From Health and Fitness

I Learned This Stress-Management Trick When I Was 3

I’ve taken the deep breaths, the warm baths, the Xanax. I’ve tried candles and crystals and sitting cross-legged. But nothing can calm me quite like rocking. Here’s what that looks like: An adult man, mid-30s, finishes work and climbs into bed. It’s early evening still, the shades are drawn, he has yet to cook dinner. The day has been hectic — deadlines, dog to the vet, a leak beneath the sink — but that’s all behind him now, a soft quiet settling in. His head rolls on the pillow, with intention and control, from side to side, each ear touching down like the taps of a metronome. Tap. Tap. Tap. His hips follow suit, and soon his whole body is in one smooth kinesis. He feels his pulse slow and his breaths even out. He’s free, dreaming of other worlds, worlds with many moons, with humming tides. Twenty minutes pass, and something brings him back to Earth — a car alarm, or his partner asking from another room what he’s making for dinner. He climbs out of bed, lighter, less burdened. Spaghetti, he thinks.

To the American Academy of Sleep Medicine, this scene might ring a bell, summoning a term that sounds like something you may see at a remarkably boring jazz show: “sleep-related rhythmic movements,” or SRRMs. Characterized by repetitive and rhythmic motor behaviors, these movements occur mostly during quiet wakefulness or the early stages of sleep. For me, they include head and body rocking and rolling, but other movements are possible as well. And if they go so far as to disturb one’s sleep or daytime function in a profound way, or even cause an injury, a disorder diagnosis is made. SRRMs are typical in infants and children, and become less prevalent with increasing age, usually disappearing spontaneously before adolescence. Rarely are they seen in adults — but somehow here I am, approaching 40, still rocking to the beat.

My earliest memory is as a 3-year-old, when I graduated from crib to training bed. My parents tucked those guardrail bumpers beneath both sides of my mattress — a drowsy toddler in a stalled spaceship. I would rock up on my hands and knees, and then somehow fall awkwardly onto my back and into a sound sleep. My parents never thought of it as worrisome or something that needed fixing. “You were such a cute Martian in there,” my mother said to me once.

As I grew up, I finessed my technique and began to rock solely in a supine position, head rolling side to side. I gained more and more control over it — from compulsion to volition — and I recognized benefits beyond the sleep-inducing. Rocking had a soothing effect. In one study published in the journal Current Biology, it is posited that “the sensory stimulation associated with a swinging motion exerts a synchronizing action in the brain that reinforces endogenous sleep rhythms,” which may explain why rocking induces that relaxed feeling. For me, it’s a shortcut to Chill Town. It makes me less anxious, more present. And beyond all that, it just feels good.

Rocking eventually became its own end, my own personal form of meditation. In high school, I could put a day’s worth of typical teen angst behind me and rock in my water bed to Ani DiFranco or Jewel on repeat, dreaming of a future as a folk singer, of crisscrossing the country in my VW van, the first boy to headline Lilith Fair. In college, I would spend time honing the practice when my roommate was in class or out drinking. I would even turn on his black-light lava lamp to really curate a mood. When he joined a frat, I was overjoyed at the idea of his scarcity — that sweet, sweet rhythmic “me time.” It was something to look forward to, and still is. The gentle to-and-fro lowers my heart rate, my muscles loosen, the clouds part. It puts me in a trancelike state, a place of freedom where the body shifts into autopilot and the spirit can wander to a distant place, safely and without fear.

David Sedaris wrote of his experience rocking in bed as a kid in his 1997 collection “Naked”: “The perpetual movement freed my mind, allowing me to mull things over and construct elaborately detailed fantasies. Toss in a radio, and I was content to rock until 3 or 4 o’clock in the morning, listening to the hit parade and discovering that each and every song was about me.” It was revelatory to read that essay: I wasn’t the only Martian out there.

That said, it isn’t the first thing I bring up with people at a party (not that I go to many of those these days): “Hi, I’m David. That’s such a cool tank top. Rocking is how I meditate. Ooh, are those crab cakes?” My close friends who know about it use words like “quirky” and “so you” on the off chance it comes up. And I suppose it’s true that rocking is not for everyone, especially those who dizzy easily. It takes time to master. But the day is long, and the rhythm is out there.

In some ways, these movements are whispering to you already. I’ve seen you. The way your head sways to that one song, your eyes close and the universe presents itself. The way your body bounces on a rattling train home, to such a perfect beat that you’re sent swiftly into a daydream. You’ve sought solace in a porch swing. A sense of balance in a hammock. Reprieve in a rocking chair. All steppingstones to the good stuff.

Later in his essay, Sedaris wrote: “What, I wondered, was an average person expected to do while stretched out in a darkened room? It felt pointless to lie there motionless and imagine a brighter life.” What better way to re-center than with a little rhythm. What better way to find stillness than to move.

Finding Comfort in the In-Between Season

Welcome. It’s been rainy in New York, humid, and in-between feeling. It’s the time that the travel industry calls “shoulder season” in this part of the world, a time of transition, technically fall but still sometimes summery. On the verge of holiday season, but we might still be reading books we started in August.

It’s the time of year when you commit to coziness, turn the lights on during the day and brew a whole pot of tea, maybe take your laptop to the couch, a blanket nest. Mid-afternoon, you’re shaken from your winter cosplay when the skies clear, the sun reasserts its relevance, almost obnoxiously illuminating each mote of dust in this indoor-cat tableau. Shoes on, get outside while you can.

It can do a number on your mood, if you weren’t already a little up and down, this noncommittal, sandwich season. Our usual rhythms are disrupted, our dependable routines scotched. I’ve been saving up bits of delight, scraps of songs, articles, recipes that I can turn to when disequilibrium sets in.

This opinion piece, “Your Work Friends Knew Exactly What Kind of Week You’d Had,” reminded me of how essential the “weak ties” our work relationships provide are to our happiness.

I’m scoring my work and walks with “Serpentine Prison,” the recent album from Matt Berninger. Watching this delirious collaborative TikTok musical that takes place in a grocery store. I’m reading favorite old books of poems, like “The Book of Nightmares” by Galway Kinnell and appreciating this thread that argues “a corgi crossed with any other breed just ends up looking like a corgi disguised as the other dog.” These small comforts help stabilize, relieve some of the strangeness in the changing season.

Tell us

What’s lifting your mood lately? Tell us: athome@nytimes.com. We’re At Home. We’ll read every letter sent. And, as always, more ideas for leading a full and cultured life at home appear below.


How to deal

ImageA female Northern Cardinal.
A female Northern Cardinal.Credit…Paul Stenquist
  • Want to attract more species of birds to your yard? We’ll help you create the ideal conditions.

  • New research shows that blood pressure levels that we’ve generally considered “normal” may be high enough to foster the development of artherosclerotic heart disease. Jane E. Brody took a look at the latest study.

  • And if you’re trying to begin a mindfulness practice, why not start with a silent breakfast?


What to eat

Image
The dough is rolled into balls right away, as opposed to chilling it first, giving these chocolate chip cookies gentle domes in the center.Credit…Ryan Liebe for The New York Times. Food Stylist: Hadas Smirnoff.
  • After countless tests, the British pastry chef Ravneet Gill has landed on what she believes is the “perfect” chocolate chip cookie recipe. Do you agree?

  • Melissa Clark was missing her favorite Australian sausage roll from Bourke Street Bakery in Manhattan. So she called up the chef, Paul Allam, and got the recipe. The result? Three variations on the classic from Down Under: lamb, pork, and mushroom.

  • And if the same old bottles are getting you down after months spent largely at home, Eric Asimov has 20 wines for under $20 that will help you escape a rut.


How to pass the time

Image
“Paris, France,” 2013Credit…Vik Muniz
  • Check out the artist Vik Muniz’s collages of the world’s most famous places, made of postcards snipped into little pieces.

  • Take a road trip with the Hotdoggers driving the Oscar Mayer Weinermobiles across the United States during the pandemic, and see how “the rolling pantheon of lunch meat” continues to bring joy and brand awareness to people’s lives.

  • And see why, on the occasion of his first record with the E Street Band in six years, Bruce Springsteen says, “I’m at a point in my playing life and artistic life where I’ve never felt as vital.”


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Trump Says He Saved 2 Million Lives From COVID. Really?

President Donald Trump has repeatedly claimed to have saved 2 million lives from COVID-19 through his actions to combat the disease.

Recently, he made the assertion during the NBC News town hall on Oct. 15 that replaced the second presidential debate.

“But we were expected to lose, if you look at the original charts from original doctors who are respected by everybody, 2,200,000 people,” Trump said. “We saved 2 million people,” he added.

He mentioned the same ballpark figure during a Sept. 15 ABC News town hall and posted a tweet about it on Oct. 13.

Others in the Trump administration have also pointed to the 2.2 million figure. Vice President Mike Pence referenced it during the vice presidential debate on Oct. 7. So did Health and Human Services Secretary Alex Azar during a Sept. 20 “Meet the Press” television interview.

Where did this number come from? And is there any truth to the idea that Trump is responsible for saving 2 million lives from COVID-19? Since Trump continues to use it to claim success, we decided to look into it.

What We Know About the ‘2 Million’

The White House and the Trump presidential campaign did not respond to our request for evidence supporting the idea that roughly 2 million lives were spared.

It appears to have first been mentioned by the president during a March 29 White House coronavirus task force press briefing, when Trump and Dr. Deborah Birx, task force coordinator, explained they were asking Americans to stay home from mid-March through the end of April, because mathematical models showed 1.6 million to 2.2 million people could die from COVID-19.

The warning stemmed from a paper authored by Neil Ferguson, an epidemiology professor at Imperial College London. He modeled how COVID-19 can spread through a population in different scenarios, including what would happen if no interventions were put in place and people continued to live their daily lives as normal.

In the paper, Ferguson wrote, “In total, in an unmitigated epidemic, we would predict approximately 510,000 deaths in [Great Britain] and 2.2 million in the US.”

Ferguson did not respond to our request to talk through the study with him. But in a July email interview with HuffPost, he said Trump’s boasting of saving 2.2 million lives isn’t true, because the pandemic isn’t over.

Andrea Bertozzi, a mathematics professor at UCLA, said it was important to remember the 2.2 million figure was derived from a modeling scenario that would almost certainly never happen — which is that neither the government nor individuals would change their behavior at all in light of COVID-19.

The study didn’t mean to say 2.2 million people were absolutely going to die, but rather to say, “Hold on, if we let this thing run its course, bad things could happen,” said Bertozzi. Indeed, the results from the study did cause government leaders in both the U.S. and the United Kingdom to implement social distancing measures.

Experts also pointed out that the U.S. has the highest COVID-19 death toll of any country in the world — more than 220,000 people — and among the highest death rates, according to the Johns Hopkins Coronavirus Resource Center.

“I don’t think we can say we’ve prevented 2 million deaths, because people are still dying,” said Justin Lessler, an associate professor of epidemiology at Johns Hopkins Bloomberg School of Public Health.

In some instances when using the 2 million estimate, Trump and others in his administration cited the China travel restrictions for saving lives, while other times they’ve credited locking down the economy. We’ll explore whether either statement holds water.

Did Travel Restrictions Do Anything?

Trump implemented travel restrictions for some people traveling from China beginning Feb. 2 and for Europe on March 11. But experts say and reports show the restrictions don’t appear to have had much effect because they were put in place too late and had too many holes.

The Centers for Disease Control and Prevention reported the first cases of coronavirus in the U.S. arrived in mid-January. So, since the travel bans were put in place after COVID-19 was already spreading in the U.S., they weren’t effective, said Josh Michaud, associate director for global health policy at the KFF. (KHN is an editorially independent program of KFF.)

A May study supports that assessment. The researchers found the risk of transmission from domestic air travel exceeded that of international travel in mid-March.

Many individuals also still traveled into the U.S. after the bans, according to separate investigations by The New York Times and the Associated Press.

Based on all this, experts said there isn’t evidence to support the idea that the travel restrictions were the principal intervention to reduce the transmission of COVID-19.

What About Lockdowns?

On the other hand, the public health experts we talked to said multiple global and U.S.-focused studies show that lockdowns and implementing social distancing measures helped to contain the spread of the coronavirus and thus can be said to have prevented deaths.

However, Trump can’t take full credit for these so-called lockdown measures, which ranged from closing down all but essential businesses to implementing citywide curfews and statewide stay-at-home orders. On March 16, after being presented with the possibility of the national death tally rising to 2.2. million, the White House issued federal recommendations to limit activities that could transmit the COVID-19 virus. But these were just guidelines and were recommended to be in effect only through April 30.

Most credit for putting in place robust social distancing measures belongs to state and local government and public health officials, many of whom enacted stronger policies than those recommended by the White House, our experts said.

“I don’t think you can directly credit the federal government or the Trump administration with the shutdown orders,” said Lessler. “The way our system works is that the power for public health policy lies with the state. And each state was making its own individual decision.”

Some studies also explore the potential human costs of missed opportunities. If lockdowns had been implemented one or two weeks earlier than mid-March, for instance, which is when most of the U.S. started shutting down, researchers estimated that tens of thousands of American lives could have been saved. A model also shows that if almost everyone wore a mask in the U.S., tens of thousands of deaths from COVID-19 could have been prevented.

Despite these scientific findings, Trump started encouraging states — even those with high transmission rates — to open back up in May, after the White House’s recommendations to slow the spread of COVID-19 expired. He has also questioned the efficacy of masks, said he wouldn’t issue a national mask mandate and instead left mask mandate decisions up to states and local jurisdictions.

Our Ruling

President Trump is claiming that without his efforts, there would have been 2 million deaths in the U.S. from COVID-19.

But that 2 million number is taken from a model that shows what would happen without any mitigation measures — that is, if citizens had continued their daily lives as usual, and governments did nothing. Experts said that wouldn’t have happened in real life.

And while lockdowns and social distancing have indeed been proven to prevent COVID-19 illness and deaths, credit for that doesn’t go solely to Trump. The White House issued federal recommendations asking Americans to stay home, but much stronger social distancing measures were enforced by states.

Travel restrictions implemented by Trump perhaps helped hold down transmission in the context of broader efforts, but on their own, they don’t seem to have significantly reduced the transmission rate of the coronavirus.

We rate this claim Mostly False.

Related Topics

Global Health Watch Public Health

“Todo lo que quieres es que te crean”: el prejuicio inconciente en la atención de salud

A mediados de marzo, Karla Monterroso voló a su casa en Alameda, California, después de una excursión al Parque Nacional Zion de Utah. Cuatro días después, comenzó a tener una tos seca y fuerte. Sentía los pulmones pegajosos.

La fiebre durante esas semanas por momentos subía tanto (100,4, 101,2, 101,7, 102,3) que, en la peor de las noches, tenía que estar bajo una ducha de agua helada, para intentar bajarla.

“Esa noche había escrito en un diario cartas a todas las personas cercanas, lo que quería que supieran si me moría”, recordó.

Al mes, surgieron nuevos síntomas: dolores de cabeza y calambres punzantes en las piernas y el abdomen que le hicieron pensar que podía estar en riesgo de tener coágulos de sangre y accidentes cerebrovasculares, complicaciones que habían informado otros pacientes con COVID-19 en sus 30 años.

Aún así, no estaba segura de si debía ir al hospital.

“Como mujeres de color, te cuestionan mucho tus emociones y la realidad de tu estado físico. Te dicen que exageras”, dijo Monterroso, quien es latina. “Así que tenía ese extraño sentimiento de ‘no quiero usar los recursos para nada’”.

Fueron necesarios cuatro amigos para convencerla de que tenia que llamar al 911.

Lo que pasó en la sala de emergencias del Hospital Alameda confirmó sus peores temores.

Monterroso dijo que durante casi toda su visita, los proveedores de salud ignoraron sus síntomas y preocupaciones. ¿La presión arterial está baja? Esa es una lectura falsa. ¿Sus niveles cíclicos de oxígeno? La máquina está mal. ¿Los dolores punzantes en la pierna? Probablemente solo sea un quiste.

“El médico entró y dijo: ‘No creo que esté pasando mucho aquí. Creo que podemos enviarte a casa’”, recordó Monterroso.

Su experiencia, razona, son parte de por qué las personas de color se ven afectadas de manera desproporcionada por el coronavirus. No es simplemente porque es más probable que tengan trabajos de primera línea que los exponen más, y las condiciones subyacentes que empeoran COVID-19.

“Eso es parte de ello, pero la otra parte es la falta de valor que la gente le da a nuestras vidas”, escribió Monterroso en Twitter detallando su experiencia.

Investigaciones muestran cómo el prejuicio inconsciente de los médicos afecta la atención que reciben las personas. Los pacientes latinos (que pueden ser de cualquier raza) y los afroamericanos suelen ser menos propensos a recibir analgésicos o a ser referidos para atención avanzada que los pacientes blancos no hispanos con las mismas quejas o síntomas. Y es más probable que las mujeres mueran en el parto por causas prevenibles.

Ese día de mayo, en el hospital, Monterroso se sentía mareada y tenía problemas para comunicarse, por lo que estaban con ella en el teléfono para ayudarla una amiga y la prima de su amiga, que es enfermera especializada en cardiología. Las dos mujeres comenzaron a hacer preguntas: ¿Qué pasa con la frecuencia cardíaca acelerada de Karla? ¿Sus bajos niveles de oxígeno? ¿Por qué sus labios están azules?

El médico salió de la habitación. Se negó a atender a Monterroso mientras sus amigas estaban al teléfono, dijo, y cuando regresó, de lo único que quería hablar era del tono de Monterroso y el tono de sus amigos.

“La implicación era que éramos insubordinadas”, dijo Monterroso.

Monterroso le dijo al médico que no quería hablar sobre su tono. Quería hablar sobre su atención médica. Estaba preocupada por posibles coágulos de sangre en su pierna y pidió una tomografía computada.

“Bueno, ya sabes, la tomografía computarizada es radiación justo al lado del tejido mamario. ¿Quieres tener cáncer de mama?”, Monterroso recuerda que le dijo el médico. “Solo me siento cómodo ordenándote esa prueba si dices que no tienes problema en tener cáncer de seno”.

Monterroso pensó para sí misma: “Trágatelo, Karla. Necesitas estar bien”. Entonces le dijo al médico: “Estoy bien con el cáncer de mama”.

Nunca ordenó la prueba.

Monterroso pidió otro médico, un abogado del hospital. Le dijeron que no. Comenzó a preocuparse por su seguridad. Quería irse. Sus amigos estaban llamando a todos los profesionales médicos que conocían para confirmar que no estaba siendo bien atendida. Vinieron a recogerla y la llevaron a la Universidad de California-San Francisco. El equipo le hizo un electrocardiograma, una radiografía de tórax y una tomografía computada.

“Una de las enfermeras entró y dijo: ‘Me enteré de tu terrible experiencia. Solo quiero que sepas que te creo. Y no te vamos a dejar ir hasta que sepamos que estás segura”, dijo Monterroso. “Comencé a llorar. Porque eso es todo lo que quieres: que te crean. Es realmente difícil que te cuestionen de esa manera”.

Alameda Health System, que opera el Hospital Alameda, se negó a comentar sobre los detalles del caso de Monterroso, pero dijo en un comunicado que está “profundamente comprometido con la equidad en el acceso a la atención médica” y que “brinda atención culturalmente sensible para todos”. ” Después que Monterroso presentó una queja ante el hospital, la gerencia la invitó a hablar con su personal y residentes, pero se negó.

Monterroso cree que su experiencia es un ejemplo de por qué a las personas de color les va tan mal con la pandemia.

“Porque cuando vamos a buscar atención, si nos defendemos, podemos ser tratados como insubordinados”, dijo. “Y si no nos defendemos, podemos ser tratados como invisibles”.

Sesgo inconsciente en la atención médica

Los expertos dicen que esto sucede de forma rutinaria y sin importar las intenciones o la raza del médico. Por ejemplo, el médico de Monterroso no era blanco.

Investigaciones muestran que todos los médicos, todos los seres humanos, tienen prejuicios de los que no son conscientes, explicó el doctor René Salazar, decano asistente de diversidad en la Escuela de Medicina de la Universidad de Texas-Austin.

“¿Interrogo a un hombre blanco con traje que llega luciendo como un profesional cuando pide analgésicos de la misma manera que a un hombre negro?”, se preguntó Salazar, señalando uno de sus posibles sesgos.

El prejuicio inconsciente suele aparecer en entornos de alto estrés, como las salas de emergencia, donde los médicos se encuentran bajo una tremenda presión y tienen que tomar decisiones rápidas y de gran importancia. Si se agrega una pandemia mortal, en la que la ciencia cambia día a día, las cosas pueden complicarse.

“Hay tanta incertidumbre”, dijo. “Cuando existe esta incertidumbre, siempre hay un nivel de oportunidad para que el sesgo se abra paso y tenga un impacto”.

A vehicle parked in Oakland, California, during the first weeks of the 2020 Black Lives Matter demonstrations.(April Dembosky)

Salazar solía enseñar en UCSF, donde ayudó a desarrollar una formación sobre prejuicios inconscientes para estudiantes de medicina y farmacia. Aunque docenas de escuelas de medicina están retomando la capacitación, dijo, no se realiza con tanta frecuencia en los hospitales. Incluso cuando se aborda un encuentro negativo como el de Monterroso, la intervención suele ser débil.

“¿Cómo le digo a mi médico, ‘Bueno, el paciente cree que eres racista’?”, apuntó Salazar. “Es una conversación difícil: debo tener cuidado, no quiero decir la palabra sobre la raza porque voy a presionar algunos botones complejos. Así que comienza a complicarse mucho”.

Un enfoque basado en datos

El doctor Ronald Copeland dijo que recuerda que los médicos también se resistían a estas conversaciones cuando eran estudiantes. Las sugerencias para talleres sobre sensibilidad cultural o prejuicios inconscientes recibían una reacción violenta.

“Era visto casi como un castigo. Es como, ‘Usted es un mal médico, por lo que su castigo es que tiene que ir a capacitarse’, explicó Copeland, quien es jefe de equidad, inclusión y diversidad en el sistema de salud de Kaiser Permanente. (KHN es un programa editorialmente independiente de KFF, que no está afiliado a Kaiser Permanente).

Ahora, el enfoque de Kaiser Permanente se basa en datos de encuestas a pacientes que preguntan si la persona se sintió respetada, si la comunicación fue buena y si quedó satisfecha con la experiencia.

Luego se desglosan estos datos por demografía, para ver si un médico puede obtener buenas calificaciones en respeto y empatía de los pacientes blancos no hispanos, pero no de los pacientes de raza negra.

“Si ves un patrón que evoluciona alrededor de un grupo determinado y es un patrón persistente, entonces eso te dice que hay algo que proviene de una cultura, de una etnia, de un género, algo que el grupo tiene en común, que no estás abordando, dijo Copeland. “Entonces comienza el verdadero trabajo”.

Cuando a los médicos se les presentan los datos de sus pacientes y la ciencia sobre el sesgo inconsciente, es menos probable que se resistan o nieguen, agregó. En su sistema de salud, han reformulado el objetivo de la capacitación en torno a brindar una atención de mejor calidad y obtener mejores resultados para los pacientes, por lo que los médicos quieren hacerlo.

“La gente no se inmuta”, dijo. “Están ansiosos por aprender más al respecto, especialmente sobre cómo mitigarlo”.

Todavía se siente mal

Han pasado casi seis meses desde que Monterroso se enfermó por primera vez y todavía no se siente bien.

Su frecuencia cardíaca sigue aumentando y los médicos le dijeron que podría necesitar una cirugía de vesícula para tratar los cálculos biliares que desarrolló como resultado de la deshidratación relacionada con COVID. Recientemente decidió dejar el Área de la Bahía y mudarse a Los Ángeles para poder estar más cerca de su familia durante su larga recuperación.

Rechazó la invitación del Hospital Alameda para hablar con su personal sobre su experiencias porque concluyó que no era su responsabilidad arreglar el sistema. Pero sí quiere que el sistema de salud más amplio asuma la responsabilidad del sesgo sistémico en hospitales y clínicas.

Reconoce que el Hospital Alameda es público y no tiene el tipo de recursos que tienen Kaiser Permanente y UCSF. Una auditoría reciente advirtió que el Sistema de Salud de Alameda estaba al borde de la insolvencia. Pero Monterroso es la directora ejecutiva de Code2040, una organización sin fines de lucro sobre equidad racial en el sector tecnológico e incluso para ella, dijo, se necesitó un ejército de apoyo para que la escucharan.

“El 90% de las personas que van a pasar por ese hospital no van a tener los recursos que yo tengo para enfrentarlos”, dijo. “Y si no digo lo que está sucediendo, entonces personas con muchos menos recursos van tener esta experiencia y se van a morir”.

Esta historia es parte de una asociación que incluye a KQED, NPR y KHN.

Related Topics

California Noticias En Español Public Health Race and Health States

Bridging the Miles — And the Pandemic — Teledentistry Makes Some Dentists Wince

Donella Pogue has trouble finding dentists in her rural area willing to accommodate her 21-year-old son, Justin, who is 6 feet, 8 inches tall, is on the autism spectrum and has difficulty sitting still when touched.

And this summer, he had a cavity and his face swelled. Pogue, of Bristol, New York, reached out to the Eastman Institute for Oral Health in Rochester, which offers teledentistry.

Dr. Adela Planerova looked into his mouth from 28 miles away as Pogue pointed her laptop’s camera into her son’s mouth. Planerova determined they did not need to make an emergency one-hour drive to her clinic. Instead, the dentist prescribed antibiotics and anti-inflammatory drugs, and weeks later he had surgery.

Teledentistry allows dental professionals like Planerova to remotely review records and diagnose patients over video. Some smile about its promise, seeing it as a way to become more efficient, to reach the one-third of U.S. adults who federal figures from 2017 estimate hadn’t seen a dentist in the previous year and to practice more safely during the pandemic.

But others see it as lesser-quality care that’s cheaper for dental professionals to provide, allowing them to make more money. At the same time, widespread adoption is hindered by issues such as spotty internet and insurance companies unwilling to reimburse for teledentistry procedures.

Dr. Christina Carter, an orthodontist in Morristown, New Jersey, said teledentistry has its place but shouldn’t replace time in the dental chair.

“It cannot be used for a full diagnosis because we need other tools, like X-rays,” she said. “We have all tried to see things on our phone or even on a Zoom call, and there is still just a different feel.”

Still, as the pandemic curbs in-person visits and reduces dentists’ revenue, more dentists are seeking guidance from Dr. Nathan Suter, a leading teledentistry advocate who owns the consulting company Access Teledentistry. Since March, he said, he’s done webinars for about 9,000 dental professionals, up from fewer than 1,000 in the three years before the pandemic.

Teledentistry providers trace the practice to 1994, when the Army launched a pilot program in which health care providers used an intra-oral camera to take photos of a patient’s mouth at a fort in Georgia and then sent them over the internet to a dental clinic at a fort 120 miles away.

Over the next two decades, dentists in upstate New York and the San Francisco Bay Area led teledentistry pilot programs for underserved children, some of whom were in preschool and already had cavities. The number of children who completed the prescribed dental treatment rose significantly.

Supporters say teledentistry can help reach the 43% of rural Americans who lack access to dental care. Medicaid and the Children’s Health Insurance Program will pay for many dental procedures for those enrolled in those programs, but only 38% of dentists participate in those programs, according to the American Dental Association. One reason: Medicaid typically reimburses at a significantly lower rate than those of private insurance plans.

Teledentistry could help dentists treat more patients and make more money a number of ways. If dentists remotely review data captured by hygienists, they can see more patients. Because video appointments save them time, dentists then have room for the people “who need the more expensive services” while also focusing on preventive care, said Kirill Zaydenman, vice president of innovation for DentaQuest, an administrator of dental insurance and oral health care provider.

Donella Pogue says that teledentistry was the best option for her 21-year-old son, Justin, when he had a cavity this summer that caused his face to swell. Justin has special needs and was able to see the dentist from the comfort of home. (Donella Pogue)

But dentists have not widely adopted teledentistry — mainly because they’ve had difficulty getting insurers to pay for it, said Dr. Dorota Kopycka-Kedzierawski, a Rochester dentist. That’s partly because of insurers’ concerns about fraud. Dr. Paul Glassman, who started the Virtual Dental Home project to reach underserved preschool children in the Bay Area, considers those fears “completely incorrect.”

“If you want to bill for something you didn’t do,” he said, “you can do that just as easily in an in-person environment as you can using teledentistry.”

Since March, as the pandemic descended, most, if not all, private dental plans have been reimbursing for teledentistry, said Tom Meyers, vice president of public policy for America’s Health Insurance Plans, a trade organization. And all state Medicaid programs now reimburse for teledentistry in some form, Glassman said, though policies differ by state and some practices may not be covered in some places.

But teledentistry isn’t reimbursable under Medicare. (Most dentistry isn’t.) Another obstacle to widespread adoption: Some dentists and lawmakers connect teledentistry to companies offering at-home teeth aligners with little or no in-person contact with a dentist. Glassman has promoted teledentistry throughout the United States and reviewed proposed legislation or regulations in states such as Idaho, Massachusetts and Texas. He said he hears concerns from dentists about the lack of an in-person exam during which X-rays are taken. Such concerns are reflected in some legislation.

SmileDirectClub, an at-home teeth-aligner company, has argued in statehouse testimony that in-person care is not always needed. The company opposed a 2019 bill in Texas that aimed to improve access to dentistry in rural areas because it included a number of restrictions on teledentistry, including one that would have required an in-person dentist’s examination if a teledentistry provider treated that patient for more than 12 months.

SmileDirect’s attorney argued at a hearing the rule “could interrupt the course of a patient’s treatment.”

The measure failed.

Proponents argue teledentistry isn’t just about making more money. Pogue, the New York woman, said it was the best option for her son with special needs.

“He is really afraid of dentistry, so when he goes to see someone, he is really tense and really jumpy, so that’s another reason the teledentistry was nice was because he was in my bedroom doing it, so he was really comfortable,” said Pogue, 53, whose son is covered by Medicaid.

A few weeks later, Justin did have to have surgery, which went “perfect,” his mom said.

Some dentists say teledentistry faces particular stumbling blocks in rural areas. Dr. Mack Taylor, 36, a dentist who grew up in the small town of Dexter, Missouri, now practices in a health center just down the road. Twenty years ago, he said, Dexter had eight dentists. Now there are only three.

Technology is a major obstacle for local residents, many of whom lack reliable internet service. Taylor recently applied for a U.S. Department of Agriculture grant that would give him $26,500 to buy equipment so that, for example, a hygienist can take photos inside the mouths of nursing home residents and send them to Taylor to review.

“It’s not like medicine where you can discuss someone’s ailments and have a good idea what’s going on,” Taylor said. “Maybe all you can tell me is ‘I have a broken tooth,’ but I can’t physically see what’s going on and prescribe the right treatment.”

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When the Doctor Is a Covid ‘Long Hauler’

I am a physician who contracted what was initially a fairly mild case of Covid-19 in early March. Seven months later, I remain substantially debilitated, with profound exhaustion and a heart rate that goes into the stratosphere with even the tiniest bits of exertion, such as pouring a bowl of cereal or making a bed. I may never get better, despite receiving the best care available. And there are likely to be thousands more like me.

My early symptoms were fairly typical, with a sore throat, headache, body aches and fatigue. When I developed shortness of breath and chest pain, an emergency department physician I was seeing via telemedicine recommended I go to the E.R. My chest X-ray and oxygen saturation were normal, so I was sent home with an inhaler and was on the mend within two weeks.

But then the sequelae — the medical word for longer-term consequences — set in. My ongoing symptoms are familiar to many of the so-called Covid “long-haulers”: in addition to the exhaustion and careening heartbeat, I have headaches, shortness of breath, tremulousness, and numb and tingling extremities. Sounds are too loud, light is too bright, nine hours is too little sleep at night. I am fortunate to have been spared some of the other symptoms that plague long-haulers, such as “brain fog,” memory problems and PTSD-like anxiety.

Like many long-haulers, I was young — 37 — and healthy when I got Covid-19. I was working full-time in private practice and teaching at an academic medical center. I was doing pro bono work, raising my daughter, exercising most days, going out to museums and shows, serving on multiple nonprofit boards, and getting ready to host 20 kindergartners for an at-home birthday party the week I got sick (we canceled it).

Post-Covid, I can still do some of these things, which is more than many long-haulers can say, but only because they are virtual and therefore sedentary: pandemic life allows for visiting museums and viewing the performing arts virtually and attending work and board meetings online. So I can do it all from a seated position. I read endlessly on the couch to my daughter, and we play pretend games with me in a supine pose, while my husband does the vertical parenting that I can no longer do. He cooks for the family, he does the bike rides with our daughter. He would replace me as the chaperone to swimming lessons and ballet class, but for the pandemic.

Thanks to my medical background, good referrals from friends and an online forum called Body Politic, which includes a discussion group for Covid long-haulers, I have been diagnosed with dysautonomia, a disorder of the autonomic nervous system that is commonly triggered by viral infections. The autonomic nervous system controls involuntary functions in our bodies such as heart rate, blood pressure and digestion. When it is damaged by an infection or other cause, these functions go out of whack.

My specific form of dysautonomia, called postural orthostatic tachycardia syndrome, or POTS, was coined in 1993 by Dr. Phillip Low and his team at the Mayo Clinic, though it went by other names throughout history. POTS precludes standing for more than a few minutes at a time, because autonomic damage prevents blood vessels in the lower extremities from properly returning blood to the heart and brain against gravity. Heart rate can double or triple on standing, and lack of oxygen to the brain and upper body lead to many of the symptoms seen in POTS patients: dizziness, headaches, shortness of breath, chest pain, “brain fog.”

If a POTS patient does stay vertical for a prolonged period, he or she can be left with massive fatigue, light and sound sensitivity, tingling extremities, temperature intolerance and gastrointestinal problems (again, all the bodily functions of the autonomic nervous system gone awry).

POTS is not life-threatening, unless a patient faints and suffers a serious head injury, but the degree of disability that it causes is equated to that of congestive heart failure or chronic obstructive pulmonary disease. Data from the Mayo Clinic shows that about half of POTS patients have some improvement in symptoms over an average of five years. It’s too soon to know how the course of Covid-induced POTS might unfold.

Increasingly, doctors are recognizing that POTS appears to account for many of the Covid long-haul symptoms being reported around the world. It’s a condition with no known cure, but the symptoms can be managed with medications, a physical rehabilitation program and dietary interventions. To even have a diagnosis and a management plan makes me one of the lucky ones.

Here’s why else I am lucky: My medical specialty is psychiatry. I can work from home using a telemedicine platform to see my patients and Zoom to do my teaching. My job is sedentary, so I can continue to work full time in my physically debilitated state. If I were a surgeon, or a gynecologist, or an ophthalmologist, let alone a construction worker or hair stylist or other professional in a physically demanding field, I would be unable to continue to work and would be a candidate for formal disability benefits.

What of other Covid long-haulers who have more physically demanding jobs than I do? What about those who are single parents? How and when will they return to work and normal parenting? What if they never can?

On good days, when my heart rate is controlled and I’m not shaky or short of breath, I go outdoors. I wear a mask (or two), keep my distance from others and avoid even outdoor restaurants. As reports about genetically confirmed repeat Covid-19 infections surface, I worry about getting infected again. If I had a repeat Covid infection, would it be more severe, or more mild, than my first? Any kind of infection tends to exacerbate POTS symptoms and could undo all the hard work I am putting into illness management.

Unlike the more than a million people lost to Covid worldwide, I am alive. That said, in addition to a disease’s mortality rate, it’s also important to consider its morbidity rate — the long-term consequences for those who do not die. How much disability will we accumulate by the end of this pandemic? How much hopelessness? Knowledge about POTS and how to manage it gives me hope. Many long-haulers, mired in morbidity, aren’t so lucky.


Depression in Pregnancy May Raise Risk of Childhood Asthma

A mother’s psychological distress during pregnancy may increase the risk for asthma in her child, a new study suggests.

Researchers had the parents of 4,231 children fill out well-validated questionnaires on psychological stress in the second trimester of pregnancy, and again three years later. The mothers also completed questionnaires at two and six months after giving birth. The study, in the journal Thorax, found that 362 of the mothers and 167 of the fathers had clinically significant psychological distress during the mothers’ pregnancies.

When the children were 10 years old, parents reported whether their child had ever been diagnosed with asthma. As an extra measure, the researchers tested the children using forced expiratory volume, or FEV, a standard clinical test of lung function.

After controlling for age, smoking during pregnancy, body mass index, a history of asthma and other factors, they found that maternal depression and anxiety during pregnancy was significantly associated with both diagnoses of asthma and poorer lung function in their children. There was no association between childhood asthma and parents’ psychological distress in the years after pregnancy, and no association with paternal psychological stress at any time.

“Of course, this could be only one of many causes of asthma,” said the lead author, Dr. Evelien R. van Meel of Erasmus University in Rotterdam, “but we corrected for many confounders, and we saw the effect only in mothers. This seems to suggest that there’s something going on in the uterus. But this is an observational study, and we can’t say that it’s a causal effect.”

Why Running Won’t Ruin Your Knees

Could running actually be good for your knees?

That idea is at the heart of a fascinating new study of the differing effects of running and walking on the knee joint. Using motion capture and sophisticated computer modeling, the study confirms that running pummels knees more than walking does. But in the process, the authors conclude, running likely also fortifies and bulks up the cartilage, the rubbery tissue that cushions the ends of bones. The findings raise the beguiling possibility that, instead of harming knees, running might fortify them and help to stave off knee arthritis.

Of course, the notion that running wrecks knees is widespread and entrenched. Almost anyone who runs is familiar with warnings from well-meaning, nonrunning family members, friends and strangers that their knees are doomed.

This concern is not unwarranted. Running involves substantial joint bending and pounding, which can fray the cushioning cartilage inside the knee. Cartilage, which does not have its own blood supply, generally is thought to have little ability to repair itself when damaged or to change much at all after childhood. So, repeated running conceivably wears away fragile cartilage and almost inevitably should lead to crippling knee arthritis.

But in real life, it does not. Some runners develop knee arthritis, but not all. As a group, in fact, runners may be statistically less likely to become arthritic than nonrunners.

The question of why running spares so many runners’ knees has long intrigued Ross Miller, an associate professor of kinesiology at the University of Maryland in College Park. In earlier research, he and his colleagues had looked into whether running mechanics matter, by asking volunteers to walk and run along a track outfitted with plates to measure the forces generated with each step.

The resulting data showed that people hit the ground harder while running, clobbering their knees far more with each stride. But they also spent more time aloft between strides, meaning they took fewer strides while covering the same distance as when walking. So, the cumulative forces moving through their knees over time should be about the same, the researchers concluded, whether someone walked or ran.

But, recently, Dr. Miller had begun to doubt whether this finding really explained why running wasn’t wrecking more knees. He knew that some recent studies with animals intimated that cartilage might be more resilient than researchers previously had believed. In those studies, animals that ran tended to have thicker, healthier knee cartilage than comparable tissues from sedentary animals, suggesting that the active animals’ cartilage had changed in response to their running.

Perhaps, Dr. Miller speculated, cartilage in human runners’ knees likewise might alter and adapt.

To find out, he again asked a group of healthy young men and women to walk and run along a track containing force plates, while he and his colleagues filmed them. The researchers then computed the forces the volunteers had generated while strolling and running. Finally, they modeled what the future might hold for the volunteers’ knees.

More specifically, they used the force-plate numbers, plus extensive additional data from past studies of biopsied cartilage pulled and pummeled in the lab until it fell apart and other sources to create computer simulations. They wanted to see what, theoretically, would happen to healthy knee cartilage if an adult walked for six kilometers (about 3.7 miles) every day for years, compared to if they walked for three kilometers and ran for another three kilometers each of those days.

They also tested two additional theoretical situations. For one, the researchers programmed in the possibility that people’s knee cartilage would slightly repair itself after repeated small damage from walking or running — but not otherwise change. And for the last scenario, they presumed that the cartilage would actively remodel itself and adapt to the demands of moving, growing thicker and stronger, much as muscle does when we exercise.

The models’ final results were eye-opening. According to the simulations, daily walkers faced about a 36 percent chance of developing arthritis by the age of 55, if the model did not include the possibility of the knee cartilage adapting or repairing itself. That risk dropped to about 13 percent if cartilage were assumed to be able to repair or adapt, which is about what studies predict to be the real-world arthritis risk for otherwise healthy people.

The numbers for running were more worrisome. When the model assumed cartilage cannot change, the runners’ risk of eventual arthritis was a whopping 98 percent, declining only to 95 percent if the model factored in the possibility of cartilage repair. In effect, according to this scenario, the damage to cartilage from frequent running would overwhelm any ability of the tissue to fix itself.

But if the model included the likelihood of the cartilage actively adapting — growing thicker and cushier — when people ran, the odds of runners developing arthritis fell to about 13 percent, the same as for healthy walkers.

What these results suggest is that cartilage is malleable, Dr. Ross says. It must be able to sense the strains and slight damage from running and rebuild itself, becoming stronger. In this scenario, running bolsters cartilage health.

Modeled results like these are theoretical, though, and limited. They do not explain how cartilage remodels itself without a blood supply or if genetics, nutrition, body weight, knee injuries and other factors affect individual arthritis risks. Such models also do not tell us if different distances, speeds or running forms would alter the outcomes. To learn more, we will need direct measures of molecular and other changes in living human cartilage after running, Dr. Miller says, but such tests are difficult.

Still, this study may quiet some runners’ qualms — and those of their families and friends. “It looks like running is unlikely to cause knee arthritis by wearing out cartilage,” Dr. Ross says.

‘All You Want Is to Be Believed’: The Impacts of Unconscious Bias in Health Care

In mid-March, Karla Monterroso flew home to Alameda, California, after a hiking trip in Utah’s Zion National Park. Four days later, she began to develop a bad, dry cough. Her lungs felt sticky.

The fevers that persisted for the next nine weeks grew so high — 100.4, 101.2, 101.7, 102.3 — that, on the worst night, she was in the shower on all fours, ice-cold water running down her back, willing her temperature to go down.

“That night I had written down in a journal, letters to everyone I’m close to, the things I wanted them to know in case I died,” she remembered.

Then, in the second month, came a new batch of symptoms: headaches and shooting pains in her legs and abdomen that made her worry she could be at risk for the blood clots and strokes that other COVID-19 patients in their 30s had reported.

Still, she wasn’t sure if she should go to the hospital.

“As women of color, you get questioned a lot about your emotions and the truth of your physical state. You get called an exaggerator a lot throughout the course of your life,” said Monterroso, who is Latina. “So there was this weird, ‘I don’t want to go and use resources for nothing’ feeling.”

It took four friends to convince her she needed to call 911.

But what happened in the emergency room at Alameda Hospital only confirmed her worst fears.

At nearly every turn during her emergency room visit, Monterroso said, providers dismissed her symptoms and concerns. Her low blood pressure? That’s a false reading. Her cycling oxygen levels? The machine’s wrong. The shooting pains in her leg? Probably just a cyst.

“The doctor came in and said, ‘I don’t think that much is happening here. I think we can send you home,’” Monterroso recalled.

Her experiences, she reasons,  are part of why people of color are disproportionately affected by the coronavirus. It is not merely because they’re more likely to have front-line jobs that expose them to it and the underlying conditions that make COVID-19 worse.

“That is certainly part of it, but the other part is the lack of value people see in our lives,” Monterroso wrote in a Twitter thread detailing her experience.

Research shows how doctors’ unconscious bias affects the care people receive, with Latino and Black patients being less likely to receive pain medications or get referred for advanced care than white patients with the same complaints or symptoms, and more likely to die in childbirth from preventable complications.

In the hospital that day in May, Monterroso was feeling woozy and having trouble communicating, so she had a friend and her friend’s cousin, a cardiac nurse, on the phone to help. They started asking questions: What about Karla’s accelerated heart rate? Her low oxygen levels? Why are her lips blue?

The doctor walked out of the room. He refused to care for Monterroso while her friends were on the phone, she said, and when he came back, the only thing he wanted to talk about was Monterroso’s tone and her friends’ tone.

“The implication was that we were insubordinate,” Monterroso said.

She told the doctor she didn’t want to talk about her tone. She wanted to talk about her health care. She was worried about possible blood clots in her leg and she asked for a CT scan.

“Well, you know, the CT scan is radiation right next to your breast tissue. Do you want to get breast cancer?” Monterroso recalled the doctor saying to her. “I only feel comfortable giving you that test if you say that you’re fine getting breast cancer.”

Monterroso thought to herself, “Swallow it up, Karla. You need to be well.” And so she said to the doctor: “I’m fine getting breast cancer.”

He never ordered the test.

A vehicle parked in Oakland, California, during the first weeks of the 2020 Black Lives Matter demonstrations.(April Dembosky)

Monterroso asked for a different doctor, for a hospital advocate. No and no, she was told. She began to worry about her safety. She wanted to get out of there. Her friends, all calling every medical professional they knew to confirm that this treatment was not right, came to pick her up and drove her to the University of California-San Francisco. The team there gave her an EKG, a chest X-ray and a CT scan.

“One of the nurses came in and she was like, ‘I heard about your ordeal. I just want you to know that I believe you. And we are not going to let you go until we know that you are safe to go,’” Monterroso said. “And I started bawling. Because that’s all you want is to be believed. You spend so much of the process not believing yourself, and then to not be believed when you go in? It’s really hard to be questioned in that way.”

Alameda Health System, which operates Alameda Hospital, declined to comment on the specifics of Monterroso’s case, but said in a statement that it is “deeply committed to equity in access to health care” and “providing culturally-sensitive care for all we serve.” After Monterroso filed a grievance with the hospital, management invited her to come talk to their staff and residents, but she declined.

She believes her experience is an example of why people of color are faring so badly in the pandemic.

“Because when we go and seek care, if we are advocating for ourselves, we can be treated as insubordinate,” she said. “And if we are not advocating for ourselves, we can be treated as invisible.”

Unconscious Bias in Health Care

Experts say this happens routinely, and regardless of a doctor’s intentions or race. Monterroso’s doctor was not white, for example.

Research shows that every doctor, every human being, has biases they’re not aware of, said Dr. René Salazar, assistant dean for diversity at the University of Texas-Austin medical school.

“Do I question a white man in a suit who’s coming in looking like he’s a professional when he asks for pain meds versus a Black man?” Salazar said, noting one of his own possible biases.

Unconscious bias most often surfaces in high-stress environments, like emergency rooms — where doctors are under tremendous pressure and have to make quick, high-stakes decisions. Add in a deadly pandemic, in which the science is changing by the day, and things can spiral.

“There’s just so much uncertainty,” he said. “When there is this uncertainty, there always is a level of opportunity for bias to make its way in and have an impact.”

Salazar used to teach at UCSF, where he helped develop unconscious-bias training for medical and pharmacy students. Although dozens of medical schools are picking up the training, he said, it’s not as commonly performed in hospitals. Even when a negative patient encounter like Monterroso’s is addressed, the intervention is usually weak.

“How do I tell my clinician, ‘Well, the patient thinks you’re racist?’” Salazar said. “It’s a hard conversation: ‘I gotta be careful, I don’t want to say the race word because I’m going to push some buttons here.’ So it just starts to become really complicated.”

A Data-Based Approach

Dr. Ronald Copeland said he remembers doctors also resisting these conversations in the early days of his training. Suggestions for workshops in cultural sensitivity or unconscious bias were met with a backlash.

“It was viewed almost from a punishment standpoint. ‘Doc, your patients of this persuasion don’t like you and you’ve got to do something about it.’ It’s like, ‘You’re a bad doctor, and so your punishment is you have to go get training,” said Copeland, who is chief of equity, inclusion and diversity at the Kaiser Permanente health system. (KHN is an editorially independent program of KFF, which is not affiliated with Kaiser Permanente.)

Now, KP’s approach is rooted in data from patient surveys that ask if a person felt respected, if the communication was good and if they were satisfied with the experience.

KP then breaks this data down by demographics, to see if a doctor may get good scores on respect and empathy from white patients, but not Black patients.

“If you see a pattern evolving around a certain group and it’s a persistent pattern, then that tells you there’s something that from a cultural, from an ethnicity, from a gender, something that group has in common, that you’re not addressing,” Copeland said. “Then the real work starts.”

When doctors are presented with the data from their patients and the science on unconscious bias, they’re less likely to resist it or deny it, Copeland said. At his health system, they’ve reframed the goal of training around delivering better quality care and getting better patient outcomes, so doctors want to do it.

“Folks don’t flinch about it,” he said. “They’re eager to learn more about it, particularly about how you mitigate it.”

Still Unwell

It’s been nearly six months since Monterroso first got sick, and she’s still not feeling well.

Her heart rate continues to spike and doctors told her she may need gallbladder surgery to address the gallstones she developed as a result of COVID-related dehydration. She decided recently to leave the Bay Area and move to Los Angeles so she could be closer to her family for the long recovery.

She declined Alameda Hospital’s invitation to speak to their staff about her experience, concluding it wasn’t her responsibility to fix the system. But she wants the broader health care system to take responsibility for the bias perpetuated in hospitals and clinics.

She acknowledges that Alameda Hospital is public, and it doesn’t have the kind of resources that KP and UCSF do. A recent audit warned that the Alameda Health System was on the brink of insolvency. But Monterroso is the CEO of Code2040, a racial equity nonprofit in the tech sector and even for her, she said, it took an army of support for her to be heard.

“Ninety percent of the people that are going to come through that hospital are not going to have what I have to fight that,” she said. “And if I don’t say what’s happening, then people with much less resources are going to come into this experience, and they’re going to die.”

This story is part of a partnership that includes KQED, NPR and KHN.

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Lost on the Frontline: Explore the Database

Journalists from KHN and the Guardian have identified 1,318 workers who reportedly died of complications from COVID-19 they contracted on the job. Reporters are working to confirm the cause of death and workplace conditions in each case. They are also writing about the people behind the statistics — their personalities, passions and quirks — and telling the story of every life lost.

Explore the new interactive tool tracking those health worker deaths.

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Despite Pandemic Threat, Gubernatorial Hopefuls Avoid COVID Nitty-Gritty

Just 15 days ahead of the election, Montana Lt. Gov. Mike Cooney laid out his ideas on how he’d handle the COVID-19 pandemic if elected governor. Details were few, but the Democrat’s plan became one of only a handful being offered by candidates in the 11 U.S. governor’s races about how they’ll approach what’s certain to be the dominant issue of their terms, should they win.

While much of the nation’s focus is on who will be president come January, voters who are deciding the next occupant of their governor’s mansion are also effectively choosing the next leader of their state’s COVID-19 response. The virus has made governors’ power highly visible to voters. As the states’ top executives, they decide whether to issue mask mandates, close businesses and order people to stay home.

All but two races for governor feature incumbents running for reelection: Montana’s Democratic Gov. Steve Bullock can’t run again because of term limits and Utah’s Republican Gov. Gary Herbert decided not to run for another term. In several other competitive races for governor this year, such as those in North Carolina and Missouri, opponents clash on the role of state mandates in slowing the virus. Still, COVID-19 often fades into the backdrop of many long-standing platforms or primarily comes up as candidates talk about the need to revive the economy.

Cooney’s proposal, released Monday, suggested using the National Guard to transport patients in extreme weather and subsidizing heating bills to help those quarantining at home. But other parts vaguely described how he would “develop a robust plan” to come.

His opponent, Republican U.S. Rep. Greg Gianforte, has acknowledged the health crisis but has focused primarily on the economy, saying the state has to “cure the economic pandemic” the virus caused.

Rep. Greg Gianforte, Mike Cooney’s Republican opponent, joins President Donald Trump at a rally at the Bozeman Yellowstone International Airport on Nov. 3, 2018, in Belgrade, Montana.(William Campbell/Corbis via Getty Images)

Bryce Ward, a health economist with the University of Montana, said Cooney’s list was one of the first times he’s seen long-term planning for COVID-19 come up in what appears to be the nation’s tightest governor’s race. But, he added, neither Montana candidate has offered a concrete plan to deal with the dual crises that risk public health when people gather and businesses’ bottom lines when they don’t. Meanwhile, the state’s number of COVID-19 cases climbs and its economy suffers.

“Whoever wins, this is going to be the bulk of their term,” Ward said. “How are the candidates going to keep people afloat as long as they can? What are we doing in terms of planning for what we think our post-COVID world is going to look like?”

An October KFF poll found 29% of registered voters said the economy was the most important issue in choosing a president, while 18% said the coronavirus outbreak was their top issue. Republican voters were more likely to pick the economy, the survey found, and Democrats were more likely to pick the coronavirus. (KHN is an editorially independent program of KFF.)

“There are voters that feel that the government needs to lead, and there are voters that feel that the government is utilizing a pandemic to become too invasive,” said Capri Cafaro, a former Democratic Ohio state senator now teaching in American University’s public administration and policy department. “People are not necessarily making their decisions on ‘Did you do contact tracing? Are you going to slow the spread?’”

Among the incumbent governors seeking reelection this year, most of their campaigns’ focus on COVID-19 has been on how well they’ve responded to the crisis. Several pledge more of what they’ve been doing. “We’ll continue to follow the science and wear masks,” Delaware Democratic Gov. John Carney said in a recent debate.

Meanwhile, their challengers generally seek to cast the incumbents as mismanaging their states’ response and promising to undo what’s been done. Those who have put out actual plans to handle the pandemic are Democratic challengers to Republican governors, and their plans are similar to what Cooney released — some specific ideas and promises to fill in the gaps later.

In Missouri, Democratic challenger Nicole Galloway, who is the state auditor, made health care the center of her campaign and released a plan to respond to the virus with a statewide mask mandate and a limit on when public school classes can meet in person based on the community’s rate of infection.

Republican Gov. Mike Parson is the apparent front-runner in that state’s race. He has pledged to lead “the greatest economic comeback that we’ve ever seen in Missouri history.” The former Polk County sheriff also has focused on supporting law enforcement amid backlash against police brutality and racial injustice.

Curbing the coronavirus has taken a back seat to boosting the economy in Parson’s campaign. And, as governor, Parson has refused to issue a statewide mask mandate, despite a White House recommendation to do so. In late September, the governor and his wife tested positive for COVID-19. Parson has returned to work, which includes traveling across the state.

One of the more heated races is in North Carolina, where Democratic Gov. Roy Cooper is defending his seat against a challenge by his lieutenant governor, Republican Dan Forest. Forest sued Cooper this year to challenge the governor’s authority to impose COVID-related restrictions by executive order.

Forest dropped the lawsuit in August after a judge made a preliminary ruling against his case, then said on Twitter, “I did my part. If y’all want your freedoms back you’ll have to make your voices heard in November.”

Cooper’s campaign called the lawsuit “a desperate tactic to garner attention” for Forest’s political campaign. Since then, the governor has slowly eased COVID restrictions, updating an executive order to allow a limited number of people in bars, sporting events, movie theaters and amusement parks. Cooper is leading the race in recent polls.

Back in Montana, the pandemic surfaced in the gubernatorial campaign after health officials announced on Oct. 16 that a Helena concert, which Gianforte attended, was linked to several COVID-19 cases. More than 100 health professionals blasted him in an open letter for flouting local health restrictions, going maskless and making light of safety precautions at campaign events. Cooney called on him to suspend his campaign events until tested. Gianforte’s campaign has said he’s taking proper precautions and accused Cooney of politicizing a public health issue.

Cooney has said he’ll keep Montana’s COVID-19 response on the track he is helping set as lieutenant governor, with science guiding that work. Gianforte, who built a tech startup in Bozeman, has touted his business experience as proof he can lead Montana’s comeback. Both have said more needs to be learned about this virus and have pitched themselves as the one to steer the state’s economy through the crisis.

Ward, the University of Montana health economist, said the details are missing, such as how the winner will support businesses through the winter without federal aid. Or what the new governor would cut from the state budget if the economic crisis hits its coffers.

The state has a public mask mandate and a plan for reopening the economy with no apparent thresholds or timelines. The option for stricter rules has been left to county governments as the state sees its largest COVID surge yet.

Jeremy Johnson, a political scientist at Carroll College in Helena, said the initial lack of detailed pandemic policy in the state’s race could be attributed to both candidates trying to win over swing voters with safe themes. President Donald Trump won Montana in 2016 by 20 points, but the state has also had a Democratic governor for 16 years. While polls show Gianforte leading Cooney slightly, election handicappers Real Clear Politics and the Cook Political Report still consider the race a toss-up.

Yet as Election Day nears, the question of how to address the pandemic only looms larger. Montana’s case count is rising, adding to its total of more than 23,000 cases in the state of roughly 1 million.

Related Topics

Elections Public Health States

Tiny Love Stories: ‘Our Refuge From Reality’

With a Touch of Love

My father, Seung-ho, has always had an eye for little details. About two months into sheltering-in-place, I asked him to grab me chocolate almond milk at the grocery store. When he came home with cashew milk, I started to complain that he got the wrong milk. He interrupted me, pointing to the bottom of the carton. There, in small text, it stated, “with a touch of almond.” My annoyance melted into a wide grin because I knew how hard he must have looked to find the most almond-like milk available for me. — Rachael Lee

ImageSelfie with my father.
Selfie with my father.

Three Stops on the Uptown Train

Fifty-ninth Street subway platform. 6 p.m. The uptown train arrives. One car stops in front of me, another in front of him. Our stares are interrupted as we board the crowded train. He races closer to me, bumping into a mother holding a baby. He comforts the baby from crying, then keeps staring at me until my 77th Street stop. I get off. He holds his foot in the door to see if I’ll turn around. When I do, he jumps off. Forty-two years later, and married, we still look at each other with the same intensity. — Mark Wolk

Image
Together in Sag Harbor, NY. John is on the left.

Learning to Live

When I was little, I would rush into my parents’ room at night to ensure they were breathing. As I grew older, I became increasingly preoccupied by death: Why do we do anything if the end is inevitable? Filled with existential dread, I’d burrow in bed for weeks. Eventually, my depressive fears found respite in knowledge. While completing my music therapy degree with an internship in hospice care, I met Seth, a registered nurse. After helping people die all day, we couldn’t help but climb in bed and be alive, honoring what feels right, right now. — Sarah Ward

Image
Camping in Yosemite to celebrate our anniversary.

Too Much Reality? Try Fiction.

At 90, my mother found fiction, something she had scorned her entire life. A news-loving, quick-witted, born-and-bred New Yorker, she breathlessly followed current events. Who needs a newsfeed with her calling me at work to announce that Tim Russert died? After two cornea transplants at 88, my mother shifted her perspective on fiction — and life. With her new sight, she views the world through a more sentimental lens. Now open to the imaginary, she devours novels, which we discuss like schoolgirls, reveling in our shared refuge from reality. — Melissa Zeph

Image
My mother, Joan, in the North Carolina mountains. 

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

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¿Pueden los pacientes de COVID tener el tratamiento de Trump? Está bien preguntar

Cuando Terry Mutter se despertó con dolor de cabeza y músculos adoloridos, el levantador de pesas amateur lo atribuyó a un entrenamiento duro.

Sin embargo, ese miércoles a la noche tuvo 101 grados de fiebre y estaba claramente enfermo. “Me sentía como si me hubiera atropellado un camión”, recuerda Mutter, que vive cerca de Seattle.

Al día siguiente le diagnosticaron COVID-19. El sábado, el hombre de 58 años estaba inscrito en un ensayo clínico para el mismo cóctel de anticuerpos que el presidente Donald Trump afirmó que le había “curado” el coronavirus.

“Lo había escuchado en las noticias”, dijo Mutter, que se unió al ensayo del laboratorio Regeneron para probar si su combinación de dos anticuerpos artificiales puede neutralizar al virus mortal.

Mutter se enteró del estudio por medio de su cuñada, quien trabaja en el Centro de Investigación del Cáncer Fred Hutchinson de Seattle, uno de decenas de sitios de ensayos en todo el país. Es uno de los cientos de miles de estadounidenses, incluido el presidente, que se arriesgaron con terapias experimentales para tratar o prevenir COVID-19.

Pero con casi 8 millones de personas infectadas y más de 217,000 muertes por COVID en el país, muchos pacientes desconocen estas opciones o no pueden acceder a ellas. Otros desconfían de los tratamientos no probados.

“Honestamente, creo que nunca hubiera recibido una llamada si no hubiera conocido a alguien que me dijera sobre el ensayo”, dijo Mutter, ejecutivo jubilado de Boeing Co.

El sitio web Clinicaltrials.gov registra más de 3,600 estudios que involucran a COVID-19 o a SARS-CoV-2, el virus que causa la enfermedad. Más de 430,000 personas se han ofrecido como voluntarias a través de la Red de Prevención de COVID-19. Otras miles han recibido terapias, como el medicamento antiviral remdesivir, que tiene una autorización federal de emergencia.

Ante un diagnóstico grave de COVID, ¿cómo saben los pacientes o sus familias si pueden, o deben, buscar agresivamente estos tratamientos? Por el contrario, ¿cómo pueden decidir si rechazarlos o no si se los ofrecen?

Tales decisiones médicas nunca son fáciles, y son aún más difíciles durante una pandemia, dijo Annette Totten, profesora asociada de informática médica y epidemiología clínica en la Universidad de Salud y Ciencias de Oregon.

“El desafío es que la evidencia no es buena porque todo con COVID es nuevo”, dijo Totten, quien se especializa en la toma de decisiones médicas.

Es comprensible que a los consumidores los haya afectado la información contradictoria sobre posibles tratamientos para COVID por parte de líderes políticos, incluido Trump, y la comunidad científica.

El fármaco contra la malaria hidroxicloroquina, promocionado por el presidente, recibió una autorización de emergencia de la Administración de Drogas y Alimentos (FDA), solo para que la decisión se revocara varias semanas después por temor a que causara daño.

El plasma convalescente, que utiliza hemoderivados de personas recuperadas de COVID-19 para tratar a las que aún están enfermas, se administró a más de 100,000 pacientes en un programa de acceso ampliado y se puso a disposición de todos a través de otra autorización de emergencia, aunque los científicos no están seguros de sus beneficios.

Regeneron y la empresa farmacéutica Eli Lilly and Co. han solicitado autorización de uso de emergencia para sus terapias con anticuerpos monoclonales, incluso cuando los científicos dicen que esto podría poner en peligro la inscripción en los ensayos que probarán si funcionan, o cuán bien funcionan.

Hasta ahora, unas 2,500 personas se han inscrito en los ensayos de Regeneron, y, de ellas, unas 2,000 reciben la terapia, dijo un vocero de la compañía. Otras han recibido el tratamiento a través de los llamados programas de uso compasivo, aunque la empresa no dijo cuántas.

La semana del 12 de octubre, los Institutos Nacionales de Salud detuvieron el ensayo de anticuerpos de Lilly después que una junta de monitoreo independiente planteara preocupaciones de seguridad.

“Con toda la información dando vueltas en los medios, es difícil para los pacientes tomar buenas decisiones, y para los médicos tomar esas decisiones”, dijo el doctor Benjamin Rome, internista e investigador de políticas de salud en el programa Portal de la Escuela de Medicina de Harvard.

Aun así, las personas que enfrentan COVID no deberían tener miedo de preguntar si tienen opciones de tratamiento disponibles, agregó Rome. “Como médico, no me importa cuando los pacientes preguntan”, dijo.

Los pacientes y las familias deben comprender cuáles podrían ser las implicaciones de esos tratamientos, aconsejó Totten. Los primeros ensayos clínicos de fase 1 se centran principalmente en la seguridad, mientras que los ensayos más amplios de fase 2 y fase 3 determinan la eficacia. Cualquier tratamiento experimental plantea la posibilidad de efectos secundarios graves.

Idealmente, los proveedores de atención médica proporcionarían la información sobre tratamientos y riesgos sin previo aviso. Pero durante una pandemia, y especialmente en un entorno de mucho estrés, es posible que no lo hagan, observó Totten.

“Es importante ser insistente”, dijo. “Y Volver a preguntar. A veces tienes que estar dispuesto a ser un poco agresivo”, sugirió.

Los pacientes y las familias deben tomar nota o grabar las conversaciones para su posterior revisión. Deberían preguntar sobre la compensación económica por participar. A muchos pacientes en los ensayos de COVID-19 se les paga cantidades modestas por su tiempo y viajes.

Y deberían pensar en cómo encaja cualquier tratamiento en su sistema más amplio de valores y objetivos, dijo Angie Fagerlin, profesora y directora del departamento de ciencias de la salud de la población de la Universidad de Utah.

“¿Cuáles son los pros y los contras?”, se preguntó Fagerlin. Una consideración puede ser el beneficio para la sociedad en general, no solo para el paciente, dijo.

Para Mutter, ayudar al avance de la ciencia fue una gran razón por la que aceptó inscribirse en el ensayo de Regeneron.

“Me interesó para que la terapéutica avanzara, necesitan personas”, dijo. “En un momento en el que hay tantas cosas que no podemos controlar, ésta sería una forma de encontrar algún tipo de solución”.

Esto fue lo que impulsó a Fred Hutch, que participa en dos ensayos de Regeneron, uno para la prevención de COVID-19 y otro para el tratamiento de la enfermedad.

“Fue una visita de seis horas”, dijo. “Son dos horas para recibir la infusión. Es un goteo intravenoso muy lento”.

Mutter fue la segunda persona inscrita en el ensayo de Fred Hutch, dijo la doctora Shelly Karuna, co-investigadora principal. El estudio está probando dosis altas y bajas del cóctel de anticuerpos monoclonales frente a un placebo.

“Me sorprende el profundo altruismo de las personas a las que estamos evaluando”, dijo.

Mutter no está seguro de cómo contrajo COVID-19. Él y su familia han tenido cuidado con las máscaras y el distanciamiento social, y han criticado a otros que no.

“La ironía ahora es que fuimos nosotros los que nos enfermamos”, dijo Mutter, cuya esposa, Gina Mutter, de 54 años, también tiene COVID.

Mutter sabe que tiene una probabilidad de 1 en 3 de recibir un placebo en lugar de una de las dos dosis de tratamiento activo, pero dijo que estaba dispuesto a correr ese riesgo. Su esposa no se inscribió.

“Dije, hay algunos riesgos involucrados. Uno de nosotros puede tomar el riesgo, no los dos”, dijo.

Hasta ahora, Mutter ha luchado contra una tos y fatiga persistente. No puede decir si su infusión ha sido útil.

“Simplemente no hay forma de saber si tengo los anticuerpos o no”, dijo. “¿Los obtuve y eso me mantuvo fuera del desastre?, ¿o tuve el placebo y mi propio sistema inmunológico hizo su trabajo?”.

Related Topics

Noticias En Español Public Health

Presidential Elections May Be Bad for Your Health

The stress of presidential elections may increase the incidence of heart attacks and strokes, researchers report.

Scientists tracked hospitalizations for acute cardiovascular disease in the weeks before and after the 2016 presidential election among about three million adults who were enrolled in the Kaiser Permanente Southern California health care system.

The study, in PNAS, found that hospitalizations for cardiovascular disease in the two days following the election were 61 percent higher than in the same two days of the preceding week. The rate of heart attack increased by 67 percent and of stroke by 59 percent in the two days following the election. The results were similar regardless of the age, race or sex of the patients.

The exact physiological mechanism is unknown, but previous studies have found similar increases in cardiovascular disease risk after traumatic public events, including earthquakes, industrial accidents and terrorist incidents like the World Trade Center attack of 2001 and the Charlie Hebdo shootings in 2015.

Psychological stressors such as anger, anxiety and depression have also been associated with sudden increases in the risk for cardiovascular events in the days, or even hours, following such events. The authors suggest that the stress of elections may provoke similar emotions.

“These are important findings,” said the lead author, Matthew T. Mefford, a postdoctoral research fellow at Kaiser Permanente Southern California. “This should really encourage health care providers to pay more attention to the ways that stress is linked to political campaigns and how election outcomes may directly impact health.”

Older COVID Patients Battle ‘Brain Fog,’ Weakness and Emotional Turmoil

“Lord, give me back my memory.”

For months, as Marilyn Walters has struggled to recover from COVID-19, she has repeated this prayer day and night.

Like other older adults who’ve become critically ill from the coronavirus, Walters, 65, describes what she calls “brain fog” — difficulty putting thoughts together, problems with concentration, the inability to remember what happened a short time before.

This sudden cognitive dysfunction is a common concern for seniors who’ve survived a serious bout of COVID-19.

“Many older patients are having trouble organizing themselves and planning what they need to do to get through the day,” said Dr. Zijian Chen, medical director of the Center for Post-COVID Care at Mount Sinai Health System in New York City. “They’re reporting that they’ve become more and more forgetful.”

Other challenges abound: overcoming muscle and nerve damage, improving breathing, adapting to new impairments, regaining strength and stamina, and coping with the emotional toll of unexpected illness.

Most seniors survive COVID-19 and will encounter these concerns to varying degrees. Even among the age group at greatest risk — people 85 and older — just 28% of those with confirmed cases end up dying, according to data from the Centers for Disease Control and Prevention. (Because of gaps in testing, the actual death rate may be lower.)

As she recovers from COVID-19, Marilyn Walters finds it difficult to put thoughts together and remember recent events. She calls it “brain fog.” “Emotionally, it’s been hard because I’ve always been able to do for myself, and I can’t do that as I like. I’ve been really nervous and jittery,” she says.(Tammia Sanders)

Walters, who lives in Indianapolis, spent almost three weeks in March and April heavily sedated, on a ventilator, fighting for her life in intensive care. Today, she said, “I still get tired real easy and I can’t breathe sometimes. If I’m walking sometimes my legs get wobbly and my arms get like jelly.”

“Emotionally, it’s been hard because I’ve always been able to do for myself, and I can’t do that as I like. I’ve been really nervous and jittery,” Walters said.

Younger adults who’ve survived a serious course of COVID-19 experience similar issues but older adults tend to have “more severe symptoms, and more limitations in terms of what they can do,” Chen said.

“Recovery will be on the order of months and years, not days or weeks,” said Dr. E. Wesley Ely, co-director of the Critical Illness, Brain Dysfunction and Survivorship Center at Vanderbilt University Medical Center. Most likely, he speculated, a year after fighting the disease at least half of the critically ill older patients will not have fully recovered.

The aftereffects of delirium — an acute, sudden change of consciousness and mental acuity — can complicate recovery from COVID-19. Seniors hospitalized for serious illness are susceptible to the often-unrecognized condition when they’re immobilized for a long time, isolated from family and friends, and given sedatives to ease agitation or narcotics for pain, among other contributing factors.

In older adults, delirium is associated with a heightened risk of losing independence, developing dementia and dying. It can manifest as acute confusion and agitation or as uncharacteristic unresponsiveness and lethargy.

“What we’re seeing with COVID-19 and older adults are rates of delirium in the 70% to 80% range,” said Dr. Babar Khan, associate director of Indiana University’s Center for Aging Research at the Regenstrief Institute, and one of Walters’ physicians.

Gordon Quinn, 77, a Chicago documentary filmmaker, believes he contracted COVID-19 at a conference in Australia in early March. At Northwestern Memorial Hospital, he was put on a ventilator twice in the ICU, for a total of nearly two weeks, and remembers having “a lot of hallucinations” — a symptom of delirium.

“I remember vividly believing I was in purgatory. I was paralyzed — I couldn’t move. I could hear snatches of TV — reruns of ‘Law & Order: Special Victims Unit’ — and I asked myself, ‘Is this my life for eternity?’” Quinn said.

Given the extent of delirium and mounting evidence of neurological damage from COVID-19, Khan said he expects to see “an increased prevalence of ICU-acquired cognitive impairment in older COVID patients.”

Ely agrees. “These patients will urgently need to work on recovery,” he said. Family members should insist on securing rehabilitation services — physical therapy, occupational therapy, speech therapy, cognitive rehabilitation — after the patient leaves the hospital and returns home, he advised.

Gordon Quinn spent nearly two weeks at Chicago’s Shirley Ryan AbilityLab while recuperating from a life-threatening case of COVID-19. Today, he’s able to walk nearly 2 miles and has returned to work, feeling almost back to normal.(Meg Gerken)

“Even at my age, people can get incredible benefit from rehab,” said Quinn, who spent nearly two weeks at Chicago’s Shirley Ryan AbilityLab, a rehabilitation hospital, before returning home and getting several weeks of home-based therapy. Today, he’s able to walk nearly 2 miles and has returned to work, feeling almost back to normal.

James Talaganis, 72, of Indian Head Park, Illinois, also benefited from rehab at Shirley Ryan AbilityLab after spending nearly four months in various hospitals beginning in early May.

Talaganis had a complicated case of COVID-19: His kidneys failed and he was put on dialysis. He experienced cardiac arrest and was in a coma for almost 58 days while on a ventilator. He had intestinal bleeding, requiring multiple blood transfusions, and was found to have crystallization and fibrosis in his lungs.

When Talaganis began his rehab on Aug. 22, he said, “my whole body, my muscles were atrophied. I couldn’t get out of bed or go to the toilet. I was getting fed through a tube. I couldn’t eat solid foods.”

In early October, after getting hours of therapy each day, Talaganis was able to walk 660 feet in six minutes and eat whatever he wanted. “My recovery — it’s a miracle. Every day I feel better,” he said.

James Talaganis began his COVID-19 rehab at Shirley Ryan AbilityLab in late August. After hours of daily therapy, his walking has measurably improved. “My recovery — it’s a miracle. Every day I feel better,” he says.(Megan Washburn)

Unfortunately, rehabilitation needs for most older adults are often overlooked. Notably, a recent study found that one-third of critically ill older adults who survive a stay in the ICU did not receive rehab services at home after hospital discharge.

“Seniors who live in more rural areas or outside bigger cities where major hospital systems are providing cutting-edge services are at significant risk of losing out on this potentially restorative care,” said Dr. Sean Smith, an associate professor of physical medicine and rehabilitation at the University of Michigan.

Sometimes what’s most needed for recovery from critical illness is human connection. That was true for Tom and Virginia Stevens of Nashville, Tennessee, in their late 80s, who were both hospitalized with COVID-19 in early August.

Ely, one of their physicians, found them in separate hospital rooms, frightened and miserable. “I’m worried about my husband,” he said Virginia told him. “Where am I? What is happening? Where is my wife?” the doctor said Tom asked, before crying out, “I have to get out of here.”

Ely and another physician taking care of the couple agreed. Being isolated from each other was dangerous for this couple, married for 66 years. They needed to be put in a room together.

When the doctor walked into their new room the next day, he said, “it was a night-and-day difference.” The couple was sipping coffee, eating and laughing on beds that had been pushed together.

“They both got better from that point on. I know that was because of the loving touch, being together,” Ely said.

That doesn’t mean recovery has been easy. Virginia and Tom still struggle with confusion, fatigue, weakness and anxiety after their two-week stay in the hospital, followed by two weeks in inpatient rehabilitation. Now, they’re in a new assisted living residence, which is allowing outdoor visits with their family.

“Doctors have told us it will take a long time and they may never get back to where they were before COVID,” said their daughter, Karen Kreager, also of Nashville. “But that’s OK. I’m just so grateful that they came through this and we get to spend more time with them.”

Related Topics

Aging Mental Health Navigating Aging

Can Ordinary COVID Patients Get the Trump Treatment? It’s OK to Ask

When Terry Mutter woke up with a headache and sore muscles on a recent Wednesday, the competitive weightlifter chalked it up to a hard workout.

By that evening, though, he had a fever of 101 degrees and was clearly ill. “I felt like I had been hit by a truck,” recalled Mutter, who lives near Seattle.

The next day he was diagnosed with COVID-19. By Saturday, the 58-year-old was enrolled in a clinical trial for the same antibody cocktail that President Donald Trump claimed was responsible for his coronavirus “cure.”

“I had heard a little bit about it because of the news,” said Mutter, who joined the study by drugmaker Regeneron to test whether its combination of two man-made antibodies can neutralize the deadly virus. “I think they probably treated him with everything they had.”

Mutter learned about the study from his sister-in-law, who works at Seattle’s Fred Hutchinson Cancer Research Center, one of dozens of trial sites nationwide. He is among hundreds of thousands of Americans — including the president — who’ve taken a chance on experimental therapies to treat or prevent COVID-19.

But with nearly 8 million people in the U.S. infected with the coronavirus and more than 217,000 deaths attributed to COVID, many patients are unaware of such options or unable to access them. Others remain wary of unproven treatments that can range from drugs to vaccines.

“Honestly, I don’t know whether I would have gotten a call if I hadn’t known somebody who said, ‘Hey, here’s this study,’” said Mutter, a retired executive with Boeing Co.

The website clinicaltrials.gov, which tracks such research, reports more than 3,600 studies involving COVID-19 or SARS-CoV-2, the virus that causes the disease. More than 430,000 people have volunteered for such studies through the COVID-19 Prevention Network. Thousands of others have received therapies, like the antiviral drug remdesivir, under federal emergency authorizations.

Faced with a dire COVID diagnosis, how do patients or their families know whether they can — or should — aggressively seek out such treatments? Conversely, how can they decide whether to refuse them if they’re offered?

Such medical decisions are never easy — and they’re even harder during a pandemic, said Annette Totten, an associate professor of medical informatics and clinical epidemiology at Oregon Health & Science University.

“The challenge is the evidence is not good because everything with COVID is new,” said Totten, who specializes in medical decision-making. “I think it’s hard to cut through all the noise.”

Consumers have been understandably whipsawed by conflicting information about potential COVID treatments from political leaders, including Trump, and the scientific community. The antimalarial drug hydroxychloroquine, touted by the president, received emergency authorization from the federal Food and Drug Administration, only to have the decision revoked several weeks later out of concern it could cause harm.

Convalescent plasma, which uses blood products from people recovered from COVID-19 to treat those who are still ill, was given to more than 100,000 patients in an expanded-access program and made widely available through another emergency authorization — even though scientists remain uncertain of its benefits.

Regeneron and the pharmaceutical firm Eli Lilly and Co. have both requested emergency use authorization for their monoclonal antibody therapies, even as scientists say such approval could jeopardize enrollment in the randomized controlled trials that will prove whether or how well they work. So far, about 2,500 people have enrolled in the Regeneron trials, with about 2,000 of them receiving the therapy, a company spokesperson said. Others have received the treatment through so-called compassionate use programs, though the company wouldn’t say how many.

Last week, the National Institutes of Health paused the Lilly antibody trial after an independent monitoring board raised safety concerns.

“With all of the information swirling around in the media, it’s hard for patients to make good decisions — and for doctors to make those decisions,” said Dr. Benjamin Rome, a general internist and health policy researcher at Harvard Medical School’s Portal program. “You shouldn’t expect that what you’ve heard about on the news is the right treatment for you.”

Even so, people facing COVID shouldn’t be afraid to question whether treatment options are available to them, Rome said. “As a doctor, I never mind when patients ask,” he said.

Patients and families should understand what the implications of those treatments might be, Totten advised. Early phase 1 clinical trials focus largely on safety, while larger phase 2 and phase 3 trials determine efficacy. Any experimental treatment raises the possibility of serious side effects.

Ideally, health care providers would provide such information about treatments and risks unprompted. But during a pandemic, especially in a high-stress environment, they might not, Totten noted.

“It’s important to be sort of insistent,” she said. “If you ask a question, you have to ask it again. Sometimes you have to be willing to be a little pushy,” she said.

Patients and families should take notes or record conversations for later review. They should ask about financial compensation for participation. Many patients in COVID-19 trials are paid modest amounts for their time and travel.

And they should think about how any treatment fits into their larger system of values and goals, said Angie Fagerlin, a professor and the chair of the population health sciences department at the University of Utah.

“What are the pros and what are the cons?” Fagerlin said. “Where would your decision regret be: Not doing something and getting sicker? Or doing something and having a really negative reaction?”

One consideration may be the benefit to the wider society, not just yourself, she said. For Mutter, helping advance science was a big reason he agreed to enroll in the Regeneron trial.

“The main thing that made me interested in it was in order for therapeutics to move forward, they need people,” he said. “At a time when there’s so much we can’t control, this would be a way to come up with some kind of a solution.”

That decision led him to Fred Hutch, which is collaborating on two Regeneron trials, one for prevention of COVID-19 and one for treatment of the disease.

“It was a six-hour visit,” he said. “It’s two hours to get the infusion. It’s a very slow IV drip.”

Mutter was the second person enrolled in the treatment trial at Fred Hutch, said Dr. Shelly Karuna, a co-principal investigator. The study is testing high and low doses of the monoclonal antibody cocktail against a placebo.

“I am struck by the profound altruism of the people we are screening,” she said.

Mutter isn’t sure how he contracted COVID-19. He and his family have been careful about masks and social distancing — and critical of others who weren’t.

“The irony now is that we’re the ones who got sick,” said Mutter, whose wife, Gina Mutter, 54, is also ill.

Mutter knows he has a 1-in-3 chance that he got a placebo rather than one of two active treatment dosages, but he said he was willing to take that chance. His wife didn’t enroll in the trial.

“I said, there’s some risks involved. We’re taking one for the team here. I don’t think we both need to do that,” he said.

So far, Mutter has struggled with a persistent cough and lingering fatigue. He can’t tell if his infusion has been helpful, never mind whether it’s a cure.

“Just no way of telling if I got the antibodies or not,” he said. “Did I get them and that kept me out of disaster, or did I get the placebo and my own immune system did its job?”

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Public Health

‘No Mercy’ Chapter 4: So, 2 Nuns Step Off a Train in Kansas … A Hospital’s Origin Story


Can’t see the audio player? Click here to listen.


Ever since Mercy Hospital went “corporate,” things just haven’t been the same — that’s what lots of locals in Fort Scott, Kansas, said when the Mercy health system shuttered the only hospital in town.

It’s been years since Catholic nuns led Mercy Hospital Fort Scott, but town historian Fred Campbell is wistful for his boyhood in the 1940s when sisters in habits walked the hallways.

“Well, I had never, ever been in a hospital. And here came these ladies in flowing robes and white bands around their faces. And I was scared to death. But it wasn’t long ’til I found that, first thing I know, they had some iced Coca-Cola. I still remember them putting their hand on my head to see if I had a fever.”

For more than 100 years, Mercy Hospital — and the nuns who started it all — cared for local people. But in recent years, Fort Scott’s economy and the hospital’s finances faltered. Campbell hoped both could survive.

“Mercy Corporation, can you stay with us longer?” he wondered.

In Chapter 4 of Season One: No Mercy, podcast host Sarah Jane Tribble carries that question to Sister Mary Roch Rocklage, the powerhouse who consolidated all the Mercy hospitals in the Midwest.

Click here to read the episode transcript.

Fred Campbell(Sarah Jane tribble/KHN)


“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

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Multimedia Public Health States

Progressive Group Highlights Trump, Tillis Weakness on Insulin Price Tags

During the first presidential debate of 2020, President Donald Trump touted his efforts to curb skyrocketing drug prices and declared that insulin is now “so cheap, it’s like water.” The response on social media was swift, and divided, with some people sharing pharmacy bills showing thousands of dollars they’d spent on insulin, while others boasted of newfound savings.

The next day, a self-described progressive political action committee called Change Now jumped into the fray by releasing an ad that circulated on Facebook attacking Trump and Sen. Thom Tillis (R-N.C.) on this issue.

In the 30-second ad, a North Carolina woman in her 30s explains she was diagnosed with Type 1 diabetes at age 4.

“Donald Trump and Thom Tillis opposed legislation that would lower the price of insulin and other prescription drugs,” she says. “People with diabetes can’t afford to wait for Trump and Tillis to fight for us. … We need affordable insulin now.”

(Posts sharing the quote were flagged as part of Facebook’s efforts to combat false news and misinformation on its news feed. Read more about PolitiFact’s partnership with Facebook.)

In recent years, politicians on both sides of the aisle have committed to addressing the cost of insulin. This election cycle — coinciding with a looming threat to the Affordable Care Act and millions of people losing jobs and employer-sponsored health insurance during the pandemic — the high price of prescription drugs has gained new significance.

Tillis is in one of the most heated Senate races in the country and has been repeatedly criticized by his opponent for receiving more than $400,000 in campaign contributions from the pharmaceutical and health product industries. Across the country, many voters say lowering prescription drug costs should be the top health priority for elected officials.

So, did Trump and Tillis really oppose policies that would accomplish that goal? We decided to take a closer look.

It turns out they’ve both opposed certain pieces of legislation that could have lowered the price of insulin and other prescription drugs, but they’ve also offered alternatives. The question is how aggressive those alternatives are and how many Americans would benefit from them.

Opposing the Strongest Reforms

Change Now pointed to two congressional bills to support the ad’s claim: one opposed by Trump, and the other by Tillis.

The first bill, known as H.R. 3, passed the House in December 2019, largely due to Democratic votes. It contains three main elements: decreasing out-of-pocket costs for people on Medicare, penalizing pharmaceutical companies that raise the price of drugs faster than the rate of inflation and — the most aggressive and controversial feature — allowing the federal government, which administers Medicare, to negotiate the price of certain drugs, including insulin. It also requires manufacturers to offer those agreed-on prices to private insurers, extending the benefits to a wider swath of Americans.

Stacie Dusetzina, an associate professor of health policy at Vanderbilt University School of Medicine, called it “the broadest-reaching policy that has been put forward” on drug pricing.

“While a lot of reform has focused on Medicare beneficiaries, that misses many insulin users,” Dusetzina said. “H.R. 3 does the most to affect prices for young consumers, like the woman in the ad.”

At the time, Trump vowed to veto that bill, saying the price controls it imposed “would likely undermine access to lifesaving medications” by decreasing the incentive for companies to innovate. When we checked in with the Trump campaign about the ad, a spokesperson reiterated this position, adding that the president continues to seek better legislative options.

The House bill in question, though, never made it to the president’s desk because the Senate didn’t take it up. Instead, the Senate Finance Committee proposed its own bill, which brings us to the second piece of legislation cited by Change Now.

Known as the Prescription Drug Pricing Reduction Act of 2019, the Senate bill echoes two aims of the House proposal: decreasing out-of-pocket costs for people on Medicare and putting an inflation-based cap on some drug prices.

That bill, too, stalled, with several Republican senators wary of the inflation cap. Among them was Tillis, who expressed concern that the measure could hamper innovation.

So, it’s true that Trump and Tillis have both opposed legislation that could lower the cost of insulin and other prescription drugs. But that’s not the full picture of what either politician has done on this issue.

Alternative Solutions for a Smaller Group of Americans

The Trump campaign provided a long list of actions taken by his administration to curb the high costs of medication, including a flurry of executive orders related to insulin and prescription drugs. Tillis’ campaign highlighted an alternative bill the senator co-sponsored to target drug costs. Let’s break them down one at a time.

One of Trump’s orders aims to have Federally Qualified Health Centers provide insulin and EpiPens at a discounted rate to the low-income individuals they serve. These centers, however, are already required to offer sliding-scale payments, and a full discount to patients who earn below the federal poverty line, said Rachel Sachs, an associate professor of law at Washington University in St. Louis, who tracks drug-pricing laws.

Another order deals with the importation of drugs from Canada, where they are often cheaper. Although the order specifically excludes biologic drugs, including insulin, the administration has requested proposals from private companies on how insulin could be safely brought in from other countries.

The president also issued a particularly ambitious order that seeks to tie the price Medicare pays for drugs to a lower international reference price. The Trump administration, however, hasn’t released final regulations to implement that policy, which could take years. If implemented, the policy is expected to be challenged in court by the drug industry.

Perhaps the most notable measure on insulin at the moment, experts said, is a federal demonstration project that Medicare plans can voluntarily opt into, to cap the monthly copay for insulin at $35 for some seniors. The project is slated to begin in January 2021, but its long-term future is uncertain, Sachs said, because it relies on parts of the Affordable Care Act, which could be struck down by a Supreme Court ruling later this year.

In Congress, Tillis and five other Republican senators introduced an alternative drug-pricing bill last December, called the Lower Costs, More Cures Act.

Tillis believes this is “the better option,” campaign spokesperson Andrew Romeo said, because “in addition to helping control drug prices, the legislation also seeks to preserve America’s capacity to research and develop lifesaving medications.” It includes a monthly cap on insulin copays for Medicare beneficiaries and requires manufacturers to disclose prices in consumer ads.

But experts said Tillis’ proposal is weaker than other options before the House and Senate. It doesn’t include an inflation cap, Sachs said, and the bill’s benefit would likely be limited to some seniors on Medicare, leaving out the more than 150 million Americans covered by private insurance.

Jason Roberts, an associate professor of political science at the University of North Carolina-Chapel Hill, said the bill is largely symbolic.

“Tillis is getting hit for not supporting a bill that could move,” Roberts said. “Instead, he introduces something that has no chance of going anywhere, and he knows that. But it’s a way of trying to deflect that criticism without getting a lot accomplished.”

Our Ruling

An ad sponsored by a progressive political action committee claims that Trump and Tillis have opposed legislation that would decrease the cost of insulin and other prescription drugs.

Based on the two pieces of drug-pricing legislation Change Now points to, that’s accurate. Trump and Tillis have voiced opposition to prominent bills that experts say could decrease the cost of insulin for a broad group of Americans.

However, both politicians have also proposed alternative policies to lower the price of insulin and other prescription drugs. Most of their proposals have not taken effect yet and are largely targeted at seniors.

We rate the ad’s claim Mostly True.

Related Topics

Health Care Costs Pharmaceuticals

My Brother Died of Brain Cancer. 20 Years Later, I Had It, Too.

It was the afternoon of Jan. 31. I was preparing for a dinner party and adding final touches to my cheese platter when everything suddenly went dark.

I woke up feeling baffled in a hospital bed. My husband filled me in: Apparently, I had suffered a massive seizure a few hours before our guests were to arrive at our Manhattan apartment. Our children’s nanny found me and I was rushed to the hospital. That had been three days earlier.

My husband and I were both mystified: I was 37 years old and had always been in excellent health. In due course, a surgeon dropped by and told me I had a glioma, a type of brain tumor. It was relatively huge but operable. I felt sick to my stomach.

Two weeks later, I was getting wheeled to the operating theater. I wouldn’t know the pathology until much later. I said my goodbyes to everyone — most importantly to my children, Sofia, 6, and Nyle, 2 — and prepared to die.

But right before the surgery, in a very drugged state, I asked the surgeon to please get photos of me and my brother from my husband. I wanted the surgeon to see them.

My brother had died two decades earlier from a different kind of brain tumor — a glioblastoma. I was 15 at the time, and he was 18. He died within two years of being diagnosed.

Those two years were the worst period of my life. Doctors in my home country of Pakistan refused to take him, saying his case was fatal. So, my parents gathered their savings and flew him to Britain, where he was able to get a biopsy (his tumor was in an inoperable location) and radiation. Afterward, we had to ask people for donations so he could get the gamma knife treatment in Singapore that my parents felt confident would save him. In the end, nothing worked, and he died, taking 18 years of memories with him.

After my brother’s death, I threw myself into my school work. It was partly to escape the depression that enveloped my house and partly to make something good of the rest of my life. I worked hard — hard enough to land at an Ivy League school (with full financial aid). I graduated with a dual degree in engineering and economics and worked as an investment banker, an investment manager and finally director of economic research at a family investment office. In the middle of it all, I got married and had children.

It was an immigrant’s dream. Until it came crashing down.

The period after my surgery is a blurry haze. I was grateful that I did not die, but I lost all my speech and most of my memories for a few days. I didn’t remember where I lived or what was happening to me. Later, I couldn’t remember how to use a credit card or where basic utensils in my home were. I would watch TV forgetting to turn on the volume — trying desperately hard to make sense of what was happening.

The pathology report arrived a few days later showing a low grade oligodendroglioma. I had been given a second chance! I had a highly treatable, even if not curable, tumor.

Oligodendrogliomas account for only 4 percent of all primary brain tumors, and, in younger patients, have a survival rate of 90 percent over five years. In contrast, a glioblastoma, the kind my brother had, is the most common and aggressive tumor, accounting for just over half of all primary brain tumors, with a median survival rate of only 12 to 18 months.

Despite the relief that came with the positive news, I’m still looking at a year’s worth of treatment with both radiation and chemotherapy. The radiation will be likely to have an adverse long-term impact on my cognitive skills. But if it’s a choice between that or more years of life, the decision is easy, especially if you have young children.

The irony is that for much of my adult life, since my brother died, I kept asking doctors to check my head for any signs of brain tumors, given my family history. Everyone told me the same thing: They are not hereditary. While I wondered if there could have been something environmental that my brother and I were exposed to, I was more worried about it being genetic. I grew up in a joint family system with both my parents, grandmother, uncles, aunts, and lots of young cousins — none of whom have it (even though they were exposed to the same environment).

Before my diagnosis, I once showed up at a doctor’s office specifically asking her to do an M.R.I., but she refused and told me kindly that tumors don’t run in families. Later, after my seizure, I confronted several neuro-oncologists, asking if they would have screened me before my diagnosis. But they all told me that they would not screen patients for brain tumors unless they were symptomatic.

Medical research is on their side. It shows there’s only a 5 percent chance of brain tumors being hereditary. My brother was the first among our eight uncles and aunts and 19 cousins, and now I’m the second.

On my insistence, the doctor ran a genetic test, checking for mutations to see if I’m predisposed to having a brain tumor. It came out negative, showing no correlation to my brother’s disease. But the doctor admitted gaps in his understanding. He had treated a man with glioblastoma, for example, whose two children had it too, and the genetic report turned out negative. “Ask me in 10 years, and I might have a different answer,” he said.

Everyone keeps telling me to be grateful. That I haven’t suffered the same fate as my brother. That I have had two extra decades of health to live and enjoy. As my husband puts it, “You’re the luckiest among the unlucky.”

In a quote attributed to the famous Sufi poet Rumi, “If you only say one prayer in a day, make it thank you.” I can’t explain why I get to live longer than my brother. Or why I got to enjoy two more decades than he did.

But for that and everything else, thank you.

Sundas Hashmi is a writer who formerly worked in finance and public policy.

Where Have All the Hospital Patients Gone?

Weathered, wiry and in his early 60s, the man stumbled into clinic, trailing cigarette smoke and clutching his chest. Over the previous week, he had had fleeting episodes of chest pressure but stayed away from the hospital.

“I didn’t want to get the coronavirus,” he gasped as the nurses unbuttoned his shirt to get an EKG. Only when his pain had become relentless did he feel he had no choice but to come in.

In pre-pandemic times, patients like him were routine at my Boston-area hospital; we saw them almost every day. But for much of the spring and summer, the halls and parking lots were eerily empty. I wondered if people were staying home and getting sicker, and I imagined that in a few months’ time these patients, once they became too ill to manage on their own, might flood the emergency rooms, wards and I.C.U.s, in a non-Covid wave.

But more than seven months into the pandemic, there are still no lines of patients in the halls. While my colleagues and I are busier than we were in March, there has been no pent-up overflow of people with crushing chest pain, debilitating shortness of breath or fevers and wet, rattling coughs.

“It’s so weird,” a colleague remarked recently. “It’s like those people have vanished.”

I remembered my colleague’s observation when I read a recent study that suggested why those patients have never returned.

Researchers from Sound Physicians, a national medical group of almost 4,000 doctors specializing in hospital medicine, critical care and emergency medicine, and the Dartmouth Institute for Health Policy and Clinical Practice gathered admissions data from more than 200 hospitals in 36 states and compared differences in patient characteristics, diagnoses and mortality rates between February and July of this year with the same time period last year. The researchers found that by mid-April, non-Covid admissions to hospitals had dropped by almost half.

But surprisingly, even months later, as Covid infection rates began falling and hospitals were again offering elective surgery and in-person visits to doctor’s offices, hospital admissions remained almost 20 percent lower than normal.

“We found it staggering that such a high number of patients who might have been hospitalized for serious issues just kind of disappeared,” said Dr. John D. Birkmeyer, lead author of the study, chief clinical officer of Sound Physicians, and adjunct professor of health policy and clinical practice at the Dartmouth Institute for Health Policy and Clinical Practice. “You have to wonder, ‘Where did they all go?’”

Some experts have pointed to patients’ overwhelming fear of contagion as a reason for the drop in the numbers seeking hospital care. But the patients in the study who had the greatest persistent drop in hospitalization were those with acutely worsening asthma or emphysema, pneumonias, sepsis, strokes and even heart attacks, all illnesses where hospitalization is generally not optional.

And those who were hospitalized were not necessarily Covid holdouts, so fearful of contagion that they came only when they were at death’s door. Analyzing hospital mortality rates, Dr. Birkmeyer and his colleagues found that apart from a small bump during the early weeks of the pandemic, hospitalized patients without Covid-19 were not dying more than they were before.

Moreover, as the pandemic wore on, fears of getting infected at the hospital may have begun to dissipate. By June, patients were going back to their doctors’ offices, with some specialists like dermatologists experiencing more demand for in-person visits than previously. “If dermatology visits are higher than pre-Covid levels,” said Jonathan Skinner, senior author of the study and a professor of economics at Dartmouth College, “I can’t imagine people not showing up at a hospital if they are having a stroke.”

The most likely explanation for persistent lower hospitalization rates “may simply be that fewer patients are getting sick in the first place,” Dr. Birkmeyer posited. Statewide stay-at-home orders aimed at curbing the coronavirus resulted in a dramatic drop in human activity and a concomitant improvement in air quality across the country. Poor air quality is linked not only to respiratory diseases like asthma and emphysema but also to other illnesses like strokes and heart attacks. Recent reports from around the world have noted decreases in hospitalizations for heart attacks and non-Covid viral respiratory illnesses like influenza during regional lockdowns and quarantines.

Research over the years has also shown that during recessions and periods of higher unemployment, people may at least temporarily adopt healthier behaviors. Individuals may smoke and drink less, get more exercise, improve their diet, lose weight and have less stress related to work or commuting.

Recent public health efforts to promote wearing masks and frequent hand-washing have also probably lowered the transmission rate of other viruses and bacteria that can be responsible for colds, pneumonias and the life-threatening infections or exacerbations of asthma and emphysema. “People keep saying, ‘Hey, I don’t remember the last time I had a cold,’” Mr. Skinner noted. “It’s because no one is hugging or shaking hands, and everyone is washing their hands.”

The published study followed hospitalization trends only through July, but the researchers have continued to gather data which shows that depressed hospital admission rates are persisting into the fall. While both Dr. Birkmeyer and Mr. Skinner concede that more work needs to be done, their study makes clear that the pandemic has had significant public health and public policy implications beyond those directly related to Covid-19.

“All of the things we are doing to reduce Covid shouldn’t necessarily disappear once we have a vaccine,” Mr. Skinner reflected.

He added: “Someday, when Covid is an answer on ‘Jeopardy!’, I hope that we won’t have forgotten the important beneficial effects of reducing pollution and stress on our health in general.”

Dr. Pauline W. Chen, the author of “Final Exam; A Surgeon’s Reflections on Mortality,” is a physician who practices in Boston.


Let’s Talk About Constipation During Pregnancy

Constipation may be two to three times more common during and after pregnancy, Finnish researchers report.

The scientists studied 877 women having babies, comparing them with 201 nonpregnant controls of the same age. They rated the women on the Rome IV criteria for diagnosing constipation, which considers five symptoms, including the amount of straining at stool, sensations of incomplete defecation, the necessity of manual maneuvering required to defecate, the firmness of stool and the frequency of bowel movements. The study is in BJOG.

Based on these criteria, 21 percent of the controls had constipation, compared with 40 percent of pregnant women and 52 percent of postpartum women. About 44 percent of women had constipation in the second trimester, and 36 percent in the third trimester. Fifty-seven percent of women who gave birth by C-section and 47 percent of those who gave birth vaginally were constipated at least for a few days afterward, but at one month postpartum, rates differed little from controls.

“For pregnant women, I would suggest that they talk about this symptom frankly,” said the senior author, Dr. Merja Kokki, an anesthesiologist at the University of Eastern Finland. “It’s more common in pregnancy than nausea and vomiting, which are always openly discussed. It’s a big problem that can cause difficult symptoms later in life — pelvic floor problems, uterine prolapse, urinary problems. These are things that can impair the quality of life.”

5 Ways Families Can Prepare as Coronavirus Cases Surge

As if parents didn’t have enough to worry about, here’s a new cause for alarm: Coronavirus cases in the United States are climbing toward a third peak, troubling epidemiologists.

Cases are rising to record levels in nearly half the states in the country, driven by uncontrolled outbreaks in the Midwest and Mountain West, where hospitals are becoming overwhelmed.

“The big concern, of course, is what’s going to happen in the winter,” said Dr. Sean O’Leary, the vice chairman of the American Academy of Pediatrics’ committee on infectious diseases. “There is some reason for hope that it won’t be horrible. But I think we don’t really know.”

While the onset of another surge may sound frightening, experts say there are things parents can do right now to start preparing. Here are five ways to help protect your family’s physical and mental health.

Make sure your family is vaccinated.

There isn’t yet a vaccine for the coronavirus, but making sure you and your family are fully vaccinated for other illnesses, including the flu, is one of the simplest ways to prepare for an oncoming surge.

Public health leaders are urging everyone to get the flu vaccine, not only for their own well-being but for the greater good. The more people stay healthy, the less chance that hospitals will become overwhelmed with sick patients this winter. Especially because it’s possible to get the flu and Covid-19 at the same time.

Experts recommend that both adults and children 6 months and older be fully vaccinated against influenza by the end of October. If your child is under 9 and has never received a flu vaccine, or has only received one dose of the vaccine in the past, the American Academy of Pediatrics recommends two doses, spaced four weeks apart, for maximal protection.

Also check with your pediatrician to make sure your child is up-to-date on other vital vaccines for diseases such as measles, tetanus and whooping cough.

Create a backup plan for child care.

Many families were caught by surprise in the spring when schools and day cares shut down. And experts warn that such closures could happen again.

“We’re going to see this roller coaster effect,” said Dr. Eric Toner, a senior scholar at the Johns Hopkins Center for Health Security and an expert on health care preparedness. “Cases go up, cases go down.”

As a result, it’s helpful for parents to plan for all possible scenarios, Dr. Toner said.

If your child falls ill, for instance, make sure you understand your day care or school policies well in advance. At what point would your child need to be tested for Covid-19? When is it OK to return to school? Rules can vary considerably, but the more you know in advance, the better you can plan.

If you have alternate options for child care — perhaps a couple of trusted babysitters or grandparents who live nearby — speak with them about their willingness and availability to assist in advance of a shutdown, rather than assuming they’ll automatically be free. Will they be able to help out every day? Two times a week? Things can change at the last minute, but it will be reassuring to have a plan should you suddenly need backup.

If your children are attending school or day care in person and become exposed to someone with Covid-19, your family may have to quarantine for 14 days. At that point, you won’t have the option of backup child care because you’ll need to stay away from people who aren’t in your immediate family. Spend some time now thinking about how you’ll get through those 14 days. If you and your partner work, can you create a staggered schedule that allows you both to care for the kids? Ask your employer about flexible working options, like family medical leave or flex time. If your workplace offers sick time, when is it permissible to use it?

As we saw in the spring, child care solutions can be tough to find.

“It’s complicated, and sometimes there are no good answers,” Dr. Toner said.

Cut yourself some slack. The Child Mind Institute, a nonprofit that provides therapy and other services to children and families with mental health and learning disorders, has advice on its website for single parents on how to manage the trifecta of child care, employment and the pandemic, but these tips can be useful to nearly anyone.

One of the recommendations: “Set the parenting bar lower.”

It’s OK if your child is getting more screen time than usual or your go-to lunch has become quesadillas.

Preserve your family’s mental health.

The uncertainty of the pandemic has already produced a great deal of anxiety in parents and children.

“What makes this marathon so much worse is that fact that we’re telling you it’s going to get muddy up ahead,” said Dr. Harold S. Koplewicz, medical director of the Child Mind Institute and a child and adolescent psychiatrist based in New York City. “When thinking about tomorrow — that’s what creates anxiety.”

Try to avoid speculating about an advancing surge and instead stay focused on the present by implementing structure and routines for your children, he said.

Stick to consistent bedtimes and mealtimes. Even simple routines like getting dressed every morning can offer much-needed structure. Weekly activities like pizza night or movie night can give the whole family something to look forward to.

Make a habit of expressing gratitude as well, Dr. Koplewicz added: Encourage everyone in your family to explain “why we are lucky this week” and challenge them to come up with a different reason each time.

Finally, consider teaching your children mindfulness exercises, Dr. Koplewicz said, which can be as simple as sitting still for one minute. It’s a way to help your kids stay rooted in the moment and feel calm. They’re great for parents, too.

“Listen to your body, listen to the environment and just let your thoughts go,” he said.

Stock up on necessary supplies (but don’t be a hoarder).

Even if your family never gets sick with Covid-19, other infections are likely to make an appearance. You’ll feel more secure knowing that you have everything you need right at your fingertips.

A sample list might include:

  • Fever reducers such as acetaminophen (Tylenol) or ibuprofen (Advil) for yourself and your children

  • Thermometers for adults and kids, as well as disposable thermometer probe covers (if you use those) and backup batteries

  • Hydrating liquids like Pedialyte, ginger ale and Gatorade

  • Disinfecting wipes (they’re starting to surface online and in stores again)

  • Alcohol and hydrogen peroxide to disinfect cuts and scrapes

  • Alcohol wipes for your electronic devices

  • Extra formula, baby wipes and diapers

Combat pandemic fatigue.

More troubling than the onset of cold and flu season is the fatigue people feel over continual social distancing, avoiding crowded indoor spaces and wearing masks, Dr. Toner said. In addition, there is bound to be additional risk as states reopen.

“The reason we’re seeing increasing cases now is because we’ve relaxed those containment measures,” he added. “Those places that somehow think they’re immune to the virus will see big spikes.”

So don’t let pandemic fatigue prevent you from keeping yourself — and others — safe.

Wear a mask if you’re going to spend time with people outside of your household; wash your hands frequently; use hand sanitizer if you don’t have access to soap and water; maintain six feet of distance from others when possible; and avoid crowded indoor spaces, Dr. O’Leary advised.

In addition, get tested for Covid-19 if you’re sick, or if you believe that you might have been in contact with someone who was.

“We have very good evidence now that this constellation of simple actions really works and has driven down the number of infections tremendously,” he added.

Staying healthy is another way to help prevent illness. Everyone in the family should get enough sleep and make a point of exercising regularly, even if all you do is take a brisk walk. Eat nutritious foods like vegetables, whole grains and lean meats as often as possible, and make sure you and your kids are getting regular checkups.

The pandemic can be exhausting. At times it can feel depressing and even interminable. But if your family makes good choices now, you’ll feel stronger and more mentally prepared to ride this out.

Doctors May Have Found Secretive New Organs in the Center of Your Head

After millenniums of careful slicing and dicing, it might seem as though scientists have figured out human anatomy. A few dozen organs, a couple hundred bones and connective tissue to tie it all together.

But despite centuries of scrutiny, the body is still capable of surprising scientists.

A team of researchers in the Netherlands has discovered what may be a set of previously unidentified organs: a pair of large salivary glands, lurking in the nook where the nasal cavity meets the throat. If the findings are confirmed, this hidden wellspring of spit could mark the first identification of its kind in about three centuries.

Any modern anatomy book will show just three major types of salivary glands: one set near the ears, another below the jaw and another under the tongue. “Now, we think there is a fourth,” said Dr. Matthijs Valstar, a surgeon and researcher at the Netherlands Cancer Institute and an author on the study, published last month in the journal Radiotherapy and Oncology.

The study was small, and examined a limited patient population, said Dr. Valerie Fitzhugh, a pathologist at Rutgers University who wasn’t involved in the research. But “it seems like they may be onto something,” she said. “If it’s real, it could change the way we look at disease in this region.”

Even without a direct therapeutic application, Dr. Yvonne Mowery, a radiation oncologist at Duke University, said she “was quite shocked that we are in 2020 and have a new structure identified in the human body.”

Dr. Valstar and his colleagues, who usually study data from people with prostate cancer, didn’t set out on a treasure hunt for unidentified spit glands. But the structures are important to researchers and doctors who deal in oncology.

Salivary glands collectively churn out about a quart of spit each day, which is responsible for “a lot of things that make you enjoy life,” Dr. Valstar said. It lubricates the mouth, making it easier to speak and swallow. It ferries the tasty chemicals in food to the microscopic cells that can sense them. It even comes imbued with crude healing powers, waging war against germs and speeding the closure of wounds.

Doctors take numerous precautions to avoid damaging the glands when administering radiation therapy, which can, with a single misdirected zap, permanently compromise the delicate tissues.

While perusing a set of scans from a machine that could visualize tissues in high detail, the researchers noticed two unfamiliar structures dead center in the head: a duo of flat, spindly glands, a couple inches in length, draped discreetly over the tubes that connect the ears to the throat.

Puzzled by the images, they dissected tissue from two cadavers and found that the glands bore similarities to known salivary glands that sit below the tongue. The new glands were also hooked up to large draining ducts — a hint that they were funneling fluid from one place to another.

It’s not completely clear how the glands eluded anatomists. But “the location is not very accessible, and you need very sensitive imaging to detect it,” said Dr. Wouter Vogel, a radiation oncologist at the Netherlands Cancer Institute and an author on the study. The body’s other large salivary glands, which sit closer to the surface of the skin, can also be poked and prodded; that’s far less feasible with this fourth pair of structures, which are tucked under the base of the skull.

The new find, Dr. Vogel said, might help explain why people who undergo radiation therapy for cancer of the head or neck so often end up with chronic dry mouth and swallowing problems. Because these obscure glands weren’t known to doctors, “nobody ever tried to spare them” from such treatments, Dr. Vogel said.

Dr. Alvand Hassankhani, a radiologist at the University of Pennsylvania, said he was hesitant to label the structures “new organs.” In addition to the three pairs of known large salivary glands, some 1,000 minor salivary glands are sprinkled across the lining of the mouth and throat. They are more petite and tougher to find through imaging or scanning than their heftier cousins. It’s possible that the Dutch researchers just happened upon a better way to image a set of underappreciated minor glands, Dr. Hassankhani said.

Dr. Fitzhugh and Dr. Mowery were slightly more persuaded, but both called for more data. “To have it one clinical data set is never enough,” Dr. Mowery said.

The patient population in the study also wasn’t very diverse, Dr. Fitzhugh said. The original group examined by the researchers was made up entirely of people with prostate or urethral gland cancer, and included only one woman among 100 subjects.

“You’d like to see more balance,” Dr. Fitzhugh said.

The imaging techniques used in the study were also specifically tailored to hunt for tumorous growths in this patient population. It may be worth widening these experiments to include a new group of people, using different methods, she said.

Dr. Fitzhugh added that it should be easier to spot the camera-shy glands with traditional techniques “now that they know to look for it,” she said.