From Health and Fitness

Benzodiazepines Tied to Higher Risk of Ectopic Pregnancy

Women who take benzodiazepines, such as Valium or Xanax, before becoming pregnant may be at increased risk for ectopic pregnancy, a new study found.

An ectopic, or tubal, pregnancy is one in which a fertilized egg grows outside the uterus, often in a fallopian tube, and it is a life-threatening event. The egg must be removed with medication or surgery. Benzodiazepines, sold by prescription under several brand names, are widely prescribed for anxiety, sleep problems and seizures.

The study, in Human Reproduction, used an insurance database of 1,691,366 pregnancies to track prescriptions for benzodiazepines in the 90 days before conception. Almost 18,000 of the of the women had used the drugs, and the scientists calculated that these women were 47 percent more likely to have a tubal pregnancy than those who did not.

The study controlled for other risks for tubal pregnancy, including sexually transmitted infections, pelvic infection, use of an intrauterine device, smoking and fertility treatments.

“Women planning a pregnancy who are using these drugs should talk to their care provider to see whether a change in treatment is possible, and then slowly change treatment before going off their contraceptive,” said the lead author, Elizabeth Wall-Wieler, a postdoctoral fellow at Stanford University. “Women for whom there is no alternative, or who have an unplanned pregnancy, should let their care provider know, and those pregnancies should be monitored carefully. The key to treating ectopic pregnancy is to treat it early.”

Police Using Rubber Bullets On Protesters That Can Kill, Blind Or Maim For Life

In cities across the country, police departments have attempted to quell unrest spurred by the death of George Floyd by firing rubber bullets into crowds, even though five decades of evidence shows such weapons can disable, disfigure and even kill.

In addition to rubber bullets — which often have a metal core — police have used tear gas, flash grenades, pepper spray gas and projectiles to control crowds of demonstrators demanding justice for 46-year-old George Floyd, who died after a Minneapolis police officer knelt on his neck, while other officers restrained his body. Some peaceful demonstrations have turned violent, with people smashing windows, setting buildings afire and looting stores.

The use by police of rubber bullets has provoked outrage, as graphic images have flashed on social media showing people who have lost an eye or suffered other injuries after being hit.

A study published in 2017 in the BMJ found that 3% of people hit by rubber bullets died of the injury. Fifteen percent of the 1,984 people studied were permanently injured by the rubber bullets, also known as “kinetic impact projectiles.”

Rubber bullets should be used only to control “an extremely dangerous crowd,” said Brian Higgins, the former police chief of Bergen County, New Jersey.

“Shooting them into open crowds is reckless and dangerous,” said Dr. Douglas Lazzaro, a professor and expert in eye trauma at NYU Langone Health.

In the past week, a grandmother in La Mesa, California, was hospitalized in an intensive care unit after being hit between the eyes with a rubber bullet. Actor Kendrick Sampson said he was hit by rubber bullets seven times at a Los Angeles protest.

In Washington, D.C., the National Guard allegedly fired rubber bullets Monday to disperse peaceful protesters near a historic church where President Donald Trump was subsequently photographed.

In a statement, Attorney General William Barr defended the actions of local and federal law enforcement officers in Washington, saying they had “made significant progress in restoring order to the nation’s capital.”

Barr did not mention the use of tear gas or rubber bullets.

Freelance photographer Linda Tirado said she was blinded by a rubber bullet at a protest in Minneapolis.

In an email, Minneapolis Police Department spokesperson John Elder said, “We use 40 mm less-lethal foam marking rounds. We do not use rubber bullets.”

No one knows how often police use rubber bullets, or how many people are harmed every year, said Dr. Rohini Haar, a lecturer at the University of California-Berkeley School of Public Health and medical expert with Physicians for Human Rights. Many victims don’t go to the hospital.

Police are not required to document their use of rubber bullets, so there is no national data to show how often they’re used, said Higgins, now an adjunct professor at the John Jay College of Criminal Justice in New York. There are no nationally agreed-upon standards for their use.

When aimed at the legs, rubber bullets can stop a dangerous person or crowd from getting closer to a police officer, Lazzaro said.

But when fired at close range, rubber bullets can penetrate the skin, break bones, fracture the skull and explode the eyeball, he said. Rubber bullets can cause traumatic brain injuries and “serious abdominal injury, including injuries to the spleen and bowel along with major blood vessels,” said Dr. Robert Glatter, an emergency physician at New York’s Lenox Hill Hospital and a spokesperson for the American College of Emergency Physicians.

Firing rubber bullets from a distance decreases both their force and their accuracy, increasing the risk of shooting people in the face or hitting bystanders, Lazzaro said.

Physicians for Human Rights, a nonprofit advocacy group based in New York, has called for rubber bullets to be banned.

The British military developed rubber bullets 50 years ago to control nationalist rioters in Northern Ireland, although the United Kingdom stopped using them decades ago. Rubber bullets are used by Israeli security forces against Palestinian demonstrators. French police were criticized for using rubber bullets last year after dozens of “yellow jacket” demonstrators were blinded and hundreds were injured.

“Rubber bullets are used almost every day somewhere in the world,” Haar said. “Using them against unarmed civilians is a huge violation of human rights.”

Many “less than lethal” police weapons can cause serious harm, according to Physicians for Human Rights.

  • Acoustic weapons, such as sound cannons that make painfully loud noises, can damage hearing.
  • Tear gas can make it difficult to see and breathe.
  • Pepper spray, while painful and irritating, doesn’t cause permanent damage, Lazzaro said.
  • Pepper spray balls, which have been used to quell recent protests, can be deadly when used incorrectly. In 2004, a 21-year-old Boston woman was hit in the eye and killed by a pepper spray pellet fired by police to disperse crowds celebrating the city’s World Series win.
  • Disorientation devices that create loud noises and bright lights, known as concussion grenade or flash-bangs, can cause severe burns and blast injuries, including damage to the ear drum. Panicked crowds can cause crush injuries.
  • Water cannons can cause internal injuries, falls and even frostbite during cold weather.
  • Physical force, such as hitting someone to subdue them, causes about 1 in 3 people to be hospitalized, said Dr. Howie Mell, a spokesperson for the American College of Emergency Physicians and former tactical physician, who worked with SWAT teams.

Rubber bullets are less harmful than subduing people by “physical force or regular bullets, Mell said. “But we’re firing a lot more of them this week than we usually do.”

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Don’t Text and Drive to Save Young Lives

Enforcement of laws against texting while driving sharply reduces fatalities among teenage drivers, according to a new analysis.

Researchers studied data on 38,215 drivers, ages 16 to 19, who were involved in fatal crashes from 2007 to 2017. In 2007, only 15 states had distracted driving laws. By 2017, 46 states had them in some form.

In states with primary texting laws — those that allow police to pull over and cite a driver for texting alone without another offense — the rate of teenage driver fatalities was 29 percent lower than in states with no texting laws at all. In states with only secondary texting laws, which don’t allow the police to pull you over simply because you are texting, it was still 15 percent lower.

Teenage passengers were also less likely to die where texting laws were in effect. There was a 38 percent lower fatality rate for states with primary laws, and a 27 percent lower rate for those with secondary enforcement. The study is in Pediatrics.

“It would be nice to make texting while driving as taboo as drunk driving,” said the lead author, Dr. Michael R. Flaherty, a pediatric critical care physician at MassGeneral Hospital for Children in Boston. “And parents should set the example for their teenagers and younger children by always refraining from using a device while driving.”

State laws vary, but according to the National Conference of State Legislatures website, Montana is today the only state with no regulations on texting while driving.

Contratar a un “ejército” diverso para rastrear COVID-19 durante la reapertura

Como rastreadora de contactos, a Teresa Ayala-Castillo a veces le preguntan si los tés de hierbas y el Vicks VapoRub pueden tratar a COVID-19.

Estas terapias no son exactamente una guía oficial de salud, pero Ayala-Castillo no se sorprende. Escucha y luego sugiere otras ideas, como descansar y beber mucho líquido.

“No quiero decirles que son cuentos, porque estos remedios son cosas con las que estoy 100% familiarizada ya que mi mamá los usó conmigo”, dijo Ayala-Castillo, una ecuatoriana-estadounidense bilingüe, de primera generación, que trabaja para la ciudad de Long Beach, California.

Los departamentos de salud de los Estados Unidos trabajan a un ritmo frenético para dotar de personal a sus “ejércitos” de rastreadores de contactos para controlar la propagación del coronavirus que causa COVID-19.

Los expertos estiman que los departamentos de salud locales y estatales tendrán que agregar entre 100.000 y 300.000 personas para que la economía vuelva a funcionar.

Mientras organizan estos grupos, muchos estados y localidades quieren contratar a personas de minorías raciales y étnicas más afectadas por el virus. Entienden la necesidad de contar con rastreadores capacitados y culturalmente competentes que puedan convertir a contactos desconfiados o renuentes en participantes entusiastas en la campaña para erradicar el virus.

Las actividades de rastreo del virus varían según el estado. La mayoría han creado planes para añadir rastreadores de contactos mediante la contratación o el voluntariado, pero los más ricos —incluidos California, Connecticut, Massachusetts, Nueva Jersey, Nueva York y Washington— llevan ventaja, aseguró Marcus Plescia, director médico de la Asociación de Funcionarios de Salud Estatales y Territoriales.

Delaware, cuya meta es comenzar las contrataciones en un mes, dará prioridad a personas de comunidades vulnerables y que sean bilingües. Y Minnesota contrata personal con cuotas de diversidad que coinciden con la demografía de los casos de COVID-19 del estado.

“No hay una fórmula mágica que asegure el éxito de esa llamada y establezca una conversación productiva”, señaló Chris Elvrum, del Departamento de Salud de Minnesota. “Tenemos que entender que existen diferentes maneras de abordar el tema para las diferentes comunidades”.

El rastreo de la enfermedad funciona así: luego que alguien da positivo para COVID-19, un investigador del departamento de salud local llama al paciente para hacerle preguntas específicas sobre su salud, sus movimientos y con quién interactuó durante un cierto período de tiempo.

Luego, un rastreador llama a las personas identificadas por el paciente para hacerles saber que estuvieron potencialmente expuestos al virus. A estos contactos se les pide permanecer en casa por 14 días. Si viven con otras personas, la recomendación puede extenderse a esos individuos.

Si se siguen las órdenes de permanecer en casa, resulta relativamente fácil averiguar quién puede haber estado expuesto a la enfermedad, dicen funcionarios de salud.

Las personas infectadas por lo general sólo han estado con familiares o amigos cercanos y a menudo advierten a los contactos que esperen una llamada del departamento de salud, explicó Emily Holman, quien maneja el área enfermedades contagiosas de Long Beach.

Pero en algunos casos se puede requerir la presencia de trabajadores de campo, indicó la doctora Kara Odom Walker, secretaria del Departamento de Salud y Servicios Sociales de Delaware.

“Hay algunas comunidades que no van a responder a una llamada telefónica, a un mensaje de texto o a una carta”, dijo Walker. “Eso podría deberse a una falta de cultura de la salud, al miedo, o al estatus migratorio”.

Hasta ahora, la mayoría sigue las instrucciones, aseguran los funcionarios. Holman estima que menos del 1% de los contactados en Long Beach se negaron a participar.

Pero surgen problemas, especialmente entre quienes no pueden trabajar desde casa o son el único sustento de sus hijos, apuntó Elvrum.

Las personas notificadas sobre su contacto con alguien con COVID pueden pensar que la llamada es parte de un fraude, o preocuparse de que la información sea compartida con las autoridades de inmigración o que les cueste su trabajo.

Los departamentos de salud no tienen que entregar la información recopilada con fines médicos a las autoridades federales de inmigración, pero se necesita un rastreador de contactos sensible, empático y conocedor de la cultura para explicar esto.

“Necesitas a alguien que sea un agente cultural para decir, no sólo que estas medidas son para protegerte, sino para decir que confíes en mí y que todo irá bien”, comentó Walker. “Yo voy a asegurarme personalmente de que tienes lo que necesitas para una cuarentena segura”.

Teresa Ayala-Castillo, quien ha trabajado para la ciudad de Long Beach durante 20 años, fue supervisora de facturación antes de ser reasignada para localizar a los pacientes con COVID-19 en marzo. Ella dice que su experiencia como ecuatoriana estadounidense de primera generación ayuda a las personas a sentirse a gusto con ella por teléfono. (Cortesía de Teresa Ayala-Castillo)

Minnesota pondrá a 1,400 empleados a trabajar en la localización de contactos para julio, informó Elvrum. Los contratos estipulan que buscan a personas de grupos raciales y étnicos proporcionales a su número en el estado o al porcentaje de casos positivos de COVID-19 en esos grupos. Lo que sea más alto.

Se contrata a personas que hablen hmong, somalí y español, según Kou Thao, quien dirige el Centro para la Equidad en la Salud del Departamento de Salud de Minnesota.

Un 23% de los casos positivos del estado se registran entre personas de raza negra, que constituye sólo el 7% de la población total del estado. Los hispanos constituyen el 19% de los casos y el 6% de la población. Sin embargo, alrededor del 22% de los casos son desconocidos.

Virginia, que cuenta con 200 rastreadores de contactos y espera contratar un total de 1,300 empleados para apoyar el esfuerzo, busca personas que hablen de mandarín, criollo haitiano, español y bengalí, según Mona Bector, comisionada del Departamento de Salud del estado.

Virginia ha recibido más de 6,000 curriculums para estos puestos, dijo Bector.

Long Beach se enorgullece de una fuerza laboral diversa que refleja la población de la ciudad. Los funcionarios sacaron a sus rastreadores de contactos e intérpretes, incluyendo a Ayala-Castillo, de los miembros del personal municipal que hablan samoano, jemer, tagalo, español, vietnamita, mandarín y otros idiomas para crear una plantilla de 60 personas. Su objetivo es tener 200 personas entrenadas y listas para ser desplegadas cuando sea necesario.

Tener trabajadores que puedan hablar con los contactos en el idioma que prefieran es un paso importante, expresó Crystal Watson, del Centro de Seguridad Sanitaria de Johns Hopkins. Ser capaz de extraer información mientras se es sensible a las preocupaciones y desconfianzas de los pacientes es primordial, añadió.

El sargento Jairo Paulino, de 38 años, miembro de la Guardia Nacional de Delaware, es uno de los militares bilingües que se ofrecen a ayudar con las llamadas a los contactos de COVID-19. Cuando empezó el trabajo a mediados de mayo, notó que había un “gran atraso” en la lista de nombres porque el estado no tenía suficientes hispanohablantes para contactarlos a todos con rapidez.

Paulino nació en la República Dominicana y llegó a Nueva York de niño. Creció traduciendo para su padre y asistiendo a la iglesia; ambas referencias ayudan a construir la confianza en la comunidad latina, dijo.

El escaso acceso a Internet también plantea un desafío. En Tulare, un condado rural en el centro de California, los trabajadores de la salud piden a los pacientes que utilicen un portal en línea para ayudar a agilizar la recopilación de datos de sus contactos. Sin embargo, entre el 5% y el 10% de las personas no pueden conectarse a Internet, explicó Tiffany Swarthout, del departamento de salud del condado. En esos casos, los trabajadores de la salud hablarán con el paciente por teléfono.

Las preocupaciones laborales representan otra área de dificultad para los rastreadores de contactos. Algunas personas son reacias a quedarse en casa porque no tienen ingresos, especialmente si la pandemia ha dejado a miembros de la familia sin trabajo, señaló Jody Menick, una enfermera que supervisa la localización de contactos en el condado de Montgomery, Maryland, en las afueras de Washington, D.C.

Algunos empleadores solicitan pruebas de que los pacientes y sus contactos pueden regresar con seguridad después de la cuarentena, y algunas jurisdicciones proporcionan cartas oficiales que especifican el período de cuarentena del trabajador.

Pero los trabajadores indocumentados, que cuentan con menos protecciones que los empleados con estatus legal, han sido presionados para que se presenten a trabajar, contó Menick, poniéndoles en una situación muy difícil.

“¿Voy a conseguir dinero para comprar comida para mi familia, o me voy a quedar en casa?”

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Tiny Love Stories: ‘Why Aren’t You Happy?’

Single Dad Lockdown

I’m trapped in the house with Tenzing, my 6-year-old son. I cook vegetables for him, set up Zoom classes, play Monopoly Junior. He wants to pillow fight when I’m working, ride on my back when I’m reading. Does he watch too much YouTube? Should we sneak into the playground? When will this end? It’s a relief when his mother picks him up for her four days. But as soon as he’s gone, I call her to ask how he’s doing. I’d rather have him driving me crazy than feel his absence in this house. — Ranjan Adiga

ImageMe and my mini me.
Me and my mini me.

Never Too Old for Butterflies

A man shows up at my nonprofit. He appears to be more interested in me than in his volunteer tasks. “I’m in a committed relationship,” I tell him the third time he comes back. He asks, “Why aren’t you happy?” Huh? I have a house, children, dog and retirement account. “I’m fine,” I reply. I’m almost 60, too old for these butterflies. Too old to remake my life. A close friend dies in a motorcycle accident. He always asked me why I put myself last. Was I happy? Six years with my new love and life, I’ve never been so happy. — Susan Murphy

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Embracing my happiness.

A Gleeful Scream on Graduation Day

Although I woke up 1,667 miles from my university on graduation day, I was greeted with diploma-shaped balloons, a whiteboard emblazoned with “Congratulations!” and childhood pictures plastered across my bedroom door. The morning continued with freshly made masala dosa and culminated with my parents competing to take a picture of my graduation slide as my name was read. My mother’s face fell when she thought she’d missed it. Upon discovering that she had captured the moment, she let out a gleeful scream. As we hugged, I decided not to mention that our online graduation was being fully recorded. — Julie Thamby

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Selfie with my mother during my graduation.

The World From Our Window

May 25, 2020, was our second anniversary. Thinking about our wedding feels like staring into the sun — so brilliant that it hurts. In photos we embrace people more freely than it seems we ever will again. But I know that’s not true. This afternoon, the street outside our Brooklyn window is closed to traffic. We spend the day watching a girl learn to ride her bike. Then another joins her. Their little circles, slowly getting wide, are a comfort. We’ll have ease again. Until then, I have a person to join me at the window and watch the world. — Lindsay Vranizan

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Together in our window.

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How a Delay in Colonoscopy Screening May Affect Cancer Risk

Current guidelines recommend a colonoscopy starting at age 45 to 50, and then one every 10 years afterward if the results are negative. Those guidelines should still be followed, though for people at low risk for colon cancer, delays in colonoscopy screening may not dramatically affect cancer risk, a new study suggests.

The analysis, in Annals of Internal Medicine, included 165,887 men and women aged 50 to 66 who had a single negative colonoscopy. At 17 years after the initial test, compared with the general population, the group had a 72 percent lower rate of colon cancer and an 81 percent lower rate of death — not significantly different from results at 10 years and earlier.

But the finding pertains only to people with no polyps or other lesions, benign or malignant, at the first colonoscopy, and who are at low risk for colon cancer. It does not apply to anyone with a family history of colorectal cancer, inflammatory bowel conditions, or any other factors that increase colon cancer risk.

Most important, the finding depends on high-quality colonoscopy performed by a skilled endoscopist on a patient with adequate bowel preparation.

“It’s impossible to achieve zero risk,” said the lead author, Dr. Nastazja Dagny Pilonis, a researcher at the National Research Institute of Oncology in Warsaw. “But if you have a negative colonoscopy, and your bowel was adequately prepared, and your endoscopist was skilled, then you are at very low risk of colon cancer for at least 17 years.”

Hiring A Diverse Army To Track COVID-19 Amid Reopening

As a contact tracer, Teresa Ayala-Castillo is sometimes asked whether herbal teas and Vicks VapoRub can treat COVID-19. These therapies aren’t exactly official health guidance, but Ayala-Castillo isn’t fazed. She listens and then suggests other ideas — like getting rest and drinking plenty of fluids.

“I don’t want to call them old wives’ tales, but these remedies are things that I’m 100% familiar with because my mom used them on me,” said Ayala-Castillo, a bilingual first-generation Ecuadorian American who works for the city of Long Beach, California.

Health departments across the U.S. are working at a furious pace to staff their armies of contact tracers to control the spread of the coronavirus that causes COVID-19. Experts estimate local and state health departments will have to add 100,000 to 300,000 people to get the economy back on track.

As they build these forces, many states and localities are trying hard to hire from the racial and ethnic minority communities hit hardest by the virus. They’re anticipating a need for skilled, culturally competent tracers who can convert suspicious or hesitant contacts into enthusiastic, willing participants in the drive to stamp out the virus.

Virus-tracking activities vary by state. Most states have created plans to add contact tracers through hiring or volunteering, but wealthier ones — including California, Connecticut, Massachusetts, New Jersey, New York and Washington — are further along than others, said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials.

Delaware, which aims to begin hiring in a month, plans to prioritize hires from vulnerable communities with bilingual language skills. Minnesota is hammering out staffing contracts with diversity quotas that match the demographics of the state’s COVID-19 cases.

“One size does not fit all for making that first call and being successful in having them pick up the phone and have a good conversation,” said Chris Elvrum, a deputy incident manager at the Minnesota Department of Health. “We need to recognize that we have to approach it in different ways for different cultural communities in the state.”

Tracking the disease works like this: After someone tests positive for COVID-19, a case investigator from the local health department calls the patient to ask detailed questions about her health, movements and whom she interacted with over a certain time frame. A contact tracer then calls everyone the patient named to let them know they were potentially exposed to the virus. These contacts are instructed to stay home and self-quarantine for 14 days after the exposure. If they live with other people, the recommendation may extend to those individuals.

Under stay-at-home orders, it’s often relatively easy to figure out who may have been exposed to the disease, health officials say. Infected people usually have been around only family or close friends and will often warn contacts to expect a call from the health department, said Emily Holman, communicable disease controller for Long Beach.

But shoe-leather fieldworkers may be required in some instances, said Dr. Kara Odom Walker, secretary of the Delaware Department of Health and Social Services. “There are some communities that aren’t going to respond to a phone call, a text message or a letter,” said Walker. “That could be due to health literacy issues, which could be due to fear, or documentation status.”

So far, most people are following instructions, say officials. Holman estimates that fewer than 1% of those contacted in Long Beach refused to participate.

Teresa Ayala-Castillo, who has worked for the city of Long Beach for 20 years, was a billing supervisor before being reassigned to contact tracing for COVID-19 patients in March. She says her background as a first-generation Ecuadorian American helps people feel at ease with her on the phone. (Courtesy of Teresa Ayala-Castillo)

But some defiance is likely, especially among those who cannot work from home or are the only provider for their children, Elvrum said. People being notified about contacts with a COVID-positive patient might think the call is a scam, or worry the information will be shared with immigration authorities or cost them their job. Health departments do not have to turn information collected for medical purposes over to federal immigration enforcement, but it takes a sensitive, empathetic and knowledgeable contact tracer to explain this.

“You need someone to be a cultural broker to say, not only are these policies in place to protect you, but I’m telling you to trust me that this will be OK,” Walker said. “I’m going to make sure you have what you need to safely quarantine.”

Minnesota plans to dedicate 1,400 staffers to contact tracing by July, Elvrum said. Contracts with two companies involved in the hiring stipulate that they bring on people of racial and ethnic groups proportional to their numbers in the state or the percentage of positive COVID-19 cases in those groups — whichever is higher.

They’re seeking hires who speak Hmong, Somali and Spanish, said Kou Thao, director of the Center for Health Equity in the Minnesota Department of Health.

About 23% of the state’s positive cases are among black people, who make up only 7% of the state population. Hispanics make up 19% of cases — and 6% of the population. However, about 22% of the cases are unknown.

Virginia, which has 200 contact tracers and hopes to hire a total of 1,300 staff to support the effort, is looking for speakers of Mandarin, Haitian Creole, Spanish and Bengali, said Mona Bector, deputy commissioner for administration at the Virginia Department of Health.

The state has received more than 6,000 résumés for these positions, Bector said.

Long Beach prides itself on a diverse workforce that reflects the city’s population. Officials pulled their contact tracers and interpreters, including Ayala-Castillo, from municipal staff members who speak Samoan, Khmer, Tagalog, Spanish, Vietnamese, Mandarin and other languages to create a staff of 60. Their goal is to have 200 people trained and ready to deploy as needed.

Having workers who can speak to contacts in the language they prefer is a step forward, said Crystal Watson, a senior scholar from the Johns Hopkins Center for Health Security. Being able to extract information while being sensitive to patients’ concerns and mistrust is paramount, she added.

Sgt. Jairo Paulino, a 38-year-old member of the Delaware National Guard, is one of several bilingual guardsmen volunteering to help call COVID-19 contacts. When he started the job in mid-May, he noticed there was a “major backlog” of names because the state didn’t have enough Spanish speakers to reach out to everyone quickly.

Paulino was born in the Dominican Republic and moved to New York as a boy. He grew up translating for his father and attending church — both elements that help build trust in the Latino community, he said.

Poor access to the internet also poses a challenge. In Tulare, a rural county in central California, health workers ask patients to use an online portal to help streamline data collection of their contacts. However, 5% to 10% of people cannot get online, said Tiffany Swarthout, an administrative specialist at the county health department. In those cases, health workers will speak to the patient on the phone.

Employment concerns represent another tricky area for contact tracers. Some people they reach out to may hesitate to stay home because they are strapped for cash, especially if the pandemic has left members of the family without work, said Jody Menick, a nurse who supervises contact tracing in Montgomery County, Maryland, just outside Washington, D.C.

Some employers are requesting proof that patients and contacts were safe to return after quarantine, and some areas provide official letters that specify the worker’s quarantine period.

But undocumented workers — who have fewer protections than employees with legal status — have been pressured to show up to work in her area, Menick said, leaving them with a difficult decision.

“Am I going to have money to buy food for my family, or am I going to stay home?”

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Pandemic Presents New Hurdles, And Hope, For People Struggling With Addiction

Before Philadelphia shut down to slow the spread of the coronavirus, Ed had a routine: most mornings he would head to a nearby McDonald’s to brush his teeth, wash his face and — when he had the money — buy a cup of coffee. He would bounce between homeless shelters and try to get a shower. But since businesses closed and many shelters stopped taking new admissions, Ed has been mostly shut off from that routine.

He’s still living on the streets.

“I’ll be honest, I don’t really sleep too much,” said Ed, who’s 51 and struggling with addiction. “Every four or five days I get a couple hours.”

KHN agreed not to use his last name because he uses illegal drugs.

Philadelphia has the highest overdose rate of any big city in America — in 2019, more than three people a day died of drug overdoses there, on average. Before the coronavirus began spreading across the United States, the opioid overdose epidemic was the biggest health crisis on the minds of many city officials and public health experts. The coronavirus pandemic has largely eclipsed the conversation around the opioid crisis. But the crisis still rages on despite business closures, the cancellation of in-person treatment appointments and the strain on many addiction resources in the city.

When his usual shelter wasn’t an option anymore, Ed tried to get into residential drug treatment. He figured that would be a good way to try to get back on his feet and, if nothing else, get a few good nights of rest. But he had contracted pinkeye, a symptom thought to be associated with the virus that leads to COVID-19, so the evaluation center didn’t want to place him in an inpatient facility until he’d gotten the pinkeye checked out. But he couldn’t see a doctor because he didn’t have a phone for a telehealth appointment.

“I got myself stuck, and I’m trying to pull everything back together before it totally blows up,” he said.

Rosalind Pichardo wants to help people in Ed’s situation. Before the pandemic, Pichardo would hit the streets of her neighborhood, Kensington, which has the highest drug overdose rate in Philadelphia. She’d head out with a bag full of snack bars, cookies and Narcan, the opioid overdose reversal drug.

She’d hand Narcan out to people using drugs, and people selling drugs — anyone who wanted it. Pichardo started her own organization, Operation Save Our City, which initially set out to work with survivors of gun violence in the neighborhood. When she realized that overdoses were killing people too, she began getting more involved with the harm reduction movement and started handing out Narcan through the city’s syringe exchange.

When Pennsylvania’s stay-at-home order went into effect, Pichardo and others worried that more people might start using drugs alone, and that fewer first responders would be patrolling the streets or nearby and able to revive them if they overdosed.

So, Pichardo and other harm reduction activists gave out even more Narcan. A representative for Prevention Point Philadelphia, the group that operates a large syringe exchange program in the city, said that during the first month of the city’s stay-at-home order, they handed out almost twice as much Narcan as usual.

After the lockdowns and social distancing began, Pichardo worried that more people would be using drugs alone, leading to more overdoses. But Philadelphia’s fatal overdose rate during the pandemic remains about the same as it was this time last year. Pichardo said she thinks that’s evidence that flooding the streets with Narcan is working — that people are continuing to use drugs, and maybe even using more drugs, but that users are utilizing Narcan more often and administering it to one another.

That is the hope. But Pichardo said users don’t always have a buddy to keep watch, and during the pandemic first responders have seemed much more hesitant to intervene. For example, she recently administered Narcan to three people in Kensington who overdosed near a subway station, while two police officers stood by and watched. Before the pandemic, they would often be right there with her, helping.

To reverse the overdoses, Pichardo crouched over the people who she said had started turning blue as their oxygen levels dropped. She injected the Narcan into their noses, using a disposable plastic applicator. Normally, she would perform rescue breathing, too, but since the pandemic began she has started carrying an Ambu bag, which pumps air into a person’s lungs and avoids mouth-to-mouth resuscitation. Among the three people, she said, it took six doses of Narcan to revive them. The police officers didn’t step in to help but did toss several overdose-reversal doses toward Pichardo as she worked.

“I don’t expect ’em to give ’em rescue breaths if they don’t want to, but at least administer the lifesaving drug,” Pichardo said.

In her work as a volunteer, she has reversed almost 400 overdoses, she estimated.

“There’s social distancing — to a limit,” Pichardo said, “I think when someone’s life is in jeopardy, they’re worth saving. You just can’t watch people die.”

Even before Philadelphia officially issued its stay-at-home order, city police announced they would stop making low-level arrests, including for narcotics. The idea was to reduce contact overall, help keep the jail population low and reduce the risk of the virus getting passed around inside. But Pichardo and other community activists said the decreased law enforcement emboldened drug dealers in the Kensington neighborhood, where open-air drug sales and use are common.

“You can tell they have everything down pat, from the lookout to the corner boys to the one actually holding the product — the one holding the product’s got some good PPE gear,” said Pichardo.

More dealers working openly on the street has led to more fights over territory, she added, which in turn has meant more violence. While overall crime in Philadelphia and other major cities has declined during the pandemic, gun violence has spiked.

Police resumed arrests at the beginning of May.

Now when she goes out to offer relief and hand out Narcan, Pichardo packs a few extra things in her bag of supplies: face masks, gloves and gun locks.

“It’s like the survival kit of the ’hood,” she said.

For those struggling with addiction who are ready to start recovery, newly relaxed federal restrictions have made it easier to get medications that curb opioid cravings and stem withdrawal. Several efforts are underway among Philadelphia-based public health groups and criminal justice advocacy organizations to give cellphones to people who are homeless or coming out of jail, so they can make a telehealth appointment and get quicker access to a prescription for those medicines.

During the pandemic, people taking medication-assisted treatment can renew their prescription every month instead of every week, which helps decrease trips to the pharmacy. It is too soon to know if more people are taking advantage of the new rules, and accessing medication-assisted treatment via telehealth, but if that turns out to be the case, many addiction medicine specialists argue the new rules should become permanent, even after the pandemic ends.

“If we find that these relaxed restrictions are bringing more people to the table, that presents enormous ethical questions about whether or not the DEA should reinstate these restrictive policies that they had going in the first place,” said Dr. Ben Cocchiaro, a physician who treats people with substance-use disorder.

Cocchiaro said the whole point of addiction treatment is to facilitate help as soon as someone is ready for it. He hopes if access to recovery can be made simpler during a pandemic, it can remain that way afterward.

This story is part of a partnership that includes WHYY, NPR and Kaiser Health News.

Related Topics

Mental Health Public Health States

California AG Seeks More Power To Battle Merger-Hungry Health Care Chains

California’s health care industry has a consolidation problem.

Independent physician practices, outpatient clinics and hospitals are merging or getting gobbled up by private equity firms or large health care systems. A single company can dominate an entire community, and in some cases, vast swaths of the state.

Such dominance can inflate prices, and consumers end up facing higher insurance premiums, more expensive outpatient services and bigger out-of-pocket costs to see specialists.

Now that COVID-19 has slammed the health care industry, especially the small practices that are barely seeing patients, the trend is likely to accelerate.

“I don’t see anything that’s going to stop this wave of consolidations amongst docs,” said Glenn Melnick, a health care economist at the University of Southern California.

“If this thing goes on a long time,” he said of the coronavirus, “then it becomes a tsunami.”

California Attorney General Xavier Becerra has made battling health care consolidation a signature issue since he took office in 2017. With the additional pressure that COVID-19 is putting on vulnerable practices and facilities, Becerra is now pressing the state legislature to expand his authority to slow health care mergers.

“We find that in these times of crisis, economic and health crisis, that the smaller health care players and stakeholders are oftentimes most at risk of being swallowed up by the big fish,” Becerra told California Healthline.

His success would fundamentally change how the health care industry merges and grows in California.

When a health care system, private equity firm or hedge fund plans to merge with or acquire another practice or facility — whether that means buying a small practice or joining a multistate hospital chain — Becerra wants to know about it. He wants written notice, and the ability to deny any sale that doesn’t deliver better access, cost or quality health care to Californians.

Becerra already can regulate mergers among nonprofit health care facilities. Under SB-977, a collaboration between Becerra’s office and the legislature, he would get the ability to regulate the for-profit sector as well.

“Certainly it would put California where it’s accustomed to being,” Becerra said. “At the head of the pack.”

The bill has support from organized labor and consumer advocacy groups. Gov. Gavin Newsom has come out against health care consolidation in the past but hasn’t taken an official stance on the bill.

Yet Becerra isn’t convinced passage will be smooth.

“The biggest concern I have is the legislation will be killed by the industry,” he said. “We’ll end up seeing over-consolidation because decent practices that got on the edge could not swim with sharks.”

Indeed, health care industry players are already lining up against the bill. Alex Hawthorne, a lobbyist for the California Hospital Association, said that hospitals are stretched thin because of the pandemic, and that now isn’t the time for Becerra to be meddling in routine agreements between practices.

“It bestows absolute and arbitrary discretion on the office of the attorney general,” Hawthorne said at a budget hearing in May.

In 2010, about 25% of California physicians worked in a practice owned by a hospital. By 2016, more than 40% of doctors worked in hospital-owned practices, according to research published in the journal Health Affairs in 2018.

There’s evidence that consolidation can hurt consumers. A separate 2018 study found that the cost of medical procedures in highly consolidated Northern California was 20% to 30% higher than in Southern California.

Since 2018, California’s attorney general has had the authority to regulate mergers among nonprofit health care systems, which Becerra exercised the same year when considering a merger between two health care giants: Dignity Health and Catholic Health Initiatives. He said he would approve the deal only if the systems agreed to certain requirements, such as starting a homelessness program.

Later that year, Becerra joined a suit against Sutter Health for using its market power to drive up health care costs in Northern California.

The lawsuit alleged that Sutter, which has 24 hospitals and 34 surgery centers, had spent years buying up practices and facilities, giving insurers little choice but to include them in their networks and agree to higher rates for services.

In October 2019, Becerra secured a $575 million settlement against Sutter, which has yet to be finalized or paid out, that requires Sutter to change how it charges insurance companies and give patients more information about prices.

Sutter Health opposes SB-977, which was introduced in February by state Sen. Bill Monning (D-Carmel). The measure is intended to address some of the challenges Becerra encountered with the Sutter case, Becerra said.

“The best way to prevent problems from occurring in a merger is just to prevent the merger altogether,” said Jaime King, associate dean at UC Hastings College of the Law in San Francisco. “It’s really hard to unwind a merger after you’ve already done it.”

Under the measure, the attorney general must be notified before a system, hedge fund or private equity firm attempts to enter into a merger, acquisition or another kind of affiliation change with another practice or facility. The bill defines a health care system as one with two or more hospitals in multiple counties, or three or more hospitals within one county.

That would trigger a public review process allowing supporters and opponents to make their cases to a review board. The board would assess the transaction, using criteria to determine whether it would improve access, quality and price.

The bill also would make it illegal for systems to act anti-competitively and give the attorney general the power to bring a civil suit against monopolistic systems.

The Senate Health Committee approved the bill, which is expected to be heard in another committee this week.

“Maybe it does mean consolidation should occur, but only because we’ve done the oversight to make sure it’s because of quality and access,” Becerra said. “Not because a big fish wants to make bigger profit.”

The measure includes waivers for rural practices and a fast-track review process for transactions under $500,000.

The California Chamber of Commerce opposes the bill, as does the California Medical Association, which represents doctors. While the California Medical Association is concerned about the survival of small physician practices, it believes the bill is too broad and should focus more tightly on hospital consolidation, said spokesperson Anthony York.

“This approach will only further force smaller providers out of business,” especially as the health systems respond to the COVID-19 emergency, the group’s legislative advocate, Amy Durbin, wrote in a letter of opposition.

For many independent practices struggling for survival, the debate over Becerra’s powers is academic.

Dr. Sarah Azad, who owns a women’s health practice in Mountain View, California, said at least three independent practices in her area have started the process to merge or sell since March because of dramatically lower patient volume.

Her practice is fine for now, despite the fact that her patient volume was only about 30% of normal in March and 60% of normal in April. Azad received a loan from the federal Paycheck Protection Program for small businesses so she could pay her five doctors in May.

“If you catch me on a bad month, I feel like we’re one disaster away from bankruptcy,” Azad said.

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

Related Topics

California Health Industry

Getting Back to ‘Normal’ May Not Be So Easy. Crisis Experts Can Help.

After 80 days of lockdown, my husband and I yearned for company. Since New York City is slowly easing restrictions, we decided to ask friends for a socially distanced lunch. I planned the social experiment with the precision I do when reporting in war zones.

We would invite only two people, for just two hours. We would choose only those we knew had been strict quarantineers and had gotten coronavirus tests. We would insist on face covers and a checklist of taboos that included touching your dinnerware but nothing else. We’d convene in the garden out back, with no lingering inside.

After tallying these rigid ground rules, we actually found a couple willing to endure the constraints. I looked forward to a relaxing reunion.

Instead I was on guard the whole time. It’s hard to police friends, and folks get sloppy when they’re happy to see each other. Everyone violated the six-foot decree. Masks slipped down. Someone touched the salad bowl without gloves. They both asked to use the bathroom.

Our encounter brought home to me how stressful this transition period, when we’re not fully taking refuge but still in danger of exposure, will be. The lockdown cave had its lonely challenges, but we were safe inside. In the cocoon, we did not go in and out of high alert in an ambiguous situation.

Now, as we venture outside with a mix of masked and unmasked faces, emerging feels like a Wild West of germs. We’re making up rules as we go along. After finally getting used to confinement, I find myself on edge figuring out how to behave with less restraints.

The assessment process of “what risks do I take?” reminds me of what I’ve done in 30 years of covering conflicts in war zones around the globe and teaching seminars for journalists to protect themselves. Except now we’re dodging pedestrians instead of land mines. I find myself constantly assessing how to avoid those cigar smokers on the corner, how to get to the deli when it’s empty, whether I can trust my own closest friends to wipe the bathroom faucets after use.

Having adjusted to lockdown, we’re stretching the emotional rubber band by loosening limitations. We don’t have a clear picture of how the new-new normal will play out. We might have to withdraw again with a new viral surge.

Humans can take only so much change.

“We are adaptable, but we’re also a little rigid,” says Gil Reyes, a clinician from Santa Barbara, Calif., who specializes in the psychology of violent and destructive events. “You want things to be the way they were before. Anything that takes us out of the known way to do things is a stressor.”

Further strain comes from the sheer number of calculations one must make when venturing out. We have so many choices at every moment of potential exposure.

“It’s exhausting,” agrees Elana Newman, an expert on psychological trauma who teaches at the University of Tulsa. “In the absence of any certainty, every person has to make a cost-benefit about every activity they engage in. Is this a high-risk or a low-risk action? Is it worth it to me?”

Anxiety about this gamble is particularly severe for those who are already hard hit by grief and financial loss, or do essential work that requires exposure, says Elissa Epel, vice chair of the department of psychiatry at the University of California, San Francisco

“Feeling safe is key to recovery from trauma and avoiding long-term mental health consequences like PTSD,” she says. That’s hard to achieve when people lack physical safety as well as the security that they are bonded with others around them who are taking the same precautions.

But there are ways to navigate this jarring new situation. Here’s the advice that these experts gave, corroborated by my years of crisis reporting and by living through this pandemic.

  • Frequently Asked Questions and Advice

    Updated June 1, 2020

    • How do we start exercising again without hurting ourselves after months of lockdown?

      Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • How many people have lost their jobs due to coronavirus in the U.S.?

      More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

    • How can I help?

      Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.


Accept. In order to keep the blood pressure down, try to embrace a Zen acceptance that life is not risk-free, says Dr. Epel. Breathe deeply. You can’t control reckless behavior by others but you can control your responses. “Exercise compassion toward their different worldview,” she says. “Maybe they’re giving haircuts too early because of financial need. Maybe they truly believe the virus is a hoax.” Fuming that they aren’t complying with safety regulations will only make you feel worse.

Seek support. Surround yourself with people who make you feel supported and positive. “Social connection is the biggest factor shoring up emotional resilience,” says Jack Saul, a psychologist and leading expert on collective trauma and healing. “Recovery comes when people connect with other people and talk about what they’ve been through and feel supported.”

Take it slow. Move outward slowly. “Don’t jump into the hustle and bustle all at once,” says Dr. Reyes. Perhaps start with a socially distanced walk. Graduate to a backyard gathering with a couple of people you trust. Make clear that safety rules are for their protection as well as yours. And continue with the hand-washing, distancing and face coverings. That much you can control.

Be clear. You have a right to set conditions in your house. Don’t feel shy reminding visitors, politely, if they’ve lapsed. It’s your home.

Practice makes perfect. This new modus operandi will be taxing at first, but after some practice it will begin to feel automatic. I find that when I first get to a dangerous country, I’m self-regulating at 100 percent. After a while I go into automatic pilot and it becomes rote to know what to look for and how to react. I identify patterns: This street is particularly problematic, that person is too reckless. We simply need time to find our footing.

Assess and debrief. Think of the first encounters as dress rehearsals. After the experimental lunch, I sat down and analyzed what worked and what didn’t. I came up with a plan. Next time I’ll hand out gloves and disposable spoons at the door. I’ll place disinfectant with a sign in the bathroom. I’ll chalk the table with six-foot marks.

And I’ll feel more at ease being prepared.

Judith Matloff teaches crisis reporting at Columbia’s Graduate School of Journalism. She just published a manual for hazards, “How to Drag a Body and Other Safety Tips You Hope to Never Need.

How You Should Read Coronavirus Studies, or Any Science Paper

A lot of people are reading scientific papers for the first time these days, hoping to make sense of the coronavirus pandemic. If you’re one of them, be advised the scientific paper is a peculiar literary genre that can take some getting used to. And also bear in mind that these are not typical times for scientific publishing.

It is hard to think of another moment in history when so many scientists turned their attention to one subject with such speed. In mid-January, scientific papers began trickling out with the first details about the new coronavirus. By the end of the month, the journal Nature marveled that over 50 papers had been published. That number has swelled over the past few months at an exponential rate, fitting for a pandemic.

The National Library of Medicine’s database at the start of June contains over 17,000 published papers about the new coronavirus. A website called bioRxiv, which hosts studies that have yet to go through peer review, contains over 4,000 papers.

In earlier times, few people aside from scientists would have laid eyes on these papers. Months or years after they were written, they’d wind up in printed journals tucked away on a library shelf. But now the world can surf the rising tide of research on the new coronavirus. The vast majority of papers about it can be read for free online.

But just because scientific papers are easier to get hold of doesn’t mean that they are easy to make sense of. Reading them can be a challenge for the layperson, even one with some science education. It’s not just the jargon that scientists use to compress a lot of results into a small space. Just like sonnets, sagas and short stories, scientific papers are a genre with its own unwritten rules, rules that have developed over generations.

The first scientific papers read more like letters among friends, recounting hobbies and oddities. The first issue of the Philosophical Transactions of the Royal Society, published on May 30, 1667, included brief dispatches with titles such as “An account of the improvement of optick glasses,” and “An account of a very odd monstrous calf.”

When natural philosophers sent their letters to 17th-century journals, the editors decided whether they were worth publishing or not. But after 200 years of scientific advances, Victorian scientists could no longer be experts on everything. Journal editors sent papers to outside specialists who understood the details of a particular branch of research better than most scientists.

By the mid-1900s, this practice evolved into a practice known as peer review. A journal would publish a paper only after a panel of outside experts decided it was acceptable. Sometimes the reviewers rejected the paper outright; other times they required the fixing of weak points — either by revising the paper or doing additional research.

Along the way, scientific papers also developed a distinctive narrative arc. A paper published in Philosophical Transactions today is no longer a gossipy letter, but a four-part story. Papers typically open with some history, giving a justification for the new research they contain. The authors then lay out the methods they used to carry out that research — how they eavesdropped on lions, how they measured chemicals in Martian dust. Then the papers present results, followed by a discussion of what those results mean. Scientists will typically point out the shortcomings in their own research and offer ideas for new studies to see if their interpretations hold water.

As a science writer, I’ve been reading scientific papers for 30 years. I’d guess that I’ve read tens of thousands of them, in search of new advances to write about, or to do background research for stories. While I’m not a scientist myself, I’ve gotten pretty comfortable navigating around them.

One lesson I’ve learned is that it can take work to piece together the story underlying a paper. If I call scientists and simply ask them to tell me about what they’ve done, they can offer me a riveting narrative of intellectual exploration. But on the page, we readers have to assemble the story for ourselves.

Part of the problem may be that many scientists don’t get much training in writing. As a result, it can be hard to figure out precisely what question a paper is tackling, how the results answer it and why any of it really matters.

The demands of peer review — satisfying the demands of several different experts — can also make papers even more of a chore to read. Journals can make matters worse by requiring scientists to chop up their papers in chunks, some of which are exiled into a supplementary file. Reading a paper can be like reading a novel and realizing only at the end that Chapters 14, 30, and 41 were published separately.

The coronavirus pandemic now presents an extra challenge: There are far more papers than anyone could ever read. If you use a tool like Google Scholar, you may be able to zero in on some of the papers that are already getting cited by other scientists. They can provide the outlines of the past few months of scientific history — the isolation of the coronavirus, for example, the sequencing of its genome, the discovery that it spreads quickly from person to person even before symptoms emerge. Papers like these will be cited by generations of scientists yet to be born.

Most won’t, though. When you read through a scientific paper, it’s important to maintain a healthy skepticism. The ongoing flood of papers that have yet to be peer-reviewed — known as preprints — includes a lot of weak research and misleading claims. Some are withdrawn by the authors. Many will never make it into a journal. But some of them are earning sensational headlines before burning out in obscurity.

In April, for example, a team of Stanford researchers published a preprint in which they asserted that the fatality rate of Covid-19 was far lower than other experts estimated. When Andrew Gelman, a Columbia University statistician, read their preprint, he was so angry he publicly demanded an apology.

“We wasted time and effort discussing this paper whose main selling point was some numbers that were essentially the product of a statistical error,” he wrote on his blog.

  • Frequently Asked Questions and Advice

    Updated June 1, 2020

    • How do we start exercising again without hurting ourselves after months of lockdown?

      Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • How many people have lost their jobs due to coronavirus in the U.S.?

      More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

    • How can I help?

      Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.


But just because a paper passes peer review doesn’t mean it’s above scrutiny. In April, when French researchers published a study suggesting that hydroxychloroquine might be effective against Covid-19, other scientists pointed out that it was small and not rigorously designed. In May, a much bigger paper was published in the Lancet suggesting that the drug could increase the risk of death. A hundred leading scientists published an open letter questioning the authenticity of the database on which the study relied.

When you read a scientific paper, try to think about it the way other scientists do. Ask some basic questions to judge its merit. Is it based on a few patients or thousands? Is it mixing up correlation and causation? Do the authors actually present the evidence required to come to their conclusions?

One shortcut that can sometimes help you learn how to read a paper like a scientist is by making judicious use of social media. Leading epidemiologists and virologists have been posting thoughtful threads on Twitter, for example, laying out why they think new papers are good or bad. But always make sure you’re following people with deep expertise, and not bots or agents of disinformation peddling conspiracy nonsense.

Science has always traveled down a bumpy road. Now it is in an extraordinary rush, with the world looking for every new preprint and peer-reviewed paper in the hope that some clue will emerge that helps save millions of lives.

Yet our current plight does not change the nature of the scientific paper. It’s never a revelation of absolute truth. At best, it’s a status report on our best understanding of nature’s mysteries.

After 6 Months, Important Mysteries About Coronavirus Endure

In the time since the world’s scientists and public health officials first became widely aware of the new coronavirus in January, they’ve had six months to learn about it.

They’ve reached many conclusions about the virus and the illness it causes, from the importance of wearing masks to contain it, to the unusual range of symptoms it provokes.

But there are major gaps in scientific knowledge about the virus. In the half year that journalists of the health and science desk of The Times have been reporting on Sars-CoV-2, we have identified some of the enduring uncertainties. How scientists resolve some of these mysteries will shape our future with the coronavirus.

How many people have been infected.

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Credit…Jens Mortensen for The New York Times

One of the epidemic’s great unknowns is how many Americans have been infected so far.

Only about 1.9 million Americans had tested positive as of May 28, according to the Centers for Disease Control and Prevention — or perhaps only about 1.7 million according to the Johns Hopkins Center for Health Security, which produces a frequently cited map of world cases.

Statisticians believe the actual number of cases is higher, but it is not clear by how much.

They have more confidence in the accuracy of data produced by states that do the most testing. On that score, New York is a leader; it has tested about 9.6 percent of its population, which is almost double the national average. (Rhode Island tested 13 percent of its people, beating New York, but its population is small.)

New York has also done tens of thousands of antibody tests for surveillance purposes. On May 22, Gov. Andrew Cuomo announced that, according to these tests, about a fifth of all New York City residents have had the virus, as had about 27 percent of thousands of black and Hispanic New Yorkers who were tested at their local churches.

If that same pattern were assumed to hold in other hard-hit big cities like Chicago, New Orleans, Detroit and Miami, it is likely that somewhere between 3 and 4 million urban Americans were infected.

Even if that figure was doubled or tripled — which is probably generous — to account for Americans infected all around the country before the lockdowns, that would still be only 9 to 12 million people.

That is in line with the low end of estimates made in mid-April, before antibody testing began; different modelers predicted then that between 3 and 10 percent of the country was infected.

In any case, since this is a country of 330 million, a mere 10 million or even 20 million infected would be a drop in the bucket. As the country comes out of lockdown, the vast majority of Americans remain vulnerable to the virus.

Nor will the country be able to spot all of those who get it. The C.D.C.’s “best estimate,” according to the pandemic scenarios it issued May 22, is that about 35 percent of those infected have no symptoms.

Currently, about 21,000 Americans are getting infected each day. If a third of them show no symptoms, almost 210,000 “silent spreaders” are created each month.

It seems impossible to imagine that any contact-tracing program, no matter how large, will be able to keep up with that.

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The amount of virus it takes to make you sick.

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Here’s what we can say for sure about the minimum number of viral particles it takes to seed a coronavirus infection: The number is somewhere between one and one million.

If you push scientists harder, they might offer a slightly smaller range of a few hundred to a few thousand — and some might even bravely throw out an estimate in the high hundreds, based on what they have learned about the behavior of the coronavirus that caused the 2002-03 SARS epidemic.

But the bottom line is that no one will know for sure until more research is completed.

“It’s very unsatisfying to tell people, ‘Oh we don’t know,’” said Angela Rasmussen, a virologist at Columbia University in New York. “People do have a lot of questions about this.”

It’s difficult to say anything definitive about the coronavirus because it behaves like an influenza virus in how easily it is transmitted, and in that people can pass it on even when they don’t seem sick. But its structure, origin in bats and overall symptoms are similar to those of its cousin coronaviruses.

So scientists cannot say whether touching a surface with a smidgen of virus or breathing air with a few droplets exhaled by a sick person will make you ill. But it is safe to say exposure to more of the coronavirus is more likely to cause infection, and also to lead to more severe symptoms. That’s why it’s important to avoid crowded indoor spaces, wear masks and wash your hands. Each of those steps can decrease your chances of being exposed to large amounts of virus.

Why some people get so much sicker than others.

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Covid-19 is a mercurial disease. While some people experience only mild, fleeting symptoms, others are knocked over with a severe flulike illness that can last several weeks. A minority of patients develop life-threatening complications. Death can ensue.

Why do some people sail through the illness, and others develop the severe inflammation and lung damage that are hallmarks of the disease? It is one of the great mysteries of Covid-19.

Experts say the patient’s immune response to the viral infection determines the severity of the illness. If the immune system goes into overdrive, it can trigger a cascade of harmful effects, injuring the lungs and other organs.

Immune function declines with age, and elderly people with Covid-19 are among the most vulnerable to poor outcomes, as are those with chronic health conditions like high blood pressure, diabetes and cardiovascular disease. Obesity, which affects 4 in 10 American adults, also appears to exacerbate the illness.

Men are at greater risk for critical illness and death, a sex disparity that may be explained by women’s more robust immune systems, scientists say.

Generally speaking, patients get sicker faster if they are exposed to a large dose of the virus when they are first infected, said Dr. William Schaffner, an infectious disease specialist at Vanderbilt University.

Much scientific inquiry has focused on the role of a receptor called angiotensin-converting enzyme 2, or ACE2, which is the entry way for coronaviruses into the cells. The receptor is found on the outer surfaces of cells in the lungs, blood vessels, intestines and other organs, as well as in the back of the throat and high up in the nasal passage.

When the pandemic started, there was concern that people taking blood pressure medications like ACE inhibitors could be at greater risk from the coronavirus, but so far studies have not found that to be the case, and doctors are urging patients to continue their medications.

Though the SARS-CoV-2 virus attaches to the receptor in order to penetrate cells, ACE2 also helps regulate blood pressure and inflammation. Some scientists have suggested that children may be less susceptible to infection with Covid-19 because they have fewer of these receptors. ACE2 is also regulated differently in men and women, according to scientists who study sex differences in medicine, and men tend to develop hypertension, or high blood pressure, at younger ages than women. But much is still unknown.

“ACE2 can play two very critical roles, getting the virus into the cell, but also modulating some of the damage that takes place in the blood vessels and the lungs,” said Dr. Ankit B. Patel, a nephrologist at Brigham and Women’s Hospital in Boston. “So it’s a double-edged sword in a sense, and that’s made the whole story all the more complicated.”

The role of children in spreading the virus.

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Credit…Jens Mortensen for The New York Times

There are many crucial unresolved questions about children and Covid-19. Finding the answers is not only important for them and their families, but for society at large, as communities plan to reopen schools, day care centers, playgrounds and other places children frequent.

  • Frequently Asked Questions and Advice

    Updated June 1, 2020

    • How do we start exercising again without hurting ourselves after months of lockdown?

      Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • How many people have lost their jobs due to coronavirus in the U.S.?

      More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

    • How can I help?

      Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.


One puzzle is what role children play in spreading the virus. They seem less likely to become seriously ill than adults, making up about 2 percent of confirmed American coronavirus cases. There are different theories about whether that is because children are less likely to become infected to begin with, or whether the virus infects them just as easily but mostly causes few or no symptoms.

Either way, a growing body of evidence suggests that infected children can transmit the virus, possibly as easily as adults. And one recent study suggests that when children attend school, they come in contact with three times as many people as average adults do, providing more opportunities for children to become infected and infect others.

Although far fewer children than adults have experienced severe symptoms, some children have become devastatingly ill and there have been at least 20 deaths of children from Covid-19 in the United States and elsewhere. Reports from hospitals suggest that the children most vulnerable to the respiratory failure adults develop are those who already have a serious medical condition. Some studies also suggest that infants and preschoolers may be more vulnerable than older children.

But a small number of other children, including teenagers, who did not have any symptoms when they were first infected, have developed a newly-identified inflammatory syndrome that can cause serious heart problems. The syndrome, which seems to occur weeks after infection and to result from a revved-up immune response to the virus, has been reported Europe and throughout the United States and has caused several deaths. Doctors are urgently trying to understand what causes the syndrome, why it afflicts some children and not others, and how to best treat or prevent it.

When or where the new coronavirus started spreading.

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Credit…Jens Mortensen for The New York Times

The notion of a single patient zero is both theatrical and real: In any new epidemic, some unlucky soul seeds the first infection, several links of which are fated to seed chains of their own and spark a viral Big Bang.

By analyzing the genetic material of people who test positive, scientists can trace the lineage of each virus back to a common ancestor, and often to an individual carrier. The first confirmed coronavirus case in the United States was a man who landed at Seattle-Tacoma Airport on Jan. 15, from China. Other introductions came in February, and scientists are now closing in on who, exactly, sparked the outbreak in Washington State.

New York confirmed its first case on March 1, and by that time there were already thousands of infected people walking around, for a week or more. Scientist have found genetic signatures on the viruses studied so far that link them to Europe, likely brought in by some of the millions of people arriving in New York in February, and it is likely that there were multiple introductions that spread widely: patients zero, plural.

The first infected arrivals in a community are not necessarily the ones who light the fuse. In a report published last week, genetic scientists argued that infected people were among both Americans and Europeans in January, but that most of those viruses fizzled out. And French doctors recently reported that a respiratory sample from a man hospitalized near Paris, in late December, tested positive. That virus, too, likely died out. France’s outbreak did not start until many weeks later.

The world’s patient zero, in China, began infecting others in the late fall of last year, the evidence thus far suggests. An analysis of the first 41 confirmed cases, all in people who had visited the same seafood market in Wuhan, indicates that the first hospital admission was on Dec. 16, 2019. The patient first noticed symptoms on Dec. 1, so the infection dates back earlier. Several scientists have estimated that the first outbreak began in late or mid-November, and have inferred a probable common viral ancestor, though additional virus samples could change the picture.

The level of detective work required to find the actual patient zero might be steeper than it appears. At least one genetic scientist has argued that the virus could have first infected humans — likely from a pangolin — well before last fall, in a form that did not cause sickness. It then evolved its pathogenic features over time, while circulating. If that’s the case, the question “Who came first?” may go without a conclusive answer for some time, perhaps for good.

How long you’ll be immune after infection.

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Are people infected with the coronavirus protected from further infection? And, if yes, for how long?

The answers to these questions have broad implications for reopening the economy and allowing the public to live with less fear of infection in the short term — and for the effectiveness of vaccines in the long term.

Scientists have made steady, if incremental, progress in getting to the answers. When the body encounters any virus, it typically makes antibodies, some of which are powerful enough to neutralize the pathogen and prevent reinfection. It also produces large numbers of immune cells that can kill the virus.

Most tests that look for antibodies to the coronavirus have been flawed. But at least one team with a reliable test reported that most people, including those who were only mildly ill, make powerful antibodies. Data on immune cells has been slower to emerge, but a few studies suggest a robust response from immune cells as well.

What remains unknown is how long this immunity will last. There have been some reports of reinfection, but scientists have said that they are a result either of faulty testing, or of viral remnants that circulate long after the active infection has ended.

They are hopeful that based on other coronaviruses that cause the common cold, SARS or MERS, immunity to the new coronavirus might last at least a year, but it remains a mystery for now.

Six Months of Coronavirus: Here’s Some of What We’ve Learned

We don’t really know when the novel coronavirus first began infecting people. But as we turn a page on our calendars into June, it is fair to say that Sars-Cov-2 has been with us now for a full six months.

At first, it had no name or true identity. Early in January, news reports referred to strange and threatening symptoms that had sickened dozens of people in a large Chinese city with which many people in the world were probably not familiar. After half a year, that large metropolis, Wuhan, is well-known, as is the coronavirus and the illness it causes, Covid-19.

In that time, many reporters and editors on the health and science desk at The New York Times have shifted our journalistic focus as we have sought to tell the story of the coronavirus pandemic. While much remains unknown and mysterious after six months, there are some things we’re pretty sure of. These are some of those insights.

We’ll have to live with this for a long time.

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Credit…Jens Mortensen for The New York Times

Summer is almost here, states are reopening and new coronavirus cases are declining or, at least, holding steady in many parts of the United States. At least 100 scientific teams around the world are racing to develop a vaccine.

That’s about it for the good news.

The virus has shown no sign of going away: We will be in this pandemic era for the long haul, likely a year or more. The masks, the social distancing, the fretful hand-washing, the aching withdrawal from friends and family — those steps are still the best hope of staying well, and will be for some time to come.

“This virus just may become another endemic virus in our communities, and this virus may never go away,” Dr. Mike Ryan, the executive director of the World Health Organization’s health emergencies program, warned last month. Some scientists think that the longer we live with the virus, the milder its effects will become, but that remains to be seen.

Predictions that millions of doses of a vaccine may be available by the end of this year may be too rosy. No vaccine has ever been created that fast.

The disease would be less frightening if there were a treatment that could cure it or, at least, prevent severe illness. But there is not. Remdesivir, the eagerly awaited antiviral drug? “Modest” benefit is the highest mark experts give it.

Which brings us back to masks and social distancing, which have come to feel quite antisocial. If only we could go back to life the way it used to be.

We cannot. Not yet. There are just enough wild cards with this disease — perfectly healthy adults and children who inexplicably become very, very sick — that no one can afford to be cavalier about catching it. About 35 percent of infected people have no symptoms at all, so if they are out and about, they could unknowingly infect other people.

Enormous questions loom. Can workplaces be made safe? What about trains, subways, airplanes, school buses? How many people can work from home? When would it be safe to reopen schools? How do you get a 6-year-old with the attention span of a squirrel to socially distance?

The bottom line: Wear a mask, keep your distance. When the time comes in the fall, get a flu shot, to protect yourself from one respiratory disease you can avoid and to help keep emergency rooms and urgent care from being overwhelmed. Hope for a treatment, a cure, a vaccine. Be patient. We have to pace ourselves. If there’s such a thing as a disease marathon, this is it.

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You should be wearing a mask.

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Credit…Jens Mortensen for The New York Times

The debate over whether Americans should wear face masks to control coronavirus transmission has been settled. Although public health authorities gave confusing and often contradictory advice in the early months of the pandemic, most experts now agree that if everyone wears a mask, individuals protect one another.

Researchers know that even simple masks can effectively stop droplets spewing from an infected wearer’s nose or mouth. In a study published in April in Nature, scientists showed that when people who are infected with influenza, rhinovirus or a mild cold-causing coronavirus wore a mask, it blocked nearly 100 percent of the viral droplets they exhaled, as well as some tiny aerosol particles.

Still, mask wearing remains uneven in many parts of the United States. But governments and businesses are beginning to require, or at least recommend, that masks be worn in many public settings.

There is also growing evidence that some kinds of masks may protect you from other people’s germs. High-grade N95 masks are cleared by federal public health agencies because they filter out at least 95 percent of particles that are 0.3 microns in diameter when properly worn. One study showed that N95s were able to capture over 90 percent of viral particles, even if the particles were about one-fifth the size of a coronavirus. Other studies have shown that flat, blue surgical masks block between 50 to 80 percent of particles, whereas cloth masks block 10 to 30 percent of tiny particles.

“Wearing a mask is better than nothing,” said Dr. Robert Atmar, an infectious disease specialist at Baylor College of Medicine. Because the coronavirus typically infects people by entering their body through the mouth and nose, covering these areas can act as the first line of defense against the virus, he said.

Donning a face covering is also likely to prevent you from touching your face, which is another way the coronavirus can be transmitted from contaminated surfaces to unsuspecting individuals. And when combined with hand washing and other protective measures, such as social distancing, masks help reduce the transmission of disease, Dr. Atmar said.

American public health infrastructure needs an update.

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Credit…Jens Mortensen for The New York Times

The United States knows how to fight wars. But, as the past few months have shown, the American response to pathogens can easily become a shambles — even though pathogens kill more Americans than many wars have.

We have no viral Pentagon. The Centers for Disease Control and Prevention is more of an F.B.I. for outbreak investigations than a war machine. For years — under both the Obama and Trump administrations — its leaders have had to seek clearance for almost every utterance.

Dr. Anthony S. Fauci, the most prominent of the doctors advising the coronavirus task force, is actually the head of a research institute, the National Institute for Allergy and Infectious Disease, rather than of the medical equivalent of a combat battalion.

The Surgeon Generalis essentially an admiral without a crew. He dispenses health warnings and recommendations, but the Public Health Services Commissioned Corps, which reports to him, are only about 6,500 strong, and many members have other jobs, often at the C.D.C.

Almost all the front-line troops — the contact tracers, the laboratory technicians, the epidemiologists, the staff in state and city hospitals — are paid by state and local health departments whose budgets have shriveled for years. These soldiers are led by 50 commanders, in the form of governors, and with that many in charge, it is amazing that any response moves forward.

The rest of the response is in the hands of thousands of private militias — hospitals, insurers, doctors, nurses, respiratory technicians, pharmacists and so on, all of whom have individual employers. Within limits, they can do what they want. When they cannot get something they need from overseasthey are largely powerless without federal logistical help.

As war does to defeated nations, pandemics expose the weaknesses of their systems. Our patchwork and uncoordinated response has produced more than 100,000 deaths; surely we can do better.

“The superpowers have their priorities all wrong,” Dr. Michael Ryan, the head of the W.H.O.’s emergencies program, said recently.

“They spend billions on missiles and submarines, and on fighting terrorism, and pennies on viruses. You can start peace talks with your enemy. You can change your policies to lessen the threat of terrorism. But you cannot negotiate with a virus, and we know that new threats are coming along every year.”

Responding to the virus is extraordinarily expensive.

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The federal government has spent hundreds of billions of dollars and promised to spend more than $2 trillion to address the coronavirus pandemic.

Of that money, $2 billion has gone to helping companies develop new vaccines, expanding testing capacity nationwide and shoring up the economic fallout since the beginning of March. (Even more could be on the way, but how much and when is unclear.)

The vast majority of this spending has been aimed at blunting the economic pain of small businesses shutting down and people losing their jobs or being furloughed. Congress also provided additional money for Medicaid and other social programs.

Hospitals, community health centers and other providers have been allocated $175 billion to cover the cost of caring for patients with Covid-19 and for the visits, procedures and surgeries that were canceled because of the pandemic. In the latest bill, $25 billion was targeted for coronavirus testing.

Many experts say more funding is needed, but there is ample controversy over how the money already allocated is being spent and which entities are getting funds. Various groups like the Committee for a Responsible Federal Budget are tracking the spending. By that organization’s calculation, roughly $1.6 trillion has already been disbursed or committed. The Federal Reserve has also provided more than $2 trillion in emergency lending, asset purchases and other activities, it said.

We have a long way to go to fix virus testing.

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The landscape for testing looks far better than it did in the early days of the outbreak, when a botched rollout of coronavirus tests failed to detect the spread of the virus in the United States.

Today, hundreds of thousands of tests a day are being conducted in the United States, and in some areas it is so widely available that public health officials have complained they do not have enough takers. In Los Angeles, where testing is free to everyone, a drive-through site at Dodgers Stadium can process 6,000 people a day.

The range of tests available is also expanding. Tests that once required a health care worker to insert a swab through the nose to the back of the throat can now be done with a swipe inside the nose, or by spitting into a cup. A handful of companies now sell at-home test kits, and a test from Abbott can detect the virus in as little as five minutes.

In addition to the tests that detect active infections, Americans can also get tested for antibodies to the virus, which shows whether they have ever been infected, and could help give a better picture for how widely the coronavirus has spread in communities.

But despite this progress, the United States still has a long way to go. Public health experts say that anywhere from 900,000 tests to millions a day will be needed to screen hospital patients, nursing home residents and employees returning to work.

And even as testing is abundant in some areas, it is still hard to come by in others. Shortages of key supplies needed to run the tests — such as swabs and chemical reagents — have persisted. The federal government has effectively delegated oversight to the states, creating a patchwork of policies and putting states in competition with one another. Even tracking the number of tests conducted has proved difficult, after the C.D.C. and several states began lumping tests for the virus as well as antibodies together, to the bafflement of epidemiologists trying to track active infections, which the antibody tests do not show.

We can’t count on herd immunity to keep us healthy.

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The idea is simplicity itself: If enough of the population has antibodies to the novel coronavirus, the virus will hit too many dead ends to continue infecting people. That is herd immunity.

That is the great hope for a vaccine. But it may not happen, even if a vaccine becomes available, as experience with flu vaccines shows.

Dr. Paul Offit of Children’s Hospital of Philadelphia and the University of Pennsylvania noted that while vaccines eliminated measles, rubella and smallpox and almost eliminated polio in the United States, vaccines against influenza and whooping cough have not stopped outbreaks. (With some parents declining measles vaccines, the disease is coming back.)

Influenza and whooping cough have spread, even after enough people in a community have been vaccinated to, in theory, stop the diseases. That’s because the antibodies that protect people against viruses infecting mucosal surfaces like the lining of the nose tend to be short-lived.

Vaccines against respiratory diseases are, at best, modestly effective, agreed Dr. Arnold Monto of the University of Michigan,

Since the coronavirus usually starts by infecting the respiratory system, Dr. Monto suspects that a Covid-19 vaccine would have a similar effect to a flu vaccine — it will reduce the incidence of the disease and make it less severe on average, but it will not make Covid-19 go away.

  • Frequently Asked Questions and Advice

    Updated June 1, 2020

    • How do we start exercising again without hurting ourselves after months of lockdown?

      Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • How many people have lost their jobs due to coronavirus in the U.S.?

      More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

    • How can I help?

      Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.


He would like the virus to disappear, of course, but a vaccine that reduces the disease’s spread and severity is a lot better than nothing.

“As an older person, what I want is not to end up on a respirator,” Dr. Monto said.

The virus produces more symptoms than expected.

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Credit…Jens Mortensen for The New York Times

Covid-19 is a viral respiratory illness. Many early descriptions of symptoms focused on patients being short of breath and eventually being placed on ventilators. But the virus does not confine its assault to the lungs, and doctors have identified a number of symptoms and syndromes associated with it.

In some patients, the virus propels the immune system into overdrive, causing the lungs to fill with fluid and damaging multiple organs, including the brain, heart, kidneys and liver.

The first symptoms of an infection are usually a cough and shortness of breath. But in April the C.D.C. added to the list of early signs sore throat, fever, chills and muscle aches. Gastrointestinal upset, such as diarrhea and nausea, has also been observed.

Another telltale sign of infection may be a sudden, profound diminution of one’s sense of smell and taste. Teenagers and young adults in some cases have developed painful red and purple lesions on the fingers and toes, but few other serious symptoms.

Severe disease leads to pneumonia and acute respiratory distress syndrome. The blood oxygen levels plummet, and patients may get supplemental oxygen or be placed on a machine, called a ventilator, to help them breathe.

But even without lung impairment, the disease can cause injury to the kidneys, heart or liver. Critically ill patients are prone to developing dangerous blood clots in the legs and the lungs. In rare cases, the disease triggers ischemic strokes that block the arteries supplying blood to the brain, or brain impairments, such as altered mental status or encephalopathy.

Death can result from heart failure, kidney failure, multiple organ failure, respiratory distress or shock.

We can worry a bit less about infection from surfaces.

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Credit…Jens Mortensen for The New York Times

The news, when it was reported, added a frightening twist to the threat from the coronavirus: A study in March in The New England Journal of Medicine found that under laboratory conditions, the virus can survive for up to three days on some surfaces, such as plastic and steel, and on cardboard for up to 24 hours.

Other studies reported finding the virus on air vents in hospital rooms and on computer mice, sickbed handrails and doorknobs.

Many people grew worried that by touching a surface that had been covered in droplets by an infected person, and then touching their own mouth, nose or eyes, they then would contract the virus.

You should still wear a mask, avoid touching your face in public and keep washing your hands. But none of these studies tested for live virus, only for traces of its genetic material. Other scientists commenting on these studies said virus on these surfaces might degrade more quickly. The Centers for Disease Control and Prevention has said since March that contaminated surfaces are “not thought to be the main way” the virus spreads.

The main driver of infection is thought to be directly inhaling droplets released when an infected person sneezes, coughs, sings or talks. The C.D.C. recently made changes to its website to make this message even more explicit.

We can also worry less about a mutating virus.

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In February, three experts on viruses published an editorial in a journal headlined “We Shouldn’t Worry When a Virus Mutates During Outbreaks.”

But worry we did. As the coronavirus pandemic swept the planet, headlines and tweets poured forth that the new coronavirus was undergoing dangerous mutations.

Many of these worries were based on a misunderstanding of what it means when a virus mutates. When an infected cell produces new viruses, it sometimes makes mistakes in copying the viral genes. Those mistakes are mutations, and it turns out that most are bad for the viruses, getting in the way of their ability to hijack our cells.

The viruses that do manage to spread to new hosts have mutations, too. But those mutations often don’t have any significant effect. The alterations they bring to a virus’s genes don’t lead to any change in how the virus works.

Scientists have identified harmless new mutations in different lineages of the new coronavirus. These lineages are not dangerous new strains.

Some of these lineages have come to be the most common version of the coronavirus in some countries. Again, that doesn’t mean that they’ve got some evolutionary edge. There’s a very common phenomenon in nature called the founder effect: Whatever mutations happen to be common in the founders of a new population will end up common in their descendants.

It is possible for viruses to gain mutations that do affect the way they work. The new coronavirus will be no different. But the only way to know if a new mutation is significant or not is to carry out research. It will take a lot of evidence to reject the more likely hypothesis: that a new mutation has no importance at all.

Fortunately, it doesn’t look like coronaviruses will be picking up these new mutations very quickly. Compared with other viruses, scientists have found, the new coronavirus has a relatively slow rate of new mutations.

That’s a big relief for vaccine makers. Influenza viruses mutate so quickly that people need to get a new flu shot each year to stay protected. H.I.V. has so much genetic diversity that an effective vaccine against it has yet to be found. The new coronavirus poses immense challenges to vaccine makers, but most of them have to do with manufacturing billions of doses in a matter of months.

We have enough worries when it comes to Covid-19; no need to add needless ones to the list.

We can’t count on warm weather to defeat the virus.

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Credit…Jens Mortensen for The New York Times

The hot and humid weather of summer will not stop the pandemic. More sunlight and humidity may slow down its spread, but we probably won’t know by how much. Other factors, like reduced travel, increased personal distance, closed schools, canceled gatherings and mask-wearing, have effects that would outweigh the influence of the weather.

A few things are known about conditions that do or do not favor the virus. The ultraviolet rays in sunlight help destroy the virus on surfaces and some studies have shown a small effect from humidity. It seems to last longest on hard surfaces like plastic and metal. It won’t survive in pool or lake or seawater. Wind disperses it. Risk of transmission is lower outdoors than indoors.

A wooden bench under a bright sun at a breezy beach is a better bet than a metal and plastic recliner on the shady side of the pool. But if someone infected sits near you and coughs, or talks a lot or sings, it doesn’t really matter where you’re sitting and how nice a day it is.

“The virus doesn’t need favorable conditions,” said Peter Juni, an epidemiologist at the University of Toronto. It has a world population with no immunity waiting to be infected. Bring on the sun; the novel coronavirus will survive.

Air conditioning may blow the virus right to your restaurant table.

On Memorial Day, many people in the United States gathered in congenial closeness in lovely weather without masks. If any of them were infected and breathing, they probably infected someone else. The same will be true on July 4. Even if the weather is glorious.

Gay Couples Can Teach Straight People a Thing or Two About Arguing

Elana Arian and Julia Cadrain, a same-sex couple in Brooklyn, recently fought about a hat.

OK, it wasn’t really about the hat. (It never is.)

Cadrain likes things tidy. Really tidy. To the point where it annoys her entire family.

“I put things away while they’re still using them,” she admitted.

So when Cadrain found one of Arian’s favorite hats lying around, she promptly scooped it up, but neglected to store it properly. Arian later discovered her hat had accidentally been crushed.

“I was irrationally so angry about that,” Arian said.

They took a long walk, and had an honest, calm conversation. Soon, they realized that Arian’s frustration was actually about something deeper.

“One of the things that came up was this stress that we’re both under as a result of the quarantine,” Cadrain, 37, said. The couple is caring for their 9-month-old daughter while also guiding their 7-year-old daughter through distance learning. Arian, 39, a freelance musician, is working much less than she typically would. They had each been coping with this in different ways.

“It feels like a very lesbian way to fight. There’s definitely never any yelling. There’s no voice-raising,” Cadrain said. “It’s more kind of tense and quiet and sort of process heavy.”

But is there really a lesbian way to fight? Or a way to address conflict that is specific to gay men? While there is not much research to draw from, the studies that do exist suggest that, on average, same-sex couples resolve conflict more constructively than different-sex couples, and with less animosity.

There are always exceptions, and even the healthiest of gay couples are not continually basking in a rainbow-hued utopia. They have problems just like everyone else.

If they did not, “I’d be out of business,” said Rick Miller, a psychotherapist in Boston who works with gay and straight couples.

Likewise, it is unfair to lump all straight couples together, and disingenuous to suggest that they are not capable of arguing in a healthy way.

But because male and female same-sex couples each have different strengths that help them endure, we can all learn from them, Miller said.

Here are some constructive methods to handle disagreements, as observed by researchers of gay couples:

Use humor to diffuse anger

Cracking a joke in the midst of a heated moment can backfire, but when done properly, “it almost immediately releases the tension,” said Robert Rave, 45, who lives with his husband, David Forrest, in Los Angeles.

Rave cited a recent car trip where Forrest, 35, used humor to help end an escalating argument over whether they should rely on Google Maps.

“For me, as a general rule, I self-admittedly will get very much in my head. And David will just simply take the piss out of it and make me laugh,” Rave said.

A 2003 study compared 40 same-sex couples with 40 heterosexual couples over the course of 12 years to learn what makes same-sex relationships succeed or fail. The findings suggested that same-sex couples tended to be more positive when bringing up a disagreement and were also more likely to remain positive after a disagreement when compared to heterosexual couples.

“Gay and lesbian couples were gentler in raising issues, far less defensive, and used more humor than heterosexual partners,” said John M. Gottman, Ph.D., the lead author of the study and co-founder of the Gottman Institute, an organization that provides resources, like workshops and online courses, to help couples strengthen relationships and offers professional training to clinicians. “These were large differences.”

Stay calm

If you find that your heart is pounding during an argument, take a break, said Julie S. Gottman, Ph.D., co-founder and president of the Gottman Institute.

“During the time when you’re apart don’t think about the fight. Instead, practice something self-soothing, like reading a book, something distracting so that your body can calm down,” she said.

But if you need to leave, you should always say when you are going to come back and rejoin the conversation, she said, adding that the minimum amount of time away should be 30 minutes and the maximum should be 24 hours.

Gay men were less likely to go into fight-or-flight mode when they were in conflict, said the Gottmans, who are married, and they also reach resolutions more quickly than different-sex couples.

Treating your partner with respect is always important, but especially during an argument when you might say things you’ll later regret. When you’re heart is racing, “all you perceive is attack, no matter what your partner is saying,” Dr. Julie Gottman said.

And that’s exactly why Rave and Forrest try to end an argument quickly.

“Life is too short to have everything be so dramatic,” Rave said.

A 2018 study suggested that when members of a same-sex couple try to influence one another, they are more likely to offer encouragement and praise rather than criticism or lectures when compared to different-sex couples.

Be mindful of each other’s emotional needs

Unlike gay men, women who are married to women are “constantly monitoring each other’s emotions and needs and responding to them — but they are doing it for each other, so it’s reciprocated,” said Debra Umberson, Ph.D., a professor of sociology and the director of the Population Research Center at the University of Texas at Austin.

Two men, in contrast, do less monitoring, which is less labor-intensive.

“They’re on the same page about it,” said Dr. Umberson, who has studied gay couples for more than a decade. Two men will tell each other what they need or speak up when there is an issue.

If a couple has similar philosophies about emotional monitoring, there is less potential for conflict between them, Dr. Umberson said.

In heterosexual couples, women are the ones who tend to do emotional monitoring and responding, but the men tend to be unaware of it and often are not doing it, she added — and that can negatively affect the couple by making them feel more frustrated, worried, irritable or upset.

Dr. Umberson’s latest study, published in May, examined the psychological toll of providing for the emotional needs of a spouse. The researchers found that the well-being of women married to women seemed to be affected less by the work of assessing and managing each other’s emotions than that of women married to men. Earlier research suggests this could be because lesbians are more reciprocal in taking care of a spouse’s emotional needs and also have a greater appreciation for doing so.

Strive for equality in your relationship

Same-sex couples do not have traditional societal roles defining which tasks each member of the couple ought to perform at home or how they ought to relate to one another, which allows them to create their own dynamic.

Straight couples should negotiate and discuss things more, Cadrain suggested, and “don’t presume certain roles or jobs in terms of who is the breadwinner or how the household is taken care of.”

Although Arian cannot remember the last time she made the bed, she has other responsibilities, like being the chef of the family — or as Cadrain calls her, “C.E.O. of the food and the nourishment.” And because Arian was a teacher for many years, she is responsible for distance learning and staying on top of their 7-year-old’s schooling.

They do not typically fight about chores, the couple said, because they try to divide them based on what they like to do best or which of them is best positioned to complete a task.

“I suspect that has to do with gender roles not being present,” Arian said.

In heterosexual couples, researchers have found more of a power difference between members of the couple than among same-sex couples, Dr. John Gottman said.

“The same-sex couples we studied were very aware to try to make the power relationships more equal between them,” he said.

And if members of a same-sex couple disagree, they are more likely to listen to one another’s point of view, he added.

The Gottmans’ 2019 study, an assessment of more than 40,000 couples worldwide who were about to begin couples therapy, found that same-sex couples have a better quality of intimacy and friendship in their relationships.

Recognize and appreciate your differences

Each person brings their own baggage and their own way of looking at the world, Miller said.

“Really appreciating those differences and similarities and figuring out how to deal with it together — that’s what makes a healthy couple. And that goes across all borders, groups and genders,” he added.

Cadrain and Arian, for example, said they tried to be mindful of each other’s different communication styles.

“I tend to kind of under-communicate when I’m upset,” said Arian, who said she has a temper but often becomes restrained and terse during arguments. “I’m not proud of it.”

Cadrain, however, likes to talk things out — sometimes before Arian is ready. Simply being aware of their differences helps them manage conflicts when they arise.

Rave and Forrest are also different in a lot of ways: Forrest likes to go out and be social; Rave is more of a homebody. This has been a point of contention in their relationship.

“Allowing space for the person to be themselves is so important, and not shaming that person into what you want them to be,” Forrest said.

Finally, when thinking about your differences, try not to focus too much on the negative.

“Look for what your partner is doing right rather than always looking for what your partner is doing wrong,” Dr. Julie Gottman said.

Pregnancy Loss Tied to Increased Risk of Type 2 Diabetes

Loss of a pregnancy may increase a woman’s risk of developing Type 2 diabetes, Danish researchers report.

Their study, in Diabetologia, included 24,774 women who developed diabetes after pregnancy and 247,740 controls who did not.

Compared with women who had been pregnant without losing a baby, those who lost one were at an 18 percent increased risk for diabetes, those who lost two were at a 38 percent higher risk and those who lost three or more had a 71 percent higher risk. The study adjusted for obesity and gestational diabetes, which are known to be associated with the development of Type 2 diabetes.

The reason for the association remains unknown. It may be that the same genetic background increases the risk for both pregnancy loss and diabetes, or that pre-diabetes present before the diagnosis of diabetes could lead to both. In any case, the authors stress that the observational finding does not prove cause and effect.

The lead author, Dr. Pia Egerup, a researcher at the Recurrent Pregnancy Loss Unit of the Rigshospitalet and Hvidovre Hospital in Copenhagen, said that the most important clinical implication is that pregnancy loss is a risk factor for diabetes.

“Pregnancy loss is not only due to fetal disease,” she said. “A large proportion are healthy fetuses lost because of maternal conditions. As clinicians, we want to optimize pregnancy success and minimize the risk for future diabetes.”

Por qué los recortes en salud perjudican siempre a los californianos más vulnerables

Shirley Madden, de 83 años, depende de un cuidador y de sus dos hijas para seguir viviendo en casa, y no en una residencia.

Sus hijas, Carrie, de 55 años, y Kristy Madden, de 60, usan sillas de ruedas y necesitan un segundo cuidador que las ayude en su vida diaria.

Pero ese apoyo crítico para el cuidado, además de otros beneficios de atención médica para millones de californianos, podrían reducirse para ayudar a cubrir el enorme déficit presupuestario provocado por el coronavirus.

El gobernador de California, Gavin Newsom, ha propuesto recortes presupuestarios drásticos a los programas de salud pública, incluyendo Medi-Cal, el programa de Medicaid de California para personas de bajos ingresos, cuando se espera un aumento de inscripciones debido a la pérdida récord de empleos por culpa de la pandemia.

Los expertos temen que estos recortes puedan poner en peligro los miles de millones de dólares en fondos federales de emergencia para la salud asignados a California.

“Entiendo que hay una pandemia y que la situación es mala y que todo el mundo sufre”, dijo Carrie Madden de Chatsworth, California. Carrie y su hermana padecen distrofia muscular y su madre ha sobrevivido a un ataque al corazón mientras lucha contra la demencia.

Los temores de Madden se ven agravados por la crisis de COVID-19, que ha afectado con más fuerza a los mayores y a quienes tienen enfermedades crónicas. No quiere que su madre, su hermana o ella misma terminen en una residencia o en cualquier centro de cuidados a largo plazo, que son los lugares con más brotes.

“Este es el enfoque equivocado”, señaló. “Hará que las personas discapacitadas terminen en residencias para mayores”.

En todo el país, los estados consideran recortes a Medicaid para equilibrar sus presupuestos. En parte porque la salud suele ser la mayor parte del gasto estatal, después de la educación.

También proyectan que más gente se inscribirá en el programa de salud pública, a medida que el número de estadounidenses desempleados alcance niveles astronómicos. Más de 20 millones de estadounidenses solicitaron el subsidio de desempleo en abril, elevando la tasa de personas sin trabajo al 14,7%, la peor desde la Gran Depresión de la década de 1930.

Nueva York aprobó recortes a Medicaid que entrarán en vigor cuando termine la emergencia federal, mientras que Georgia ha dado instrucciones a todas sus agencias para reducir el gasto en un 14%.

En California, donde casi 2,9 millones de personas han solicitado el desempleo en los últimos dos meses, Newsom describió los recortes propuestos como “prudentes” y “estratégicos”, un giro enorme a los grandes planes que dio a conocer a principios de este año para ampliar la atención médica a algunos de los residentes más necesitados.

Para hacer frente a un déficit estimado de $54 mil millones en el presupuesto estatal 2020-21, Newsom propone un recorte de $205 millones —una reducción del 7% en las horas de los cuidadores— al programa de Servicios de Apoyo en el Hogar del que dependen los Maddens.

El programa, financiado principalmente por Medi-Cal, paga a los cuidadores para dar de comer a las personas que necesitan ayuda para vivir de forma independiente, lavar su ropa, bañarlos, administrarles tratamientos médicos y mantener su hogar limpio.

La lista de los otros recortes es larga: reducirá o eliminará programas que permiten a los mayores de bajos ingresos y a los discapacitados vivir en su propio hogar, como la atención médica diurna y el apoyo de los trabajadores sociales.

Propone facilitar al estado el cobro del pago póstumo de los fallecidos, mayores de 55 años, y afiliados a Medi-Cal, por una amplia gama de gastos médicos a través del controvertido “Programa de Recuperación de Bienes“. Sugiere que se reinstauren requisitos de ingresos más estrictos para que algunas personas mayores y las que tengan discapacidades puedan tener derecho a Medi-Cal gratuito.

Y ha pedido a los legisladores que eliminen $54,7 millones en beneficios “opcionales” de Medi-Cal, como la atención de podología para adultos, gafas, terapia del habla y exámenes de audición; beneficios que los mismos legisladores restauraron recientemente después de recortarlos durante la última recesión.

“No son beneficios opcionales para una persona que ha sufrido un derrame cerebral o necesita dientes para comer”, explicó Tricia Berke Vinson, una abogada de la Sociedad de Ayuda Legal del condado de San Mateo.

“Entiendo que estamos en una crisis presupuestaria”, añadió. “Pero no creo que se pueda equilibrar a costa de adultos mayores y enfermos”.

Médicos, dentistas y otros proveedores de atención de salud que tratan a pacientes de Medi-Cal también podrían perder $1,200 millones en pagos suplementarios que se derivan de la Propuesta 56, un impuesto sobre el tabaco que los votantes aprobaron en 2016.

La propuesta del gobernador demócrata incluye un “detonante” automático para eliminar los recortes si el estado obtiene más dólares federales para la crisis de la COVID, trasladando la responsabilidad al Congreso para negociar otro paquete de estímulo.

No se sabe si los legisladores aceptarán los enormes recortes a Medi-Cal que el gobernador ha propuesto. Por ejemplo, el plan del Senado estatal preserva la financiación de Medi-Cal y supone que el Congreso aprobará otro proyecto de ley de estímulo.

Ambas cámaras de la legislatura deben llegar a un acuerdo y presentar su versión del presupuesto al gobernador antes del 15 de junio.

“Salvar estos programas es salvar vidas y ahorrar dinero”, indicó el legisador Jim Wood (demócrata de Santa Rosa), presidente del Comité de Salud de la Asamblea. “Corten estos programas y los costos aumentarán y se perderán vidas”.

Tanto los expertos como algunos legisladores temen que el enfoque de Newsom pueda poner en peligro los miles de millones de dólares, en fondos federales de emergencia para la salud, que ya están asignados a California.

Los estados que abandonan a los inscritos en Medicaid, o reducen sus beneficios, corren el riesgo de perder los pagos federales de salud adicionales autorizados por el Congreso esta primavera, expresó Edwin Park, experto en Medicaid y profesor de la Escuela McCourt de Política Pública de la Universidad de Georgetown.

“El gobierno federal ha dicho que no se puede reducir la elegibilidad ni cancelar o recortar los beneficios”, dijo Park, y señaló que los legisladores de Nueva York retrasaron los recortes de Medicaid del estado hasta después de que terminara la emergencia federal, para asegurarse de que recibirán la ayuda federal ahora.

Los Centros de Servicios de Medicare y Medicaid no respondieron a las solicitudes de comentarios. La guía publicada en su sitio web sugiere que los estados deben mantener intactos los programas de Medicaid.

Se espera que California reciba $5.1 mil millones en fondos federales adicionales para Medi-Cal hasta el 30 de junio de 2021, según el presupuesto que Newsom hizo público a mediados de mayo.

La administración Newsom no cree que los recortes presupuestarios de Medi-Cal le cuesten al estado el dinero federal adicional ya aprobado por el Congreso.

“Nunca hay una garantía hasta que hablemos con el gobierno federal. Así que hasta entonces, es difícil decir qué se va a hacer a nivel federal”, dijo Yang Lee, analista del Departamento de Finanzas del estado.

La administración Newsom calcula que unos dos millones de californianos se inscribirán en Medi-Cal para julio como resultado de la pandemia, lo que eleva la inscripción en el programa a 14.5 millones, más de un tercio de todos los californianos.

La administración estima $3,100 millones en gastos adicionales para cubrir a los nuevos inscritos. La Legislative Analyst’s Office cree que esa cifra representa un exceso de $750 millones, en parte porque los nuevos inscritos serán principalmente personas más jóvenes y saludables que no necesitan tanta atención como los mayores de bajos ingresos y las personas con discapacidades.

Para muchos de los inscritos, las propuestas de Newsom recortarían múltiples beneficios.

Cynde Soto, de 63 años, dijo que se sintió como si “alguien me hubiera dado un puñetazo en el estómago” cuando supo que el plan del gobernador recortaría el presupuesto de los Servicios de Apoyo en el Hogar. Esta residente de Long Beach, que es tetrapléjica,  teme que los recortes del estado la obliguen a ir a una residencia de mayores. Además, teme perder la atención dental y de visión de Medi-Cal si se aprueban los otros recortes de Newsom.

“Es una pesadilla. No sé qué voy a hacer”, comentó Soto. “¿Por qué siempre somos los primeros a los que golpean?”.

Related Topics

California Cost and Quality Insurance Medi-Cal Noticias En Español States

‘An Arm And A Leg’: The $7,000 COVID Test And Other Lessons From SEASON-19


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Host Dan Weissmann spoke with three people who have very different reflections on what the COVID-19 pandemic is costing us.

  • A doctor and advocate in Brooklyn looked back on the wave of black and brown patients that filled her clinic in March.
  • A nurse practitioner in Texas shared how new tech is — and isn’t — helping the older patients she cares for.
  • One of the country’s top insurance nerds conceded that her initial policy ideas to keep people from getting stuck with expensive bills for COVID tests were wrong.

Here’s the season recap: A new abnormal. A shortage of hugs. And the $7,000 COVID test.

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Cost and Quality Health Care Costs Multimedia

‘Why Do We Always Get Hit First?’ Proposed Budget Cuts Target Vulnerable Californians

Shirley Madden, 83, relies on a caregiver and her two grown daughters to remain living at home — and not in a nursing home.

Her daughters, 55-year-old Carrie and 60-year-old Kristy Madden, both use wheelchairs and need a second caregiver to help them navigate their own daily lives.

But that critical caregiving support, along with other health care benefits for millions of Californians, could be scaled back to help plug a massive budget deficit triggered by the coronavirus.

California Gov. Gavin Newsom has proposed sweeping budget cuts to safety-net health care programs ― including Medi-Cal, California’s Medicaid program for low-income people ― just as enrollment is projected to spike because of record job losses related to the pandemic.

Health care experts also fear the cuts could jeopardize billions of dollars in emergency federal health funding allotted to California.

“I understand there’s a pandemic and it’s really bad and everybody is hurting,” said Carrie Madden of Chatsworth, California. Carrie and her sister have muscular dystrophy and their mother is a heart attack survivor who struggles with dementia.

Madden’s fears are compounded by the COVID-19 crisis, which has hit older people and those with chronic health conditions the hardest. She doesn’t want her mother, her sister or herself to end up in a nursing home or other long-term care facility — the settings with the most outbreaks of COVID-19.

“This is the wrong approach,” she said. “This will make disabled people end up in nursing homes.”

States across the country are eyeing Medicaid cuts to balance their budgets, in part because health care is usually the biggest portion of state spending, after education. They also project that more people will sign up for the public health care program, as the number of unemployed Americans hits astronomical heights. More than 20 million Americans filed for unemployment in April, raising the unemployment rate at least to 14.7%, the worst since the Great Depression of the 1930s.

New York approved Medicaid cuts that will take effect after the federal emergency ends, while Georgia has instructed all its agencies to reduce spending by 14%.

In California, where almost 2.9 million people have filed for unemployment in the past two months, Newsom described the proposed budget cuts as “prudent” and “strategic,” a huge pivot from the grand plans he unveiled earlier this year to expand health care to some of the neediest residents.

To address an estimated $54 billion deficit in the 2020-21 state budget, Newsom proposes a $205 million cut — or a 7% reduction in caregiver hours — to the In-Home Supportive Services program the Maddens rely on. The program, primarily funded by Medi-Cal, pays caregivers to make meals for people who need help to live independently, do their laundry, bathe them, administer medical treatments and keep their home clean.

The list of his other proposed cuts is lengthy: He would scale back or eliminate other programs intended to keep low-income seniors and people with disabilities in their own homes, such as adult day health care and support from social workers. He proposes to make it easier for the state to collect posthumous payback from deceased Medi-Cal enrollees 55 and older for a broad range of medical costs through the controversial “Estate Recovery Program.” He suggests reinstituting stricter income requirements for some older people and those with disabilities to qualify for free Medi-Cal.

And he is calling on lawmakers to remove $54.7 million in “optional” Medi-Cal benefits, such as adult podiatry care, eyeglasses, speech therapy and hearing exams — benefits that lawmakers recently restored after they were cut during the last recession.

“These don’t feel optional to people if they have had a stroke or need teeth to eat their food,” said Tricia Berke Vinson, an attorney with the Legal Aid Society of San Mateo County.

“I understand we are in a budget crisis,” she added. “I just don’t think it can be balanced on the old and the sick.”

Physicians, dentists and other health care providers who treat Medi-Cal patients also stand to lose $1.2 billion in supplemental Medi-Cal payments that flow from Proposition 56, a tobacco tax that voters approved in 2016.

The Democratic governor’s proposal includes an automatic “trigger” to restore the cuts if the state gets more federal COVID relief dollars, shifting the responsibility to Congress to negotiate another stimulus package.

Whether lawmakers will make the sweeping Medi-Cal cuts the governor has proposed is uncertain. For example, the state Senate plan preserves Medi-Cal funding and assumes Congress will pass another stimulus bill.

Both houses of the legislature must come to an agreement and present their version of the budget to the governor for consideration by June 15.

“Save these programs and you save lives and money,” said Assembly member Jim Wood (D-Santa Rosa), chair of the Assembly Health Committee. “Cut these programs and costs will increase and lives will be lost.”

Health care experts and some lawmakers also fear Newsom’s approach could jeopardize billions of dollars in emergency federal health funding already allotted to California.

States that drop Medicaid enrollees or reduce benefits risk losing out on additional federal health payments authorized by Congress this spring, said Edwin Park, an expert on Medicaid and a professor at Georgetown University McCourt School of Public Policy.

“The federal government has said you can’t cut eligibility or disenroll or cut benefits,” Park said. He noted that New York lawmakers delayed their state Medicaid cuts until after the federal emergency ends to ensure they still receive the added federal help now.

The Centers for Medicare & Medicaid Services did not respond to requests for comment. Guidance posted on its website suggests states must keep Medicaid programs intact.

California is expected to receive $5.1 billion in additional federal funding for Medi-Cal through June 30, 2021, according to the proposed budget Newsom released in mid-May.

The Newsom administration is not convinced its Medi-Cal budget cuts will cost the state the additional federal money already approved by Congress.

“There’s never a guarantee until we have that conversation with the federal government. So until then, it’s hard for us to tell what the fed’s going to do,” said Yang Lee, an analyst at the state Department of Finance.

Newsom’s administration predicts about 2 million Californians will sign up for Medi-Cal by July as a result of the pandemic, bringing the program’s enrollment to 14.5 million, more than one-third of all Californians.

The administration anticipates $3.1 billion in added costs to cover the new enrollees. The Legislative Analyst’s Office believes that figure is $750 million too high, in part because new sign-ups will primarily be younger and healthier individuals who do not need as much care as low-income seniors and people with disabilities.

For many current enrollees, Newsom’s proposals would cut into multiple benefits.

Cynde Soto, 63, said it felt like “someone had punched me in the gut” when she heard about the governor’s plan to cut the In-Home Supportive Services budget. As a quadriplegic, the Long Beach resident worries state cutbacks could force her into a nursing home. On top of that, she fears she might lose her Medi-Cal dental and vision care if Newsom’s other cuts are approved.

“I’ve had nightmares about it. I don’t know what I’m going to do,” Soto said. “Why do we always get hit first?”

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

Related Topics

California Cost and Quality Insurance Medi-Cal Medicaid States

Finding Euphoria in Bangkok’s Food Scene

With travel restrictions in place worldwide, we’ve launched a new series, The World Through a Lens, in which photojournalists help transport you, virtually, to some of our planet’s most beautiful and intriguing places. This week, Louise Palmberg shares a collection of photographs from the markets and food stands in Bangkok.


Early this year, in search of inspiration beyond the food scene in New York (and not yet locked down by the spread of Covid-19), I spent two weeks visiting and documenting life among the fresh markets and street vendors in and around Bangkok.

It made for an unlikely itinerary since tourists in Thailand often spend only a day or two in the capital before heading south toward the country’s many islands.

But, energized by Thailand’s rich culinary heritage, I ventured — by train, motorcycle taxi and tuk-tuk — into an endless array of scenes and exchanges.

ImageCrispy peanut chips at a street stall in Bangkok.
Crispy peanut chips at a street stall in Bangkok.

What struck me more than anything was the mobility of the various food operations. At the Maeklong Railway Market in Samut Songkhram, about 40 miles southwest of Bangkok, an active rail line slices a clean path directly through the vendors’ stations; their awnings and umbrellas are retracted, with mere inches to spare, each time a train arrives and departs.

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A boy walks down the train tracks at Maeklong Railway Market.

The aromas here are rich and pungent — smoked, cured, dried and fresh seafood, along with many forms of meat, both raw and cooked. The awnings over the stalls create a shadowy atmosphere that’s punctuated by thin streaks of dancing light.

In the wake of the coronavirus pandemic, which has been linked to the sale of wildlife at a market in Wuhan, China, the practices at some of Bangkok’s markets have raised concerns about the potential spread of diseases between animals and humans — though nothing overtly problematic ever caught my eye.

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Staples of the market include smoked, cured, dried and fresh seafood.
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A child waves from a train car at Maeklong.

The views on the train ride to and from the market were equally enthralling. I watched my fellow passengers, their hair billowing in the wind, and gazed out at the steady stream of sea-salt farms aglow in the distance.

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A woman stands between two train cars on the train to Maeklong Railway Market.
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The salt fields outside of Bangkok.

At the nearby Damnoen Saduak floating market, vendors paddle past in wooden boats overflowing with goods: fruits, vegetables, noodles, spices, flowers.

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A vendor paddles along the Damnoen Saduak floating market.

One vendor, now in her 80s, said she’d been serving noodles by boat here for 60 years.

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Now in her 80s, this vendor has been serving noodles from her boat since she was in her 20s.
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At the Khlong Toei market, one of Bangkok’s largest and most trafficked, I lost my way in a maze of tiny alleyways — and, despite spending several hours here, I experienced only a small fraction of what was on offer.

Observing the vendors themselves is breathtaking: their poise, their efficiency, the fluidity of their movements. I watched, transfixed, as one woman fried spring roll wrappers on a large skillet, expertly crafting three at once. The dexterity and precision of her movements were truly mesmerizing.

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A woman makes spring roll wrappers at Khlong Toei market.

The markets here draw a fair number of tourists. But they’re also essential to local restaurateurs and chefs. It’s common to see departing tuk-tuks and motorbikes that are fully laden with vegetables, soon to be featured as fresh ingredients on plates and in bowls throughout the city.

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Bangkok’s markets are essential to local restaurateurs and chefs, who can often be seen loading tuk-tuks and motorbikes with fresh goods.
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Though I didn’t know it at the time, this trip would prove to be my last for a while. Lately I find myself thinking back on all the moments of closeness — squeezing through alleyways in a crowded market, or sitting atop brightly colored plastic stools in narrow street stalls, or drinking beers alongside new acquaintances. It’s hard to reconcile those moments with my present reality, where I’m stuck alone inside my Brooklyn apartment for months on end, talking to no one but my plants.

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A motorcycle taxi glides through one of the city’s narrow alleys.

For a while, that dissonance made it hard for me to look back at the pictures and videos from my trip; I longed for the warmth and the thrill I’d just experienced. But as time has passed I’ve settled into the silence of my quarantine, I can view them now with a certain fondness. In the end, there’s no doubt that I left with an abundance of creative inspiration — from both the people I met and the many food cultures in which I was invited to participate.


Louise Palmberg is a Swedish photographer and director who lives in New York. You can follow her work on Instagram.

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.

How Do You Decide if Children Can Play Together Again?

As some parts of the country “open up” and families venture beyond their households, parents are faced with hard decisions about what children can do. There are no official guidelines, so I asked smart and experienced pediatricians from around the country what questions they are getting from parents, and how they’re answering them. Spoiler alert: There are no easy answers.

“I’m getting it every day in my office: what do we do, we can’t stay home forever, we need some activities,” said Dr. Sally Goza, the president of the American Academy of Pediatrics, who is a primary care private practice pediatrician in Fayetteville, Ga. “I try to explain to parents, this virus is not gone, it’s still here, we need to be smart in how we go about being around other people.”

Despite the “novelty” of the virus, these dilemmas are not entirely new — this is what parents do: weigh risks, look at what the experts say, figure out where your own level of comfort is, and then make decisions that affect the health and safety of the people you love best.

Making these decisions is going to involve choosing other families you feel you can trust. “There’s a certain amount of selecting out families with the same level of risk aversion,” said Dr. David Rubin, director of PolicyLab at the Children’s Hospital of Philadelphia.

“People are wondering how they sort of stick their toe in the water and try to re-engage outside of their homes,” said Dr. Terri McFadden, associate professor of pediatrics at Emory School of Medicine and medical director for primary care at Hughes Spalding Hospital in Atlanta. “I’m getting that especially for teens — the teens feel invincible, they don’t feel like they’re in any danger at all, and they’re itching to get out and interact with their peers.

Still, she said in an email, “I caution families to be very careful about potentially exposing their children or themselves to Covid-19 while infection rates remain high. This is especially true for high risk groups that have been disproportionately affected, which is many of my patients: African-Americans, Hispanics and families with pre-existing conditions or elderly care givers.”

If you are contemplating a play date, taking into account all these risks, you will need good communication with the other parents. “A start would be, hi, our kids have been asking about getting together, and as you know, this is a complicated conversation right now,” said Dr. Dipesh Navsaria, an associate professor of pediatrics at the University of Wisconsin School of Medicine and Public Health. A parent could continue, “I wanted to start with an open conversation, see where you are, tell you where I am, and see if it’s possible to send a consistent message to our kids.”

And then you can get down to the details: indoors, outdoors, duration of contact, masks, food and drink, parental supervision to make sure that rules are observed. “I’m less worried about a parent or a business getting all the rules right, because we don’t know what ‘right’ is,” Dr. Navsaria said, “and more concerned about them being intentionally thoughtful.”

It’s not so different, he said, from the conversations that pediatricians advise parents to have with other parents about whether there are unsecured firearms in the house, or whether the pool is fully fenced and locked; it’s basically a conversation about whether you feel your child is safe at someone else’s home, in someone else’s care.

Don’t frame it so that the more restrictive parent is the bad guy, and try for an honest conversation that respects differences of opinion. Remember that other parents may have reasons you don’t know about to be more wary of possible infections. That’s what it means to present a consistent message to a child: This is about keeping everyone safe, and sometimes that means waiting a little longer. And if there’s going to be a play date with limitations, make sure the child understands what those limitations are, and rehearse the possible activities.

Families should not feel pressure to change their rules, even if they are living in areas that are opening up. If there is a vulnerable adult — or child — in the home, they may want to be more strict, rather than less strict, as others relax their restrictions. And not all children — or adolescents — are necessarily pushing for those in-person social contacts. We need to give each other time, and treat each other gently.

Take it step by step, Dr. Goza said. Start with carefully chosen contacts, and don’t jump right to large gatherings. “You spent all this time trying to isolate and social distance,” she said. “You don’t want to go out there and just blow it all.” The parents she’s talked to, she said, have been very conscientious, planning out social encounters with neighbors getting together outside for a barbecue.

Dr. Goza advised that parents encourage children to spend their time together outside, she said, to wear masks, to wash their hands regularly. Pools are probably relatively safe, she said, according to current thinking about transmission, but supervision is important, both because of water safety and to try to prevent kids from being too close together.

What about when family and friends disagree? “I say, if they don’t wear masks, I would try not to be in an enclosed place,” Dr. Goza said. “Wear a mask yourself, say, ‘I respect your opinion but we feel like we want to keep a bit of distance.’”

To reduce risk, everyone’s No. 1 piece of advice is that if there is going to be socializing, keep it outdoors as much as possible. Keep the time periods limited — maybe a short session outside in the afternoon, rather than a sleepover. Encourage hand-washing, send children with hand sanitizer, and yes, make it clear beforehand that masks are to be worn. If there’s going to be a meal together, meaning that masks will come off, kids need to be sitting far enough apart.

But if you decide you’re ready to relax your isolation, don’t expect the impossible. Dr. Navsaria cautioned parents “not to expect 100 percent hand hygiene and proper mask use, because children are children, and even older kids that quote unquote should know better.”

Dr. Rubin said, “It’s a good moment for teaching kids individual responsibility.” That includes asking older kids to be honest if they have relaxed the rules, which may mean, he said, that parents will want to practice some social distancing at home around adolescents who may be taking risks.

With adolescents, it’s important to review your family stands on alcohol and other substance use, and the ways they can affect judgment, and to talk frankly about sex in the context of social distancing.

  • Frequently Asked Questions and Advice

    Updated May 28, 2020

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • How many people have lost their jobs due to coronavirus in the U.S.?

      More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.

    • Is ‘Covid toe’ a symptom of the disease?

      There is an uptick in people reporting symptoms of chilblains, which are painful red or purple lesions that typically appear in the winter on fingers or toes. The lesions are emerging as yet another symptom of infection with the new coronavirus. Chilblains are caused by inflammation in small blood vessels in reaction to cold or damp conditions, but they are usually common in the coldest winter months. Federal health officials do not include toe lesions in the list of coronavirus symptoms, but some dermatologists are pushing for a change, saying so-called Covid toe should be sufficient grounds for testing.

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

    • How can I help?

      Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.


Talk to your children about why this all matters, Dr. Goza said. “Give them science so they can understand why it’s so important, to protect them, protect their friend, protect their parents and grandparents and their friend’s parents and grandparents.”

“Not every lapse of self-protection activity is going to necessarily mean that the worst is going to happen,” Dr. Navsaria said. “We need to teach and redirect and guide with kindness and compassion, including our own kids, because everyone is doing the best they can.”

Pediatricians are also concerned that with children looking for summer recreation, but not supervised in camps or formal programs, there may be a higher risk of injuries, including bicycle-related accidents and trampoline mishaps, and especially drownings. No activities are completely risk-free, but taking precautions (bike helmets, locked gates around pools, proper adult supervision) and talking things through with your children can make everyone safer.

So here we all are, parents and pediatricians, trying to keep children as safe as possible, while letting them take some steps out into the world.

“Summer is going to be different,” Dr. Goza said. “We just need to be kind to each other — people are going to have different ideas, and we need to try to be considerate about what other people think, knowing we have to do what’s right for our families.”


Do you have questions for Dr. Perri Klass? Join her and Tara Parker-Pope, the founder of Well, for a New York Times event, “Living Well: Ask a Pediatrician” Monday June 1 at 1 p.m. Eastern. They’ll talk about kids, coping, playtime and more.

Democratic Super PAC Uses Familiar Political Play To Hit Trump On Medicare

Priorities USA Action, a Democratic super PAC, announced a new digital and TV ad series criticizing President Donald Trump’s response to the coronavirus pandemic.

Among the ads is a 15-second spot, titled “Pause,” that alleges Trump is trying to cut Medicare during the global health emergency.

“Our lives are on pause. We’re worried about our health. So why is Trump still trying to cut our Medicare? $451 billion in cuts in the middle of a deadly pandemic. Trump is putting us at risk,” the commercial’s narrator says.

The PAC, which was formed in 2011 to support President Barack Obama’s reelection campaign, has been tapped by Joe Biden, the presumptive Democratic presidential nominee, as his preferred choice among Democratic super PACS for big-donor giving.

This ad caught our attention for two reasons. First, the term “Medicare cuts” has long been volleyed between both Republicans and Democrats in Congress and the White House — and often has proven to be a powerful political tool.

Second, the connection between “cuts” to Medicare and the coronavirus pandemic was a new concept we wanted to explore.

We reached out to Priorities USA Action to ask for the basis of these statements.

Josh Schwerin, a PAC spokesperson, sent us links to news articles and confirmed that the “$451 billion in cuts” referred to Trump’s 2021 proposed budget for Medicare.

Asked to pinpoint where the $451 billion came from, Schwerin pointed us to a February ABC News article that said the president’s budget plan would “whack away at federal spending on health care over the next 10 years … including $451 billion less spent on Medicare.” He also sent us links to a February Washington Blade article and February press release from Rep. Jahana Hayes (D-Conn.) — both of which also cited that figure.

Cuts Or A Reduction In Spending? An Argument That’s Been Around

In fall 2010, a few months after the Affordable Care Act was enacted, Republicans aired midterm campaign ads attacking Democrats for “cutting” or “gutting” Medicare. The reason was the law included a $500 billion reduction in projected spending for Medicare over 10 years, which would be used to help fund the ACA.

The Obama administration said the reductions in spending would come from lowering payments to Medicare Advantage plans and providers and would not affect the level of care that Medicare beneficiaries received. They also said it would help make the Medicare system more financially stable.

Now, almost 10 years later, Democrats are using the same language to criticize the White House’s long-term plan for Medicare spending.

“‘Cuts’ is a term that has been thrown around for many years,” said Tricia Neuman, executive director of the Program on Medicare Policy at the Kaiser Family Foundation. “This is a semantic issue that often gets politicized, often in an election year.” (Kaiser Health News is an editorially independent program of the foundation.)

Neuman explained that what is being considered here is a reduction in the projected increase in spending over a certain period. This reduction is based on estimates of how much the government is projected to spend on programs — factoring in proposed policy changes — for the following 10 years, taking into account current levels of spending, assumptions about economic growth and trends in the use of Medicare coverage, said Neuman.

Trump’s 2021 budget blueprint for Medicare estimated that spending would increase each of the 10 years. But the estimate also suggested that the administration’s proposed policy changes would reduce the spending increase compared with estimates of what would be spent if the changes were not implemented.

“Let’s say Medicare spends $100 in 2020 and is projected to spend $200 in 2021,” Neuman said. “If the budget said we’re going to reduce the growth in spending by $25, that’s a reduction in an increase. But other people might call that a cut.”

The Number Itself And What It Means

We reached out to the Department of Health and Human Services, which oversees Medicare, for its take on that $451 billion figure but have not heard back.

Marc Goldwein, senior policy director for the nonpartisan Committee for a Responsible Federal Budget, said the actual figure could be anywhere from $400 billion to $600 billion, depending on how calculations are done. His analysis relied on the executive branch’s Office of Management and Budget calculations and landed on a figure close to $505 billion. Other variables, such as “likely savings from drug price reform” — yet to be enacted — move it closer to $600 billion.

The left-leaning Center on Budget and Policy Priorities came up with a similar estimate: $501 billion. The Congressional Budget Office’s estimate, not including savings generated from proposed drug pricing reforms, was closer to $400 billion.

In all cases, though, the reductions in Medicare spending would be achieved through proposals such as lowering payments to providers and paying the same amount for the same health service offered in different settings.

Goldwein said these proposals for Medicare reform are largely bipartisan and “either mimic or build upon” those advanced during the Obama era. He also said that, in his organization’s view, the “cuts” are savings to the Medicare program and beneficiaries, who would see lower premiums and out-of-pocket medical costs.

The policy experts said it’s likely the reductions in spending wouldn’t directly affect the care that Medicare beneficiaries receive. But provider groups have complained that lower reimbursements might drive some doctors to leave Medicare. Hospitals have argued against the proposal for equalizing payments for similar services because they say their overhead expenses are higher than those of a doctor’s office or off-site clinic and their higher rates help finance other necessary services.

Timing Matters

The Priorities USA Action ad also alleges that Trump is trying to cut Medicare “in the middle of a deadly pandemic.” But the timeline of events doesn’t support this statement.

The White House released the 2021 budget proposal on Feb. 10 — well before the COVID-19 outbreak had become a part of our national consciousness.

The first domestic case of COVID-19 was announced by the Centers for Disease Control and Prevention on Jan. 21. The World Health Organization declared the outbreak of the novel coronavirus a “public health emergency of international concern” on Jan. 30.

On Feb. 10, the day the budget was released, the CDC put out a press release stating there were 13 cases of the disease in the U.S. CNN also published an article that day stating the vast majority of COVID-19 cases and deaths had occurred in China. Authorities didn’t announce the first U.S. death from COVID-19 until Feb. 29. The WHO declared a pandemic on March 11.

“These budget proposals were probably developed well before the pandemic hit the U.S. and hit it hard,” said Neuman. However, she added, “the administration hasn’t disavowed these proposals, but they also haven’t pushed them forward.”

Joseph Antos, a scholar in health care and retirement policy at the right-leaning American Enterprise Institute, said it was a “ridiculous statement to connect cutting Medicare spending to the COVID crisis.”

“The implication of the video that this is going on actively while we’re in the middle of this crisis, that’s dead wrong,” said Antos.

Our Ruling

The Priorities ad said Trump is trying to make $451 billion in Medicare cuts “in the middle of a deadly pandemic.”

This is an exaggerated attack, even before the pandemic is layered on top of it. The dollar figure itself is “in the ballpark” of what the policy proposals would generate in spending reductions, giving this ad a sliver of truth. However, in the Trump budget, the amount is spread over 10 years — important context that was omitted.

What’s in Trump’s budget proposal is not a direct cut to Medicare. Instead, Priorities uses the age-old political tactic — employed on both sides of the aisle — of holding up a reduction in projected spending growth as a “cut.”

Moreover, the ad leaves the impression that Trump is trying to whack Medicare for seniors at a time when panic is particularly high because of the coronavirus. But that connection to the pandemic is also misleading. The presidential budget was released weeks before most of the nation began to comprehend the threat of COVID-19.

The claim contains an element of truth but ignores critical facts and context that would give a different impression. We rate it Mostly False.

Related Topics

Medicare States The Health Law

Coronavirus Surprise: IRS Allows Midyear Insurance And FSA Changes

The economic upheaval and social disruption caused by the coronavirus pandemic have upended the assumptions many people made last fall about which insurance plan to sign up for, or how much of their pretax wages to sock away in health or dependent care flexible spending accounts.

You may find yourself in a high-priced health plan you can no longer afford because of a temporary pay cut, unable to get the medical care you might have planned and budgeted for, or not sending the kids to day care. Normally you’d be stuck with the choices you made unless you had a major life event such as losing your job, getting married or having a child. But this year, things may be different.

Last month, the Internal Revenue Service announced it would let employees add, drop or alter some of their benefits for the remainder of 2020. But there’s a catch: Your employer has to allow the changes.

The new guidance applies to employers that buy health insurance to cover their workers as well as those that pay claims on their own, called self-insuring. It’s unclear how many employers will take advantage of the new flexibility to offer what amounts to a midyear open enrollment period. If you’re wondering what your company will do, ask.

“If a consumer finds themselves economically strapped and their finances have changed, and they’re in a situation where they really would like to rethink their coverage, they may want to approach their employer and see if they’re planning to adopt any of these changes,” said Jay Savan, a partner at human resources consultant Mercer.

Some health care policy experts are unimpressed with the new coverage options, noting that earlier this spring the Trump administration opted not to create a special enrollment period for uninsured workers to buy subsidized health insurance on the Affordable Care Act’s health insurance marketplaces.

“It’s not likely that many people will take up this new coverage opportunity, and it won’t address the problem of lack of coverage that many people are facing,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

Assuming you still have employer-sponsored coverage, here are examples of circumstances workers may face and what the IRS changes could mean for them.

You want to switch to a cheaper plan to put more money into savings during these uncertain times. Can you do that?

If your employer decides to allow it, you can.

One consideration: If you switch plans midyear, you may have to start all over again paying down your deductible and working toward reaching your annual out-of-pocket maximum spending limit for the year, said Katie Amin, a principal at Groom Law Group in Washington, D.C., a firm specializing in health care and benefits.

“Some employer plans would credit you under the new option if you switched plans,” Amin said. “It depends.”

You’ve got a high-deductible plan and are worried about high medical bills if you get COVID-19. Can you switch to a plan with more generous coverage?

The IRS guidance allows it, but your employer probably won’t, say experts. It’s impossible for workers or their bosses to know who will develop COVID-19. But the concern among employers is that people willing to pay more for generous coverage may be sicker and have higher health care costs than other workers, and could therefore cost the plan more, a phenomenon called adverse selection.

In addition to evaluating whether employees could benefit from midyear changes, an employer will weigh financial considerations, said Steven Wojcik, vice president of public policy at the Business Group on Health, which represents large employers.

They’ll ask, “What is the adverse selection risk, and what is going to be the uptake [in coverage] if you open up enrollment?” he said.

Under the new rules, if you haven’t had health insurance on the job before but would like to sign up now, you can do that, too, if the employer decides to permit it.

What if one spouse gets laid off but the other is still employed? Can the couple switch their family coverage to the employed spouse’s plan?

Yes. But this was already allowed before the new IRS guidance came out. Under long-standing rules, if workers’ life circumstances change they’re entitled to change their coverage during the year.

Can you drop your employer coverage altogether?

Yes, if your employer permits it. Normally, once you sign up for health insurance through your employer and agree to have your premiums deducted from your paycheck, you can’t drop coverage during the year unless you experience a qualifying life event. Under the new IRS rules, you can drop your coverage, but only if you replace it with another form of comprehensive coverage such as through a health insurance exchange or Tricare, the military health insurance program.

One thing that won’t qualify as comprehensive coverage: a short-term plan, said Amin. The Trump administration has encouraged the adoption of limited-duration plans with terms that can last for nearly a year. They don’t typically cover preventive care or preexisting conditions, and renewal is not guaranteed.

You’ve put thousands of dollars into a flexible spending account to cover day care expenses this year, but now the kids are home full time. Can you change the amount?

Yes, but once again this is allowed only if your employer agrees to it. Likewise, if you want to increase your pretax contribution because you need to hire someone to care for your kids at home while you work, you can do that, too. You can also establish a new flexible spending account for dependent care expenses in 2020 if you don’t already have one.

Employees are legally entitled to put up to $5,000 annually into a dependent care FSA to pay for day care, preschool, after-school programs or summer camp.

“Since it’s the employees’ money, my guess is employers will allow them to make changes,” said David Speier, who is in charge of the benefit accounts group at human resources consultant Willis Towers Watson.

You planned to use money left over in last year’s FSA to cover the cost of a medical procedure in early March. But that was postponed because of the coronavirus and you’ve missed the March 15 deadline for using those funds. Do you have any recourse?

Under the new IRS guidance, employers can opt to extend the grace period for using leftover 2019 FSA funds through the end of 2020. Typically, those funds would have disappeared under “use it or lose it” rules if they hadn’t been used by March 15. In 2019, the maximum pretax contribution to a health care FSA was $2,700; this year it’s $2,750.

Similar to the changes now permitted for dependent care FSAs, employers can also decide to permit workers to prospectively decrease or rescind their elected health care FSA amounts altogether.

If you decide to stop contributing to your FSA, you can spend down the money that’s accumulated there on health care expenses, but you can’t cash out the account, said Amin. For example, if you’ve accumulated $500 in your FSA, you can use that money for eyeglasses or other approved expenses through the end of the year. But your employer can’t give you the $500 outright, essentially cashing out the account.

Employers have expressed a lot of interest in implementing the flexible spending account changes, said Mercer’s Savan.

“We expect them to have a lot of traction,” he said.

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Will Protests Spark a Second Viral Wave?

Mass protests against police brutality that have brought thousands of people out of their homes and onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases.

While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus.

More than 100,000 Americans have already died of Covid-19, the disease caused by the new coronavirus. People of color have been particularly hard hit, with rates of hospitalizations and deaths among black Americans far exceeding those of whites.

The protests in dozens of cities have been spurred most recently by the death last week of George Floyd at the hands of the police in Minneapolis. But the unrest and outrage spilling out into the streets from one city to the next also reflects the dual, cumulative tensions arising from decades of killings by police and the sudden losses of family and friends from the virus.

The spontaneous outpouring of protests are occurring as many states have warily begun reopening after weeks of stay-at-home orders with millions of American unemployed. Restaurants, schools, beaches and parks are under scrutiny as the public tentatively practices new forms of social distancing.

In Los Angeles, where demonstrations led to the closing of virus testing sites on Saturday, Mayor Eric Garcetti warned that the protests could become “super-spreader events,” referring to the types of gatherings, usually held in indoor settings, that can lead to an explosion of secondary infections.

Gov. Larry Hogan of Maryland, a Republican, expressed concern that his state would see a spike in cases in about two weeks, which is about how long it takes for symptoms to emerge after someone is infected, while Atlanta’s mayor, Keisha Lance Bottoms, advised people who were out protesting “to go get a Covid test this week.”

Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission. In addition, many of the demonstrators were wearing masks, and in some places, they appeared to be avoiding clustering too closely.

“The outdoor air dilutes the virus and reduces the infectious dose that might be out there, and if there are breezes blowing, that further dilutes the virus in the air,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University. “There was literally a lot of running around, which means they’re exhaling more profoundly, but also passing each other very quickly.”

The crowds tended to be on the younger side, he noted, and younger adults generally have better outcomes if they become ill, though there is a risk they could transmit the virus to relatives and household members who may be older and more susceptible.

But others were more concerned about the risk posed by the marches. Dr. Howard Markel, a medical historian who studies pandemics, likened the protest crowds to the bond parades held in American cities like Philadelphia and Detroit in the midst of the 1918 influenza pandemic, which were often followed by spikes in influenza cases.

“Yes, the protests are outside, but they are all really close to each other, and in those cases, being outside doesn’t protect you nearly as much,” Dr. Markel said. “Public gatherings are public gatherings — it doesn’t matter what you’re protesting or cheering. That’s one reason we’re not having large baseball games and may not have college football this fall.”

Though many protesters were wearing masks, others were not. SARS-CoV-2, the virus that causes the Covid-19 disease, is mainly transmitted through respiratory droplets spread when people talk, cough or sneeze; screaming and shouting slogans during a protest can accelerate the spread, Dr. Markel said.

Tear gas and pepper spray, which police have used to disperse crowds, cause people to tear up and cough, and increase respiratory secretions from the eyes, nose and mouth, further enhancing the possibility of transmission. Police efforts to move crowds through tight urban areas can result in corralling people closer together, or end up penning people into tight spaces.

And emotions have been running high, Dr. Markel said. “People get lost in the moment, and they lose awareness of who is close to them, who’s not, who’s wearing a mask, who’s not,” he said.

The biggest concern is the one that has bedeviled infectious disease experts since the pandemic began, and it’s the coronavirus’s secret weapon: that it can be transmitted by people who don’t display any symptoms and feel healthy enough to participate in protests.

“There are a huge number of asymptomatic carriers, and that makes it hugely risky,” Dr. Markel said.

  • Frequently Asked Questions and Advice

    Updated May 28, 2020

    • My state is reopening. Is it safe to go out?

      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

    • How can I protect myself while flying?

      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • How many people have lost their jobs due to coronavirus in the U.S.?

      More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.

    • Is ‘Covid toe’ a symptom of the disease?

      There is an uptick in people reporting symptoms of chilblains, which are painful red or purple lesions that typically appear in the winter on fingers or toes. The lesions are emerging as yet another symptom of infection with the new coronavirus. Chilblains are caused by inflammation in small blood vessels in reaction to cold or damp conditions, but they are usually common in the coldest winter months. Federal health officials do not include toe lesions in the list of coronavirus symptoms, but some dermatologists are pushing for a change, saying so-called Covid toe should be sufficient grounds for testing.

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.

    • How can I help?

      Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.


Dr. Ashish Jha, a professor and director of the Harvard Global Health Institute, said more than half of coronavirus infections are spread by people who are asymptomatic, including some who are infected but never go on to develop symptoms and others who don’t yet know they are sick.

ImageA patriotic parade in Philadelphia helped spread the influenza epidemic of 1918, historians have found.
A patriotic parade in Philadelphia helped spread the influenza epidemic of 1918, historians have found.Credit…U.S. Naval History and Heritage Command, via Associated Press

Arresting, transporting or jailing protesters increases the potential for spreading the virus. Dr. Jha called on protesters to refrain from violence, and urged the police to exercise restraint.

Dr. Scott Gottlieb, a former commissioner of the Food and Drug Administration, appearing on CBS’ “Face The Nation” on Sunday, also predicted the protests would lead to new “chains of transmission.”

He said social and economic inequities, including poor access to health care, discrimination in health care settings, greater reliance on public transportation and differences in employment were all factors leading to a greater burden of Covid-19 disease among people of color.

“Stopping the pandemic is going to depend on our ability to take care of our most medically and socially vulnerable,” Dr. Gottlieb said. “We absolutely need to resolve these underlying problems to eliminate the risk of pandemic spreading of the epidemic.”

Must-Reads Of The Week

The Big News

It was a short work week for those still able to work, but there was a considerable amount of health care news. That hasn’t changed.

The story that probably got the most attention was that the death toll in the United States from COVID-19 passed 100,000 people. It can be hard to get a handle on what that means. The Washington Post looked at the people who count the deaths and track the deaths.

There will be more. The Texas Tribune noted how the coronavirus was a threat to people living in homeless shelters. Nursing homes continue to be a major hot spot in this pandemic. Same goes for areas where poorer people live.

The Reopening

But another source of infections just might be the crowds of people who think all danger has passed and it’s time to frolic in close proximity with others.

You probably saw the photos and video of the crowds Memorial Day weekend in the pool at Lake of the Ozarks, Missouri, or on the boardwalk of Ocean City, Maryland. Missouri health officials pondered how to somehow place the partiers in self-quarantine, but that is unlikely. Cities, states and counties may also play fast and loose with the metrics that indicate when it is safe. The Centers for Disease Control and Prevention quietly removed a recommendation to limit singing in churches. (Singing has been shown to propel saliva particles.) So on it goes.

Disneyland is likely to open in July. Las Vegas casinos also announced their reopening and issued rules. Players can’t touch cards and slot machines will be fewer and farther apart.

Things That Don’t Change

Meanwhile, health care providers continue to find ways to make consumers pay more. The federal government’s Department of Health and Human Services said it will watch for “upcoding” of medical procedures — billing for a more expensive procedure.

We are already seeing it. KHN reporter Phil Galewitz wrote about a large bill for what was supposed to be a free COVID test. (This was not a fluke. We’ve already heard of other similar cases and will be writing about them.)

Drugmakers are also a source of concern. Critics note that the development of remdesivir, a possible COVID treatment, was heavily subsidized by the government, yet Gilead Sciences will be able to place whatever price tag it wants on the drug. Not that what was available went to the right places, The Washington Post reported.

And Stat did an excellent analysis of how there was a lot less to President Donald Trump’s announcement Tuesday about lower insulin prices for seniors. Stat also reported how executives of Moderna, a drug company that reported it was having success with a COVID vaccine, cashed out as the share price soared. The shares have since fallen as investors took another look at the hype.

And NPR noted a White House staffer with some interesting health care investments.

Toolkits

All of us are looking for ways to measure the epidemic, to quantify it, to find patterns that either agitate or reassure. Here are a few classics and newer ones that I and the staff at KHN found this week.

ProPublica created a quite amazing tool that tracks the companies that won federal contracts related to COVID-19. It helped them develop several very interesting stories about some of those contractors. (Related stories: The federal government’s efforts to get Americans tested for the virus are still failing in myriad ways.)

Stuff You Should Know

For the past couple of weeks, you could hear discussion of “herd immunity” protecting us from the coronavirus bubbling up in conversations on cable TV news shows, on Twitter and among neighbors still observing social distancing. It’s the notion that if enough people are immune from a disease, the few who are not are protected. It’s the basic concept that makes measles shots so important; it protects the young children and vulnerable people who can’t be immunized. It’s why we want a coronavirus vaccine so quickly.

So The Upshot at The New York Times looked at the possibility of herd immunity in a series of tight graphics. Their conclusion: “Even in some of the hardest-hit cities in the world, the studies suggest, the vast majority of people still remain vulnerable to the virus.”

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