Tagged States

Adding To COVID Stress, Families Of Health Workers Fight For Denied Workers’ Comp Benefits

James “Mike” Anderson was a hospital employee in suburban Philadelphia with a low-profile though critical job: changing air filters in COVID patients’ rooms.

By late March, new COVID cases in Bucks County, Pennsylvania, had ramped up to as many as 90 per day. At the hospital, Anderson handled air filters and other surfaces that might have been contaminated with the deadly virus, also known to hang in the air.

In early April, Anderson, 51, came down with what he thought was a cold, according to his family’s lawyer, David Stern. On April 13 Anderson was rushed to the hospital, where he died of acute respiratory distress syndrome from COVID-19, according to the county coroner. He left behind a wife and two children, ages 5 and 9.

James “Mike” Anderson, a maintenance mechanic at St. Mary’s Medical Center outside of Philadelphia, died of COVID-19 complications on April 13.(Courtesy of Stephanie Anderson)

Anderson was exposed to the virus at work, the lawyer contends, making his family eligible for workers’ compensation death benefits paid by his employer’s insurer.

“His family deserves to have that income replaced,” Stern said. “Their husband and father certainly can’t be.”

But in a June 16 response to Stern’s death benefits claim, St. Mary Medical Center denied all allegations.

As the COVID toll climbs, sick workers and families of the dead face another daunting burden: fighting for benefits from workers’ compensation systems that, in some states, are stacked against them.

In interviews with lawyers and families across the nation, KHN found that health care workers ― including nurses’ aides, physician assistants and maintenance workers ― have faced denials or long-shot odds of getting benefits paid. In some cases, those benefits amount to an ambulance bill. In others, they would provide lifetime salary replacement for a spouse.

Legal experts say that in some states COVID-19 falls into a long-standing category of diseases like a cold or the flu — conditions not covered by workers’ compensation — with no plans to change that. Other states force workers to prove they caught the virus at work, rather than from a family member or in the community.

“We are asking people to risk their lives every single day — not just doctors, nurses and first responders, but also nurses’ aides and grocery store clerks,” said Laurie Pohutsky, a Democratic Michigan lawmaker who proposed a bill to help essential workers get coverage more easily. “These people are heroes, but we have to actually back those words up with actions.”

In at least 16 states and Puerto Rico, officials have passed measures to make it easier for workers infected with the coronavirus to qualify for benefits for lost wages, hospital bills or death. Similar bills are pending in other states, but some face opposition from business groups over costs.

Many of the proposed actions would turn the tables on the status quo, forcing employers to prove workers did not catch the virus at work. Bills vary in the scope of workers they cover. Some protect all who left home to work during stay-at-home orders. Others are limited to first responders and health care workers. Some would cover only workers who get sick during states of emergency, while others would cover a longer period.

An early glimpse of data shows that health care workers and first responders, two groups hit hard by the virus, make up the majority of those seeking benefits. Data from the Centers for Disease Control and Prevention shows that more than 95,000 health care workers have been infected, a figure the agency acknowledges is an undercount. KHN and The Guardian U.S. have identified more than 700 who have died and told the story of 139 of them. For these workers’ families, the stakes of the pending laws are enormous.

In Virginia, attorney Michele Lewane is representing a nurse and a physician assistant who contracted the coronavirus while working at the same urgent care center. The physician assistant, who administered COVID tests, was hospitalized with COVID-19 and pneumonia for about a week. He missed five weeks of work.

When the physician assistant asked the urgent care center for paperwork to file a workers’ compensation claim to cover his hospital bill, an administrator refused to hand it over, saying coronavirus treatment wouldn’t be covered, Lewane said. He was laid off days later and left with a $60,000 hospital bill.

Lewane said the law in Virginia will likely consider COVID-19 an “ordinary disease of life,” akin to a cold or the flu. She said she’d have to prove by “clear and convincing evidence” that he caught the coronavirus at work.

The bar is so high, she said, that she’s waiting to file a claim in hopes that Virginia joins many other states passing laws that make it easier for health workers to prove their cases.

Craig Davis, president-elect of the Virginia Trial Lawyers Association, said he took on a test case and received a quick denial of workers’ compensation benefits for a COVID-positive physician assistant.

“We think there’s an infinitesimal possibility of prevailing under our laws as currently written,” he said. His group is pushing for a legislative change.

In Montana, which has largely been spared by the pandemic, workers face even longer odds. A 64-year-old nurse at a small hospital there was hospitalized for eight days with COVID-19 in April, according to her Great Falls lawyer, Thomas Murphy. She remains at home on oxygen, unable to work.

The woman filed a workers’ compensation claim, which could qualify her for up to $800 a week in lost wages plus lifetime coverage of medical bills related to her condition. Instead of agreeing to those benefits, Murphy said, the insurer offered to settle for $17,000, which she declined because it would not cover her medical bills.

Murphy said the employer, which he did not name to protect his client from retaliation, is arguing that she was the first person at the hospital to contract the virus, so she likely didn’t get it at work. However, he noted that two other hospital employees and six patients tested positive within the next two weeks and his client went few places other than work.

In Montana law, the burden of proof lies on the employee to show an illness was work-related.

“We’re going to have to try to piece together all of the sources” that might have infected her — “and prove that it’s more probable than not that she got it at work,” Murphy said. “Women like this woman are going to have a hard road ahead of them.”

The Montana Legislature isn’t set to meet until January, and an executive order appears unlikely.

In New Jersey, attorney Rick Rubenstein is representing the widow of a man who worked as a housekeeper at a nursing home, doing laundry and occasional patient care. Not given protective gear by his employer, the man caught COVID-19 and had a lengthy stay in the intensive care unit before he died.

His wife has the virus now and was faced with a default — no answer in 35 days — after seeking benefits in New Jersey’s workers’ compensation system. They would cover her husband’s $188,000 hospital bill and survivor’s pay of $308 per week.

“She’s isolated, doesn’t know what her own health future holds and doesn’t have an explanation of why this stuff is happening,” Rubenstein said. “It’s terrible.”

A bill proposed in New Jersey would make it easier for essential workers who got COVID-19 during the state of emergency to prove that they got it on the job. The bill was passed by the state Senate and is pending before the General Assembly.

The New Jersey Business & Industry Association has opposed the bill, saying it would push higher workers’ compensation insurance rates onto businesses that are “struggling to survive.”

“Our concerns are primarily that the cost of these claims can overwhelm the system, which was not designed to handle claims during a worldwide pandemic,” NJBIA Chief Government Affairs Officer Chrissy Buteas said in a statement.

While there are no national estimates of how many are filing claims for workers’ compensation ― or getting approvals ― Massachusetts provided KHN with a summary of its coronavirus reports from March, April and May.

During those months, employers filed 3,482 “first reports of injury” regarding a worker with COVID-19 ― 2,915 were for health care workers. Insurers denied benefits to 216 health care workers, according to Massachusetts records.

Florida posted similar data, showing a higher rate of denied claims for health care workers. While 1,740 health care workers sought benefits related to COVID-19, about 30%, or 521 claims, were fully denied. Among the 1,200 who were paid benefits, the amount paid added up to $1.3 million.

The cost of covering 9.6 million first responders and health workers nationally could range from $1 billion to $16 billion, according to the National Council on Compensation Insurance, which provides insurance rate recommendations for 38 states. The bill is paid by employers who buy workers’ compensation insurance, employers that self-insure and taxpayers, who support government agencies.

Those estimates do not include New York or California, where Gov. Gavin Newsom’s executive order broadening coverage through July 5 is projected to add about $1.2 billion to California’s costs.

In many states, business associations consider proposals to expand workers’ compensation too costly and too broad.

A proposed California bill would extend Newsom’s executive order and put the burden on employers to prove that “critical workers,” including those in retail, warehousing and delivery, who got the coronavirus did not get it at work. The bill has critics.

“California employers have been significantly impacted by this crisis and simply cannot be the safety net for this pandemic by providing workers’ compensation benefits for all employees, even when they are not injured at work,” according to a letter of concern signed by the California Chamber of Commerce, California Hospital Association and others.

A federal backstop may become available. Sen. Tammy Duckworth (D-Ill.) and a bipartisan group of lawmakers introduced a bill that would create a federal fund for essential workers, including health care personnel, who get sick or die from the coronavirus. The Pandemic Heroes Compensation Act would be modeled after the September 11th Victim Compensation Fund.

In Pennsylvania, there is no presumption that COVID-19 is acquired on the job.

Stern, the lawyer for Anderson’s family, filed a “fatal claim” in May with the state workers’ compensation board, which passed it on to the employer.

A St. Mary Medical Center spokesperson confirmed in an email that Anderson worked there for 23 years and was a maintenance mechanic. She would not discuss his case. “We are extremely saddened by his death,” she wrote. “We are not able to provide additional information out of respect for his and his family’s privacy.”

Mark Banchi volunteers with hospital chaplains and knew Anderson for over 30 years. He said co-workers are reeling from the death of a man who “was enthusiastic, gregarious, friendly.”

“His loss to the hospital is real,” Banchi said. “Some people lift spirits, some people make you glad you came that day, and Mike was one of those people.”

In addition to working at St. Mary for $22 an hour, Anderson had a cleaning job at a car dealership. Stern said Anderson was unlikely to be exposed to the virus there. If Stern prevails, the family would receive two-thirds of Anderson’s combined pay, capped at $1,081 a week.

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Public Health States

Ex-West Virginia Health Chief Says Cuts Hurt Virus Response

CHARLESTON, W.Va. — The former West Virginia public health leader forced out by the governor says decades-old computer systems and cuts to staff over a period of years had made a challenging job even harder during a once-in-a-century pandemic.

Republican Gov. Jim Justice demanded Dr. Cathy Slemp’s resignation on June 24. He complained about discrepancies in the number of active cases and accused Slemp of not doing her job. He has refused to elaborate.

In her first comments about what happened, Slemp declined in a series of interviews to directly discuss the governor’s decision, saying she wanted to focus on improving the public health system. She defended how the data was handled and she detailed how money dwindled over the years. That meant fewer staff members, and they were hobbled by outdated technology that slowed their everyday work and their focus on the coronavirus.

Among the challenges: a computer network so slow that employees would sometimes lose their work when it timed out; the public’s demand for real-time data; and a struggle to feed information into systems designed when faxes were considered high-speed communication.

“We are driving a great-aunt’s Pinto when what you need is to be driving a Ferrari,” Slemp said.

A joint investigation published this month by KHN and The Associated Press detailed how state and local public health departments across the country have been starved for decades, leaving them underfunded and without adequate resources to confront the pandemic.

In West Virginia, spending on public health fell by 27% from 2010 to 2018, according to an AP/KHN analysis of data provided by the Association of State and Territorial Health Officials. Full-time jobs in the state public health department dropped from 875 in 2007 to 620 in 2019, according to the group.

Slemp said the staffing numbers were even worse than that when the pandemic hit because between 20% and 25% of all health department jobs were vacant. In epidemiology, the vacancy rate was 30%.

Those kinds of cuts “absolutely” had an effect on the department’s operations, she said.

At the beginning of the pandemic, Slemp said, workers received stacks of faxed lab reports that had to be entered manually, even though they had spent two decades trying to persuade some hospital and commercial labs to send their results electronically. After her department required it, she said, 37 labs started filing electronically within a week.

“There was a political will and a societal will to say, ‘We need to fix this,’” Slemp said.

Public health staffers had to come up with time-consuming workarounds, such as entering information about disease outbreaks onto paper forms because their computer systems weren’t designed for such work. That was the source of Justice’s complaints, which centered on exactly how many active cases of COVID-19 were in a prison, she said.

In Randolph County, where the prison is, a top local health official said confusion about the number of cases at the facility emerged because the state’s cumbersome electronic reporting system required thorough information on an infected person’s contacts before a case could be deemed cleared.

In an email, Bonnie Woodrum of the Randolph-Elkins Health Department said that it “hurt a little to be singled out as reporting inaccurate numbers” but that “it’s just a case of a small health department attempting to use an electronic reporting system that has never been easy to use.”

The problem had no impact on the ability to track new diseases in the state, Slemp said. Indeed, she said, the disputed data from the prison outbreak was being tracked, but it wasn’t getting entered as quickly as the more critical data for new cases, which they prioritized.

“Because that’s where the public health action is most critical,” Slemp said.

Slemp’s forced resignation drew criticism from leading national figures in public health, including Tom Inglesby of the Johns Hopkins Bloomberg School of Public Health. Inglesby, who serves with Slemp on the board of scientific counselors at the federal Centers for Disease Control and Prevention, praised Slemp’s management of the coronavirus in West Virginia.

He said the issue appeared to be a clerical error that was easily fixed.

“It’s a little like shooting the messenger,” Inglesby said.

Slemp said the governor never discussed his complaints with her before he demanded her resignation.

It’s challenging to be a public health leader “in a world that wants immediate information and definitive answers, when reality is, there are nuances,” she said. “Sometimes political expediency can conflict with public health practice.”

Smith reported from Providence, Rhode Island. KHN data reporter Hannah Recht contributed to this report

This story is a collaboration between The Associated Press and KHN.

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Public Health States

Must-Reads Of The Week

Another week has gone by, and the biggest news remains that COVID numbers aren’t looking much better as the disease spreads quickly through Florida, Arizona, Texas and California.

Three million cases and 133,000 deaths in the United States. Testing still takes too long, KHN reported — the Atlanta mayor had to wait eight days for results! — and, no, more testing isn’t skewing the numbers.

With nearly 60,000 new cases in one day, the United States set another COVID record. The United States leads the world, but not in a good way, as a headline in a KHN morning newsletter put it this week. Indeed, it is quite possible that President Donald Trump’s recent rally in Tulsa, Oklahoma, contributed to the spike, Reuters reported.

COVID News, Lots of It

The focus of the arguing this week was on back-to-school plans. School districts are trying to make that hard decision in order to protect children, staff members and parents. (Well, and the economy, for that matter.) The Atlantic published some suggestions. The Centers for Disease Control and Prevention is under pressure from Trump to water down its reopening safety recommendations so, as Trump put it in a tweet Monday, “SCHOOLS MUST OPEN IN THE FALL!!!” Colleges are coming up with various plans to allow some students back on campus but offer few in-person classes.

Meanwhile, even more Americans have lost faith in Trump’s handling of the epidemic, according to a new poll released by ABC News/Ipsos: 33% approve, down from 41% three weeks ago.

The beleaguered World Health Organization, to which Trump says he will cut U.S. funding, got embroiled in a controversy over whether airborne particles transmit the coronavirus. Scientific American attempted to sort out a confusing story, while WHO acknowledges the evidence.

KHN published, with the Los Angeles Times, a very good story about how COVID-19 is starting to kill inmates on California’s death row at San Quentin. A prosecutor of one of the murderers who died wasn’t sympathetic. The Texas Tribune reports how the disease is ravaging Texas prisons and killing people who had very short sentences.

A few other stories from the week that shouldn’t be missed because they give you a good look at how government officials still struggle to get a handle on this crisis: Stat reports that the Food and Drug Administration “again risks being pulled into an ugly political fracas” over hydroxychloroquine. Jim Fallows at the Atlantic did a masterful job of telling the story of the inept coronavirus response, in the style of an aviation accident report. It’s well worth reading. This article in BMJ, the medical journal, is a little harder to read, but worth the effort for the provocative and contrary point it makes: The U.S. purchase of much of the world’s supply of the drug remdesivir, a possible COVID treatment, may be a boon to the rest of the world.

Put these two on your list for weekend reading, perhaps: The Washington Post’s horrific look inside a nursing home wracked with COVID infections and a New York Times story on the racial inequity of the coronavirus in a series of maps and graphics.

The Toolkit

Every week there are new online graphics and other visual displays of COVID data that make it easier to understand what is going on in the epidemic. A few that I and the KHN staff found:

A COVID vaccine progress tracker from The New York Times.

Another smart vaccine tracker, this one from the Milken Institute.

County-level data on COVID infections and risk calculations from the Harvard Global Health Institute. (Their server can be a bit slow. Be patient.)

Follow who is getting federal bailout money with this tool from ProPublica.

But wait: If you are assembling a toolkit, the great health reporter Charlie Ornstein of ProPublica has already done much of the work for you. Open up this Google Doc to find his very good collection.

Oddly Important News, More Odd Than Important

Well, for all the attention it was getting, some people seemed to think Kanye West running for president was big news. Forbes interviewed him, and here is one thing he said that was health care-related:

“It’s so many of our children that are being vaccinated and paralyzed. … So when they say the way we’re going to fix Covid is with a vaccine, I’m extremely cautious. That’s the mark of the beast. They want to put chips inside of us, they want to do all kinds of things, to make it where we can’t cross the gates of heaven.”

The Italian Mafia has innovated in the health care industry. The Financial Times reports: “By corrupting local officials, organised criminals have been able to make vast profits from contracts given to their own front companies, establishing monopolies on services ranging from delivering patients in faulty ambulances to transporting blood to taking away the dead.”

Here’s a well-told story of a socialite spreading COVID at a party of fellow swells.

To end on an uplifting note, because that’s important in these times, a video of a light display over Seoul with 300 drones telling Koreans to wear masks and wash their hands. (And they do. Korea has one of the lowest infection rates in the world.)

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Colorado, Like Other States, Trims Health Programs Amid Health Crisis

As a teenager, Paulina Castle struggled for years with suicidal thoughts. When her mental health was at its most fragile, she would isolate herself, spending days in her room alone.

“That’s the exact thing that makes you feel significantly worse,” the 26-year-old Denver woman said. “It creates a cycle where you’re constantly getting dug into a deeper hole.”

Part of her recovery involved forcing herself to leave her room to socialize or to exercise outside. But the COVID-19 pandemic has made all of that much harder. Instead of interacting with people on the street in her job as a political canvasser, she is working at home on the phone. And with social distancing rules in place, she has fewer opportunities to meet with friends.

“Since the virus started,” she said, “it’s been a lot easier to fall back into that cycle.”

Between the challenges of the pandemic, the social unrest and the economic crisis, mental health providers are warning that the need for behavioral health services is growing. Yet faced with budgetary shortfalls, Colorado is cutting spending on a number of mental health and substance use treatment programs.

Across the country, the recession has cut state revenues at the same time the pandemic has increased costs, forcing lawmakers into painful decisions about how to balance their budgets. State legislatures have been forced to consider health care cuts and delay new health programs even in the midst of a health care crisis. But many lawmakers and health experts are concerned the cuts needed to balance state budgets now could exacerbate the pandemic and the recession down the line.

“Health care cuts tend to be on the table, and of course, it’s counterproductive,” said Edwin Park, a health policy professor at Georgetown University. When there’s a recession, people lose their jobs and health insurance, he noted, the very moment when people need those health programs the most.

‘Everything Has To Be On The Table’

In Colorado, for example, lawmakers had to fill a $3.3 billion hole in the budget for fiscal year 2020, which started July 1. That included cuts to a handful of mental health programs, with small overall savings but potentially significant impact on those who relied on them.

They cut $1 million from a program designed to keep people with mental illness out of the hospital and another million from mental health services for juvenile and adult offenders. Lawmakers reduced funding for substance abuse treatment in county jails by $735,000 and eliminated $5 million earmarked for addiction treatment programs in underserved communities. And that’s all on top of a 1% cut to Medicaid community providers who offer health care to the state’s poorest residents.

Some of those cuts were offset by $15.2 million in federal CARES Act funding allocated to behavioral health care programs. But some programs were completely defunded. Cuts were targeted primarily at programs that hadn’t started yet or hadn’t been fully implemented. The rationale: Those cuts wouldn’t have as deep an impact.

Doyle Forrestal, CEO of the Colorado Behavioral Healthcare Council, which represents 23 behavioral health care providers, worries that resources won’t be there for an emerging wave of people who have developed mental health or addiction issues during the pandemic.

“People who are isolated at home are drinking a lot more, maybe having other problems — isolation, economic despair,” she said. “There’s going to be a whole new influx once all of this takes hold.”

State legislators said they tried to avoid cutting programs that would hamper the response to the pandemic or the economic recovery.

“There was a desire on both sides to do everything we could to protect health care spending in Colorado,” said Democratic Rep. Dylan Roberts. “But when you’re looking at across-the-board cuts, everything has to be on the table.”

Every state is facing a similar conundrum. With tax filing deadlines pushed back to July 15, states are unsure how much income tax revenue they will collect.

So in addition to cutting back where possible, states are raiding discretionary funds — Colorado repurposed money from the tobacco settlement and marijuana taxes — to shore up their budgets. States are also tapping rainy day funds, which, according to the National Association of State Budget Officers, grew to record levels after the 2008 recession.

New Policies Delayed

Overall, at least 43 states have made some changes to facilitate access to Medicaid or the Children’s Health Insurance Program as many people have lost their job-based health insurance in the COVID crisis. And in late June, voters in Oklahoma approved expanding Medicaid to more residents. But since the start of the pandemic, states including Kansas and California have put off plans to expand eligibility for Medicaid, which provides health care to low-income people.

“These are symptoms of states that can’t deficit-spend, despite this great need for more coverage,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, an independent health policy research foundation based in New York. “If they spend more in one area, that means cuts in another.”

Paulina Castle uses weekly routines to manage her mental health — made worse from isolation during the coronavirus pandemic. “We need to start treating mental health the same as we do physical health,” she says. “This is an issue we need to stop keeping in the dark.”(Courtesy of Paulina Castle)

Colorado has had an aggressive health agenda in recent years but had to defer plans for a public health insurance option that could have provided a more affordable plan for people buying insurance on their own.

The legislature killed a proposal to create an annual mental health checkup. The measure would have cost the state only $13,000, but Democratic Gov. Jared Polis signaled he wouldn’t sign any bills that included new mandates for insurance companies.

Democratic Rep. Dafna Michaelson Jenet, who sponsored the checkup measure, was disappointed.

“Not every one of us is going to catch COVID, but every single one of us will have a mental health impact,” she said.

Long-Term Implications

Once the economic crisis eases, Roberts said, lawmakers will look to restore funding to some of the programs they cut.

But cuts are often easier to make than to restore — as illustrated by cutbacks made during the 2008 recession, according to Georgetown’s Park.

“Many cuts were never fully restored, even though we were in one of the longer economic expansion periods in our country’s history,” Park said.

He also worries many of the smaller primary care and behavioral health providers, who saw fewer patients come through their doors because of stay-at-home orders during the pandemic, might not survive.

“That means less access to care, including routine care like vaccinations,” he said. “If kids aren’t vaccinated, they may be more vulnerable to flu and measles, making them more vulnerable to COVID-19. That makes it more difficult for a stressed health care system to try to deal with a potential second wave of infections.”

The longer-term mental health toll may be harder to catalog.

Castle, for one, has focused on establishing routines to help her manage her mental health during the pandemic. Every Wednesday night, she plays games online with her friends. And every Friday night, she and her boyfriend build a fire in the backyard.

“If I know people are expecting me to be somewhere at 6 o’clock, that obligation encourages me to go out,” she explained. “There are days it’s a struggle. I have to focus on baby steps.”

Still, Castle worries about others who may be struggling during the pandemic. She has signed on to work with the Colorado chapter of Young Invincibles, which lobbies for health care, higher education and workforce policies to help young adults. Even as states and the federal government have found the money to help hospitals and doctors treat the physical effects of the COVID pandemic, she doesn’t see the same commitment to treating its mental health toll.

“We need to start treating mental health the same as we do physical health,” she said. This is an issue we need to stop keeping in the dark.”

If you or someone you know is thinking about suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Chat, both available 24 hours a day, seven days a week.

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Más pruebas para COVID, pero esperas demasiado largas por los resultados

El 15 de junio, Elliot Truslow fue a una farmacia CVS en Tucson, Arizona, para hacerse el test para el coronavirus. El hisopado nasal en el sitio de pruebas al paso tardó menos de 15 minutos.

Más de 22 días después, el estudiante graduado de la Universidad de Arizona todavía estaba esperando los resultados.

Primero le dijeron que tomaría de dos a cuatro días. Después, CVS dijo cinco o seis. El sexto día, la farmacia estimó que los tendría en 10.

Elliot Truslow fue a hacerse el test a un sitio de pruebas al paso en Tucson, Arizona, el 15 de junio. El 22 todavía estaba esperando los resultados.(Courtesy of Elliot Truslow)

“Es indignante”, dijo Truslow, de 30 años, que ha estado en cuarentena en su casa desde que fue a una manifestación de apoyo a Black Lives Matter en su universidad. Truslow nunca ha tenido síntomas. En este punto, los resultados de la prueba ya casi no importan.

La experiencia de Truslow es un ejemplo extremo de las crecientes y a menudo terribles esperas de los resultados de las pruebas para COVID-19 en los Estados Unidos.

En un hospital, los pacientes pueden tenerlos en un día. Pero las personas que se hacen las pruebas en clínicas de urgencias, en centros de salud comunitarios, farmacias y sitios de pruebas al paso que maneja el gobierno suelen esperar una semana o más.

Durante la primavera, la espera era de cuatro a cinco días.

Esto significa que los pacientes, y sus médicos, no tienen la información necesaria para saber si deben modificar conductas. Expertos en salud aconsejan a las personas que, mientras esperan, actúen como si tuvieran COVID-19, lo que significa que deben ponerse en cuarentena y evitar estar cerca de otras personas.

Pero reconocen que esto no es realista si la gente tiene que esperar una semana o más.

La alcaldesa de Atlanta, Keisha Lance Bottoms, quien anunció el lunes 6 de julio que había dado positivo para el virus, se quejó de que esperó ocho días por sus resultados en una entrevista en MSNBC el miércoles 8.

Durante ese tiempo, tuvo una serie de reuniones con funcionarios y electores de la Ciudad: “cosas que yo habría hecho de otra manera si hubiera sabido que había un resultado positivo en mi casa”, dijo en el programa Morning Joe.

“Por la lentitud en tener los resultados es que estamos en esta espiral ascendente de casos”, remarcó.

Esta lentitud también podría retrasar el regreso de los estudiantes a los campus escolares este otoño. Y ya está evitando que algunos equipos profesionales de béisbol entrenen a finales de julio.

Los retrasos podrían incluso frustrar el plan de Hawaii para recibir a más turistas. El estado había estado exigiendo a los visitantes que permanecieran en cuarentena durante 14 días, pero anunció el mes pasado que a partir del 1 de agosto se levantaría el mandato para los viajeros que pudieran demostrar que habían dado negativo para COVID en los tres días anteriores a su arribo a las islas.

En California, el gobernador Gavin Newsom habló de este problema con periodistas el miércoles 8. “Realmente estábamos progresando como nación, no solo como estado, y ahora estamos empezando a ver retrasos de varios días”, dijo.

Los retrasos incluso afectan a personas en poblaciones vulnerables de alto riesgo, dijo Newsom, citando un brote masivo en la prisión estatal de San Quintín, que ha estado enviando sus pruebas al laboratorio Quest.

El estado ahora está considerando asociarse con laboratorios locales, con la esperanza de que puedan proporcionar una respuesta más rápida.

El doctor Amesh Adalja, experto en enfermedades infecciosas del Centro Johns Hopkins para la Seguridad de la Salud en Baltimore, dijo que las largas esperas complican la respuesta nacional a la pandemia.

“Neutralizan la utilidad de la prueba”, dijo. “Necesitamos encontrar una manera de hacer que las pruebas sean más rápidas para que las personas sepan si pueden reanudar sus actividades normales o volver al trabajo”.

El problema es que los laboratorios que las realizan están abrumados por la demanda, que se ha disparado en el último mes.

“Reconocemos que los resultados de estas pruebas contienen información necesaria para guiar tratamientos y los esfuerzos de salud pública”, dijo Julie Khani, presidenta de la Asociación Americana de Laboratorios Clínicos, un grupo comercial.

Azza Altiraifi de Vienna, Virginia, se hizo el test para COVID en un CVS el 1 de julio. El 7 de julio todavía estaba esperando los resultados. Todavía tiene síntomas, incluyendo fatiga.(Courtesy of Azza Altiraifi)

La doctora Temple Robinson, CEO del Bond Community Health Center en Tallahassee, Florida, dijo que los resultados de las pruebas pasaron de estar en tres días a 10 en las últimas semanas.

Muchos pacientes pobres no tienen la capacidad de aislarse fácilmente porque viven en hogares pequeños con muchas personas. “La gente está tratando de cumplir con las reglas, pero no se les está dando las herramientas para ayudarlas si no saben si dieron positivo o negativo”, dijo.

Robinson no culpa a los grandes laboratorios. “Nadie estaba preparado para este volumen de pruebas”, dijo. “Es un momento muy aterrador”.

Azza Altiraifi, de 26 años, de Vienna, Virginia, lo sabe muy bien. Comenzó a sentirse enferma y con problemas para respirar el 28 de junio. A los pocos días tuvo escalofríos y dolor en las articulaciones, y luego una sensación de punción en los pies. Fue al CVS de su vecindario para hacerse la prueba el 1 de julio. Todavía estaba esperando el resultado.

Lo más frustrante de su situación es que su esposo es paramédico y su empleador no le permite ir a trabajar porque puede haber estado expuesto al virus. Su esposo se hizo la prueba el 6 de julio y está esperando noticias. No ha presentado síntomas.

Charlie Rice-Minoso, vocero de CVS Health, dijo que los pacientes esperan en promedio de cinco a siete días por los resultados. “Hay más espera a medida que aumenta la demanda de pruebas”, dijo.

En el sur de Florida, el Distrito de Atención Médica del condado de Palm Beach, que ha examinado a decenas de miles de pacientes desde marzo, dijo que los resultados demoran entre siete y nueve días.

CityMD, una gran cadena de atención de urgencias en el área de la ciudad de Nueva York, les dice a los pacientes que probablemente tengan que esperar al menos siete días para obtener resultados debido a demoras en Quest Diagnostics.

Quest Diagnostics, uno de los laboratorios más grandes de los Estados Unidos, dijo que el tiempo promedio ha aumentado de cuatro a seis días en las últimas dos semanas. La compañía ha realizado casi 7 millones de pruebas para COVID este año.

“Quest está haciendo todo lo posible para agregar capacidad de prueba en medio de esta crisis y las demandas sin precedentes”, dijo la vocera Kimberly Gorode.

En Treasure Coast Community Health, en Vero Beach, Florida, les dicen a los pacientes que deben esperar de 10 a 12 días por los resultados.

La directora ejecutiva, Vicki Soule, dijo que Treasure Coast está inundada de llamadas diarias de pacientes que quieren conocer sus resultados.

“La ansiedad está en aumento”, expresó.

Julie Hall, de 48 años, de Chantilly, Virginia, se hizo la prueba el 27 de junio en un centro de atención de urgencias después de enterarse que su esposo había dado positivo para COVID-19 mientras se preparaba para la cirugía de reemplazo de cadera.

Estaba consternada por tener que esperar hasta el 3 de julio para obtener una respuesta. Hall dijo que ni ella ni su esposo presentaron síntomas. La mujer resultó negativa.

“Pero fue horrible por la incógnita y no saber si había expuesto a alguien más”, dijo sobre la cuarentena en casa esperando los resultados. “Cada vez que estornudabas, alguien decía ‘COVID’ a pesar de que te sentías completamente bien”.

La corresponsal Anna Maria Barry-Jester en California colaboró con esta historia.

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As COVID Testing Soars, Wait Times For Results Jump To A Week — Or More

Elliot Truslow went to a CVS drugstore on June 15 in Tucson, Arizona, to get tested for the coronavirus. The drive-thru nasal swab test took less than 15 minutes.

More than 22 days later, the University of Arizona graduate student was still waiting for results.

Elliot Truslow had a drive-thru COVID test at a CVS in Tucson, Arizona, on June 15. CVS told Truslow to expect results in two to four days, but 22 days later, still nothing.(Courtesy of Elliot Truslow)

Truslow was initially told it would take two to four days. Then CVS said five or six days. On the sixth day, the pharmacy estimated it would take 10 days.

“This is outrageous,” said Truslow, 30, who has been quarantining at home since attending a large rally at the school to demonstrate support of Black Lives Matter. Truslow has never had any symptoms. At this point, the test findings hardly matter anymore.

Truslow’s experience is an extreme example of the growing and often excruciating waits for COVID-19 test results in the United States.

While hospital patients can get the findings back within a day, people getting tested at urgent care centers, community health centers, pharmacies and government-run drive-thru or walk-up sites are often waiting a week or more. In the spring, it was generally three or four days.

The problems mean patients and their physicians don’t have information necessary to know whether to change their behavior. Health experts advise people to act as if they have COVID-19 while waiting — meaning to self-quarantine and limit exposure to others. But they acknowledge that’s not realistic if people have to wait a week or more.

Atlanta Mayor Keisha Lance Bottoms, who announced Monday that she had tested positive for the virus, complained she waited eight days for her results in an interview on MSNBC Wednesday. During that time, she held a number of meetings with city officials and constituents — “things that I personally would have done differently had I known there was a positive test result in my house,” she said on “Morning Joe.”

“We’ve been testing for months now in America,” she added. “The fact that we can’t quickly get results back so that other people are not unintentionally exposed is the reason we are continuing in this spiral with COVID-19.”

The slow turnaround for results could also delay students’ return to school campuses this fall. It’s already keeping some professional baseball teams from training for a late July start of the season. The lag times could even foil Hawaii’s plan to welcome more tourists. The state had been requiring visitors to quarantine for 14 days, but it announced last month that starting Aug. 1 that mandate would be lifted for people who could show they tested negative within three days before arriving in the islands.

In California, Gov. Gavin Newsom noted the problem when addressing reporters Wednesday. “We were really making progress as a nation, not just as a state, and now you’re starting to see, because of backlogs with [the lab company] Quest and others, that we’re experiencing multiday delays,” he said.

The delays even apply to people in high-risk, vulnerable populations, he said, citing a massive outbreak at San Quentin State Prison, which has been sending its tests to Quest. The state is now looking at partnering with local labs, hoping they can provide faster turnaround.

Dr. Amesh Adalja, an infectious disease expert at the Johns Hopkins Center for Health Security in Baltimore, said the long waits spell trouble for individuals and complicate the national response to the pandemic.

“It defeats the usefulness of the test,” he said. “We need to find a way to make testing more robust so people can function and know if they can resume normal activities or go back to work.”

The problem is that labs running the tests are overwhelmed as demand has soared in the past month.

Azza Altiraifi of Vienna, Virginia, got her COVID test at CVS on July 1. She still has symptoms, including fatigue — but as of July 7, she was still awaiting the result.(Courtesy of Azza Altiraifi)

“We recognize that these test results contain actionable information necessary to guide treatment and inform public health efforts,” said Julie Khani, president of the American Clinical Laboratory Association, a trade group. “As laboratories respond to unprecedented spikes in demand for testing, we recognize our continued responsibility to deliver accurate and reliable results as quickly as possible.”

Dr. Temple Robinson, CEO of Bond Community Health Center in Tallahassee, Florida, said test results have gone from a three-day turnaround to 10 days in the past several weeks. Many poor patients don’t have the ability to easily isolate from others because they live in smaller homes with other people. “People are trying to play by the rules, but you are not giving them the tools to help them if they do not know if they tested positive or negative,” she said.

“If we are not getting people results for at least seven or eight days, it’s an exercise in futility because either people are much worse or they are better” by then, she said.

Given the lag in testing results from big lab companies, Robinson said her health center this month bought a rapid test machine. She held off buying the machine due to concerns the tests produced a high number of false-negative results but went ahead earlier this month in order to curtail the long waits, she said.

Robinson doesn’t blame the large labs and points instead to the surge in testing. “We are all drinking through a firehose, and none of the labs was prepared for this volume of testing,” she said. “It’s a very scary time.”

Azza Altiraifi, 26, of Vienna, Virginia, knows that all too well. She started feeling sick with respiratory symptoms and had trouble breathing on June 28. Within a few days she had chills, aches and joint pain and then a needling sensation in her feet. She went to her local CVS to get tested on July 1. As of July 7, she was still awaiting the result.

What is most frustrating about her situation is that her husband is a paramedic, and his employer won’t let him work because he may have been exposed to the virus. He was tested July 6 and is still awaiting news.

“This is completely absurd,” Altiraifi said. She also worries that her husband may have unknowingly passed on the virus on one of his ambulance calls to nursing homes and other care facilities before he began isolating at home. He has not shown any symptoms.

Altiraifi, who still has symptoms including fatigue, said she was initially told she would have results in two to four days, but she was suspicious because after using a nasal swab to give herself the test, the box to put it in was so full it was hard to close.

Charlie Rice-Minoso, a spokesperson for CVS Health, said patients are waiting five to seven days on average for test results. “As demand for tests has increased, we’ve seen test result turnaround times vary due to temporary processing capacity limitations with our lab partners, which they are working to address,” he said.

In South Florida, the Health Care District of Palm Beach County, which has tested tens of thousands of patients since March, said findings are taking seven to nine days, several days longer than in the spring.

CityMD, a large urgent care chain in the New York City area, said it now tells patients they will likely wait at least seven days for results because of delays at Quest Diagnostics.

Quest Diagnostics, one of the largest lab companies in the United States, said average turnaround time has increased from three to five days to four to six days in the past two weeks. The company has performed nearly 7 million COVID tests this year.

“Quest is doing everything it can to add testing capacity to reduce turnaround times for patients and providers amid this crisis and the unprecedented demands it places on lab providers,” said spokesperson Kimberly Gorode.

At Treasure Coast Community Health in Vero Beach, Florida, officials are advising patients of a 10- to 12-day wait for results.

CEO Vicki Soule said Treasure Coast is deluged with calls every day from patients wanting to know where their test results are.

“The anxiety on the calls is way up,” she said.

Julie Hall, 48, of Chantilly, Virginia, got tested June 27 at an urgent care center after learning that her husband had tested positive for COVID-19 as he prepared for hip replacement surgery. She was dismayed to have to wait until July 3 to get an answer.

“I was thrilled to be negative, but by that point it likely did not matter,” she said, noting that neither she nor her husband, Chris, showed any symptoms.

“It was awful and terrible because of the unknowns and not knowing if you exposed someone else,” she said of being quarantined at home awaiting results. “Whenever you would sneeze, someone would say ‘COVID’ even though you feel completely fine.”

Senior correspondent Anna Maria Barry-Jester in California contributed to this article.

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Amid Surge, Hospitals Hesitate To Cancel Nonemergency Surgeries

Three months ago, the nation watched as COVID-19 patients overwhelmed New York City’s intensive care units, forcing some of its hospitals to convert cafeterias into wards and pitch tents in parking lots.

Hospitals elsewhere prepped for a similar surge: They cleared beds, stockpiled scarce protective equipment, and — voluntarily or under government orders — temporarily canceled nonemergency surgeries to save space and supplies for coronavirus patients.

In most places, that surge in patients never materialized.

Now, coronavirus cases are skyrocketing nationally and hospitalizations are climbing at an alarming rate. But the response from hospitals is markedly different.

Most hospitals around the country are not canceling elective surgeries — nor are government officials asking them to.

Instead, hospitals say they are more prepared to handle the crush of patients because they have enough protective gear for their workers and know how to better treat coronavirus patients. They say they will shut down nonessential procedures at hospitals based on local assessments of risk, but not across whole systems or states.

Some hospitals have already done so, including facilities in South Florida, Phoenix and California’s Central Valley. And in a few cases, such as in Texas and Mississippi, government officials have ordered hospitals to suspend elective surgeries.

Hospitals’ decisions to keep operating rooms open are being guided partly by money. Elective surgeries account for a significant portion of hospital revenue, and the American Hospital Association estimates that the country’s hospitals and health care systems lost $202.6 billion between March 1 and June 30.

“What we now realize is that shutting down the entire health care system in anticipation of a surge is not the best option,” said Carmela Coyle, president of the California Hospital Association. “It will bankrupt the health care delivery system.”

The association projects that California hospitals will lose $14.6 billion this year, of which $4.6 billion has so far been reimbursed by the federal government.

But some health care workers fear that continuing elective surgeries amid a surge puts them and their patients at risk. For instance, some nurses are still being asked to reuse protective equipment like N95 masks and gowns, even though hospitals say they have enough gear to perform elective surgeries, said Zenei Cortez, president of the National Nurses United union.

“They continue to put us at risk,” Cortez said. “They continue to look at us as if we are disposable material.”

Elective surgeries, generally speaking, are procedures that can be delayed without harming patients, such as knee replacements and cataract surgery.

At least 33 states and the District of Columbia temporarily banned elective surgeries this spring, and most hospitals in states that didn’t ban them, such as Georgia and California, voluntarily suspended them to make sure they had the beds to accommodate a surge of coronavirus patients. The U.S. surgeon general, the Centers for Disease Control and Prevention and the American College of Surgeons also recommended health care facilities suspend nonemergency surgeries.

The suspension was always intended to be temporary, said Dr. David Hoyt, executive director of the American College of Surgeons. “When this all started, it was simply a matter of overwhelming the system,” he said.

Today, case counts are soaring after many states loosened stay-at-home orders and Americans flocked to restaurants, bars and backyards and met up with friends and family for graduation parties and Memorial Day celebrations.

Nationally, confirmed cases of COVID-19 have topped 3 million. In California, cases are spiking, with a 52% jump in the average number of daily cases over the past 14 days, compared with the two previous weeks. Hospitalizations have gone up 44%.

Governors, county supervisors and city councils have responded by requiring people to wear masks, shutting down bars and restaurants — again — and closing beaches on the July Fourth holiday weekend.

But by and large, government leaders are not calling on hospitals to proactively scale back elective surgeries in preparation for a surge.

“Our hospitals are telling us they feel very strongly and competent they can manage their resources,” said Holly Ward, director of marketing and communications at the Arizona Hospital and Healthcare Association. If they feel the situation warrants it, “they on their own will delay surgeries.”

In some states, like Colorado, public health orders that allowed hospitals to resume nonemergency surgeries in the spring required hospitals to have a stockpile of protective equipment and extra beds that could be used to treat an influx of COVID-19 patients.

States also set up overflow sites should hospitals run out of room. In Maryland, for example, the state is using the Baltimore Convention Center as a field hospital. The state of California last week reactivated four “alternative care sites” — including a hospital that was on the verge of closure in the San Francisco Bay Area — to take COVID-19 patients should hospitals fill up.

But the decision to reduce elective surgeries in California will not come from the state. It will be made by counties in consultation with hospitals, said Rodger Butler, a spokesperson for the California Health and Human Services Agency.

The question is whether hospitals have systems in place to meet a surge in COVID-19 patients when it occurs, said Glenn Melnick, a professor of health economics at the University of Southern California.

“To some extent, elective care is good care,” Melnick said “They’re providing needed services. They are keeping the system going. They are providing employment and income.”

In Los Angeles County, more than 2,000 COVID patients are currently hospitalized, according to county data. While that number is projected to go up by a couple of hundred people over the next few weeks, hospitals believe they can accommodate them, said county Health Services Director Christina Ghaly. In the meantime, hospitals are preparing to bring on additional staff members if needed and informing patients who have scheduled surgeries that they could be delayed.

“There’s more patients with COVID in the hospitals than there has been at any point previously in Los Angeles County during the pandemic,” Ghaly said. “Hospitals are more prepared now for handling that volume of patients than they were previously.”

While hospitals have not stopped elective surgeries, many have not ramped up to the full schedule they had before COVID-19. And they say they are picking and choosing surgeries based on what’s happening in their area.

“We were all things COVID when it was just starting,” said Joshua Adler, executive vice president for physician services at UCSF Health. “We didn’t know what we were facing.”

But after a couple of months of treating patients, hospitals have learned how to resupply units, how to transfer patients, how to simultaneously care for other patients and how to improve testing, Adler said.

At Scripps Health in San Diego, which has taken more than 230 patients from hard-hit Imperial County to the east, its hospitals have scaled back how many transfers they will accept as confirmed COVID-19 cases rise in their own community, said Chris Van Gorder, president and CEO of Scripps Health.

A command center set up by the hospital system reviews patient counts and medical supplies and coordinates with county health officials to study how the virus is spreading. Only patients who need urgent surgeries are being scheduled, Van Gorder said.

“We’re only allowing our doctors to schedule cases two weeks out,” Van Gorder said. “If we see a sudden spike, we have to delay.”

In California’s Central Valley and in Phoenix, where cases and hospitalizations are surging, Mercy hospitals have suspended elective surgeries to focus resources on COVID-19 patients.

But the other hospitals in the CommonSpirit Health system, which has 137 hospitals in 21 states, are not ending elective surgeries — as they did in the spring — and are treating patients with needs other than COVID, said Marvin O’Quinn, the system’s president and chief operating officer.

“In many cases their health deteriorated because they didn’t get care that they needed,” said O’Quinn, whose hospitals lost close to a $1 billion in two months. “It’s not only a disservice to the hospital to not do those cases; it’s a disservice to the community.”

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

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In Texas, Individual Freedoms Clash With Efforts To Slow The Surge Of COVID Cases

HOUSTON — The Fourth of July was a little different this year here in Texas’ biggest city. Parades were canceled and some of the region’s beaches were closed. At the city’s biggest fireworks show, “Freedom Over Texas,” fireworks were shot higher in the air to make it easier to watch from a distance. Other fireworks displays encouraged people to stay in their cars.

After weeks of surging COVID-19 cases and dire warnings that Houston’s massive medical infrastructure would not be able to keep pace, Republican Gov. Greg Abbott issued an executive order on July 2 requiring Texans to wear masks in public, after previously reversing course on the state’s reopening by again closing bars and reducing restaurant capacity.

While most Houstonians appear to be taking heed, not everyone is on board. Small protests against the orders occurred over the holiday weekend. Lawsuits have been filed. At least one Houston-area law enforcement agency said it would not enforce the mask requirement. The State Republican Executive Committee plans to hold its mid-July convention downtown, drawing an expected 6,000 people from around the state.

Democratic Mayor Sylvester Turner said he and other local leaders sent a letter to GOP leaders asking them to convert the convention into a virtual event. But the party remains steadfast.

“There simply is no substitute for the in-person debate we value so strongly,” Texas GOP Chairman James Dickey said, adding that the party committee explicitly affirmed it would not voluntarily cancel the convention. He said there would be thermal scanners, social distancing, deep cleaning between meetings, hand sanitizer and thousands of donated masks available for those in attendance.

“My sincerest sympathies go out to anyone who is affected by any severe disease, including this one,” he said. “But on a per capita basis, Harris County, and Texas in general, are both dramatically better than most of the states in the United States.”

However, confirmed cases in Houston’s surrounding county, Harris, more than doubled in a month to reach more than 37,000 positive cases as of July 6. Hospitals in the Texas Medical Center had 2,261 COVID-positive patients that day in intensive care or medical-surgical units, up from 1,747 the week before, according to the center’s tracking website. All told, the nine-county Houston region has had more than 52,000 confirmed cases and 572 deaths.

The Texas Medical Center has predicted that unless the spread of the virus is mitigated, Houston hospitals could exceed existing capacity by mid-July. A federal assessment team came to Houston to determine how the federal government can help the city respond to the current surge.

Local officials had tried to protect Houston. Early in the pandemic, Harris County Judge Lina Hidalgo, a Democrat who serves as the county’s top elected leader, implemented business closures and stay-at-home and masking orders. But Lt. Gov. Dan Patrick and U.S. Rep. Dan Crenshaw, both Republicans, called them an “overreach” that “could lead to unjust tyranny.” On April 27, Abbott overruled the county guidance, and announced plans to reopen businesses and relax social distancing guidelines.

For those who live in Houston, it’s all meant lots of confusion.

“This whole thing has been a messaging nightmare from the beginning,” said Joe Garcia, 50, who works in data management. “When a flood happens, when a hurricane happens, nobody cares what side you’re on — blue, red, whatever else — all you know is it’s a disaster and everybody comes in and helps. That’s just the way things are. This wasn’t treated as a disaster.”

Public discourse about the pandemic has been disheartening, said Norma Ybarbo, 55, who avoids leaving home beyond socially distant visits with her father and attending a lightly populated early morning mass. She said the political arguments and conflicting communication from the Texas Medical Center in June about hospital capacity have made an already stressful situation worse.

“It’s worrisome, for sure,” Ybarbo said. “It’s really hard to determine what is right and what is true.”

Marine veteran S.D. Panter, 44, said it all has deepened his concern about bias in doctors and politicians who are advocating for businesses to be shut down. Panter, who doesn’t deny the virus is troublesome, said he prefers to do his own research because, for him, the dire picture being painted by those in the spotlight doesn’t make sense. He does wear a mask in public, even though he is not sure it is necessary.

“There’s just so much information. Just let me make my own decision, my own informed decision,” said Panter, who helps his parents and his wife’s parents stay socially isolated. “The older population should probably stay indoors, and let’s protect them the best we can.”

The state’s reopening this spring coincided with Mother’s Day, graduations, Memorial Day and Black Lives Matter protests. Once Texans were released from pandemic-induced restrictions, many happily took advantage of the chance to socialize.

Alyssa Guerra, 27, who lost her job when the store she managed closed, said she now knows people who have contracted the virus, and a few who have become sick or lost loved ones. She has friends who went to bars and social events, without masks, when the state reopened. She went out to eat once, but felt so uncomfortable she hasn’t done it since.

“It’s affecting us in greater numbers now because of the selfish decisions we are making,” said Guerra. “At some point, yes, we are going to have to start living our lives again, but we did it so quickly this time that people just had no care in the world.”

While the number of confirmed COVID-19 infections is rising in all age groups here, those seeing the most rapid growth in positive tests and hospitalizations are 20 to 40 years old. Dr. David Persse, public health authority with the Houston Health Department, said recently that 15% of COVID patients being admitted to the hospital are younger than 50, and 30% are younger than 60.

That could explain lower rates of death now than earlier in the pandemic, said Dr. Angela Shippy, chief medical and quality officer at Memorial Hermann Health System. Another reason for the lower death rates could be that providers have learned more effective treatments for the virus, using different respiratory and drug therapies to avoid intensive care units and intubation.

Still, Houston’s hospitals are being challenged by the rapid spike in COVID patients as a whole. Without taking steps to slow the spread of the virus, hospitals could become unable to manage the load. That has been the message from hospitals — including in multiple full-page ads in the Houston Chronicle advising people to stay home or wear a mask in public.

“We still have the ability to grow capacity, but there will come a limit to how much capacity you can grow,” said Roberta Schwartz, executive vice president, chief innovation officer and CEO of Houston Methodist Hospital.

The area’s public hospitals, which had been steadily handling COVID cases since March, have been transferring adult patients the past several weeks to private hospitals, including Texas Children’s Hospital, which had 29 COVID patients as of July 6. Houston Fire Chief Sam Peña said it has been taking an hour, in some cases, to transfer patients from ambulances to some emergency rooms — which Schwartz said have been “inundated.”

The fire and police departments have large numbers of staff in quarantine. Hospitals report staffers are testing positive, which they attribute to contracting the virus outside the hospital. Some area hospitals are bringing in traveling nurses to help.

“We encourage everyone to do their part and always wear a mask when leaving home, wash your hands often and maintain social distance,” Mark A. Wallace, president and CEO of Texas Children’s Hospital, said in an emailed statement. “This is the best way to protect yourself, your loved ones and our health care workers.”

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COVID Cuts A Lethal Path Through San Quentin’s Death Row

The old men live in cramped spaces and breathe the same ventilated air. Many are frail, laboring with heart disease, liver and prostate cancer, tuberculosis, dementia. And now, with the coronavirus advancing through their ranks, they are falling one after the next.

This is not a nursing home, not in any traditional sense. It is California’s death row at San Quentin State Prison, north of San Francisco. Its 670 residents are serial killers, child murderers, men who killed for money and drugs, or shot their victims as part of their wasted gangster lives. Some have been there for decades, growing old behind bars. One is 90, and more than 100 are 65 or older.

Executions have been on hold in California since 2006, stalled by a series of legal challenges. And they won’t resume anytime soon: In 2019, two months after taking office, Gov. Gavin Newsom declared a moratorium on executions and ordered that San Quentin’s death chamber be dismantled. But death has come to San Quentin nonetheless.

In recent days, five death row inmates have died after contracting COVID-19. Almost 200 others are thought to be ill with the virus, according to a Newsom administration official not authorized to speak publicly. Scores more are refusing to be tested. For now, there is no clear remedy and no end in sight.

“San Quentin’s staff — especially medical staff — is simply drowning among the chaos,” State Public Defender Mary McComb said in a letter last week to the state Senate Public Safety Committee. “San Quentin desperately needs a significant number of additional personnel, and quickly.”

Correctional officers are working double and even triple shifts. Doctors have been working 12-plus-hour days, seven days a week, for the past six weeks, McComb wrote: “Men (including some who have tested positive) report not having access to doctors, not receiving medication for symptoms such as coughs, and not receiving regular oxygen-level or blood pressure checks.”

San Quentin’s coronavirus outbreak could prove to be the worst at any prison in the nation. It began in mid-June, shortly after the California Department of Corrections and Rehabilitation transferred 121 inmates to San Quentin from the state prison in Chino, east of Los Angeles, in a failed effort to stem an outbreak there. At least 20 of the Chino transfers subsequently tested positive for the disease.

Now, more than 1,400 San Quentin inmates have the virus, or more than a third of the prison’s 4,000 inmates. And death row has been hit particularly hard. Of the six inmate deaths that prison authorities have formally attributed to the coronavirus, three were on death row. Two more death row inmates who died in recent days also tested positive for the virus, though the official cause of death is pending.

San Quentin, which opened in 1852, is renowned for its rehabilitative programs. Most San Quentin inmates are classified as minimum or medium security risks and will be released one day. They take college courses and participate in job-training programs. Some work on the prison’s award-winning podcast and newspaper.

An additional 670 at San Quentin are condemned, and ineligible for release, no matter how old or infirm.

About 500 of them are housed in East Block, a hangar-size structure that is five tiers high. They live one to a cell, 10.5 feet by 4.75 feet. The doors are steel mesh. They cannot help but breathe one another’s air. Sixty-four of the best-behaved inmates are housed on the traditional death row, known as North Seg. There’s a Mickey Mouse clock in the officers’ area emblazoned with the words “The Happiest Place on Earth.” North Seg, East Block and a third unit for condemned inmates, Donner, were built in 1934, 1930 and 1913, none with a pandemic in mind.

COVID-19 has infiltrated 20 of California’s 34 prisons, though it has been especially bad at nine. As of Tuesday, more than 5,300 inmates statewide had tested positive for the virus and 29 had died.

The plague raging inside San Quentin’s walls is spreading into the outside world. Dozens of San Quentin inmates are being treated in community hospitals, including at least 20 death row inmates as of last week. Each is guarded by two correctional officers round-the-clock.

The exact number of death row inmates who have the virus is not known. Complicating matters, about 40% have refused to be tested, McComb and others said. By law, they cannot be compelled to undergo the test unless they are deemed mentally incompetent.

McComb addressed the refusals in her letter, saying some of the condemned inmates worry they will be moved to a segregated unit typically reserved for discipline if they test positive, while others fear the procedure is unsafe.

“And third, a general hopelessness has set in among the population; there is no reason to be tested when medical staff, despite their best efforts, are stretched too thin to respond to those in need of care,” McComb wrote.

One who refused to be tested was Richard Stitely. He was found dead in his cell the night of June 24. The Marin County coroner found he was infected with the coronavirus, though the exact cause of death is still to be determined.

Stitely, 71, was sentenced to death in 1992 for the murder of Carol Unger, a 47-year-old mother. The two had met in a San Fernando Valley bar, and he offered to drive her home. Her body was found in the valley in January 1990.

Andrew R. Flier was a 28-year-old L.A. County deputy district attorney who prosecuted Stitely for the rape and murder of Unger, and for the previous rape of a 16-year-old girl. Now in private practice, Flier said evidence suggested Stitely could have choked Unger for five minutes, first with a cord and then with his hands. He sees Stitely’s apparent death from a disease that deprives victims of their breath as “poetic justice.”

“A terrible disease is infecting our world, and it found someone terrible to infect,” Flier said. “I shed no tears. Evil is evil, and I thought he was evil.”

Over the years, the California Supreme Court had upheld the death sentences of Stitely and the four other condemned inmates who died after contracting the virus. Two of the men had killed children, including a 75-year-old convicted of a 1979 murder. Three of the inmates were in their late 50s.

No matter their crimes, some people say, inmates don’t deserve to die of COVID-19, especially after it likely was introduced by the ill-fated decision to transfer infected inmates from Chino to San Quentin.

“It is the death penalty by other means. It is a miscarriage of justice,” said Assembly member Marc Levine, a Democrat whose district includes San Quentin.

In a hearing last week, U.S. District Court Judge Jon S. Tigar in San Francisco, presiding over a long-running suit challenging California prison conditions, urged the state to release elderly and infirm inmates who pose no public safety threat — and are not on death row — to free up cells so infected prisoners could be isolated and the COVID-19 spread slowed.

“These releases need to happen immediately. There simply is no time to wait,” Tigar said, directing his comments at Newsom.

On Monday, Newsom said San Quentin’s population would be reduced to about 3,000 in coming weeks. “We’ve been working on this every single day for the last three weeks,” he said.

Corrections spokesperson Terry Thornton said the department has installed six tents to treat San Quentin inmates and “is working closely with health care and public health experts on all isolation and quarantine protocols recommended by the Centers for Disease Control and Prevention to address COVID-19 in correctional settings.”

While the virus infects death row, California’s capital punishment law is in a state of limbo. With executions on hold, Levine last year introduced legislation to place a measure on the statewide ballot to abolish capital punishment. That measure has stalled.

Last month, the California Supreme Court indicated it is weighing the legality of one aspect of the state’s death penalty statute: Must jurors agree on aggravating factors that led them to recommend death? As it is, jurors need not be unanimous.

The justices posed the question based on a single case involving a 2004 killing, though a decision could set a precedent that would affect the sentences of scores of condemned inmates. Any decision is likely months away, presumably after the COVID-19 rampage has run its course on San Quentin’s death row.

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

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California Public Health States

‘Please Tell Me My Life Is Worth A LITTLE Of Your Discomfort,’ Nurse Pleads

When an employee told a group of 20-somethings they needed face masks to enter his fast-food restaurant, one woman fired off a stream of expletives. “Isn’t this Orange County?” snapped a man in the group. “We don’t have to wear masks!”

The curses came as a shock, but not really a surprise, to Nilu Patel, a certified registered nurse anesthetist at nearby University of California-Irvine Medical Center, who observed the conflict while waiting for takeout. Health care workers suffer these angry encounters daily as they move between treacherous hospital settings and their communities, where mixed messaging from politicians has muddied common-sense public health precautions.

“Health care workers are scared, but we show up to work every single day,” Patel said. Wearing masks, she said, “is a very small thing to ask.”

Patel administers anesthesia to patients in the operating room, and her husband is also a health care worker. They’ve suffered sleepless nights worrying about how to keep their two young children safe and schooled at home. The small but vocal chorus of people who view face coverings as a violation of their rights makes it all worse, she said.

That resistance to the public health advice didn’t grow in a vacuum. Health care workers blame political leadership at all levels, from President Donald Trump on down, for issuing confusing and contradictory messages.

“Our leaders have not been pushing that this is something really serious,” said Jewell Harris Jordan, a 47-year-old registered nurse at the Kaiser Permanente Oakland Medical Center in Oakland, California. She’s distraught that some Americans see mandates for face coverings as an infringement upon their rights instead of a show of solidarity with health care workers. (Kaiser Health News produces California Healthline, is not affiliated with Kaiser Permanente.)

Jewell Harris Jordan is a registered nurse in the labor and delivery department at Kaiser Permanente Oakland Medical Center. In the midst of a shortage of personal protective equipment for health care workers, she says, the public’s refusal to don a face covering in public feels like a “slap in the face.” (Courtesy of Jewell Harris Jordan)

“If you come into the hospital and you’re sick, I’m going to take care of you,” Jordan said. “But damn, you would think you would want to try to protect the people that are trying to keep you safe.”

In Orange County, where Patel works, mask orders are particularly controversial. The county’s chief health officer, Dr. Nichole Quick, resigned June 8 after being threatened for requiring residents to wear them in public. Three days later, county officials rescinded the requirement. On June 18, a few days after Patel visited the restaurant, Gov. Gavin Newsom issued a statewide mandate.

Meanwhile, cases and hospitalizations continue to rise in Orange County.

The county’s flip-flop illustrates the national conflict over masks. When the coronavirus outbreak emerged in February, officials from the U.S. Centers for Disease Control and Prevention discouraged the public from buying masks, which were needed by health care workers. It wasn’t until April that federal officials began advising most everyone to wear cloth face coverings in public.

One recent study showed that masks can reduce the risk of coronavirus infection, especially in combination with physical distancing. Another study linked policies in 15 states and Washington, D.C., mandating community use of face coverings with a decline in the daily COVID-19 growth rate and estimated that as many as 450,000 cases had been prevented as of May 22.

Dr. Megan Hall went viral on Facebook after publishing photos that showed her oxygen saturation levels remained consistent no matter what type of face mask she wore. The pediatrician hopes that both the public and officials have a “change of heart” about face coverings. (Courtesy of Megan Hall)

But the use of masks has become politicized. Trump’s inconsistency and nonchalance about them sowed doubt in the minds of millions who respect him, said Jordan, the Oakland nurse. That has led to “very disheartening and really disrespectful” rejection of masks.

“They truly should have just made masks mandatory throughout the country, period,” said Jordan, 47. Out of fear of infecting her family with the virus, she hasn’t flown to see her mother or two adult children on the East Coast during the pandemic, Jordan said.

But a mandate doesn’t necessarily mean authorities have the ability or will to enforce it. In California, where the governor left enforcement up to local governments, some sheriff’s departments have said it would be inappropriate to penalize mask violations. This has prompted some health care workers to make personal appeals to the public.

After the Fresno County Sheriff-Coroner’s Office announced it didn’t have the resources to enforce Newsom’s mandate, Amy Arlund, a 45-year-old nurse at the COVID unit at the Kaiser Permanente Fresno Medical Center, took to her Facebook account to plead with friends and family about the need to wear masks.

Amy Arlund is a registered nurse at Kaiser Permanente Fresno Medical Center’s dedicated COVID-19 unit. She lives in a separate zone of her house to protect the rest of her family from potential exposure to the coronavirus, and says that her husband was recently ridiculed for wearing a mask at a hardware store. (Courtesy of Amy Arlund)

“If I’m wrong, you wore a silly mask and you didn’t like it,” she posted on June 23. “If I’m right and you don’t wear a mask, you better pray that all the nurses aren’t already out sick or dead because people chose not to wear a mask. Please tell me my life is worth a LITTLE of your discomfort?”

To protect her family, Arlund lives in a “zone” of her house that no other member may enter. When she must interact with her 9-year-old daughter to help her with school assignments, they each wear masks and sit 3 feet apart.

Every negative interaction about masks stings in the light of her family’s sacrifices, said Arlund. She cites a woman who approached her husband at a local hardware store to say he looked “ridiculous” in the N95 mask he was wearing.

“It’s like mask-shaming, and we’re shaming in the wrong direction,” Arlund said. “He does it to protect you, you cranky hag!”

After seeing a Facebook comment alleging that face masks can cause low oxygen levels, Dr. Megan Hall decided to publish a small experiment. Hall, a pediatrician at the Conway Medical Center in Myrtle Beach, South Carolina, wore different kinds of medical masks for five minutes and then took photos of her oxygen saturation levels, as measured by her pulse oximeter. As she predicted, there was no appreciable difference in oxygen levels. She posted the photo collection on June 22, and it quickly went viral.

Cynthia Butler is a floating registered nurse at the Fawcett Memorial Hospital in Port Charlotte, Florida, who is also a COVID-19 survivor. Despite skyrocketing case numbers, Butler estimates that about 75% of residents in her community do not wear masks in public. She doesn’t feel she has the time or energy to educate people about the risk. (Courtesy of Cynthia Butler)

“Some of our officials and leaders have not taken the best precautions,” said Hall, who hopes for “a change of heart” about masks among local officials and the public. South Carolina Gov. Henry McMaster has urged residents to wear face coverings in public, but he said a statewide mandate was unenforceable.

In Florida, where Gov. Ron DeSantis has resisted calls for a statewide order on masks despite a massive surge of COVID-19 cases and hospitalizations, Cynthia Butler, 62, recently asked a young man at the register of a pet store why he wasn’t wearing a mask.

“His tone was more like, this whole mask thing is ridiculous,” said Butler, a registered nurse at Fawcett Memorial Hospital in Port Charlotte. She didn’t tell him that she had just recovered from a COVID-19 infection contracted at work. The exchange saddened her, but she hasn’t the time to lecture everyone she encounters without a mask — about three-quarters of her community, Butler estimated.

“They may think you’re stepping on their rights,” she said. “It’s not anything I want to get shot over.”

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California Health Industry Public Health States

Life Beyond COVID Seclusion: Seniors See Challenges And Change Ahead

Months into the coronavirus pandemic, older adults are having a hard time envisioning their “new normal.”

Many remain fearful of catching the virus and plan to follow strict precautions — social distancing, wearing masks and gloves, limiting excursions to public places — for the indefinite future.

Mortality is no longer an abstraction for those who have seen friends and relatives die of COVID-19. Death has an immediate presence as never before.

Many people are grieving the loss of their old lives and would love nothing better than to pick up where they left off. Others are convinced their lives will never be the same.

“We’re at the cusp of a new world,” said Harry Hutson, 72, an organizational consultant and executive coach who lives in Baltimore.

He’s among nearly a dozen older adults who discussed the “new normal” in lengthy conversations. All acknowledged their vulnerability as states across the country lift stay-at-home orders. (Adults 65 and older are more likely to become critically ill if infected with the coronavirus.) Here’s some of what they said:

(Courtesy of Willetha and Harold Barnette)

Willetha, 67, and Harold, 68, Barnette, of Durham, North Carolina. The Barnettes are an unusual couple: They divorced in 1995 but began living together again in 2014 when both Willetha and her elderly mother became ill and Harold returned to help.

For Willetha, who has Crohn’s disease and is immunocompromised, the “new normal” is characterized by vigilance — masks, gloves, disinfectants, social distancing, working remotely (she’s a development officer at a school).

“I’m not going to be comfortable freely moving around this world until they’re able to do reliable antibody testing and there is a vaccine,” she said. “Right now, I think we all have to learn to live smaller.”

Harold believes that self-reliance and local support networks are more important than ever. “To me, the pandemic reveals troubling things about the state of institutions in our society. The elder care system is rotten and the health care system full of neglect,” he said.

“I’m preparing myself for a different social order. I’m thinking that will be built on relationships with family and people near to us and we’ll all be helping each other out more.”

(Courtesy of Patricia Griffin)

Patricia Griffin, 80, of Oxford, Pennsylvania. Griffin is a retired microbiologist who lives alone in a continuing care community and loves to travel. In March, as the coronavirus pandemic gathered steam, she was due to take a trip to the Amazon, which was canceled.

“I envision conditions for seniors being restrictive until we have a vaccine,” Griffin said. “That makes me angry because I don’t have that many years left. And I would like to do the things I want to do. At the moment, I’m leaning toward being cautious but not being completely a prisoner.”

A big frustration for Griffin is the lack of clear guidance for healthy older adults like her who do not have underlying medical conditions. “All we see are statistics that lump all of us together, the healthy with those that have multiple issues,” she said. I’m wondering what my odds of getting really sick from this virus are.”

(Courtesy of Wilma Jenkins)

Wilma Jenkins, 82, of South Fulton, Georgia. Jenkins, who has coped with depression most of her life and describes herself as an introvert, lives alone in a small house just outside Atlanta.

“I confess I’m going to be afraid for a while,” she said.

During the pandemic, her three adult children and grandchildren have created a new tradition: Zoom meetings every Sunday afternoon. Previously, the entire family got together once a year, at Thanksgiving. “It helps me a lot, and I think it will last because we have so much fun,” Jenkins said.

Before her life ground to a halt, Jenkins regularly gave presentations at senior centers across Atlanta on what it’s like to grow old. “My work is helping little old people like me,” she said, “and when I can get out again, I’ll be reminding them that we have reached a point when we can wear the crown of age and we should be doing that proudly.”

(Courtesy of Ed and Marian Hollingsworth)

Marian and Ed Hollingsworth, 66 and 72, of La Mesa, California. Ed has a rare gastrointestinal cancer and is enrolled in a clinical trial of a new drug.

“My vision of the future is somewhat limited, given my age and my prognosis,” he said. “There’s a constant fear and uncertainty. I don’t see that changing anytime soon. We’ll be in the house a lot, cooking a lot, watching a lot of Netflix.”

“I’m looking at least a year or two of taking strong precautions,” said Marian, a patient safety advocate.

“I always was the person who was active and doing for others: Now I’m the one at home having to ask for help, and it feels so foreign,” she said. Her most immediate heartache: “We don’t know when we’ll see our [four] kids again.”

(Courtesy of Richard Chady)

Richard Chady, 75, of Chapel Hill, North Carolina. Chady, a former journalist and public relations professional, lives in a retirement community and participates in the North Carolina Coalition on Aging.

“This pandemic has given me a greater appreciation of how precious family and friends are,” he said. “I think it will cause older people to examine their lives and their purpose a little more carefully.”

Chady is optimistic about the future. “I’ve been involved in progressive causes for a long time and I think we have a great opportunity now. With all that’s happened, there’s more acceptance of the idea that we need to do more to improve people’s lives.”

(Courtesy of Edward Mosley)

Edward Mosley, 62, of Atlanta. Mosley lives alone in Big Bethel Village, an affordable senior housing community. Disabled by serious heart disease, he relies on Supplemental Security Income and Medicaid. In the past year, he has had multiple hospitalizations.

“The pandemic, it affected me because they canceled my doctors’ appointments and I was in a bad way,” said Mosley, who had a pacemaker implanted in his chest before COVID-19 emerged. “But I’m doing better now. I can walk with a cane, though not very far.”

The hardest thing for Mosley is not being able to mingle with other people “because you don’t know where they’ve been or who they’ve been with. You feel like you’re in solitary confinement.”

(Courtesy of Vicki Ellner)

Vicki Ellner, 68, of Glenwood Landing, New York. Ellner ran Senior Umbrella Network of Brooklyn for 20 years. Today she works as a consultant for an elder care attorney on Long Island.

Before the coronavirus upended life in and around New York City, Ellner and the attorney were planning to launch an initiative aimed at older women. Now, they’ve broadened it to include older men and address issues raised during the pandemic. The theme: “You’re not done yet.”

Ellner explains it this way: “Maybe you were on a path and had a vision of your life in mind. Then all of a sudden you have these challenges. Maybe you lost your job, or maybe things have happened in your family. What we want to help people understand is you’re not done yet. You still have the ability to redirect your life.”

In her personal life, Ellner, who lives with a “significant other,” is determined to keep fear at bay. “We tell ourselves we’re doing everything we can to stay vital and get through this. We try to turn that into a positive.”

(Courtesy of Harry Hutson)

Harry Hutson, 72, of Baltimore. Hutson, an organizational consultant and executive coach, is married and has five grown children. He believes “an enormous change in lifestyle” is occurring because of the pandemic.

“We’re all more careful, but we’re also more connected,” he said. “Older friends are coming out of the woodwork. Everyone is Zooming and making calls. People are more open and vulnerable and willing to share than before. We’re all trying to make meaning of this new world.”

“We’re all having a traumatic experience — an experience of collective trauma,” Hutson said. As the future unfolds, “the main thing is self-care and compassion. That’s the way forward for all of us.”

(Courtesy of Annis Pratt)

Annis Pratt, 83, of Birmingham, Michigan. A retired English professor, novelist and environmental activist, Pratt lives alone in a home in suburban Detroit.

“What I’m looking forward to is getting back to interacting with real people. Much of my human contact now is on Zoom, which I consider about 75% of a personal encounter,” she said. “But every day, I make myself go out and talk to someone — like taking a vitamin pill.”

Pratt now has a “do not put me on a ventilator” order in her front hallway, along with a “do not resuscitate” order. “I know it’s very likely that if I get to the point where I have to go to the hospital, I’ll probably die,” she said. “Of course, I’m going to die anyway: I’m 83. But somehow, this pandemic has brought it all home.”

Going forward, Pratt sees two possibilities. “Our moral imaginations will have grown because of what we’ve all gone through and we will do better. Or nothing will have changed.”

Most of all, she said, “I would like to get my wonderful, wonderful life back.”

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Aging States

What Seniors Should Know Before Going Ahead With Elective Procedures

For months, Patricia Merryweather-Arges, a health care expert, has fielded questions about the coronavirus pandemic from fellow Rotary Club members in the Midwest.

Recently people have wondered “Is it safe for me to go see my doctor? Should I keep that appointment with my dentist? What about that knee replacement I put on hold: Should I go ahead with that?”

These are pressing concerns as hospitals, outpatient clinics and physicians’ practices have started providing elective medical procedures — services that had been suspended for several months.

Late last month, KFF reported that 48% of adults had skipped or postponed medical care because of the pandemic. Physicians are deeply concerned about the consequences, especially for people with serious illnesses or chronic medical conditions.

To feel comfortable, patients need to take stock of the precautions providers are taking. This is especially true for older adults, who are particularly vulnerable to COVID-19. Here are suggestions that can help people think through concerns and decide whether to seek elective care:

Before you go in. Give yourself at least a week to learn about your medical provider’s preparations. “You want to know in advance what’s expected of you and what you can expect from your providers,” said Lisa McGiffert, co-founder of the Patient Safety Action Network.

Merryweather-Arges’ organization, Project Patient Care, has developed a guide with recommended questions. Among them: Will I be screened for COVID-19 upon arrival? Do I need to wear a mask and gloves? Are there any restrictions on what I can bring (a laptop, books, a change of clothing)? Are the areas I’ll visit cleaned and disinfected between patients?

Also ask whether patients known to have COVID are treated in the same areas you’ll use. Will the medical staffers who interact with you also see these patients?

If you’re getting care in a hospital, will you be tested for COVID-19 before your procedure? Is the staff being tested and, if so, under what circumstances?

Hospitals, medical clinics and physicians are offering this kind of information to varying degrees. In the New York City metropolitan area, Mount Sinai Health System has launched a comprehensive “Safety Hub” on its website featuring extensive information and videos.

Mount Sinai also encourages physicians to reach out to patients with messages tailored to their conditions. People “want to hear directly from their providers,” said Karen Wish, the system’s chief marketing officer.

Don’t hesitate to press for more details, said Dr. Allen Kachalia, senior vice president of patient safety and quality at Johns Hopkins Medicine: “Where people get in trouble is when they’re afraid to bring their concerns forward.”

Seeking care. Wendy Hayum-Gross, 57, a counselor who lives in Naperville, Illinois, had been waiting since mid-March to get blood tests that would help doctors diagnose the underlying cause of a new condition, a goiter. A few weeks ago, she decided it was time.

The hospital lab she went to, operated by Edward-Elmhurst Health, told Hayum-Gross to wear a mask and gave her a number to call when she arrived in the parking lot. Outside the front door, she was met by a staffer who took her temperature, asked several screening questions and gave her hand sanitizer.

“Once I passed that, a phlebotomist met me on the other side of the door and took me to a chair that was still wet with disinfectant. She wore a mask and gloves, and there was no one else around,” Hayum-Gross said. “When I saw the precautions they had put in place and the almost military precision with which they were carrying them out, I felt much better.”

Marjorie Helsel DeWert, 67, of Athens, Ohio, was similarly impressed when she visited her dentist recently and noticed circular yellow signs on the floor of the office, spaced 6 feet apart, indicating where people should stand. Staffers had even put pens used to fill out paperwork in individual containers and arranged to disinfect them after use.

DeWert, a learning scientist, came up with a patient safety checklist and distributed it to family and friends. Among her questions: Can necessary forms be completed online before a medical visit? Can I wait in the car outside until called? What kind of personal protective equipment is the staff using? And is the staff being checked for symptoms daily?

Bringing a caregiver. Some medical centers are allowing caregivers to accompany patients; others are not. Be sure to ask what policies are in place.

If you feel your presence is necessary — for instance, if you want to be there for a relative who is frail or cognitively compromised — be firm but also respectful, said Ilene Corina, president of the Pulse Center for Patient Safety Education & Advocacy.

Be prepared to wear a gown, gloves and mask. “You’re not there for yourself: You’re there to support the health care team and the patient,” said Corina, whose organization offers training to caregivers.

In Orland Park, Illinois, debi Ross, an interior designer, and her sister live with her 101-year-old mother. Eight years ago, when her mother had a tumor removed from her colon, Ross and her sister wiped down every electric socket, cord, surface and door handle in her mother’s hospital room.

“Unless Mom absolutely needs [medical] care, we’re not going to take her anywhere,” Ross said. “But I assure you, if she does have to go see somebody, we’re going to clean that place down from top to bottom, I don’t care what anybody says.”

If you are not allowed into a medical facility, get a phone number for the physician caring for a loved one and make sure they have your number as well, Merryweather-Arges said. Ask that you be contacted immediately if there are any complications.

Afterward. Patients leaving hospitals are fearful these days that they may have become infected with COVID-19, unwittingly. Ask your physician or a nurse what equipment you’ll need to monitor yourself. Will a pulse oximeter and a thermometer be necessary? Will you need masks and gloves at home if someone is coming in to help you out with the transition? Can someone provide that equipment?

“Family caregivers need instructions that are clear,” said Martin Hatlie, chief executive of Project Patient Care. “They need to know who to call 24/7 if they have a question. And they need clear guidance about infection control in the home.”

If home care is being ordered, ask the agency whether they have trained staff to recognize COVID symptoms. And have home care workers been tested for COVID-19 or had symptoms?

If follow-up care is being provided via telehealth, make sure the setup works before your loved one comes home. Ask your physician’s office what kind of equipment you will need, which service they use (Zoom? Skype?) and whether you can arrange a test in advance.

Finally, as you resume activities, help protect others against COVID-19 as well as yourself. When you go out into the world again, “mask up, socially distance and wash your hands,” said Kachalia of Johns Hopkins. “And if you’re sick or have symptoms, by all means, let your doctor’s office know before you come in for a checkup.”

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Coronavirus Crisis Disrupts Treatment For Another Epidemic: Addiction

Shawn Hayes was thankful to be holed up at a city-run hotel for people with COVID-19.

The 20-year-old wasn’t in jail. He wasn’t on the streets chasing drugs. Methadone to treat his opioid addiction was delivered to his door.

Hayes was staying at the hotel because of a coronavirus outbreak at the 270-bed Kirkbride Center addiction treatment center in Philadelphia, where he had been seeking help.

From early April to early May, 46 patients at Kirkbride tested positive for the virus and were isolated. The facility is now operating at about half-capacity because of the pandemic.

Drug rehabs around the country — including in Pennsylvania, Illinois, Indiana, Minnesota and Florida — have experienced flare-ups of the coronavirus or COVID-related financial difficulties that have forced them to close or limit operations. Centers that serve the poor have been hit particularly hard.

And that has left people who have another potentially deadly disease — addiction — with fewer opportunities for treatment, while threatening to reverse their recovery gains.

“It’s hard to underestimate the effects of the pandemic on the community with opioid use disorder,” said Dr. Caleb Alexander, a professor of epidemiology and medicine at the Johns Hopkins Bloomberg School of Public Health. “The pandemic has profoundly disrupted the drug markets. Normally that would drive more people to treatment. Yet treatment is harder to come by.”

Keeping Clients Safe

Drug rehabs aren’t as much of a COVID “tinderbox” as nursing homes, Alexander said, but both are communal settings where social distancing can be difficult.

Shared spaces, double-occupancy bedrooms and group therapy are common in rehabs. People struggling with addiction are generally younger than nursing home residents, but both populations are vulnerable because they’re more likely to suffer from other health conditions, such as diabetes or cardiovascular disease, that leave them at risk of succumbing to COVID-19.

To keep clients safe, some addiction treatment centers employ safety precautions similar to hospitals, like testing all incoming patients for COVID-19, noted Dr. Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security. But drug rehabs must avoid some strategies, such as keeping potentially intoxicating hand sanitizer on the premises.

Adalja said he hopes safety measures make people feel more comfortable about seeking addiction help.

“There’s not going to be anything that’s zero risk, in the absence of a vaccine,” he said. “But this is in a different category than going to a birthday party. You don’t want to postpone needed medical care.”

Still, some people requiring drug or alcohol rehab have stayed away for fear of contracting COVID-19. Marvin Ventrell, CEO of the National Association of Addiction Treatment Providers, said many of its roughly 1,000 members saw their patient numbers down by much as 40% to 50% in March and April before bouncing back to 80%.

Unlike many other centers, Recovery Works, a 42-bed treatment center in Merrillville, Indiana, has seen more clients than normal during the pandemic. The facility had to close for a few days early on after a suspected COVID-19 case, but reopened after the person tested negative. It has since split its therapy sessions into three groups, staggered mealtimes and banned visitors, CEO Thomas Delegatto said. It then had an influx of patients.

“I think there are a variety of reasons why,” Delegatto said. “A person who was struggling with a substance use disorder, and who was laid off and a nonessential worker, might have seen this as an opportunity to go to treatment without having to explain to their employer why they’re taking two, three, four weeks off.”

He also noted that alcohol sales went up at the beginning of the pandemic as anxiety and isolation rose, and sheltering in place may have made some families realize that a loved one needed help for an addiction.

Kirkbride Center, an addiction treatment center in Philadelphia, is running at about half-capacity after a recent COVID-19 outbreak.
Dr. Fred Baurer, Kirkbride’s medical director, says, “I’m starting to feel more confident we’re past the worst of this, at least for now.” (Courtesy of Dr. Fred Baurer)

Centers Serving The Poor Hit Hard

Homeless and poor Americans, because they often live in close quarters, have been particularly prone to catching COVID-19 — leaving drug rehabs dedicated to this population especially vulnerable.

Haymarket Center, a 380-bed treatment and sober living facility in Chicago’s West Loop that serves many people who are homeless, recently had an outbreak of 55 coronavirus cases among clients and staff members.

Two employees there tested positive for COVID-19 in late February, but testing was available then only for people showing symptoms, said Haymarket president and CEO Dan Lustig.

Haymarket worked with nearby Rush University Medical Center to test its clients. Twenty-six men, though asymptomatic, were found to be positive for COVID-19.

The center isolated those patients and eventually went from double- to single-occupancy rooms, improved its air filtration system and changed the way it served food. It now tests all new admissions.

“What we found was by doing serial testing we could tamp down the epidemic, not just at Haymarket but the whole city,” said Dr. David Ansell, senior vice president for community health equity at Rush, which partnered with the city and other health systems on a COVID-19 response for Chicago’s homeless population.

The pandemic’s economic fallout has also forced some facilities to scale back. The Salvation Army is shuttering a handful of its roughly 100 adult rehabilitation centers nationwide due to COVID-related revenue losses. Those rehabs were funded by the organization’s resale shops, which were forced to close during stay-at-home orders.

“A lot of what we do relies on donations or items that were donated and then sold in our stores,” said Alberto Rapley, who oversees business development for the Salvation Army’s rehab facilities in the Midwest. “When financially we struggle, that is then felt on the other side.”

For instance, the Salvation Army drug rehab in Gary, Indiana, which is set to close in September, treated as many as 80 men at a time in its free, abstinence-based program. The next closest facility will be in Chicago, more than 30 miles away.

Outbreak Contained, But Beds Still Limited

Philadelphia’s Kirkbride Center also serves a mostly homeless and low-income population. Dr. Fred Baurer, the facility’s medical director, said Kirkbride was “flying blind” early in the pandemic, with little testing capacity and personal protective equipment.

On April 8, the first COVID-19 case appeared on Kirkbride’s long-term men’s wing. Over the next week, six more men on the unit showed symptoms and tested positive, as did 12 of the remaining 22. All quarantined at a local Holiday Inn Express.

Kirkbride started requiring face masks, testing all new clients for COVID-19 and prohibiting people in its various units from mingling.

The rehab has been about half-full lately — it’s usually closer to 90% occupied — partly because it stopped taking walk-in clients and confined new admissions to single rooms.

“I’m starting to feel more confident we’re past the worst of this, at least for now,” Baurer said.

Hayes, who has recovered from COVID-19 without experiencing any symptoms, was discharged from the facility June 15 to a sober living house. He plans to attend 12-step meetings regularly. He hopes to get his GED and eventually enter the mental health field.

He recognizes the need to stay vigilant about his recovery now, at a time of increased anxiety and despair.

“Regardless of the coronavirus or not, the addiction crisis is still there,” Hayes said. “It’s bad. It’s really bad.”

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Public Health States

‘I Couldn’t Let Her Be Alone’: A Peaceful Death Amid the COVID Scourge

As her mother lay dying in a Southern California hospital in early May, Elishia Breed was home in Oregon, 800 miles away, separated not only by the distance, but also by the cruelty of the coronavirus.

Because of the pandemic, it wasn’t safe to visit her mom, Patti Breed-Rabitoy, who had entered a hospital alone, days earlier, with a high fever and other symptoms that were confirmed to be caused by COVID-19.

Breed-Rabitoy, 69, had suffered from lung and kidney disease for years but remained a vital, bubbly presence in the lives of her husband, Dan Rabitoy, and three grown children. She was a longtime church deacon and youth leader in Reseda, California, a fan of garage sales, bingo games and antique dolls. Then came COVID-19, likely contracted in late April following one of her thrice-weekly dialysis sessions. Now she lay sedated and on a ventilator, her life ebbing, with no family by her side.

“I had seen these things on TV and I would pray for those people and say, ‘I can’t imagine what they’re going through,’” said Breed, 44. “And now I was living it.”

A single mom of two young sons, she was wrenched with guilt at not being with her mother. “You always picture you’re going to be right by your parent’s side,” she said.

Unlike many families of dying COVID patients, Breed and her family were able to find some comfort in her mother’s final hours because of the 3 Wishes Project, a UCLA Health end-of-life program repurposed to meet the demands of the coronavirus crisis. In the U.S., where more than 120,000 people have died of COVID, it’s part of a wider push for palliative care during the pandemic.

At 5 p.m. on May 10, Mother’s Day, before Breed-Rabitoy’s life support was removed, more than a dozen family members from multiple cities and states gathered on a Zoom call to say goodbye. John Denver’s “Rocky Mountain High,” one of her soft-rock ’70s favorites, played on speakers. Online, a chaplain prayed.

Breed-Rabitoy had been deeply sedated for more than a week, since a terrible night when she struggled to breathe and asked doctors to place her on the ventilator. Confusion abounded, Breed said. Could her mom still hear in that state? Two nights in a row, Breed asked nurses to prop a phone near her mom’s ear.

“I prayed with her. I sang her favorite songs. I read her the Bible,” she said.

Finally, a nurse gently explained that her mother was too sick to recover. If they removed the ventilator, it would be to allow her to die.

That’s when hospital staffers described the 3 Wishes program and asked whether the family had any personal requests for her last moments. They decided on the music and the family Zoom call. Dan Rabitoy requested that a nurse hold his wife’s hand as she died.

After it was over, family members received keychains stamped with her fingerprint and a copy of the electrocardiogram of the last beats of her heart.

“I’m grateful to have these keepsakes,” Breed said. “All these things have been healing.”

Dr. Thanh Neville co-founded the 3 Wishes Project at UCLA Health in 2017. Since then, the program has fulfilled nearly 1,600 wishes for dying patients in the ICU.(Courtesy of Robert Hernandez/UCLA Health)

The project was developed in Canada but co-launched at UCLA Health in 2017 by Dr. Thanh Neville, an intensive care physician who serves as 3 Wishes’ medical director. It aims to make the end of life more dignified and personalized by fulfilling small requests for dying patients and their families in the ICU.

Before COVID-19, the program had granted nearly 1,600 wishes for more than 450 patients, nearly all in person. The deathbed scenarios have varied, from music and aromatherapy at the bedside to meeting a patient’s request for one last mai tai cocktail.

“We’ve done weddings and mariachi bands and opera singers and 20 to 30 family members who could come in and celebrate,” said Neville, 41. “And none of this is possible anymore.”

COVID-19 has “changed everything,” said Neville, a researcher who focuses on improving ICU care for the dying. Also a clinician, she spent weeks this spring tending to seriously ill COVID patients. Since March, her hospital system has seen more than two dozen COVID deaths.

In the beginning, visitors were strictly prohibited. Now, some may come — but many don’t.

“I would still say the majority of COVID patients die without families at their bedside,” Neville said. “There are a lot of reasons why they can’t come in. Some are sick or old or they have small kids. A lot of people don’t want to take that risk and bring it home.”

It has been hard to keep 3 Wishes going during a time when in-person memorials and celebrations are banned and infection control remains the primary focus. Neville even had to change the way the fingerprint keychains were made. Now, they’re treated with germicidal irradiation, the same method that lets health care workers reuse N95 masks.

The 3 Wishes Project is offered when death is imminent: Patients are enrolled after a decision has been made to withdraw life-sustaining technology or if the chance of death is greater than 95%. The program was created to help patients, caregivers and clinicians navigate the dying process in a less clinical, more humane way. Wishes needn’t be limited to three, and they can be articulated by patients, family members or hospital staffers.

The program is based on palliative care tenets that focus on the humanity of the patient amid intensive medical care, said Dr. Rodney Tucker, president of the American Academy of Hospice and Palliative Medicine. Seemingly small acts that honor an individual life help counter the efficiency-driven environment of the ICU, which can be dehumanizing. They’re at the core of care that has been shown to ease both angst for the dying and grief for those who loved them. “It helps the family that’s left behind cope more successfully with the loss,” he said.

Such efforts also remind providers of the humanity of their practice, which can help them cope with the stress of witnessing death daily, especially during something as extraordinary as a pandemic, he said.

A study published by Neville and colleagues last year found that 3 Wishes is a “transferrable, affordable, sustainable program” that benefits patients, families, clinicians and their institutions. They calculated that the mean cost of a single wish, funded by grants and donations, was $5.19.

Genevieve Arriola, 36, has been a critical care nurse for eight years. When the pandemic struck, she found herself juggling medical care and emotional support more than ever. She took care of Breed-Rabitoy for three days straight, all the while communicating with the dying woman’s family.

“This was a very delicate situation for someone who is married to her for over 20 years and a daughter who was miles away in Oregon and couldn’t see her mom,” she said.

She was also the nurse who held Breed-Rabitoy’s hand as she died.

“I pretty much felt honored to be that person,” Arriola said. “I couldn’t let her be alone. If no one can be there, I can.”

Weeks after her mother’s death, Breed is grappling with the loss. The last time she saw her mom was March 16, at a McDonald’s off Interstate 5 near Grants Pass, Oregon.

The pair met for less than 30 minutes before Breed-Rabitoy headed south down the interstate, her long-planned family visit cut short by concerns about COVID. She had just learned that the local dialysis center was closed to outside patients, and she was worried about growing reports of infection and death. “She told me, ‘I feel like this disease is coming after me,’” Breed recalled.

Now, the keepsakes from 3 Wishes are placed where Breed can see them every day.

“It added such a level of love and dignity we weren’t expecting,” she said. “It made the process of losing a loved one to COVID-19 so much more bearable.”

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

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A pesar del aumento de casos, California frena fondos multimillonarios para pruebas de COVID

En abril, el gobernador Gavin Newsom lanzó una iniciativa estatal multimillonaria para que las pruebas de COVID-19 llegaran a las personas y a los lugares con menos acceso: pueblos rurales y vecindarios desfavorecidos del centro de la ciudad.

Pero ahora, citando costos, California está frenando esta expansión, incluso cuando el estado está teniendo devastadores récords de nuevas infecciones y aumentos de dos dígitos en las hospitalizaciones.

El estado ya no financiará nuevos sitios de prueba, a pesar de las súplicas de los condados para obtener asistencia adicional. También ha cerrado algunos espacios y los ha trasladado a otros lugares.

Y el gobierno ha amenazado con cerrar los sitios subutilizados, de acuerdo con casi dos docenas de entrevistas con funcionarios de salud pública de los condados.

Aunque es pronto para evaluar, han surgido algunos ganadores y perdedores: el condado de El Dorado, al este de Sacramento, perdió uno de sus sitios de prueba en la ciudad de Shingle Springs en junio por no agendar suficientes citas, mientras que el condado de Fresno ganó un sitio que había sido retirado de otra parte, dijo el doctor Rais Vohra, su oficial de salud.

Sin embargo, el condado de San Mateo ha pedido tres veces a los funcionarios estatales un segundo lugar de pruebas financiado por el estado para abordar las brechas en las pruebas en los vecindarios de minorías de raza negra y de trabajadores agrícolas, pero se le ha “dicho que no repetidamente”, dijo Justin Mates, subdirector del condado.

Por eso, el condado transformó su único sitio estatal en una unidad de prueba itinerante.

“La equidad es ciertamente una preocupación para nosotros”, dijo Mates. “Realmente necesitamos ayuda con el acceso a pruebas si vamos a llegar a nuestros residentes latinos y lugares como East Palo Alto”, una ciudad diversa cuya población es principalmente latina, afroamericana, asiática y de nativos de las Islas del Pacífico.

California ha comprometido hasta $132 millones en contratos con dos compañías privadas de pruebas para COVID-19, Verily Life Sciences y OptumServe, para ofrecer pruebas gratuitas en más de 100 sitios que la administración de Newsom ha identificado como “desérticos para pruebas”.

La expansión ha elevado drásticamente los números de pruebas generales del estado, que aumentaron de 16,000 por día en abril a 105,000 el lunes 29 de junio.

Las pruebas también están disponibles en ubicaciones financiadas por condados, farmacias privadas, hospitales y clínicas comunitarias.

Mark Ghaly, secretario estatal de Salud y Servicios Humanos, confirmó que el estado está retirando los sitios de los condados que no están generando números lo suficientemente altos y cortando fondos para nuevos espacios.

“Lo que quieres es que el dinero vaya a donde más se necesita”, dijo Ghaly. “No sería prudente o sabio mantener el gasto en un lugar donde no se están utilizando los recursos”.

El propio Newsom ha expresado su preocupación por los precios, dados los déficits presupuestarios “sin precedentes”. “Hay un gran costo asociado con las pruebas”, dijo a fines de junio.

Un funcionario de la administración de Newsom confirmó que el estado quiere ver que los condados llenen al menos el 80% de las citas para pruebas en cada ubicación. Y si las pruebas caen por debajo del 50% durante unos días o más, se les advierte que los sitios podrían transferirse a otro lugar.

Los condados argumentan que existe un beneficio para la salud pública al mantener abiertas las ubicaciones de bajo rendimiento, simplemente para garantizar que las pruebas estén disponibles para las comunidades rurales y postergadas.

En todo el estado, están luchando para salvar sitios financiados por el estado, incluso cuando están siendo abrumados por los crecientes casos de coronavirus vinculados en gran medida a reuniones sociales.

“Es cómo podemos identificar rápidamente dónde está el virus y si hay puntos calientes”, dijo la doctora Olivia Kasirye, oficial de salud del condado de Sacramento, donde celebraciones familiares y reuniones con alto consumo de alcohol están elevando las tasas de infección.

El condado de Contra Costa vio caer sus números de pruebas en junio y corría el riesgo de perder un sitio financiado por el estado hasta que demostrara que podía cumplir con las citas a cerca del 80% de su capacidad, dijo el doctor Chris Farnitano, su oficial de salud.

Al condado de Riverside se le advirtió el 16 de junio de que un sitio financiado por el estado al norte de Temecula sería “trasladado a otro condado” si no cubría el 50% de sus citas, según un correo electrónico del grupo de trabajo de pruebas del estado.

Lo mismo se le dijo al condado de Mendocino, que podría perder su sitio financiado por el estado, la única prueba gratuita disponible a dos horas de manejo para algunos residentes de áreas rurales.

El condado de Alameda se sintió tan frustrado con los requisitos estatales que emprendió una expansión de pruebas por cuenta propia.

“Nos dimos cuenta que no podíamos depender del estado, especialmente para llegar a nuestras comunidades vulnerables”, dijo la doctora Jocelyn Freeman Garrick, doctora de la sala de emergencias del Hospital Highland en Oakland, quien lidera la fuerza de pruebas del condado.

El condado de El Dorado, que perdió su sitio, hasta ahora ha mantenido un recuento relativamente bajo de casos de COVID-19.

Ghaly dijo que el estado está trabajando con los condados en peligro de perder sitios para darles la oportunidad de llenar los espacios de prueba. Los funcionarios estatales se negaron a decir cuántos condados han perdido sitios, pero a medida que las nuevas infecciones se han disparado, los números de las pruebas están comenzando a recuperarse.

La lista de condados en riesgo de perder un sitio ha disminuido de alrededor de una docena a principios de junio a unos pocos la última semana de junio.

Expertos en salud pública dicen que enfocándose tan intensamente en los números de las pruebas y no en las pruebas adecuadas en los vecindarios de minorías, se corre el riesgo de abandonar las comunidades que ya enfrentan enormes barreras para la atención médica como el racismo y la pobreza.

“Si ignoras estas comunidades, seguiremos viendo las mismas urgencias que estamos viendo ahora”, dijo el doctor Tony Iton, ex alto funcionario de salud del condado de Alameda y ahora vicepresidente senior de California Endowment, que está trabajando con los condados para expandir las pruebas en vecindarios desatendidos.

Las barreras socioeconómicas arraigadas también hacen que sea difícil obtener y mantener los números de prueba. Por ejemplo, las personas que desean hacerse la prueba en sitios estatales a menudo necesitan acceso a Internet y una dirección de correo electrónico. La mayoría son al paso, por lo que deben tener un vehículo.

Muchas personas de bajos ingresos no pueden cumplir con esos requisitos, y los inmigrantes indocumentados temen que proporcionar información personal para obtener una prueba pueda exponerlos a los funcionarios de inmigración, dijo el doctor Marty Fenstersheib, ex funcionario de salud del condado de Santa Clara que lidera el programa de pruebas.

“Si las personas tienen miedo de venir y hacerse la prueba, no habrá ningún beneficio”, dijo.

Los contratos estatales que financian los sitios de prueba se extendieron en junio, pero expirarán el 31 de agosto, y los funcionarios de la administración no han dicho a los condados si el estado continuará financiándolos, dijo Mimi Hall, presidenta de la Asociación de Ejecutivos de Salud del Condado de California y directora de salud pública del condado de Santa Cruz.

“Es difícil planificar cuando no sabemos cuánto tiempo podremos mantenerlos”, expresó Hall.

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

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Among Those Disrupted By COVID-19: The Nation’s Newest Doctors

July 1 is a big day in medical education. It’s traditionally the day newly minted doctors start their first year of residency. But this year is different. Getting from here to there — from medical school to residency training sites — has been complicated by the coronavirus.

“We were all really freaking out,” said Dr. Christine Petrin, who just graduated from medical school at Tulane University in New Orleans and is starting a combined residency in internal medicine and pediatrics at MedStar Georgetown University Hospital in Washington, D.C. Students “matched” — the term for finding out where they will spend their next several years training — in March, just as everything was shutting down because of the pandemic.

After getting the news of their placements, Petrin said, some of her friends were worried about being able to enter states that were closing their borders. They “just rapidly picked up and moved. Found an apartment, packed up the car, and went.”

Petrin said she was lucky. Although she shopped apartments online, her sister, who lives in Washington, could check them out in person. Dr. Erin Fredrickson was not as fortunate. She graduated in May from Campbell University School of Osteopathic Medicine near Raleigh, North Carolina, and matched in a family practice residency at the University of Washington in Seattle.

She and her partner were already planning to drive across the country with their dog, but the trip turned out to be much different than the leisurely journey they had envisioned. “We were going to visit friends in different places along the way,” she said. “We were going to camp, but a lot of places to camp were closed. We ended up staying in Airbnb guest houses” in an effort to minimize contact with anyone else.

Meanwhile, she said, she was forced to pick out housing remotely. “I did a lot of FaceTime tours of apartments” in Seattle, she said.

Dr. Janis Orlowski, chief health care officer for the Association of American Medical Colleges, agreed this has been a year like no other. “It’s been really messy,” she said. “But it looks like it’s coming together.”

Among other things, graduates traveling from states that are or have been hot spots are being asked to quarantine for 14 days upon arrival. That has required more flexibility than usual from administrators used to starting programs at an exact time.

“Everyone is pretty much going to start July 1 — or a little after,” she said.

In some instances, the medical students graduating this year — some of whom graduated early to help in the hospitals attached to their medical schools — have it easier than students directly behind them.

Almost from the start of the outbreak, third- and fourth-year students who would typically spend much or all of their time in the hospital were shut out to avoid being exposed to the coronavirus. Even the newly graduated doctors were generally kept away from COVID-19 patients.

The restrictions were intended not only for their own safety, said Orlowski, but also to help protect patients. “If you have a COVID patient, you don’t need 14 people marching into the room,” she said. “We wanted to decrease the team size.” And shortages of personal protective equipment made smaller care teams necessary.

For most of the graduating seniors, required rotations were generally finished by the time the virus had upset their plans. Those that were not could be made up.

But for third-year students, the time out of the hospital will be more difficult to recoup as the pandemic drags on — and continues to spread. For the moment, most students are also barred from rotations at hospitals other than their own. (Students frequently work at hospitals that have programs their home hospital does not offer.)

At the same time, those soon-to-be fourth-year students who normally would be traveling around the country to interview for residencies will be limited to online visits only. That’s a real shame, said Petrin, because being on-site in some cases “changed my perception for better or worse.”

But right now it’s about safety, Orlowski said. “We’re trying to cut down on any travel,” she said. “But we’re also trying to make it fair. We don’t want some students to have in-person interviews and others not.”

For those starting residency this week, one of the hardest things, said Fredrickson, is getting through all the errands she won’t have time for later. “I moved to a new state and I need a new driver’s license and license plates,” she said. “And the DMV is still closed.”

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Un sistema de salud pública devastado enfrenta más recortes en medio del virus

El sistema de salud pública de los Estados Unidos ha subsistido en la precariedad durante décadas y carece de los recursos necesarios para enfrentar la peor crisis de salud en un siglo.

Mientras enfrentan juntos una pandemia que ha enfermado al menos a 2.3 millones de personas en el país, y matado a más de 120,000, y que ha costado millones de empleos y $3 mil millones en dinero de rescate federal, a los trabajadores de salud de los gobiernos estatales y locales a veces se les paga tan poco que califican para ayuda pública. Rastrean al coronavirus en registros compartidos por fax. Trabajando los siete días de la semana por meses, temiendo que se congelen sus salarios, que los despidan, e incluso la reacción negativa del público.

Desde 2010, el gasto para los departamentos de salud pública estatales ha disminuido un 16% per cápita, y el gasto para los departamentos de salud locales ha bajado un 18%, según un análisis de KHN y Associated Press. Al menos 38,000 empleos de salud pública locales y estatales han desaparecido desde la recesión de 2008, dejando en algunos lugares una fuerza laboral esquelética.

KHN y AP entrevistaron a más de 150 trabajadores de salud pública, legisladores y expertos, analizaron registros de gastos de cientos de departamentos de salud estatales y locales, e indagaron en las legislaturas estatales. La investigación reveló que, a todo nivel, el sistema está amenazado por la falta de financiación y medios.

A lo largo del tiempo, los departamentos de salud estatales y locales han recibido tan poco apoyo que se encontraron sin dirección, ignorados e incluso vilipendiados.

En medio de la recesión económica causada por la pandemia, los estados, las ciudades y los condados han comenzado a cesantear y despedir al personal, aun cuando los estados están reabriendo y comienzan a aumentar los casos de COVID.

“No le decimos al departamento de bomberos, ‘lo siento. No hubo incendios el año pasado, por lo que vamos a quitarle el 30% de su presupuesto’. Eso sería una locura, ¿verdad?”, dijo el doctor Gianfranco Pezzino, oficial de salud en el condado de Shawnee, en Kansas. “Pero lo hacemos con la salud pública, día tras día”.

El Departamento de Salud del condado de Toledo-Lucas, en Ohio, gastó solo $40 por persona en 2017. Cuando atacó el coronavirus, tenía tan poco personal que las tareas de Jennifer Gottschalk, supervisora ​​de salud ambiental, incluían supervisar las inspecciones de campamentos y piscinas, y el control de roedores, además de la preparación para brotes.

Cuando Gottschalk, de 42 años, y cinco colegas se enfermaron con COVID-19, se encontró respondiendo llamadas de trabajo desde su cama del hospital. “Tienes que hacer lo que tienes que hacer para que el trabajo se haga”, expresó.

Casi dos tercios de los estadounidenses viven en condados que gastan más del doble en vigilancia policial que en la atención médica no hospitalaria, que incluye la salud pública.

La subvaloración de la salud pública contrasta con su papel multidimensional. A diferencia del sistema de atención médica que está dirigido a las personas, el de salud pública se centra en la salud de las comunidades en general. Las agencias están legalmente obligadas a proporcionar una amplia gama de servicios esenciales.

Jennifer Gottschalk, supervisora de salud del medio ambiente del Departamento de Salud del condado de Toledo-Lucas, en su oficina en Toledo, Ohio. “La semana pasada los gritos de los residentes por dos horas seguidas sobre regulaciones que no puedo controlar me dejaron completamente agotada”, dijo a mediados de junio.(AP Photo/Paul Sancya)

“A la salud pública le encanta decir: cuando hacemos nuestro trabajo, no pasa nada. Pero nadie nos da una medalla por eso”, dijo Scott Becker, director ejecutivo de la Asociación de Laboratorios de Salud Pública. “Les hacemos pruebas al 97% de los bebés de los Estados Unidos para detectar trastornos metabólicos, y otros problemas. Testeamos el agua. ¿Te gusta nadar en el lago y no te gusta que tenga excremento? Piensa en nosotros”.

El público no ve los desastres que se evitan. Y es fácil no prestar atención a lo que no vemos.

Una historia de privaciones

Las promesas ocasionales del gobierno federal de apoyar los esfuerzos locales de salud pública han sido efímeras.

Por ejemplo, la Ley de Cuidado de Salud a Bajo Precio (ACA) estableció el Fondo de Prevención y Salud Pública, que se suponía alcanzaría los $2 mil millones anuales para 2015. Pero la administración Obama y el Congreso lo postergaron por otras prioridades, y ahora la administración Trump está presionando para derogar ACA, lo cual lo eliminaría.

Si no se hubiera tocado, los departamentos de salud estatales y locales hubieran recibido eventualmente un monto adicional de $12.4 mil millones, lo que los hubiera fortalecido frente a la actual pandemia.

Los líderes locales y estatales tampoco lograron priorizar la salud pública. En Carolina del Norte, por ejemplo, la fuerza laboral de salud pública del condado de Wake se redujo de 882 personas en 2007 a 614 una década después, incluso cuando la población creció un 30%.

Años de recortes financieros dejaron frágil a esta fuerza laboral predominantemente femenina. En 2017, más de una quinta parte de los trabajadores de salud pública en los departamentos locales o regionales fuera de las grandes ciudades ganaron $35,000 o menos al año, según una investigación realizada por la Asociación de Oficiales de Salud Territoriales y Estatales y la Fundación Beaumont.

Casi la mitad de los trabajadores de salud pública planean retirarse o irse de sus organizaciones en los próximos cinco años, y la razón que encabeza la lista es una remuneración deficiente.

María Fernanda rastrea contactos de personas con COVID en el Departamento de Salud del condado de Miami-Dade, en su oficina de El Doral, en Florida, en mayo. En los estados, los departamentos de salud locales, encargados de realizar este trabajo de detectives tienen una fuerza laboral mucho menor de la que se requiere para esta tarea.(AP Photo/Lynne Sladky)

Hace dos años, Julia Crittendon, ahora de 46 años, aceptó un trabajo en el departamento de salud estatal de Kentucky. Pasaba sus días reuniendo información sobre las parejas sexuales de las personas para combatir la propagación del VIH y la sífilis. Ganaba tan poco que calificó para Medicaid, el programa de salud federal gerenciado por los estados para los estadounidenses de bajos recursos. Al no ver oportunidades de crecimiento, renunció.

Desde que comenzó la pandemia, líderes de salud pública estatales y locales han renunciado en masa. Desde abril, al menos 32 presentaron su renuncia, se retiraron o fueron despedidos en 16 estados, según una revisión de KHN/AP.

De mal en peor

Scott Lockard, director de salud pública para el Departamento de Salud del distrito Kentucky River, en Appalachia, está luchando contra el virus con un servicio celular 3G, registros en papel y un tercio de los empleados comparado con los que tenía el departamento hace 20 años.

En la zona rural de Missouri, Melanie Hutton, administradora del Centro de Salud Pública del condado de Cooper, dijo que su estado le dio $18,000 al servicio de ambulancias local para combatir COVID y proporcionó máscaras a los departamentos de bomberos y policía.

“Para nosotros, ni una moneda de cinco centavos, ni una máscara”, contó. “Obtuvimos [cinco] galones de desinfectante de manos casero hecho por prisioneros”.

La Asociación de Oficiales de Salud Territoriales y Estatales dijo que, desde que comenzó la pandemia, el gobierno federal ha asignado más de $13 mil millones para actividades de los departamentos de salud estatales y locales, incluyendo rastreo de contactos, control de infecciones y actualizaciones tecnológicas.

En el condado de Fairfax, en Virginia, las pruebas para COVID-19 han estado disponibles sin costo y sin una orden del doctor. El día de la foto, el 23 de mayo, de 10 am a 6 pm, oficiales planeaban hacerle la prueba a unas 1,000 personas, mientras cientos hacían fila en autos y a pie, en este sitio de pruebas al paso en Annandale.(AP Photo/Jacquelyn Martin)

Pero al menos 14 estados ya han recortado los presupuestos o los empleos del departamento de salud, o estuvieron considerando activamente estos recortes en junio, según una revisión de KHN/AP.

Las reducciones amenazan con limitar programas cruciales como clínicas de inmunización, control de mosquitos, diabetes y programas de nutrición para adultos mayores. Estos recortes pueden hacer que las comunidades ya vulnerables lo sean aún más, dijo E. Oscar Alleyne, jefe de programas y servicios de la Asociación Nacional de Oficiales de Salud del Condado y la Ciudad.

Las personas que han pasado sus vidas trabajando en la salud pública temen estar viendo un patrón que les resulta familiar: los funcionarios descuidan esta infraestructura y luego, cuando surge una crisis, responden con una rápida inyección de efectivo.

Si bien ese dinero temporal es necesario para combatir la pandemia, expertos en salud pública dicen que no solucionará la base erosionada, que es la encargada de proteger la salud de la nación mientras miles continúan muriendo.

Contribuyeron con este informe: los escritores de Associated Press Mike Stobbe en Nueva York; Mike Householder en Toledo, Ohio; Lindsay Whitehurst en Salt Lake City, Utah; Brian Witte en Annapolis, Maryland; Jim Anderson en Denver; Sam Metz en Carson City, Nevada; Summer Ballentine en Jefferson City, Missouri; Alan Suderman en Richmond, Virginia; Sean Murphy en Oklahoma City, Oklahoma; Mike Catalini en Trenton, New Jersey; David Eggert en Lansing, Michigan; Andrew DeMillo en Little Rock, Arkansas; Jeff Amy en Atlanta; Melinda Deslatte en Baton Rouge, Louisiana; Morgan Lee en Santa Fe, New Mexico; Mark Scolforo en Harrisburg, Pennsylvania; y el escritor de Economía de AP Christopher Rugaber, en Washington, D.C.

Hollowed-Out Public Health System Faces More Cuts Amid Virus

The U.S. public health system has been starved for decades and lacks the resources to confront the worst health crisis in a century.

Marshaled against a virus that has sickened at least 2.6 million in the U.S., killed more than 126,000 people and cost tens of millions of jobs and $3 trillion in federal rescue money, state and local government health workers on the ground are sometimes paid so little that they qualify for public aid.

They track the coronavirus on paper records shared via fax. Working seven-day weeks for months on end, they fear pay freezes, public backlash and even losing their jobs.

Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to a KHN and Associated Press analysis of government spending on public health. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce for what was once viewed as one of the world’s top public health systems.

KHN and AP interviewed more than 150 public health workers, policymakers and experts, analyzed spending records from hundreds of state and local health departments, and surveyed statehouses. On every level, the investigation found, the system is underfunded and under threat, unable to protect the nation’s health.

Dr. Robert Redfield, the director of the Centers for Disease Control and Prevention, said in an interview in April that his “biggest regret” was “that our nation failed over decades to effectively invest in public health.”

So when this outbreak arrived — and when, according to public health experts, the federal government bungled its response — hollowed-out state and local health departments were ill-equipped to step into the breach.

Over time, their work had received so little support that they found themselves without direction, disrespected, ignored, even vilified. The desperate struggle against COVID-19 became increasingly politicized and grew more difficult.

States, cities and counties in dire straits have begun laying off and furloughing members of already limited staffs, and even more devastation looms, as states reopen and cases surge. Historically, even when money pours in following crises such as Zika and H1N1, it disappears after the emergency subsides. Officials fear the same thing is happening now.

“We don’t say to the fire department, ‘Oh, I’m sorry. There were no fires last year, so we’re going to take 30% of your budget away.’ That would be crazy, right?” said Dr. Gianfranco Pezzino, the health officer in Shawnee County, Kansas. “But we do that with public health, day in and day out.”

Ohio’s Toledo-Lucas County Health Department spent $17 million, or $40 per person, in 2017.

Jennifer Gottschalk, 42, works for the county as an environmental health supervisor. When the coronavirus struck, the county’s department was so short-staffed that her duties included overseeing campground and pool inspections, rodent control and sewage programs, while also supervising outbreak preparedness for a community of more than 425,000 people.

When Gottschalk and five colleagues fell ill with COVID-19, she found herself fielding calls about a COVID-19 case from her hospital bed, then working through her home isolation. She stopped only when her coughing was too severe to talk on calls.

“You have to do what you have to do to get the job done,” Gottschalk said.

Now, after months of working with hardly a day off, she said the job is wearing on her. So many lab reports on coronavirus cases came in, the office fax machine broke. She faces a backlash from the community over coronavirus restrictions and there are countless angry phone calls.

Things could get worse; possible county budget cuts loom.

But Toledo-Lucas is no outlier. Public health ranks low on the nation’s financial priority list. Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health.

Jennifer Gottschalk, environmental health supervisor of the Toledo-Lucas County Health Department, works in her office in Toledo, Ohio. “Being yelled at by residents for almost two hours straight last week on regulations I cannot control left me feeling completely burned out,” she said in mid-June.(AP Photo/Paul Sancya)

More than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware, according to data provided to KHN and AP by the State Health Expenditure Dataset project.

That money represents less than 1.5% of most states’ total spending, with half of it passed down to local health departments.

The share of spending devoted to public health belies its multidimensional role. Agencies are legally bound to provide a broad range of services, from vaccinations and restaurant inspections to protection against infectious disease. Distinct from the medical care system geared toward individuals, the public health system focuses on the health of communities at large.

“Public health loves to say: When we do our job, nothing happens. But that’s not really a great badge,” said Scott Becker, chief executive officer of the Association of Public Health Laboratories. “We test 97% of America’s babies for metabolic or other disorders. We do the water testing. You like to swim in the lake and you don’t like poop in there? Think of us.”

But the public doesn’t see the disasters they thwart. And it’s easy to neglect the invisible.

We don’t say to the fire department, ‘Oh, I’m sorry. There were no fires last year, so we’re going to take 30% of your budget away.’ That would be crazy, right? But we do that with public health, day in and day out.

Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas

A History of Deprivation

The local health department was a well-known place in the 1950s and 1960s, when Harris Pastides, president emeritus of the University of South Carolina, was growing up in New York City.

“My mom took me for my vaccines. We would get our injections there for free. We would get our polio sugar cubes there for free,” said Pastides, an epidemiologist. “In those days, the health departments had a highly visible role in disease prevention.”

The United States’ decentralized public health system, which matches federal funding and expertise with local funding, knowledge and delivery, was long the envy of the world, said Saad Omer, director of the Yale Institute for Global Health.

“A lot of what we’re seeing right now could be traced back to the chronic funding shortages,” Omer said. “The way we starve our public health system, the way we have tried to do public health outcomes on the cheap in this country.”

A stack of paperwork detailing positive COVID-19 test results sits in a box at the Toledo-Lucas County Health Department offices. Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to an analysis of government spending on public health by KHN and The Associated Press.(AP Photo/Paul Sancya)

In Scott County, Indiana, when preparedness coordinator Patti Hall began working at the health department 34 years ago, it ran a children’s clinic and a home health agency with several nurses and aides. But over time, the children’s clinic lost funding and closed. Medicare changes paved the way for private services to replace the home health agency. Department staff dwindled in the 1990s and early 2000s. The county was severely outgunned when rampant opioid use and needle sharing sparked an outbreak of HIV in 2015.

Besides just five full-time and one part-time county public health positions, there was only one doctor in the outbreak’s epicenter of Austin. Indiana’s then-Gov. Mike Pence, now leading the nation’s coronavirus response as vice president, waited 29 days after the outbreak was announced to sign an executive order allowing syringe exchanges. At the time, a state official said that only five people from agencies across Indiana were available to help with HIV testing in the county.

The HIV outbreak exploded into the worst ever to hit rural America, infecting more than 230 people.

At times, the federal government has promised to support local public health efforts, to help prevent similar calamities. But those promises were ephemeral.

Two large sources of money established after Sept. 11, 2001 — the Public Health Emergency Preparedness program and the Hospital Preparedness Program — were gradually chipped away.

The Affordable Care Act established the Prevention and Public Health Fund, which was supposed to reach $2 billion annually by 2015. The Obama administration and Congress raided it to pay for other priorities, including a payroll tax cut. The Trump administration is pushing to repeal the ACA, which would eliminate the fund, said Carolyn Mullen, senior vice president of government affairs and public relations at the Association of State and Territorial Health Officials.

Former Iowa Sen. Tom Harkin, a Democrat who championed the fund, said he was furious when the Obama White House took billions from it, breaking what he said was an agreement.

“I haven’t spoken to Barack Obama since,” Harkin said.

If the fund had remained untouched, an additional $12.4 billion would eventually have flowed to local and state health departments.

But local and state leaders also did not prioritize public health over the years.

In Florida, for example, 2% of state spending goes to public health. Spending by local health departments in the state fell 39%, from a high of $57 in inflation-adjusted dollars per person in the late 1990s to $35 per person last year.

In North Carolina, Wake County’s public health workforce dropped from 882 in 2007 to 614 a decade later, even as the population grew by 30%.

In Detroit, the health department had 700 employees in 2009, then was effectively disbanded during the city’s bankruptcy proceedings. It’s been built back up, but today still has only 200 workers for 670,000 residents.

Many departments rely heavily on disease-specific grant funding, creating unstable and temporary positions. The CDC’s core budget, some of which goes to state and local health departments, has essentially remained flat for a decade. Federal money currently accounts for 27% of local public health spending.

Years of such financial pressure increasingly pushed workers in this predominantly female workforce toward retirement or the private sector and kept potential new hires away.

More than a fifth of public health workers in local or regional departments outside big cities earned $35,000 or less a year in 2017, as did 9% in big-city departments, according to research by the Association of State and Territorial Health Officials and the de Beaumont Foundation.

Maria Fernanda works on COVID contact tracing at the Florida Department of Health in Miami-Dade County in Doral, Florida, in May. In state after state, local health departments charged with doing the detective work of running down the contacts of coronavirus patients are falling well short of the number of people needed to do the job.(AP Photo/Lynne Sladky)

Even before the pandemic, nearly half of public health workers planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons.

Armed with a freshly minted bachelor’s degree, Julia Crittendon took a job two years ago as a disease intervention specialist with Kentucky’s state health department. She spent her days gathering detailed information about people’s sexual partners to fight the spread of HIV and syphilis. She tracked down phone numbers and drove hours to pick up reluctant clients.

The mother of three loved the work but made so little money that she qualified for Medicaid, the federal-state insurance program for America’s poorest. Seeing no opportunity to advance, she left.

“We’re like the redheaded stepchildren, the forgotten ones,” said Crittendon, 46.

Public health loves to say: When we do our job, nothing happens. But that’s not really a great badge. We test 97% of America’s babies for metabolic or other disorders. We do the water testing. You like to swim in the lake and you don’t like poop in there? Think of us.

Scott Becker, chief executive officer of the Association of Public Health Laboratories

Such low pay is endemic, with some employees qualifying for the nutrition program for new moms and babies that they administer. People with the training for many public health jobs, which can include a bachelor’s or master’s degree, can make much more money in the private health care sector, robbing the public departments of promising recruits.

Dr. Tom Frieden, a former CDC director, said the agency “intentionally underpaid people” in a training program that sent early-career professionals to state and local public health departments to build the workforce.

“If we paid them at the very lowest level at the federal scale,” he said in an interview, “they would have to take a 10-20% pay cut to continue on at the local health department.”

As low pay sapped the workforce, budget cuts sapped services.

In Alaska, the Division of Public Health’s spending dropped 9% from 2014 to 2018 and staffing fell by 82 positions in a decade to 426. Tim Struna, chief of public health nursing in Alaska, said declines in oil prices in the mid-2010s led the state to make cuts to public health nursing services. They eliminated well-child exams for children over 6, scaled back searches for the partners of people with certain sexually transmitted infections and limited reproductive health services to people 29 and younger.

Living through an endless stream of such cuts and their aftermath, those workers on the ground grew increasingly worried about mustering the “surge capacity” to expand beyond their daily responsibilities to handle inevitable emergencies.

When the fiercest of enemies showed up in the U.S. this year, the depleted public health army struggled to hold it back.

A Decimated Surge Capacity

As the public health director for the Kentucky River District Health Department in rural Appalachia, Scott Lockard is battling the pandemic with 3G cell service, paper records and one-third of the employees the department had 20 years ago.

He redeployed his nurse administrator to work round-the-clock on contact tracing, alongside the department’s school nurse and the tuberculosis and breastfeeding coordinator. His home health nurse, who typically visits older patients, now works on preparedness plans. But residents aren’t making it easy on them.

“They’re not wearing masks, and they’re throwing social distancing to the wind,” Lockard said in mid-June, as cases surged. “We’re paying for it.”

In Virginia’s Fairfax County, COVID-19 testing was available at no cost and without a doctor’s order. Officials had planned on testing about 1,000 people from 10 a.m. to 6 p.m. on May 23, as hundreds lined up in cars and on foot at this site in Annandale.(AP Photo/Jacquelyn Martin)

Even with more staff since the HIV outbreak, Indiana’s Scott County Health Department employees worked evenings, weekends and holidays to deal with the pandemic, including outbreaks at a food packing company and a label manufacturer. Indiana spends $37 a person on public health.

“When you get home, the phone never stops, the emails and texts never stop,” said Hall, the preparedness coordinator.

All the while, she and her colleagues worry about keeping HIV under control and preventing drug overdoses from rising. Other health problems don’t just disappear because there is a pandemic.

“We’ve been used to being able to ‘MacGyver’ everything on a normal day, and this is not a normal day,” said Amanda Mehl, the public health administrator for Boone County, Illinois, citing a TV show.

Pezzino, whose department in Kansas serves Topeka and Shawnee County, said he had been trying to hire an epidemiologist, who would study, track and analyze data on health issues, since he came to the department 14 years ago. Finally, less than three years ago, they hired one. She just left, and he thinks it will be nearly impossible to find another.

While epidemiologists are nearly universal in departments serving large populations, hardly any departments serving smaller populations have one. Only 28% of local health departments have an epidemiologist or statistician.

Strapped departments are now forced to spend money on contact tracers, masks and gloves to keep their workers safe and to do basic outreach.

Melanie Hutton, administrator for the Cooper County Public Health Center in rural Missouri, pointed out the local ambulance department got $18,000, and the fire and police departments got masks to fight COVID-19.

“For us, not a nickel, not a face mask,” she said. “We got [5] gallons of homemade hand sanitizer made by the prisoners.”

Public health workers are leaving in droves. At least 34 state and local public health leaders have announced their resignations, retired or been fired in 17 states since April, a KHN-AP review found. Others face threats and armed demonstrators.

Ohio’s Gottschalk said the backlash has been overwhelming.

“Being yelled at by residents for almost two hours straight last week on regulations I cannot control left me feeling completely burned out,” she said in mid-June.

Jennifer Gottschalk underwent a test for COVID-19 in a Toledo, Ohio, hospital on March 24. As the environmental health supervisor for the Toledo-Lucas County Health Department, she fielded calls about COVID-19 cases from a hospital bed while fighting the disease herself. She then worked throughout her home isolation, stopping only when her coughing was too severe to talk.(Jennifer Gottschalk via AP)

Gottschalk walks down a hallway of the department’s offices in Toledo, Ohio, on June 24. When the coronavirus pandemic struck earlier in the year, the county’s department was so short-staffed that her duties included overseeing campground and pool inspections, rodent control and sewage programs, while also supervising outbreak preparedness for a community of more than 425,000 people.(AP Photo/Paul Sancya)

Many are putting their health at risk. In Prince George’s County, Maryland, public health worker Chantee Mack died after, family and co-workers believe, she and several colleagues contracted the disease in the office.

A Difficult Road Ahead

Pence, in an op-ed in The Wall Street Journal on June 16, said the public health system was “far stronger” than it was when the coronavirus hit.

It’s true that the federal government this year has allocated billions for public health in response to the pandemic, according to the Association of State and Territorial Health Officials. That includes more than $13 billion to state and local health departments, for activities including contact tracing, infection control and technology upgrades.

A KHN-AP review found that some state and local governments are also pledging more money for public health. Alabama’s budget for next year, for example, includes $35 million more for public health than it did this year.

But overall, spending is about to be slashed again as the boom-bust cycle continues.

Roland Mack holds a poster with pictures and messages made by family members in memory of his sister, Chantee Mack, in District Heights, Maryland, on June 19. The Prince George’s County, Maryland, public health worker died of COVID-19 after, family and co-workers believe, she and several colleagues contracted the disease in their office.(AP Photo/Federica Narancio)

In most states, the new budget year begins July 1, and furloughs, layoffs and pay freezes have already begun in some places. Tax revenues evaporated during lockdowns, all but ensuring there will be more. At least 14 states have already cut health department budgets or positions or were actively considering such cuts in June, according to a KHN-AP review.

Since the pandemic began, Michigan temporarily cut most of its state health workers’ hours by one-fifth. Pennsylvania required more than 65 of its 1,200 public health workers to go on temporary leave, and others lost their jobs. Knox County, Tennessee, furloughed 26 out of 260 workers for eight weeks.

Frieden, formerly of the CDC, said it’s “stunning” that the U.S. is furloughing public health workers amid a pandemic. The country should demand the resources for public health, he said, just the way it does for the military.

“This is about protecting Americans,” Frieden said.

Cincinnati temporarily furloughed approximately 170 health department employees.

Robert Brown, chair of Cincinnati’s Primary Care Board, questions why police officers and firefighters didn’t face similar furloughs at the time or why residents were willing to pay hundreds of millions in taxes over decades for the Bengals’ football stadium.

“How about investing in something that’s going to save some lives?” he asked.

In 2018, Boston spent five times as much on its police department as its public health department. The city recently pledged to transfer $3 million from its approximately $60 million police overtime budget to its public health commission.

Looking ahead, more cuts are coming. Possible budget shortfalls in Brazos County, Texas, may force the health department to limit its mosquito-surveillance program and eliminate up to one-fifth of its staff and one-quarter of immunization clinics.

Months into the pandemic response, health departments are still trying to ramp up to fight COVID-19. Cases are surging in states including Texas, Arizona and Florida.

Meanwhile, childhood vaccinations began plunging in the second half of March, according to a CDC study analyzing supply orders. Officials worry whether they will be able to get kids back up to date in the coming months. In Detroit, the childhood vaccination rate dipped below 40%, as clinics shuttered and people stayed home, creating the potential for a different outbreak.

Cutting or eliminating non-COVID activities is dangerous, said E. Oscar Alleyne, chief of programs and services at the National Association of County and City Health Officials. Cuts to programs such as diabetes control and senior nutrition make already vulnerable communities even more vulnerable, which makes them more likely to suffer serious complications from COVID. Everything is connected, he said.

It could be a year before there’s a widely available vaccine. Meanwhile, other illnesses, including mental health problems, are smoldering.

The people who spend their lives working in public health say the temporary coronavirus funds won’t fix the eroded foundation entrusted with protecting the nation’s health as thousands continue to die.

Contributing to this report were: Associated Press writers Mike Stobbe in New York; Mike Householder in Toledo, Ohio; Lindsay Whitehurst in Salt Lake City, Utah; Brian Witte in Annapolis, Maryland; Jim Anderson in Denver; Sam Metz in Carson City, Nevada; Summer Ballentine in Jefferson City, Missouri; Alan Suderman in Richmond, Virginia; Sean Murphy in Oklahoma City, Oklahoma; Mike Catalini in Trenton, New Jersey; David Eggert in Lansing, Michigan; Andrew DeMillo in Little Rock, Arkansas; Jeff Amy in Atlanta; Melinda Deslatte in Baton Rouge, Louisiana; Morgan Lee in Santa Fe, New Mexico; Mark Scolforo in Harrisburg, Pennsylvania; and AP economics writer Christopher Rugaber, in Washington, D.C.

Related Topics

Cost and Quality Public Health States

How We Reported ‘Underfunded And Under Threat’

To assess the state of the public health system in the United States, KHN and The Associated Press analyzed data on government spending and staffing at national, state and local levels.

What reporters found was a mix of survey and budget data, each measuring a slightly different concept of “public health.”

Some datasets track only state public health systems, not agencies that operate at a county, city or regional level. Other data, including some from the U.S. Census Bureau, covers spending on all non-hospital health care. Public health efforts are mixed in with the costs of providing local medical transportation, running community clinics and offering mental health services.

The lack of comprehensive data specifically about public health makes assessing community programs, agencies and staffing levels difficult, experts say. Public health information is scattered and can’t be easily compared, unlike data about hospitals and medical treatment, according to Betty Bekemeier, a public health systems researcher and professor at the University of Washington. She is seeking to fix this as the leader of a multistate effort to standardize local health department spending data.

“We will not be able to improve our systems if we don’t have a better idea of how it works,” she said.

KHN and AP calculated 2016-18 average annual state spending directly on public health initiatives using the State Health Expenditure Dataset. To create the dataset, a team of researchers encoded data from the Census Bureau’s “Annual Survey of State Government Finances,” isolating public health costs to get the clearest sense of what governments spend only on public health efforts.

The data includes spending by all state agencies and their transfers to local governments. To account for inflation for this and all spending data, KHN and the AP adjusted amounts to 2019 dollars using a price deflator from the Bureau of Economic Analysis targeted toward government expenses.

A decade of data on state public health agencies’ expenditures and full-time equivalent staffing came from the Association of State and Territorial Health Officials. The data was reported directly by the state public health agencies through a national survey.

When creating national percentage change estimates, reporters excluded a handful of states missing comparable spending or staffing data.

The analysis included census finance data from state and local governments to compare spending on non-hospital health with other priorities such as policing and highway construction and maintenance.

At the local level, the National Association of County and City Health Officials’ “National Profile Study” surveys local health departments every three years and weights answers to account for nonresponse.

Beyond that, some states collect local health department spending and staffing data. Reporters used detailed data on local health departments in Florida, Minnesota, Missouri, North Carolina, Ohio and Washington — along with census population estimates — to examine per capita trends over time.

Finally, AP statehouse reporters posed an identical set of questions to states to get a sense of recent and upcoming budget and staffing changes to state public health departments. The AP gathered responses from 43 states.

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Public Health States

Six Takeaways Of The KHN-AP Investigation Into The Erosion Of Public Health

Local and state public health departments across the country work to ensure that people in their communities have healthy water to drink, their restaurants don’t serve contaminated food and outbreaks of infectious diseases don’t spread. Those departments now find themselves at the forefront of fighting the coronavirus pandemic.

But years of budget and staffing cuts have left them unprepared to face the worst health crisis in a century.

KHN and The Associated Press sought to understand the scale of the cuts and how the decades-long starvation of public health departments by federal, state and local governments has affected the system meant to protect the nation’s health.

Here are six key takeaways from the KHN-AP investigation:

  • Since 2010, spending for state public health departments has dropped by 16% per capita, and for local health departments by 18%. Local public health spending varies widely by county or town, even within the same state.
  • At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce in what was once viewed as one of the world’s top public health systems.
  • Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health.
  • More than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware.
  • Some public health workers earn so little that they qualify for government assistance. During the pandemic, many have found themselves disrespected, ignored or even vilified. At least 31 state and local public health leaders have announced their resignations, retired or been fired in 15 states since April.
  • States, cities and counties whose tax revenues have declined during the current recession have begun laying off and furloughing public health staffers. At least 15 states have cut health department budgets or positions, or were actively considering such cuts in June, even as coronavirus cases surged in several states.

Related Topics

Public Health States

As Cases Spike, California Pauses Multimillion-Dollar Testing Expansion

In April, Gov. Gavin Newsom launched a multimillion-dollar state initiative to bring COVID-19 testing to the people and places with the least access: rural towns and disadvantaged inner-city neighborhoods.

California is now halting its expansion, citing costs, even as the state is getting walloped by record-setting spikes in new infections and double-digit increases in hospitalizations.

The state will no longer fund new testing sites despite pleas from counties for additional assistance — and it has closed some locations and moved them elsewhere. It also has threatened to pull testing out of underused sites, according to nearly two dozen interviews with county public health officials.

While it’s early, some winners and losers have emerged: El Dorado County, east of Sacramento, lost its testing site in the town of Shingle Springs in June because it couldn’t fill enough appointment slots, while Fresno County gained a site that had been pulled from elsewhere, said its health officer, Dr. Rais Vohra.

Yet San Mateo County has asked state officials three times for a second state-funded testing venue to address testing gaps in Black and farmworker neighborhoods, but has been “told no, repeatedly,” said Justin Mates, deputy county manager. So the county transformed its sole state site into a roving testing unit.

“Equity is certainly a concern for us,” Mates said. “We really need help with testing access if we’re going to reach our Latino residents and places like East Palo Alto,” a diverse city whose population is mainly Latino, African American and Asian/Pacific Islander.

California has committed up to $132 million in contracts with two private COVID-19 testing companies, Verily Life Sciences and OptumServe, to offer free coronavirus tests at more than 100 sites that the Newsom administration has identified as “testing deserts.” The expansion has dramatically increased the state’s overall testing numbers, which swelled from 16,000 tests per day in April to 105,000 on Monday.

Testing is also available at county-funded locations, private pharmacies, hospitals and community clinics.

State Health and Human Services Secretary Mark Ghaly confirmed that the state is pulling sites out of counties that aren’t generating high enough numbers and cutting off funding for new locations.

“With every asset and resource — especially when it’s scarce — you want it to go to places where it’s most needed,” Ghaly said. “It wouldn’t be prudent or wise to maintain spending in a place where resources aren’t being used.”

Newsom himself has voiced concern about the price tag, given “unprecedented” budget shortfalls. “There is a big cost associated with testing,” he said in late June.

A Newsom administration official confirmed the state wants to see counties fill at least 80% of testing slots at each location. And if testing drops below 50% for a few days or longer, counties are warned the sites could be transferred elsewhere.

Counties argue there’s a public health benefit to keeping underperforming locations open — simply to ensure that testing is available to rural and disenfranchised communities. Across the state, they are fighting to save state-funded sites even as they are being overwhelmed by rising coronavirus cases linked largely to social gatherings.

“It’s how we are able to quickly identify where the virus is and if there are hot spots,” said Dr. Olivia Kasirye, health officer for Sacramento County, where holiday celebrations and booze-fueled gatherings among family and friends are sending infection rates soaring.

Contra Costa County saw its testing numbers drop in June and was at risk of losing a state-funded site until it proved it could keep appointments near 80% of capacity, said its health officer, Dr. Chris Farnitano.

Riverside County was warned June 16 that a state-funded site north of Temecula would be “moved to another county” if it didn’t get its testing above 50%, according to an email from the state’s testing taskforce. The state told Mendocino County it could lose its state-funded site, the only free testing available within a two-hour drive for some rural residents, if it didn’t push numbers up.

Alameda County grew so frustrated with state requirements that it undertook a testing expansion of its own.

“We realized we couldn’t depend on the state, especially to reach our vulnerable communities,” said Dr. Jocelyn Freeman Garrick, an emergency room doctor at Highland Hospital in Oakland, who is leading the county’s testing task force.

El Dorado County, which lost its site, so far has maintained a relatively low count of COVID-19 cases. It can’t afford to replace the site but will “make do,” said county spokesperson Carla Hass.

Ghaly said the state is working with counties in danger of losing sites to give them a chance to fill testing slots. State officials declined to say how many counties have lost sites, but as new infections have soared, testing numbers are starting to pick back up. The list of counties at risk of losing a site has dwindled from around a dozen in early June to a few last week.

Public health experts say focusing so intently on testing numbers, and not on adequately testing in Black and Latino neighborhoods, risks abandoning communities that already face immense barriers to health care like racism and poverty.

“If you ignore these communities, then we’ll keep seeing the kinds of surges that we’re seeing now,” said Dr. Tony Iton, formerly the top health official for Alameda County and now a senior vice president of the California Endowment, which is working with counties to expand testing in underserved neighborhoods.

Entrenched socioeconomic barriers also make it difficult to get, and keep, testing numbers up. For instance, people who want to be tested at state sites often need Internet access and an email address. Most are drive-thru, requiring access to a vehicle.

Many low-income people can’t meet those requirements, and undocumented immigrants fear that providing personal information to obtain a test could expose them to immigration officials, said Dr. Marty Fenstersheib, a former health officer of Santa Clara County who is leading its testing program.

“We can have all the tests we want, but if people are afraid to come and get tested, it’s not going to be of any benefit,” he said.

State contracts funding the testing sites were extended this month but are set to expire Aug. 31, and administration officials have not told counties whether the state will continue funding them after that, said Mimi Hall, president of the County Health Executives Association of California and director of public health for Santa Cruz County.

Counties can’t afford to keep the sites running, said Hall, who is on the state’s testing task force.

“It’s hard to plan when we don’t know how long we’ll be able to keep them,” Hall said.

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

Related Topics

California Public Health Race and Health States

Hospital Executive Charged In $1.4B Rural Hospital Billing Scheme

A Miami entrepreneur who led a rural hospital empire was charged in an indictment unsealed Monday in what federal prosecutors called a $1.4 billion fraudulent lab-billing scheme.

In the indictment, prosecutors said Jorge A. Perez, 60, and nine others exploited federal regulations that allow some rural hospitals to charge substantially higher rates for laboratory testing than other providers. The indictment, filed in U.S. District Court in Jacksonville, Florida, alleges Perez and the other defendants sought out struggling rural hospitals and then contracted with outside labs, in far-off cities and states, to process blood and urine tests for people who never set foot in the hospitals. Insurers were billed using the higher rates allowed for the rural hospitals.

Perez and the other defendants took in $400 million since 2015, according to the indictment. Many of the hospitals run or managed by Perez’s Empower companies have since failed as they ran out of money when insurers refused to pay for the suspect billing. Half of the nation’s rural hospital bankruptcies in 2019 were affiliated with his empire.

“This was allegedly a massive, multi-state scheme to use small, rural hospitals as a hub for millions of dollars in fraudulent billings of private insurers,” said Assistant Attorney General Brian Benczkowski of the Justice Department’s Criminal Division in a statement.

Attempts to reach Perez for comment Monday evening were unsuccessful. But last year when Perez spoke to KHN, he said he was losing sleep over the possibility he could go to jail after propping up struggling rural hospitals.

“I wanted to see if I could save these rural hospitals in America,” Perez said. “I’m that kind of person.”

Pam Green, a former night charge nurse at the now-shuttered Horton Community Hospital in Horton, Kansas (population under 1,700), said she hopes Perez and his colleagues receive long prison sentences.

“He just devastated so many people, not just in Kansas, but in Oklahoma and all the other places where he had hospitals,” said Green, 58, of nearby Muscotah, Kansas. “I went months and months without pay, without health insurance. He robbed the community.”

Green recalled that money was so tight under Perez’s management of her former hospital that the electricity was shut off at least twice and staffers had to bring in their own supplies. She said she is owed about $12,000 in back pay, as well as money for uncovered dental expenses and a workplace injury that would have been covered had employees’ insurance or workers’ compensation premiums been paid.

A KHN investigation published in August 2019 detailed the rise and fall of Perez’s rural hospitals. At the height of his operation, Perez and his Miami-based management company, EmpowerHMS, helped oversee a rural empire encompassing 18 hospitals across eight states. Perez owned or co-owned 11 of those hospitals and was CEO of the companies that provided their management and billing services.

Perez styled himself a savior of rural hospitals, swooping into small towns with promises to save their struggling facilities using his “secret sauce” of financial ventures. Multiple employees told KHN they had no idea what happened to the money their hospitals earned after Perez and his associates took control, since the facilities seemed perpetually starved for cash.

Over the past two years, amid mounting legal challenges and concerns about the lab-billing operation, insurers cut off funding and his empire crumbled. Overall, 12 of the hospitals have entered bankruptcy and eight have closed. The staggering collapse left hundreds of employees without jobs and small towns across the Midwest and South without lifesaving medical care.

The four rural hospitals named in the indictment are Campbellton-Graceville Hospital in Graceville, Florida; Regional General Hospital of Williston, Florida; Chestatee Regional Hospital in Dahlonega, Georgia; and Putnam County Memorial Hospital in Unionville, Missouri.

The indictment marks the third major case federal prosecutors have filed alleging billing fraud at Perez-affiliated hospitals. In October, David Byrns pleaded guilty to a federal charge of conspiracy to commit health care fraud involving a Missouri hospital he managed with Perez. A Missouri Auditor General report previously found that the 15-bed hospital, Putnam County Memorial in Unionville, had received about $90 million in questionable insurance payments in less than a year.

In July 2019, Kyle Marcotte, owner of a Jacksonville Beach, Florida, addiction treatment center pleaded guilty for his part in a $57 million lab-billing scheme involving two Perez-affiliated hospitals, Campbellton-Graceville and Regional General Hospital. Marcotte admitted cooperating with unnamed hospital managers to provide urine samples from his patients for lab testing that was billed through the rural hospitals and, in exchange, getting a cut of the proceeds.

Perez, on his own and through Empower-affiliated companies, in 2016 and 2017 purchased South Florida properties that totaled more than $3.7 million, including three condos on Key Largo, according to property records. He told KHN last year that the Florida properties were bought with earnings from unrelated software companies but declined to give details. He and his brother Ricardo Perez, if convicted, must forfeit over $46 million, according to the indictment, as well as two Key Largo condos and other properties.

Another defendant, Aaron Durall, if convicted, could lose $184.4 million and a six-bedroom, 6,500-square-foot home in the affluent Parkland district north of Fort Lauderdale, Florida.

Perez-affiliated hospitals also face ongoing lawsuits in Missouri and other states filed by dozens of insurers asking for hundreds of millions in restitution for allegedly fraudulent billings. In those court documents, Perez repeatedly has denied wrongdoing. He told KHN last year that his lab-billing setup was “done according to Medicare and state guidelines.”

For former employees of EmpowerHMS and members of the affected communities, the indictment represents vindication. As the company foundered, hundreds of employees worked without pay in vain efforts to keep their hospitals afloat. They would discover later that, along with the missing paychecks, their insurance premiums had not been paid and their medical policies had been discontinued. In the June 2019 interview, Perez acknowledged that, as finances withered, he stopped paying employee payroll taxes.

“It’s nice to think he might be held accountable,” said Melva Price Lilley, a former X-ray technician at Washington County Hospital in Plymouth, North Carolina, which has reopened with new owners under a new name. “At least there’s a chance that he might have to suffer some consequences. That gives me some hope.”

Lilley, 56, said she and other employees could not retrieve their retirement savings from the bankrupt hospital until about three weeks ago. She has been trying to pay off about $68,000 in medical bills from a back surgery she needed for a workplace injury that wasn’t covered by workers’ compensation insurance premiums that went unpaid for hospital employees. She remains unable to work full time.

I-70 Community Hospital, an Empower facility in Sweet Springs, Missouri, has remained closed since February 2019. Tara Brewer, head of the Sweet Springs Chamber of Commerce and the local health department, said she was almost shocked to hear that Perez had gotten indicted after months of wondering if anything would happen.

While she hopes these charges bring closure to her community, she said, the charges do little to fix the closed hospital doors for a county that has had one of the highest per capita rates of coronavirus cases in Missouri.

“What he did to us will linger on for a long time,” Brewer said.

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Workers Filed More Than 4,100 Complaints About Protective Gear. Some Still Died.

COVID-19 cases were climbing at Michigan’s McLaren Flint hospital. So Roger Liddell, 64, who procured supplies for the hospital, asked for an N95 respirator for his own protection, since his work brought him into the same room as COVID-positive patients.

But the hospital denied his request, said Kelly Indish, president of the American Federation of State, County and Municipal Employees Local 875.

On March 30, Liddell posted on Facebook that he had worked the previous week in both the critical care unit and the ICU and had contracted the virus. “Pray for me God is still in control,” he wrote. He died April 10.

Roger Liddell(Courtesy of Bill Sohmer)

The hospital’s problems with personal protective equipment (PPE) were well documented. In mid-March, the state office of the Occupational Safety and Health Administration (OSHA) received five complaints, which described employees receiving “zero PPE.” The cases were closed April 21, after the hospital presented paperwork saying problems had been resolved. There was no onsite inspection, and the hospital’s written response was deemed sufficient to close the complaints, a local OSHA spokesperson confirmed.

The grief and fear gripping workers and their families reflect a far larger pattern. Since March, more than 4,100 COVID-related complaints regarding health care facilities have poured into the nation’s network of federal and state OSHA offices, which are tasked with protecting workers from harm on the job.

A KHN investigation found that at least 35 health care workers died after OSHA received safety complaints about their workplaces. Yet by June 21, the agency had quietly closed almost all of those complaints, and none of them led to a citation or a fine.

The complaint logs, which have been made public, show thousands of desperate pleas from workers seeking better protective gear for their hospitals, medical offices and nursing homes.

The quick closure of complaints underscores the Trump administration’s hands-off approach to oversight, said former OSHA official Deborah Berkowitz. Instead of cracking down, the agency simply sent letters reminding employers to follow Centers for Disease Control and Prevention guidelines, said Berkowitz, now a director at the National Employment Law Project.

“This is a travesty,” she said.

A third of the health care-related COVID-19 complaints, about 1,300, remain open and about 275 fatality investigations are ongoing.

During a June 9 legislative hearing, Labor Secretary Eugene Scalia said OSHA had issued one coronavirus-related citation for violating federal standards. A Georgia nursing home was fined $3,900 for failing to report worker hospitalizations on time, OSHA’s records show.

“We have a number of cases we are investigating,” Scalia said at the Senate Finance Committee hearing. “If we find violations, we will certainly not hesitate to bring a case.”

Texts between Barbara Birchenough and her daughter, (in blue) Kristin Carbone.(Courtesy of Kristin Carbone)

A March 16 complaint regarding Clara Maass Medical Center in Belleville, New Jersey, illustrates the life-or-death stakes for workers on the front lines. The complaint says workers were “not allowed to wear” masks in the hallway outside COVID-19 patients’ rooms even though studies have since shown the highly contagious virus can spread throughout a health care facility. It also said workers “were not allowed adequate access” to PPE.

Nine days later, veteran Clara Maass registered nurse Barbara Birchenough texted her daughter: “The ICU nurses were making gowns out of garbage bags. … Dad is going to pick up large garbage bags for me just in case.”

Kristin Carbone, the eldest of four, said her mother was not working in a COVID area but was upset that patients with suspicious symptoms were under her care.

In a text later that day, Birchenough admitted: “I have a cough and a headache … we were exposed to six patients who we are now testing for COVID 19. They all of a sudden got coughs and fevers.”

“Please pray for all health care workers,” the text went on. “We are running out of supplies.”

By April 15, Birchenough, 65, had died of the virus. “They were not protecting their employees in my opinion,” Carbone said. “It’s beyond sad, but then I go to a different place where I’m infuriated.”

OSHA records show six investigations into a fatality or cluster of worker hospitalizations at the hospital. A Labor Department spokesperson said the initial complaints about Clara Maass remain open and did not explain why they continue to appear on a “closed” case list.

Nestor Bautista, 62, who worked closely with Birchenough, died of COVID-19 the same day as she did, according to Nestor’s sister, Cecilia Bautista. She said her brother, a nursing aide at Clara Maass for 24 years, was a quiet and devoted employee: “He was just work, work, work,” she said.

Barbara Birchenough(Courtesy of Kristin Carbone)

Nestor Bautista(Courtesy of Cecilia Bautista)

Responding to allegations in the OSHA complaint, Clara Maass Medical Center spokesperson Stacie Newton said the virus has “presented unprecedented challenges.”

“Although the source of the exposure has not been determined, several staff members” contracted the virus and “a few” have died, Newton said in an email. “Our staff has been in regular contact with OSHA, providing notifications and cooperating fully with all inquiries.”

Other complaints have been filed with OSHA offices across the U.S.

Twenty-one closed complaints alleged that workers faced threats of retaliation for actions such as speaking up about the lack of PPE. At a Delaware hospital, workers said they were not allowed to wear N95 masks, which protected them better than surgical masks, “for fear of termination or retaliation.” At an Atlanta hospital, workers said they were not provided proper PPE and were also threatened to be fired if they “raise[d] concerns about PPE when working with patients with Covid-19.”

Of the 4,100-plus complaints that flooded OSHA offices, over two-thirds are now marked as “closed” in an OSHA database. Among them was a complaint that staffers handling dead bodies in a small room off the lobby of a Manhattan nursing home weren’t given appropriate protective gear.

More than 100 of those cases were resolved within 10 days. One of those complaints said home health nurses in the Bronx were sent to treat COVID-19 patients without full protective gear. At a Massachusetts nursing home that housed COVID patients, staff members were asked to wash and reuse masks and disposable gloves, another complaint said. A complaint about an Ohio nursing home said workers were not required to wear protective equipment when caring for COVID patients. That complaint was closed three days after OSHA received it.

It remains unclear how OSHA resolved hundreds of the complaints. A Department of Labor spokesperson said in an email that some are closed based on an exchange of information between the employer and OSHA, and advised reporters to file Freedom of Information Act requests for details on others.

“The Department is committed to protecting America’s workers during the pandemic,” the Labor Department said in a statement. “OSHA has standards in place to protect employees, and employers who fail to take appropriate steps to protect their employees may be violating them.”

The agency advised its inspectors on May 19 to place reports of fatalities and imminent danger as a top priority, with a special focus on health care settings. Since late March, OSHA has opened more than 250 investigations into fatalities at health care facilities, government records show. Most of those cases are ongoing.

According to the mid-March complaints against McLaren Flint, workers did not receive needed N95 masks and “are not allowed to bring them from home.” They also said patients with COVID-19 were kept throughout the hospital.

Patrick Cain and his wife, Kate(Courtesy of Kelly Indish)

Filing complaints, though, did little for Liddell, or for his colleague, Patrick Cain, 52. After the complaints were filed, Cain, a registered nurse, was treating people still awaiting the results of COVID-19 diagnostic tests — potentially positive patients ― without an N95 respirator. He was also working outside a room where potential COVID-19 patients were undergoing treatments that research supported by the University of Nebraska has since shown can spread the virus widely in the air.

At the time, there was a debate over whether supply chain breakdowns of PPE and weakened CDC guidelines on protective gear were putting workers at risk.

Cain felt vulnerable working outside of rooms where COVID patients were undergoing infection-spreading treatments, he wrote in a text to Indish on March 26.

Texts between union president Kelly Indish and Patrick Cain (right)(Courtesy of Kelly Indish)

“McLaren screwed us,” he wrote.

He fell ill in mid-March and died April 4.

McLaren has since revised its face-covering policy to provide N95s or controlled air-purifying respirators (CAPRs) to workers on the COVID floor, union members said.

A spokesperson for the McLaren Health Care system said the OSHA complaints are “unsubstantiated” and that its protocols have consistently followed government guidelines. “We have always provided appropriate PPE and staff training that adheres to the evolving federal, state, and local PPE guidelines,” Brian Brown said in an email.

Separate from the closed complaints, OSHA investigations into Liddell and Cain’s deaths are ongoing, according to a spokesperson for the state’s Department of Labor and Economic Opportunity.

Nurses at Kaiser Permanente Fresno Medical Center also said the complaints they aired before a nurse’s death have not been resolved. (KHN is not affiliated with Kaiser Permanente.)

On March 18, nurses filed an initial complaint. They told OSHA they were given surgical masks, instead of N95s. Less than a week later, other complaints said staffers were forced to reuse those surgical masks and evaluate patients for COVID without wearing an N95 respirator.

Several nurses who cared for one patient who wasn’t initially suspected of having COVID-19 in mid-March wore no protective gear, according to Amy Arlund, a Kaiser Fresno nurse and board member of the National Nurses Organizing Committee board of directors. Sandra Oldfield, a 53-year-old RN, was among them.

Arlund said Oldfield had filed an internal complaint with management about inadequate PPE around that time. Arlund said the patient’s illness was difficult to pin down, so dozens of workers were exposed to him and 10 came down with COVID-19, including Oldfield.

Sandra Oldfield(Courtesy of Lori Rodriguez)

Lori Rodriguez, Oldfield’s sister, said Sandra was upset that the patient she cared for who ended up testing positive for COVID-19 hadn’t been screened earlier.

“I don’t want to see anyone else lose their life like my sister did,” she said. “It’s just not right.”

Wade Nogy, senior vice president and area manager of Kaiser Permanente Fresno, confirmed that Oldfield had exposure to a patient before COVID-19 was suspected. He said Kaiser Permanente “has years of experience managing highly infectious diseases, and we are safely treating patients who have been infected with this virus.”

Kaiser Permanente spokesperson Marc Brown said KP “responded to these complaints with information, documents and interviews that demonstrated we are in compliance with OSHA regulations to protect our employees.” He said the health system provides nurses and other staff “with the appropriate protective equipment.”

California OSHA officials said the initial complaints were accurate and the hospital was not in compliance with a state law requiring workers treating COVID patients to have respirators. However, the officials said the requirement had been waived due to global shortages.

Kaiser Fresno is now in compliance, Cal/OSHA said in a statement, but the agency has ongoing investigations at the facility.

Arlund said tension around protective gear remains high at the hospital. On each shift, she said, nurses must justify their need for a respirator, face shield or hair cap. She expressed surprise that the OSHA complaints were considered “closed.”

“I’m very concerned to hear they are closing cases when I know they haven’t reached out to front-line nurses,” Arlund said. “We do not consider any of them closed.”

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KHN’s ‘What The Health?’: High Court’s Surprising Abortion Decision


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The Supreme Court surprised both sides in the polarized abortion battle Monday by ruling, 5-4, that a Louisiana law requiring doctors who perform the procedure to have admitting privileges at a nearby hospital is an unconstitutional infringement of a woman’s right to an abortion.

As expected, the court’s four liberals in the case, June Medical Services v. Russo, said that the law did not provide any protections for women and merely made it harder for them to obtain an abortion and that it was nearly identical to a Texas law struck down in 2016. The four conservatives said the Louisiana law should be upheld, although that would have left the state with only a single abortion provider. The swing vote was Chief Justice John Roberts, who, in a concurring opinion, said he disagreed with the ruling in the Texas case but it is now precedent and thus should not be overturned.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico and Jennifer Haberkorn of the Los Angeles Times.

The panelists broke down the decision along several lines, including:

  • Why a court with five justices who have all voted to back abortion restrictions did not uphold the first major abortion law to come before it since Anthony Kennedy retired and was replaced by Brett Kavanaugh.
  • How the ruling could have gone much further than merely upholding the Louisiana law. The court had been asked to use the case to overturn Roe v. Wade in its entirety and to bar abortion providers from filing suit on behalf of their patients. The justices did neither.
  • Why Justice Roberts’ vote in this case does not suggest he will vote with abortion-rights supporters in other cases, but might offer a clue on how he will vote in the upcoming case challenging the constitutionality of the Affordable Care Act.
  • How this case could play at the polls in November.

“What the Health?” is taking a break on Thursday but will return July 9.


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