than more-sedentary people to develop or die from a host of health problems, including heart disease, diabetes, dementia, cancer, obesity and many others. Active people also tend to live longer and feel happier.

But we still know surprisingly little about just how exercise changes us for the better. What are the many, interconnected biological steps and transmutations that allow a walk today to add to our life span decades from now?

That question has been driving considerable interest recently in research looking at exercise “omics” — the study of all of the molecules in our blood or other tissues that are part of a particular biological process. Genomics, for instance, quantifies the many, many molecules involved in genetic activities. Proteomics does the same for proteins, microbiomics for the multiple contents of our microbiomes and metabolomics for molecules related to metabolic processes. (There can be overlap between various ’omics, obviously.)

Understanding how exercise affects the levels of the various molecules within us is important, because these changes are likely to be the preliminary step in a complex cascade of further biological actions that contribute to better health. Increase some molecules, decrease others, and you jump-start inter-organ messaging, gene expression and other processes that subsequently alter how we make and use insulin, burn or store fat, respond to cholesterol and so on.

A number of important recent studies have delved into the ’omics of exercise, including a fascinating experiment showing that a short workout rapidly changes the levels of 9,815 molecules in people’s bloodstreams. But that study, like most other examinations of exercise and ’omics, involved relatively few volunteers — 36, in that case — and did not link molecular changes with subsequent health outcomes.

So, for the new study, which was published in September in Circulation, researchers at Massachusetts General Hospital in Boston and other institutions decided to up the number of exercisers whose ’omics would be parsed and also try to find connections between the ’omics data and later health.

Conveniently, they had access to a large group of potential volunteers among men and women already enrolled in the long-term Framingham Heart Study, which is overseen primarily by researchers at Massachusetts General Hospital. The scientists now asked 411 middle-aged volunteers enrolled in the study to visit the lab and exercise, by pedaling to exhaustion on a stationary bicycle. Most riders’ efforts lasted for a little less than 12 minutes. The researchers drew blood before the ride and afterward, within about a minute of when, worn out, the cyclists quit.

The scientists then ran the blood samples through a mass spectrometer, a machine that counts and quantifies molecules. The researchers focused on metabolites, which are molecules related to metabolic processes. The label “metabolite” is somewhat arbitrary, but for this study, the researchers focused mostly on molecules that could affect people’s insulin, fat burning, cholesterol, blood sugar and other aspects of cellular fueling.

They found plenty. Of 588 metabolites checked, the levels of more than 80 percent generally grew or dropped during the short rides. To reinforce those findings, the scientists repeated the experiment with another 783 Framingham volunteers, checking their blood before and after exercise for changes in about 200 of the molecules that had been most altered in the first group. Again, these metabolites changed in the same ways as before.

Last and perhaps most intriguing, the researchers created what they called molecular “signatures” of the levels of a few, representative metabolites that changed with exercise. They then looked for these same patterns of metabolites in stored blood samples gathered decades before from past Framingham participants, while also checking to see if and when any of these volunteers had passed away.

The relevant signatures popped up in some of the blood samples, the researchers found, and these samples tended to be from people who had not died prematurely, suggesting that the kinds of metabolite changes that occur with exercise might influence and improve health well into the future.

That idea is “speculative,” though, says Dr. Gregory Lewis, the section head of the heart failure program and director of the cardiopulmonary exercise laboratory at Massachusetts General Hospital, who oversaw the new study. The decades-old blood samples were drawn during standard medical testing, not after exercise, he says, so some people with desirable metabolite signatures might have been born that way and not needed workouts to remodel their metabolites.

Even among the current volunteers, he points out, different people’s molecules responded somewhat differently to their exercise. Over all, people with obesity developed fewer changes than leaner riders, suggesting they might somehow resist some of the benefits of exercise. Men and women, as groups, also showed slightly discordant molecular signatures, but age did not influence people’s molecular responses.

Larger future ’omics studies should help scientists tease out how and why we each react as we do to exercise, Dr. Lewis says, and enable researchers to define more-precise molecular signatures that might indicate, with a blood test, how fit someone is or how their bodies may respond to different types of exercise.

But for now, the current study underscores just how pervasive and immediate the effects of exercise can be. “This was barely 10 minutes of exercise,” Dr. Lewis says, “but it shifted so much” inside people.

California Businesses Go From Simmer to Boil Over Newsom’s Fine Dining

California Gov. Gavin Newsom’s maskless dinner with medical industry lobbyists and others at a Napa County restaurant where meals cost a minimum of $350 per head was just about the last straw for some beleaguered California small-business owners.

With their livelihoods on the line, a growing number of them are openly defying the latest orders to shut down as COVID cases skyrocket in California — and pointing to Newsom’s bad behavior.

“We are definitely not complying. We have enough information to make an educated decision: The data do not back another shutdown,” said Miguel Aguilar, founder and owner of Self Made Training Facility, based in Temecula, California, which leases space to physical trainers and nutrition advisers and has 40 locations across 11 states, including 15 in California.

The news of Newsom’s Nov. 6 dinner at the French Laundry in Yountville only strengthened Aguilar’s resolve. “Yes, we all make mistakes, but his apology was pathetic,” Aguilar said. “He told us he was outdoors, but then the photos surfaced. He can attend in-person gatherings, but we can’t? There’s absolutely no trust there.”

New COVID-19 cases and hospitalizations have surged at an alarming rate in California, with a seven-day average of over 11,500 cases Saturday, more than triple the number of a month earlier. Hospitalizations have doubled over the same period, according to the Los Angeles Times, part of a national trend that has pushed total COVID infections in the U.S. above 12 million.

In most California counties, restaurants, fitness clubs, yoga studios, churches, movie theaters and museums that have already been through two previous shutdowns and reopenings since March are once again required to cease indoor operations — just as winter hits. Some are laying off workers for the third time this year.

Add to that the failure of Congress to pass another stimulus package and, in many cases, a preexisting mistrust of government mandates. It all amounts to more disgruntled entrepreneurs.

Larry McNamer, owner of Major’s Diner in the tiny San Diego County community of Pine Valley, said he is continuing to serve people indoors, even though the county closed indoor dining on Nov. 14 in accordance with state regulations. He doesn’t believe the government has the right to impose such an ordinance on him. And, he said, Newsom’s dinner fiasco helped him make his decision to stay open.

“We’re having to deal with all of the lying, the hypocrisy — you’ve got a governor that’s running around ignoring his own mandates,” McNamer said.

McNamer knows the pandemic is real, he said. He is seating only a quarter of his normal indoor capacity and has added distance between tables. But after closing the restaurant from March 15 to May 23, laying off half his employees and falling $200,000 behind on rent and other bills, McNamer isn’t sure how much more his business can take.

Last Wednesday, he was hit with a cease-and-desist order from the county, threatening him with a fine of $1,000 for each offense. San Diego County law enforcement officers are aggressively pursuing violations of public health orders, and the county has issued at least 83 citations to businesses since Nov. 16.

In many other counties, including Riverside, Orange, San Bernardino and Placer, sheriffs and police departments have rejected the COVID ordinances or expressed reluctance to enforce them.

Last week, Newsom announced that 41 of California’s 58 counties — representing 94% of the population — were in the state’s “purple” tier — the most severe of four color-coded risk levels that impose increasingly restrictive limits on business activities. That was up from 13 purple counties the week before.

A few days later, the governor ordered a curfew, requiring people in the purple counties to stay at home between 10 p.m. and 5 a.m. unless they’re performing essential activities, including certain jobs, grocery shopping or going to the doctor.

Los Angeles County went a step further Sunday, banning outdoor dining for at least three weeks. Unlike earlier in the year when that measure was ordered, now no federal financial aid is available to restaurants or their employees. Indoor dining has been shut down in the county for months.

Despite plunging revenue, mounting debt and the frustrating uncertainty of shifting goal posts, many small-business owners are not defying the latest public health restrictions, either out of a sense of responsibility or fear of enforcement actions — or of contracting the virus themselves.

Those who do flout public health ordinances are doing so for a variety of reasons, with economics topping the list.

“There are people who are protecting their employment, protecting their income,” said Vickie Mays, a clinical psychologist and professor of health policy and management at UCLA’s Fielding School of Public Health. “There are no stimulus checks coming. There’s no alternative.”

Many people who own their own businesses “have taken other risks in their lives, and the risks they have taken have paid off, so there’s a belief that despite this risk, you’re not going to get infected,” Mays said.

Many business owners, whether they comply with the health orders or not, believe their industries are being unfairly targeted and that the risk of viral spread in their establishments is not as great as officials say.

Scott Slater, who owns two restaurants in San Diego’s seaside community of La Jolla, said he was frustrated by the public health focus on restaurants when a lot of COVID transmission is happening in private home gatherings.

“We’re a perfect scapegoat,” Slater said. “They can control us, but they can’t control someone’s own home.” He called Newsom’s dinner “a slap in the face” but said he and his wife are complying with the new restrictions, scraping by on catering, takeout and delivery — though he estimates they are $200,000 behind on rent.

Francesca Schuler, CEO of Stockton, California-based In-Shape Health Clubs, which has more than 60 fitness centers and just laid off most of its staff for the third time this year, said gyms should be viewed as part of the solution, not the problem.

“I look at people who are dying of COVID, and it’s people who are overweight, who have high blood pressure or diabetes,” said Schuler, who is respecting the closure orders despite her objection to them. “There are a lot of people who are trying to exercise to stay healthy, yet they shut down gyms while people can still go to tattoo parlors, to McDonald’s and to liquor stores. I just don’t get it.”

Mays, however, said gyms are considered high-risk because “people are breathing hard; they are expelling air further.”

And there are multiple ways people can stay fit without going to a gym, though outdoor exercise can be difficult sometimes because of heat and wildfire smoke, or in high-crime areas.

In many cases, the pandemic restrictions are crushing enterprises small-business owners have struggled to build over a lifetime. They’ve invested their savings, time, sweat and dreams in building something from the ground up, and now it’s threatened.

Aguilar, who owns the training facility company, said he comes from a broken family, was homeless and penniless at age 16 and later got his start giving physical training lessons out of his garage. From that, he built his coast-to-coast chain.

“At this point,” he said, “if I’m going to lose it all, I might as well go down fighting.”

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

Related Topics

Public Health

How to Stay Safe in the Kitchen With Kids

How to Stay Safe in the Kitchen With Kids

Alice Callahan

Alice CallahanReporting from Eugene, Ore. 🥣

Handle raw meat and poultry safely.

Always thaw and marinate meat in the fridge, not on the countertop.

Don’t rinse raw poultry such as turkey or chicken before cooking. You’re more likely to splatter harmful germs around your sink and beyond than you are to wash them away.

Cutting boards, dishes, knives and utensils that have touched raw meat should be washed with hot, soapy water before be used with other foods.

Tiny Love Stories: ‘We Could Only See Each Other’s Eyes’

A Mint Lifesaver

After the funeral, I tidied the guest room for my mother, who was moving in temporarily while adjusting to life without my father. I was restless, believing I should have convinced him to see a doctor sooner. When I pulled a cloth along the closet shelf, a shower of mint Lifesavers rained down, left behind from my father’s last visit. An ex-smoker, he always kept his mouth busy. I unwrapped one, placing it, Communion-like, on my tongue. I wasn’t able to save my father’s life; the lung cancer was a wildfire. But as the Lifesaver dissolved, it cleansed me. — Julia Bruce

With my father circa 1977 on the boardwalk in Point Pleasant, N.J.
With my father circa 1977 on the boardwalk in Point Pleasant, N.J.

Within His Radius

Visiting my parents in Seattle, I expected my Tinder match with Jason to go like all the rest: warm hello, flirty banter, gradual trailing off. Back then, I traveled constantly for work, swiping everywhere, jaded but still looking despite myself. I returned home to Boston before Jason and I could meet. We communicated constantly. Discovering that neither of us had plans for Thanksgiving, we decided to meet somewhere between us (Nashville) and celebrate. We ate turkey and potatoes on our first date. One year married, Jason admits that he wasn’t looking for anyone outside of a five-mile radius. — Ian McKinley

At our wedding last year in Aberdeenshire, Scotland. Jason is on the right.

She’s Back in Our Bed

In 1998, I decided to get rid of my very 1980s-looking bachelor furniture. After posting on Craigslist, a gentleman came over with a tape measure. Everything would fit, including my king-size platform bed. He just needed run it by his girlfriend. The next day, the doorbell rang. When I opened the door, I saw the man and my ex-girlfriend from 20 years earlier. We shared our surprise, then moved on to the bedroom set. They said it was perfect. I said to my ex, “That was ours — are you sure you want it?” “Absolutely.” And off they went. — Paul Weinberg

 The view from my front door.

Eyes Only

Two travel nurses, we arrived in New Mexico to help with the pandemic. We met in the hospital’s Covid-19 tent, glimmers of desert sun streaming in. Pushing through 12-and-a-half-hour shifts, we interacted as we treated patients and tested the sick. A quiet connection grew. With our faces covered, we could only see each other’s eyes. I didn’t see his hidden smile for weeks. When I did, it felt like seeing weeks of masked smiles in an instant. His face, once unknown, soon became home. His heart, a remedy for uncertainty. — Jacqueline McMahon

Our smiling eyes.

See more Tiny Love Stories at nytimes.com/modernlove. Submit yours at nytimes.com/tinylovestories.

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Masks Offer Covid Protection, Provided You Wear Them Right

Is it time to upgrade your mask?

By now most of us have settled on a preferred cloth mask to protect ourselves and others from coronavirus. But new research shows that a few simple upgrades in fabric, filters and fit are likely to provide even more protection.

Linsey Marr, professor of civil and environmental engineering at Virginia Tech and one of the world’s leading aerosol scientists, led the research, which tested 11 different mask materials. The findings confirmed what other labs have found: You don’t need a gold-standard N95 medical mask to stay safe from coronavirus. The right cloth mask, properly fitted, does a good job of filtering viral particles of the size most likely to cause infection.

But Dr. Marr and her colleagues found that small improvements to your mask can go a long way toward improving how well the mask protects you and others from potential infectious particles. They found that:

Three layers are better than two. The best mask has two tightly woven layers of outer material with a filter material sandwiched in the middle, Dr. Marr said. You can use surgical mask material or even a piece of a vacuum bag as a filter between two pieces of fabric. Coffee filters are an option, but can be less breathable. If you like your two-layer mask, you can just wear it over a surgical mask when you want added protection. A well-fitting fabric mask with a third filter layer can stop 74 to 90 percent of risky particles, the researchers found.

Flexible material is better. Stiff material creates gaps. Look for a mask made of tightly woven flexible material that contours to your face. Masks with wire that can be molded around the nose also fit better by closing gaps where air can escape out and seep in.

Ties are better than ear loops. Masks that tie around your head fit better and can be more comfortable. Ear loop masks can leave bigger gaps around your face and cause ears to become sore with longer use.

Face shields should be used with a mask. Face shields alone offered little to no protection. Although the clear plastic shield is impermeable, air seeps out and comes in around the edges of the shield. “It was the worst of everything,” said Jin Pan, a civil and environmental engineering Ph.D. student who was a co-author of the study. A face shield combined with a mask offers added protection, particularly for the eyes.

A well-fitted mask protects the wearer. Dr. Marr and her colleagues tested cloth masks for how well they protected others (outward protection) as well as the wearer (inward protection). Although masks are most efficient at filtering outgoing germs, they do stop incoming germs at nearly the same rate in most cases, the researchers found. Masks that did a poor job protecting the wearer were those made of stiffer materials and those worn loosely and with gaps around the edges.

A recent study from Denmark suggested that masks don’t protect the wearer, but Dr. Marr noted that in that study, many people weren’t using masks properly. “Fewer than half wore them as instructed,” Dr. Marr said. Although Dr. Marr’s findings come from a lab, rather than the real world, she said her group’s latest research should offer reassurance to people who wear well-fitted masks that they are getting additional protection from other people’s germs.

The research should also reassure people about the benefits of cloth masks, Dr. Marr said. She noted that masks can’t do “100 percent of the work,” and it’s important to combine mask wearing with other measures, like hand-washing and restricting social contacts.

“Something is better than nothing,” Dr. Marr said. “Even the simplest cloth mask of one layer of material blocks half or more of aerosols we think are important to transmission. If you go to a tighter weave and more layers, you’ll get even better performance.”

The Virginia Tech study was published online and has not yet been peer reviewed.

Masks Offer Covid Protection, Provided You Wear Them Right

Is it time to upgrade your mask?

By now most of us have settled on a preferred cloth mask to protect ourselves and others from coronavirus. But new research shows that a few simple upgrades in fabric, filters and fit are likely to provide even more protection.

Linsey Marr, professor of civil and environmental engineering at Virginia Tech and one of the world’s leading aerosol scientists, led the research, which tested 11 different mask materials. The findings confirmed what other labs have found: You don’t need a gold-standard N95 medical mask to stay safe from coronavirus. The right cloth mask, properly fitted, does a good job of filtering viral particles of the size most likely to cause infection.

But Dr. Marr and her colleagues found that small improvements to your mask can go a long way toward improving how well the mask protects you and others from potential infectious particles. They found that:

Three layers are better than two. The best mask has two tightly woven layers of outer material with a filter material sandwiched in the middle, Dr. Marr said. You can use surgical mask material or even a piece of a vacuum bag as a filter between two pieces of fabric. Coffee filters are an option, but can be less breathable. If you like your two-layer mask, you can just wear it over a surgical mask when you want added protection. A well-fitting fabric mask with a third filter layer can stop 74 to 90 percent of risky particles, the researchers found.

Flexible material is better. Stiff material creates gaps. Look for a mask made of tightly woven flexible material that contours to your face. Masks with wire that can be molded around the nose also fit better by closing gaps where air can escape out and seep in.

Ties are better than ear loops. Masks that tie around your head fit better and can be more comfortable. Ear loop masks can leave bigger gaps around your face and cause ears to become sore with longer use.

Face shields should be used with a mask. Face shields alone offered little to no protection. Although the clear plastic shield is impermeable, air seeps out and comes in around the edges of the shield. “It was the worst of everything,” said Jin Pan, a civil and environmental engineering Ph.D. student who was a co-author of the study. A face shield combined with a mask offers added protection, particularly for the eyes.

A well-fitted mask protects the wearer. Dr. Marr and her colleagues tested cloth masks for how well they protected others (outward protection) as well as the wearer (inward protection). Although masks are most efficient at filtering outgoing germs, they do stop incoming germs at nearly the same rate in most cases, the researchers found. Masks that did a poor job protecting the wearer were those made of stiffer materials and those worn loosely and with gaps around the edges.

A recent study from Denmark suggested that masks don’t protect the wearer, but Dr. Marr noted that in that study, many people weren’t using masks properly. “Fewer than half wore them as instructed,” Dr. Marr said. Although Dr. Marr’s findings come from a lab, rather than the real world, she said her group’s latest research should offer reassurance to people who wear well-fitted masks that they are getting additional protection from other people’s germs.

The research should also reassure people about the benefits of cloth masks, Dr. Marr said. She noted that masks can’t do “100 percent of the work,” and it’s important to combine mask wearing with other measures, like hand-washing and restricting social contacts.

“Something is better than nothing,” Dr. Marr said. “Even the simplest cloth mask of one layer of material blocks half or more of aerosols we think are important to transmission. If you go to a tighter weave and more layers, you’ll get even better performance.”

The Virginia Tech study was published online and has not yet been peer reviewed.

6 Steps to a Great Thanksgiving Nap

Scientists have debunked the theory that Thanksgiving naps are caused solely by a rush of tryptophan, an amino acid in turkey and other poultry. Most agree that the towering heaps of carbohydrates eaten with the turkey are more likely to induce sleep.

But what if we’ve been looking at the question the wrong way? What if, instead of treating the nap as an unfortunate side effect of the meal, we saw it as a goal we should strive for? If you experience insomnia you should probably avoid napping, but if you don’t, Sara E. Alger, a sleep scientist at the Walter Reed Army Institute of Research in Silver Springs, Md., suggested these ways you can arrange Thanksgiving to ensure a really productive and restorative nap:

1. Eat early.

In our natural circadian rhythms, most of us experience a dip in alertness between 1 and 3 p.m. “If you can time your nap to happen at that time, you’ll get a really great restorative nap,” Dr. Alger said.

2. Eat heartily.

Digesting a big meal takes a lot of energy, which leaves you sleepy.

3. Hold off on caffeine.

Coffee after the turkey may keep you from falling asleep. A cup right after you wake up, though, can help cut through the post-nap fog.

4. Get some privacy.

Rather than falling asleep in front of the television in the busiest room of the house, Dr. Alger recommends retreating to a cool, quiet bedroom. Draw the shades or wear an eye mask. Act as if you mean it.

5. Sleep as long as you like.

Although it’s easier to bounce back from a 20-minute “power nap,” staying under for 60 to 90 minutes can bring you to a deeper, more refreshing stage of sleep. “The longer the nap, the more benefits you’ll get,” Dr. Alger said.

6. Don’t wait too long.

Naps taken late in the day can make it harder to sleep at night.

This Thanksgiving, It’s Time to Stop Nap-Shaming

Like many Americans, the chef Nicole Pederson enjoys stretching out on the couch after the turkey and stuffing have been cleared, closing her eyes and losing consciousness for a short time. But 2012 was when she proved she was no ordinary Thanksgiving napper.

She had opened a new restaurant that fall in Evanston, Ill. By Thanksgiving Day, when she showed up at the house of a friend who was going to cook an elaborate, multicourse Caribbean-inspired menu, the long hours had caught up with her.

She took her first nap of the day before noon, shortly after downing a glass of Champagne. She returned to the couch after the appetizer, a squash-and-cheese empanada, and was awakened in time to eat the hearts-of-palm salad. From that point on, she said, “I think I slept between every course.”

Ms. Pederson has never equaled the daring structure and heroic commitment of her serialized nap of 2012, but her friends nevertheless expect her to make at least some effort each November. “They feel like it wasn’t Thanksgiving if they haven’t seen me pass out on the couch somewhere,” she said.

As Ms. Pederson’s friends understand, a great Thanksgiving Day nap can be an inspiration. For some reason, though, journalism on the subject tends to be written as if curling up on the nearest piece of upholstery were a criminal activity.

Some newspaper and magazine accounts of Thanksgiving naps use language more typically found in court reporting and police-blotter items. A 2014 article in The Washington Post noted that while some people had attempted to “blame the turkey” for the grogginess we feel after Thanksgiving dinner, the sides and desserts had been revealed as “the real culprits.” Men’s Journal concurred, reporting that “the bird may not be guilty after all.”

Other writers borrow from medical literature, identifying the relaxed condition caused by drumsticks and gravy as a “food coma.” In this metaphor, the fault is not the meal’s. It is ours, for eating so greedily that we succumb to a self-inflicted, though temporary, brain injury.

One may well wonder how a quick swoon on the sofa became so fraught. We find it adorable that cats, dogs and babies take a short afternoon snooze, but when adults do it one day a year, something must be wrong.

Instead of asking how to prevent naps, why aren’t there more articles giving advice on the best ways to induce one? After all, a napping Thanksgiving guest is a guest who isn’t insulting a family member’s romantic choices, or spouting political beliefs so retrograde they would have shocked George Wallace, or doing any number of other things people don’t do when they’re unconscious.

The subtle shaming of Thanksgiving nappers comes as no surprise to sleep experts. Sara E. Alger, a sleep scientist at the Walter Reed Army Institute of Research in Silver Spring, Md., has been a public advocate for naps, particularly in the workplace, except in cases of insomnia. Along the way, she has had to fight anti-nap prejudice.

“Naps in general have a stigma attached to them as something you only do when you’re lazy or when you’re sick,” Dr. Alger said.

Wrapped inside nap phobia in the United States is often a message reminding us to be productive during what we now think of as normal working hours, although that concept is relatively new.

Modern attitudes about napping go back to the Industrial Revolution, according to Matthew J. Wolf-Meyer, an anthropologist at Binghamton University in New York and the author of “The Slumbering Masses: Sleep, Medicine, and Modern American Life.”

“For a long time, people had flexible sleep schedules,” Dr. Wolf-Meyer said. Farmers and tradespeople had some autonomy over their time. They could choose to rest in the hottest part of the day, and might take up simple tasks during a wakeful period in the middle of the night, between two distinct bouts of sleep.

As the 1800s went on, more and more Americans worked in factories on set shifts that were supervised by a foreman. “They work for a total stranger, and a nap becomes totally nonnegotiable,” he said.

Staying awake all day and getting one’s sleep in a single long stretch at night came to be seen as normal. With that came a strong societal expectation that we ought to use our daylight hours productively.

“Even on a holiday, we’re not exempt from those expectations about productivism,” Dr. Wolf-Meyer said. “Even on Thanksgiving. You’re supposed to be doing something, even if it’s watching TV. Our labor on holidays is to interact with our relatives. So the nap is kind of a problem.”

Credit…Craig Frazier

Whether we will have any relatives in the room to interact with this Thanksgiving is another question. Americans are being warned that if they make the trip over the river and through the woods to Grandmother’s house, Grandmother might not make it to Christmas.

To allow families to gather together even though they are gathering separately, Zoom will lift its 40-minute limit for free calls on Thanksgiving. This will allow people to schedule their naps around the video conference, a skill many of them began learning after work-from-home orders came down this spring.

Although there are no hard data so far on whether naps have been on the rise during 2020, sleep scientists like Dr. Alger think it’s likely. The many people who now work remotely no longer need to worry about the disapproving eyes of their colleagues if they want a brief, discreet period of horizontality in the afternoons.

If most offices reopen next year, as now seems possible, perhaps greater tolerance toward the adult nap will be one of the things salvaged from the smoking wreckage of the working-from-home era. (In a tweet last week, Dr. Wolf-Meyer called the pandemic “the largest (accidental) experiment with human #sleep ever conducted.”) In any case, this would be a good year to destigmatize the Thanksgiving nap.

Experts say that people who get seven to nine hours of sleep a day are less prone to catching infectious diseases, and better at fighting off any they do catch. Afternoon sleep counts toward your daily total, according to Dr. Alger.

This immunity boost, she said, is in addition to other well-known dividends of a good nap, like added energy, increased alertness, improved mood and better emotional regulation.

Included under the last rubric is a skill that seems especially useful for dealing with families, even if you never get closer to your relatives this year than a “Hollywood Squares”-style video grid: “Napping helps you be more sensitive to receiving other people’s moods,” Dr. Alger said. “So you’re not perceiving other people as being more negative than they are.”

Napping also helps you remember facts you learned right before nodding off. Given the way things have been going lately, of course, you may not see this as a plus. You could look at it from the reverse angle, though: Every hour before Jan. 1 that you spend napping is another hour of 2020 you won’t remember.

Rural Areas Send Their Sickest Patients to Cities, Straining Hospitals

Registered nurse Pascaline Muhindura has spent the past eight months treating COVID patients at Research Medical Center in Kansas City, Missouri.

But when she returns home to her small town of Spring Hill, Kansas, she’s often stunned by what she sees, like on a recent stop for carryout food.

“No one in the entire restaurant was wearing a mask,” Muhindura said. “And there’s no social distancing. I had to get out, because I almost had a panic attack. I was like, ‘What is going on with people? Why are we still doing this?’”

Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencing record-high infection and death rates.

Critically ill rural patients are often sent to city hospitals for high-level treatment and, as their numbers grow, some urban hospitals are buckling under the added strain.

Kansas City has a mask mandate, but in many smaller communities nearby, masks aren’t required — or masking orders are routinely ignored. In the past few months, rural counties in both Kansas and Missouri have seen some of the highest rates of COVID-19 in the country.

At the same time, according to an analysis by KHN, about 3 in 4 counties in Kansas and Missouri don’t have a single intensive care unit bed, so when people from these places get critically ill, they’re sent to city hospitals.

A recent patient count at St. Luke’s Health System in Kansas City showed a quarter of COVID patients had come from outside the metro area.

Two-thirds of the patients coming from rural areas need intensive care and stay in the hospital for an average of two weeks, said Dr. Marc Larsen, who leads COVID-19 treatment at St. Luke’s.

“Not only are we seeing an uptick in those patients in our hospital from the rural community, they are sicker when we get them because [doctors in smaller communities] are able to handle the less sick patients,” said Larsen. “We get the sickest of the sick.”

Dr. Rex Archer, head of Kansas City’s health department, warns that capacity at the city’s 33 hospitals is being put at risk by the influx of rural patients.

“We’ve had this huge swing that’s occurred because they’re not wearing masks, and yes, that’s putting pressure on our hospitals, which is unfair to our residents that might be denied an ICU bed,” Archer said.

study newly released by the Centers for Disease Control and Prevention showed that Kansas counties that mandated masks in early July saw decreases in new COVID cases, while counties without mask mandates recorded increases.

Hospital leaders have continued to plead with Missouri Republican Gov. Mike Parson, and with Kansas’ conservative legislature, to implement stringent, statewide mask requirements but without success.

Parson won the Missouri gubernatorial election on Nov. 3 by nearly 17 percentage points. Two days later at a COVID briefing, he accused critics of “making the mask a political issue.” He said county leaders should decide whether to close businesses or mandate masks.

“We’re going to encourage them to take some sort of action,” Parson said Thursday. “The holidays are coming and I, as governor of the state of Missouri, am not going to mandate who goes in your front door.”

In an email, Dave Dillon, a spokesperson for the Missouri Hospital Association, agreed that rural patients might be contributing to hospital crowding in cities but argued that the strain on hospitals is a statewide problem.

The reasons for the rural COVID crisis involve far more than the refusal to mandate or wear masks, according to health care experts.

Both Kansas and Missouri have seen rural hospitals close year after year, and public health spending in both states, as in many largely rural states, is far below national averages.

Rural populations also tend to be older and to suffer from higher rates of chronic health conditions, including heart disease, obesity and diabetes. Those conditions can make them more susceptible to severe illness when they contract COVID-19.

Rural areas have been grappling with health problems for a long time, but the coronavirus has been a sort of tipping point, and those rural health issues are now spilling over into cities, explained Shannon Monnat, a rural health researcher at Syracuse University.

“It’s not just the rural health care infrastructure that becomes overwhelmed when there aren’t enough hospital beds, it’s also the surrounding neighborhoods, the suburbs, the urban hospital infrastructure starts to become overwhelmed as well,” Monnat said.

Unlike many parts of the U.S., where COVID trend lines have risen and fallen over the course of the year, Kansas, Missouri and several other Midwestern states never significantly bent their statewide curve.

Individual cities, such as Kansas City and St. Louis, have managed to slow cases, but the continual emergence of rural hot spots across Missouri has driven a slow and steady increase in overall new case numbers — and put an unrelenting strain on the states’ hospital systems.

The months of slow but continuous growth in cases created a high baseline of cases as autumn began, which then set the stage for the sudden escalation of numbers in the recent surge.

“It’s sort of the nature of epidemics that things often look like they’re relatively under control, and then very quickly ramp up to seem that they are out of hand,” said Justin Lessler, an epidemiologist at Johns Hopkins Bloomberg School of Public Health.

Now, a recent local case spike in the Kansas City metro area is adding to the statewide surge in Missouri, with an average of 190 COVID patients per day being admitted to the metro region’s hospitals. The number of people hospitalized throughout Missouri increased by more than 50% in the past two weeks.

Some Kansas City hospitals have had to divert patients for periods of time, and some are now delaying elective procedures, according to the University of Kansas Health system’s chief medical officer, Dr. Steven Stites.

But bed space isn’t the only hospital resource that’s running out. Half of the hospitals in the Kansas City area are now reporting “critical” staffing shortages. Pascaline Muhindura, the nurse who works in Kansas City, said that hospital workers are struggling with anxiety and depression.

“The hospitals are not fine, because people taking care of patients are on the brink,” Muhindura said. “We are tired.”

This story is from a reporting partnership that includes KCUR, NPR and KHN.

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For Nurses Feeling the Strain of the Pandemic, Virus Resurgence Is ‘Paralyzing’

For Christina Nester, the pandemic lull in Massachusetts lasted about three months through summer into early fall. In late June, St. Vincent Hospital had resumed elective surgeries, and the unit the 48-year-old nurse works on switched back from taking care of only COVID-19 patients to its pre-pandemic roster of patients recovering from gallbladder operations, mastectomies and other surgeries.

That is, until October, when patients with coronavirus infections began to reappear on the unit and, with them, the fear of many more to come. “It’s paralyzing, I’m not going to lie,” said Nester, who’s worked at the Worcester hospital for nearly two decades. “My little clan of nurses that I work with, we panicked when it started to uptick here.”

Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus. The push-pull of those forces, amid a fight against a deadly disease, is straining this vital backbone of health providers nationwide, and that could accumulate to unstainable levels if the virus’s surge is not contained this winter, advocates and researchers warn.

Nurses spend the most sustained time with a patient of any clinician, and these days patients are often incredibly fearful and isolated, said Cynda Rushton, a registered nurse and bioethicist at Johns Hopkins University in Baltimore.

“They have become, in some ways, a kind of emotional surrogate for family members who can’t be there, to support and advise and offer a human touch,” Rushton said. “They have witnessed incredible amounts of suffering and death. That, I think, also weighs really heavily on nurses.”

A study published this fall in the journal General Hospital Psychiatry found that 64% of clinicians working as nurses, nurse practitioners or physician assistants at a New York City hospital screened positively for acute distress, 53% for depressive symptoms and 40% for anxiety — all higher rates than found among physicians screened.

Researchers are concerned that nurses working in a rapidly changing crisis like the pandemic — with problems ranging from staff shortages that curtail their time with patients to enforcing visitation policies that upset families — can develop a psychological response called “moral injury.” That injury occurs, they say, when nurses feel stymied by their inability to provide the level of care they believe patients require.

Dr. Wendy Dean, co-founder of Moral Injury of Healthcare, a nonprofit organization based in Carlisle, Pennsylvania, said, “Probably the biggest driver of burnout is unrecognized unattended moral injury.”

In parts of the country over the summer, nurses got some mental health respite when cases declined, Dean said.

“Not enough to really process it all,” she said. “I think that’s a process that will take several years. And it’s probably going to be extended because the pandemic itself is extended.”

Sense of Powerlessness

Before the pandemic hit her Massachusetts hospital “like a forest fire” in March, Nester had rarely seen a patient die, other than someone in the final days of a disease like cancer.

Suddenly she was involved with frequent transfers of patients to the intensive care unit when they couldn’t breathe. She recounts stories, imprinted on her memory: The woman in her 80s who didn’t even seem ill on the day she was hospitalized, who Nester helped transport to the morgue less than a week later. The husband and wife who were sick in the intensive care unit, while the adult daughter fought the virus on Nester’s unit.

“Then both parents died, and the daughter died,” Nester said. “There’s not really words for it.”

During these gut-wrenching shifts, nurses can sometimes become separated from their emotional support system — one another, said Rushton, who has written a book about preventing moral injury among health care providers. To better handle the influx, some nurses who typically work in noncritical care areas have been moved to care for seriously ill patients. That forces them to not only adjust to a new type of nursing, but also disrupts an often-well-honed working rhythm and camaraderie with their regular nursing co-workers, she said.

At St. Vincent Hospital, the nurses on Nester’s unit were told one March day that the primarily postsurgical unit was being converted to a COVID unit. Nester tried to squelch fears for her own safety while comforting her COVID-19 patients, who were often elderly, terrified and sometimes hard of hearing, making it difficult to communicate through layers of masks.

“You’re trying to yell through all of these barriers and try to show them with your eyes that you’re here and you’re not going to leave them and will take care of them,” she said. “But yet you’re panicking inside completely that you’re going to get this disease and you’re going to be the one in the bed or a family member that you love, take it home to them.”

When asked if hospital leaders had seen signs of strain among the nursing staff or were concerned about their resilience headed into the winter months, a St. Vincent spokesperson wrote in a brief statement that during the pandemic “we have prioritized the safety and well-being of our staff, and we remain focused on that.”

Nationally, the viral risk to clinicians has been well documented. From March 1 through May 31, 6% of adults hospitalized were health care workers, one-third of them in nursing-related occupations, according to data published last month by the Centers for Disease Control and Prevention.

As cases mount in the winter months, moral injury researcher Dean said, “nurses are going to do the calculation and say, ‘This risk isn’t worth it.’”

Juliano Innocenti, a traveling nurse working in the San Francisco area, decided to take off for a few months and will focus on wrapping up his nurse practitioner degree instead. Since April, he’s been seeing a therapist “to navigate my powerlessness in all of this.”

Innocenti, 41, has not been on the front lines in a hospital battling COVID-19, but he still feels the stress because he has been treating the public at an outpatient dialysis clinic and a psychiatric hospital and seen administrative problems generated by the crisis. He pointed to issues such as inadequate personal protective equipment.

Innocenti said he was concerned about “the lack of planning and just blatant disregard for the basic safety of patients and staff.” Profit motives too often drive decisions, he suggested. “That’s what I’m taking a break from.”

Building Resiliency

As cases surge again, hospital leaders need to think bigger than employee assistance programs to backstop their already depleted ranks of nurses, Dean said. Along with plenty of protective equipment, that includes helping them with everything from groceries to transportation, she said. Overstaff a bit, she suggested, so nurses can take a day off when they hit an emotional cliff.

The American Nurses Association, the American Association of Critical-Care Nurses (AACN) and several other nursing groups have compiled online resources with links to mental health programs as well as tips for getting through each pandemic workday.

Kiersten Henry, an AACN board member and nurse practitioner in the intensive care unit at MedStar Montgomery Medical Center in Olney, Maryland, said that the nurses and other clinicians there have started to gather for a quick huddle at the end of difficult shifts. Along with talking about what happened, they share several good things that also occurred that day.

“It doesn’t mean that you’re not taking it home with you,” Henry said, “but you’re actually verbally processing it to your peers.”

When cases reached their highest point of the spring in Massachusetts, Nester said there were some days she didn’t want to return.

“But you know that your friends are there,” she said. “And the only ones that really truly understand what’s going on are your co-workers. How can you leave them?”

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